Edward Milman, MD, director, MRI Services, St. Joseph’s Regional Medical Center, reviews and reports on images from a diagnostic PACS workstation.

Over the last two decades, PACS has grown from a bleeding edge technology that delivered a massive productivity bang as sites transitioned from film to digital image management to a mature, commoditized system. The radiology-centric focus has been replaced by an enterprise view that considers image-intense specialties like orthopedic surgery and emergency medicine as well as IT ramifications and system integration. In short, PACS is an enterprise business essential.

A 2010 PACS deployment is not the same as the initial transition from film to digital, says Greg Spencer, MD, chief medical officer of Crystal Run Healthcare in Middletown, N.Y. “We see a slow, steady incremental gain in workflow,” he explains. Plus, new systems have more fleeting lifespans with most lasting three to four years rather than the 10 to 12 years expected with early digital image management systems. With fewer, more elusive gains; terabytes of legacy data and hoards of diverse enterprise users, the recipe for a successful enterprise deployment can be a tenuous proposition.

Despite the challenges, many sites have carved a path to enterprise success. The common denominators are a user-centric focus, integration and value.  This month, a trio of successful sites shares their rules for success with Health Imaging & IT.

Rule #1: Adopt an enterprise focus

PACS is not just for radiology anymore. True success in the digital image management world hinges on rich use across the enterprise. When St. Joseph’s Regional Medical Center in Paterson and Wayne, N.J., replaced multiple, disconnected PACS with an enterprise system (Infinitt), the planning team engaged users across the enterprise.

The emergency department came to the table with a fresh perspective and made requests that the radiology department hadn’t considered, shares Ed Milman, MD, director, MRI services. For example, the chair of the emergency department asked for an integrated feedback mechanism, so that physicians could receive a streamlined confirmation or disagreement of preliminary results.

Similarly, ABQ Health Partners of Albuquerque, N.M., focused on needs across the enterprise as it planned its PACS deployment (NovaRad). “We realized heavy users like orthopedic surgery, podiatry and the hand clinic would need diagnostic quality image access as soon as it existed,” explains Susan Thomas, PACS project manager. The multi-physician specialty group carefully differentiated diagnostic users from patient relations users, providing the latter with low-bandwidth access needed for sharing images with patients and equipping heavy image users with rapid access and diagnostic workstations.

Thomas recommends pulling all users into the tent early to fully grasp their needs and ensure that they receive adequate training. The practice also supplemented vendor training with internal workflow training; radiology team members played various parts so all users understood what go-live day would look like. Super-users stationed across the practice’s 17 locations during go-live ensured a smooth experience.

Similarly, Miguel Hernandez, director of information technology at Crystal Run Healthcare, touts a comprehensive approach to workflow assessment and staff training. “Document workflow from beginning to end and train all users from radiologists to technologists. Every user needs to understand how the system will change his workflow and how individual workflow ties to others in the system.”

Rule #2: Insist on integration

“Crystal Run Healthcare is a very high-volume facility with 2,800 to 3,000 patient visits daily. We want our providers seeing patients not flipping through charts,” Spencer says. The model requires a seamless, rapid interface between PACS (Carestream) and the EHR. The integrated practice also prioritized integration with RIS and voice recognition as well as never-before integrated diagnostic imaging modalities including mammography and DEXA. “It’s all about physician efficiency,” shares Spencer.

As the enterprise PACS team surveyed the landscape, they rigorously tested various systems. “We wanted workflow to reduce clicking, and we didn’t take anyone’s word regarding performance,” Spencer says. The team also made sure that the new system presented information to physicians in a unified way, so physicians didn’t squander any time looking for what they needed.

The Era of PACS-free Image Management?

Wooster Community Hospital in Wooster, Ohio, may re-write the rules of PACS deployment. The two radiologist/60,000 procedure per year community hospital leases a good PACS (Sectra) that meets its needs, says Dave Harrison, director of radiology. The hospital also uses HL7 interfaces and an internal network to share its radiology workload with a teleradiology provider. The partnership is built on a common work pool that shares studies across onsite and offsite radiologists and enables an impressive 30 to 40 minute turn-around time on stat studies and expedited cases. Patients and referring physicians are happy with the arrangement that provides rapid, sub-specialty interpretation. Next year, when the PACS lease expires the hospital may use the outside provider’s PACS and maintain only a store and forward image server onsite as well as its third-party offsite archive. “It would improve workflow because we wouldn’t have to push images,” shares Harrison. The other plus could be drastically reduced costs if the hospital eliminates its $350,000 annual PACS lease. Harrison estimates the offsite model would cost approximately $150,000 annually as the hospital would require only an onsite HL7 portal for technologist Q&A, and it would continue to maintain diagnostic workstations for radiologists and other heavy image consumers like the ED and hospitalists. “We are still in the early stages of planning, but the rules are changing,” sums Harrison.

On a related IT note, the integrated practice equipped users with new workstations, updated its servers and invested in the fastest network available. It also segmented PACS onto a separate switch to further boost speed and efficiency.

St. Joseph’s Regional Medical Center’s primary PACS priorities included a fully integratable system. The PACS is integrated across the HIS and ambulatory system.  Remote access allows users to read from everywhere. Prior to the deployment, a pair of radiologists read x-rays from hospital reading rooms.

Now, all radiologists read from everywhere. The results speak for themselves. Exam volume has increased about 8 percent annually, yet in the six months since PACS go-live the center has achieved six steadily decreasing times in report turnaround, shares John Hart, administrative director of radiology.

Rule #3: Plan for maximum value and efficiency

With ultra-slim budgets and razor-thin margins, it’s critical to squeeze every possible ounce of value and efficiency from the PACS investment.

Crystal Run Healthcare not only planned its PACS to keep physicians across the enterprise working at maximum efficiency, it also invested in outside expertise to save funds in the long run. “Data migration is a challenge. There can be a lot of hidden costs,” shares Hernandez. The integrated practice worked with its new vendor to emphasize its responsibilities in the migration process and also hired a consultant to facilitate the migration and bypass costly surprises.

According to St Joseph’s Regional Medical Center CIO Jim Cavanagh, “The biggest issue in an enterprise PACS project is the rate of change.” The era of a 10 to 12 year investment has ended, so the enterprise needs to be very tactical in PACS design. St. Joseph’s insisted on an independent storage infrastructure for its enterprise system. Because storage is hospital rather than PACS infrastructure, it delivers more performance at the same price, allowing the hospital to use the system for EMR data, email and digital echo as well as image storage.

The final rule

The last rule? Rules are flexible. Although some parameters—efficiency, integration and an enterprise focus—are universal, each enterprise is unique. Sites that want the ideal enterprise PACS need to survey the internal and external landscape and then write their own rules for success.