Imaging Centers Going with the Workflow

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Believe the ‘buzz’

There are few buzzwords bigger than ‘workflow’ within the radiology industry. It is uttered so much that it seems to begin to lose its meaning, at least until you visit an imaging center. Upon investigating multiple centers across the nation, it quickly becomes apparent that ‘workflow’ is not really a buzz word at all. It is simply a crucial piece of reality.

In this age of decreasing radiology reimbursements, increasing competition, rising costs of operation, and growing demands from referring physicians—just to name a few—imaging centers had better be running Cracker Jack operations. Knowing your workflow, addressing what needs fixing, and adopting the right technologies to facilitate your goals is the path to a well-oiled, fine-tuned imaging facility.

RIS/PACS integration

To improve workflow, no single element seems more essential than integrating the patient information in your radiology information system with the images and reports in your picture archiving and communications system. Of course, ‘integration’ also is a huge buzzword, but in the life of a radiologist, streamlining the process by which each image is acquired, read, and reported is vital. A PACS driven by a RIS can massively improve every department within an imaging center.

Centers that don’t have a strong RIS pine for one. That’s the case at US Imaging, a network of seven imaging centers across Texas. The multi-modality centers, which manage about 125,000 images each year, have seen turnaround times reduced 20 to 25 percent following the adoption of a ScImage PicomEnterprise PACS. However, the facility could potentially improve even further with the implementation of a new RIS system, says Chief Information Officer Kyle Richie.

US Imaging is proof, however, that a successful PACS implementation alone can provide big workflow benefits overall. At US Imaging, the ScImage system has allowed radiologists to work together at one facility so they can consult onsite with one another. Also, Richie says that they have been able to make productivity gains by adding more modalities due to some of the savings they’ve seen.

Yet, some imaging practices—those with the financial wherewithal at least—set out to structure their entire organizations around the idea that having an integrated RIS/PACS is essential.

“Integration is key. It has probably accounted for 80 percent of the efficiency that we’ve received,” says Jim Busch, MD, radiologist, director of Specialty Networks, Diagnostic Radiology Consultants, a private practice radiology group in Chattanooga, Tenn., that services North Georgia and Southeast Tennessee. “What RIS/PACS integration does is allow me to organize my workflow into a unified environment, which allows me to focus almost entirely on image interpretation because the reporting system is integrated with the images. And all of the patient data are already there and don’t have to be restated and rechecked every time I interpret an exam,” he adds.

Such efficiency is very important when you’re processing about 200,000 exams every year for hospitals, outpatient imaging centers and also multi-specialty practice groups. To handle the load, the group invested in a full syngo suite from Siemens, including a RIS (syngo Workflow) and PACS (syngo Imaging) and syngo Voice—an integrated voice recognition software. To boot, they added a NextGen EPM (enterprise practice management) system which handles all scheduling and registration. These technologies offer the entire platform from registration, scheduling, imaging at the technologist level, interpretation with a radiologist, and distribution. Billing will be added in the future, says Busch.

The whole goal was to improve efficiency. “I expected between 10 to 12 percent efficiency gained once the full system was in place. So far we have already seen the efficiency of a full FTE (full time employee) lost out of 11 doctors—which is a 10 percent increase already and we do not yet have 60,000 exams on the system yet,” says Busch. “A full FTE is very important. Probably the biggest cost for a radiology practice is the radiologist. If you can eliminate one, it goes a long way to pay for your system.”

Busch also is a big advocate for integrating your voice transcription software with your RIS. “What that does is provide functionality that you could never achieve with just a third-party voice transcription software interface. What happens is that when you open an examination, the RIS understands what exam you’ve opened and it is able to automatically populate predetermined fields, or bring up a dictation template associated with that examination, which is modality and body part specific,” says Busch.

Another imaging center that had the luxury of designing itself around the notion of RIS/PACS integration is the Imaging Center for Cardinal Health System, a joint venture between Ball Memorial Hospital and the Radiology Associates of Muncie in Indiana. The center covers the east-central portion of the state.

Though the center is associated with the health system and the hospital, it remains its own free-standing, multi-modality imaging facility that handles “all comers” from the surrounding community, says Eric Tharp, director of Medical Imaging Services. The center also is connected to a 15-bed critical access facility called Blackford County Hospital, as well as Jay County Hospital that isn’t directly linked but has its images “pumped in” for interpretation, says Tharp.

The Imaging Center uses a Kodak Carestream PACS and RIS along with Kodak Mammography Workstations. The PACS was installed in May 2005 when the center launched, though the RIS was implemented later in the year.

The biggest gains seem to have come from use of the RIS, together with the PACS, which open like one system. This deep integration facilitates scheduling, image viewing, dictation, transcription, and sends billing messages to the billing service/system software. Tharp believes that there is a big advantage for using a RIS and PACS from the same vendor because systems from different vendors don’t always “play well” together. Eventually their RIS/PACS will connect each of the hospitals and the Imaging Center.

Most facilities installing these types of systems surely expect turnaround improvements. However, Tharp was actually surprised by some of the improvements they’ve seen. “I didn’t expect we’d knock as much time from the process of an exam being done and a preliminary report being available,” Tharp says. In regard to the hospital, for example, the turnaround time for providing a preliminary report went from an average of 16 ½ hours to 3 ½ hours.

The RIS has the ability to fax complete preliminary reports to referring physicians, and then another when it is signed. Referring physicians also can use the web-PACS portal to read the images and reports.

Also, the RIS has made the facility “paper-lite.” Using less paper translates into workflow benefits by giving radiologists access to data electronically, whereas before they had to rely on paper. For example, the center “created electronic versions of the requisition that live within the RIS. The technologists electronically enter in all of their patient history and exam information and the physicians can access that while they’re reading. This has improved workflow because we used to have to distribute paper copies of these requisitions where are the physicians are reading. Now all they do is click and it’s there,” Tharp says.

The Kodak system also includes a mammography form that is typically used by a technologist to take down patient history and mark a breast diagram with descriptions of physical attributes. The digital version of this form within the system enables radiologists to reference it when reading images rather than relying on paper.

Also, Tharp’s team—with the help of Kodak—created reports in the system to help them meet their MQSA (Mammography Quality Standards Act) requirements. The reports can easily be printed out of the RIS if there is an inspection of the center. The financial and time savings generated with this have been substantial, as the center used to have an outside vendor to generate these types of documents, says Tharp.

Centralizing Resources

Allocation of personnel on nearly every level can be simplified a great deal through the use of RIS and PACS. For a small network of imaging centers, no longer is it necessary to have transcriptionists or schedulers at every office. Even more essential, a radiologist need not be at every office. In fact, they might not even be in an office, the might be reading images at home or at another site. The tools are the same provided they have access to images and the appropriate equipment.

Such is the case with Zwanger-Pesiri Radiology Group on Long Island which includes five free-standing, multi-modality imaging centers all connected through a Merge Fusion RIS and Fusion PACS installed in late 2004. In 2005, the system logged 180,000 studies and expects to reach 200,000 this year.

“Now all of our transcriptionists are in one place, the majority of our radiologists are in one place, scheduling is in one place, so we have everything centralized,” says Bob Day, chief MRI/CT technologist.

In the past, five locations could theoretically require 10 transcriptionists, but with the RIS, six or seven transcriptionists can cover the work which is funneled to one location, says Day, who adds that they’ve saved a good deal of money as a result. All reductions in personnel, however, have been done through attrition.

“We don’t look at the practice now as five individual sites, but rather as one large unit—making the resources much easier to allocate in that way,” says Day. “We used to have to staff each site with two to three radiologists, but now we only need one radiologist at each imaging center and then we can pool the rest of them.”

Practice Administrator Maria Ball says “many of Zwanger-Pesiri’s radiologists have subspecialties, and their expertise can be utilized across the five centers much more effectively now.

“If we have a patient for a brain MRI who is 20 miles away from our radiologist who is a specialist in neuro, it is not an issue,” she says. That’s a big benefit to patients—whether it’s a neuroradiology, orthopedics, or musculoskeletal exam—because the images are simply sent to where the appropriate radiologist is sitting at the moment, Ball adds.

Zwanger-Pesiri’s RIS/PACS Manager Matt Dewey is currently working on a new feature of the FusionRIS 3.0 software that will eventually enable them to pull up a patient’s prior images via a simple two-click process. The software will eventually help them to target prior images that are relevant to a patient’s current visit rather than highlighting all prior images, Dewey says.

Another tool they are beginning to use is a decision support software called STATDx from Amirsys.

Interestingly, they have found the web-based Referral Physician Portal to be a great workflow tool in that it helps them distribute reports more quickly, but it also has proven to be great for marketing. It gives them a way to reach out to physicians and offer a tool that will improve the referring physician’s workflow as well, says Day.

Reducing your clicks

Some imaging centers view the technologies they implement as more of a means to an end. It’s the process that matters most in this view, and once you know how efficient you want your process to be, and how you envision making that happen, the technology just helps you see it to fruition.

“When implementing a PACS, the efficiencies are going to be gained based upon the workflow you design and build, not necessarily with the tools the PACS has. It is all about workflow,” says Dan Braga, PACS Administrator, Proscan Imaging, which includes 25 imaging centers nationally, and performs reads for hundreds of other facilities across the country in every modality.

Echoing others, Braga emphasizes the benefit of integrating PACS—in this case an Intelerad IntelePACS installed 11 months ago—with RIS. But he adds that the big draw for them was the capabilities of the Intelerad system’s API (advanced programming interface) that allows it to talk with other systems.

“In the radiologist world, it’s all about workflow, and how you can make their processes easier. It’s true, one PACS might have MPR (multi-planar reconstruction), and another PACS might have something else, but that’s not what is boosting workflow efficiency. It’s how many clicks of a button it takes to complete a certain task,” says Braga.

Proscan has had a good deal of success consolidating radiologists’ tools at their workstation, which is the same if a radiologist is at home or at the office. Within the integrated workstation environment, radiologists have access to dictation, RIS, PACS, and report sign-off all in one location.

And despite the recent drops in radiologist reimbursements, Braga feels that “radiologists can either work longer hours to make the same amount of money or choose to work smarter and be more efficient. That is why good workflow is important,” he says.

With or without RIS, although many PACS operate in very similar ways and offer very similar tools, the benefits to radiology workflow should not be underestimated.

Working with a PACS can make you a “reading powerhouse,” says Lawrence Tanenbaum, Larry Tanenbaum, MD, FACR, section chief MRI, CT and neuroradiology at Edison Imaging - NJ Neuroscience Institute, Seton Hall School of Graduate Medical Education in New Jersey, which includes nine imaging centers and processes 150,000 studies every year.

Six years ago, Edison installed a GE Centricity PACS and shortly thereafter a Centricity RIS. Back when the system was first installed, Tanenbaum says working with the PACS was a surprise because he was able to get to the studies much more quickly, as opposed to manual film handling. Most radiologists think they are going to be less efficient with PACS but in the end they are more efficient, he says.

And PACS continue to evolve, gaining tools that will make radiologists’ lives much easier. One of the latest developments is the integration of workstation functionality into the PACS itself, says Tanenbaum.

“Now instead of having to go to a workstation to interact with data in a 3D fashion, with one click of a button the 3D information comes right up within my PACS. It’s an enormous help to me to not have to go to another interface to see things in 3D,” he adds.

Every room is a reading room

When the Kaiser Permanente imaging centers that serve northern California first installed a Philips/Stentor iSite PACS back in 2003, they had trouble adjusting away from the hard copy days of film-reading-room focused thinking.

“But what we found is that for us as we were growing and adding radiologists, it ceased to make sense having dedicated areas that the radiologists went to. We sort of broke the mold and decided to repurpose the reading rooms as radiologist offices and have every office able to be a reading room. And the radiologists really liked it,” says Skip Kennedy, assistant direct for Radiology Informatics within the Radiology Department, Kaiser Permanente. “The idea of scheduling the radiologists to be at a certain place at a certain time and to make the films available, and all the other things we had to do before just sort of evaporated. It became sort of a virtual process, radiologists just showed up and they read.”

Each radiologist is provided with a full PACS configuration including digital dictation and all the other tools he or she needs. Radiologists stay put unless they are going to do an interventional procedure or doing fluoroscopy, for example.

Cost savings can be found in this approach, in that reading rooms are terribly expensive and radiologists offices can be converted at much less cost, Kennedy says. Other savings will likely be seen later this year as many of their radiologists are hoping to start reading from home which will replace the need for them to outsource overnight radiology services.

Another new reality and workflow booster is the changing role of technologists in the imaging QA process. They are the final line of defense before a button is pushed and the image is on its way.

“We’ve always had the file room as a safety net. The techs have focused appropriately on image quality as their primary deliverable, and if they got the patients’ name and study identifier on there correctly, then that was gravy,” says Kennedy. “If the identifier wasn’t right, then someone in the file room would correct it and get it to the providers. Now the tech hits the button and the provider has access to the image instantly.”

Kaiser has instituted training called “Point-of-Care QA” that reinforces the point with the techs that once they hit that button, it’s their deliverable to get right, says Kennedy.

With all of this quick access, the bar keeps rising to make the images and preliminary reports almost instantly available. As this bar goes higher and higher, radiology’s job gets harder and harder. Meanwhile, other departments are co-evolving their workflow to adjust to radiology’s push to all digital, adds Kennedy.


Tight RIS/PACS integration is a crucial component of any strategy within an imaging center to improve overall workflow. The RIS must drive the PACS and together function as a single system for best results. Beyond that, centralization of operations and staff allocation at all levels will benefit operations, but also—and most importantly—provide greater care for patients. Consolidation of radiologist tools within a workstation also is highly beneficial.

Finally, training is useful to guarantee that personnel—especially technologists—fully understand the new challenges and responsibilities they face in the age of PACS.