Enterprise PACS in a New Enterprise

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Sky Ridge Medical Center opened its doors on Aug. 20, 2003. The 106-bed full-service, acute-care hospital serves the younger, tech-savvy communities southwest of Denver. The new hospital strives to provide comprehensive care and features private rooms, healing gardens, a medical library for patients, business center and amenity suites. A significant investment in cutting-edge technology and commitment to the filmless and paperless model complements our patient-centered environment.

Adjacent to the hospital is a new, fully leased four-story medical office building housing more than 100 physicians representing various medical specialties. A second building mirroring the first is due to be completed this April.

The initial vision for Sky Ridge focused on bringing high-quality, community-based care to rapidly growing suburban areas. The first goal was achieved when the hospital opened in August. The hospital administration is planning for a fairly robust expansion. The long-term plan calls for a 335-bed hospital and potentially a third medical office building. Moreover, hospital administration and cardiologists aim to become a top-tier community hospital for heart disease.


SELECTING A PACS

Building a new hospital brings a unique opportunity to create the ideal model. You can develop an enterprise based on streamlined workflow and optimized clinical care. One of the drivers that ultimately determine the success in meeting these goals is the picture archiving and communications system (PACS).

At Sky Ridge, as in any new hospital, we had a number of factors working to our advantage. We did not have to contend with any legacy issues or integrate older equipment into the system. The hospital is completely wired with fiber. The core network is Gigabit fiber, CAT 5, which runs throughout the hospital and to communications closets in the medical office buildings. The core network is Layer 3 and redundant with T1 backup connectivity. The PACS network resides on a separate VLAN, with the Radiology Imaging Associates network and Merge eFilm serving as backup. We rely on a multiple RAID, EMC CX600 with six usable Terabytes for storage. A Plasmon DVD deep archive provides long-term storage.

On the human side, referring physicians had not established image viewing patterns in this hospital. This gave us the opportunity to establish the standard. Still, as with any new venture, we encountered some constraints. Nothing in the hospital could be truly tested before going live on day one. Everything - the PACS, HIS, RIS, phone lines, workflow patterns - was uncharted territory. To further complicate matters, key members of the PACS team were working at other sites or had numerous additional tasks during the installation process. We needed to find and deploy a solution that could be up and running smoothly at the outset.

The PACS process began 18 months before Sky Ridge opened its doors. We employed a team approach that involved radiologists, other specialty physicians and administration. The team thoroughly researched PACS to understand what the technology offers in terms of workflow, dissemination of information, patient care and costs. Then we established a vision for our hospital.

Our first goal was similar to most facilities. We wanted efficient, fairly intuitive image distribution for our referring physicians. This enhances their workflow and speeds patient care. We knew PACS also could help with technologists' and nurses' workflow by cutting down on the number of repeat studies and other workflow interruptions, such as the calling of results. Another consideration was the tight labor market. PACS is an attractive proposition because it increases job satisfaction and identifies a hospital as a forward-thinking, technology-based organization - which helps lure technologists motivated to continue growing and learning through their careers.

Another hospital goal focused on excellence in cardiology. The new enterprise PACS was an opportunity to bring other specialties into the electronic storage and dissemination arena. Cardiology was a natural fit because the hospital aims to establish itself as a cardiac care facility. Finding a PACS solution that satisfied both cardiologists and radiologists was a challenge. We needed a PACS that stored echocardiograms, EKGs and cardiac catheterization images and reports, allowed segmented worklists for radiologists and cardiologists, and provided referring physicians with uniform access to all cases, whether they were in cardiology or radiology. After we visited several PACS sites to more closely evaluate systems from various vendors, the team opted for GE Medical Systems' Centricity Enterprise PACS.


INSTALLATION AND DEPLOYMENT

The new system was installed in the six weeks prior to the hospital opening. Pivotal workstations were deployed the week before the hospital opened, and some were added in the initial days after opening, with a current total of 40 workstations throughout the hospital. Diagnostic PACS workstations running Centricity software are located in the radiology, cardiology and ER departments and at our group's sister hospitals and corporate off-site reading center. The entire hospital, including ICUs, clinical wards, conference rooms and medical office building, is connected to PACS. There is also PACS in the OR suites; we don't print film for surgery. In fact, of the 800-plus referring physicians we currently serve, we only print film for three physicians who need it because they perform surgery at non-PACS sites. Other clinicians view images electronically, or we provide images on CD-ROM and fax a report from the MediTech RIS.

We knew integrating different PACS and modality vendors could be a problem. The reality of an installation is that there will be minor glitches, which can balloon into larger issues. When these incidents happen, it can be difficult to facilitate coordination among vendors. Sky Ridge sidestepped this issue by implementing a single-vendor solution throughout the enterprise. The package deal simplified connectivity issues and dropped the overall expense. It also means there's one call to make and no finger pointing if an issue does arise.

In many ways, the installation process at Sky Ridge was a well-researched leap of faith. Most members of the PACS team were employed at other hospitals until weeks before the hospital opening. We had limited ability to gradually modify the installation, train techs on true patients or troubleshoot unforeseen issues with the vendor. Likewise, techs' first live experience with the system came on Day 1 - Aug. 20th. Opening day posed the real test for Centricity. We hit the ground running with zero patients but quickly discovered the breadth of the system.

Within weeks, our ER volume reached what we had projected for spring 2006 - with our four techs handling well over 1,200 exams from the ER during the first full month. The high, unanticipated early volume strained our technologists, but PACS and digital radiology enabled them to maintain rapid exam turn-around until we could fill out the roster.

In the six months since the hospital opened, our enterprise PACS has worked out exceptionally well. It's seamlessly integrated into the network, and allowed us to staff the hospital very efficiently. Our virtually paperless system is also working flawlessly. Techs rely on paper requisitions for transport, but use a portable scanner and a scanning program to convert the bit-map into DICOM and attach requisitions to patient jackets within the PACS.

Centricity has additionally allowed us to maximize the subspecialty expertise in our 60-physician radiology practice. With this system and GE PACS at our sister sites, we can provide subspecialty expertise to community hospitals. Cases can be automatically distributed to subspecialty worklists and sites to maximize subspecialty interpretation of films and bring a network of radiologists, both on and off-site, to bear on the studies from a smaller hospital. Referring physicians benefit with faster, more accurate results, which, in turn, enhances clinical care.

Moreover, PACS boosts our job satisfaction as radiologists. It not only enables us to practice our subspecialties but also facilitates off-site reading. We staff the practice 24/7/365 with radiologists reading entirely offsite after hours. Fully diagnostic, offsite reading stations are seamlessly connected to the primary system via a redundant network.


GOING FORWARD

The long-term vision for Sky Ridge Medical Center includes an expanded hospital and medical campus, and we aim to become a premiere site for medical conferences. Right now, the PACS is connected to overhead projectors in the conference rooms, making it easy to retrieve and present images for discussion and education.

In the short term, we're looking forward to integrated reconstruction and 3D utility in the PACS. This will further streamline workflow and enhance patient care as cumbersome reconstruction and 3D processes can discourage radiologists from employing these tools.

We believe this system will continue to enhance patient care in the longer term as well. In the future, it may be possible to integrate other modalities such as endoscopy and pathology into Centricity, thus providing radiologists and clinicians a more complete repository of information for decision-making.

The bar is set pretty high at Sky Ridge. The hospital is growing fast, and we've proven that our PACS can keep pace with our volume increases and new technology.




Andy Fisher, MD, MBA, is medical director of Radiology at Sky Ridge Medical Center and a partner with Radiology Imaging Associates of Colorado.