Expanding Access: Fantastic growth with web-based PACS

It doesn't matter whether PACS are installed for use in a single department, an imaging center, or a large health system. With their web capabilities, current web-based PACS are helping facilities greatly increase their referring physician user base, creating speedier in-house operations to boot, and providing greater patient care. To put it simply, they're fantastic.

Imaging Centers with big PACS reach

Epic Imaging
Portland, Oregan

As John Griffith, CRA, CIO of Epic Imaging, sees it, when it comes to web capability there are really two PACS camps. "You've got web-based PACS and then there are web-enabled PACS. Web-enabled [systems] allow you to at least distribute and update via the web but aren't truly web-based."

Truly web-based PACS provide users off-site with the same access and tools via a web interface that they have sitting at the PACS workstation within a hospital or imaging center.

Epic Imaging is a two campus facility, which Griffith says with a laugh, is "cutting edge" because it's already in the replacement cycle for PACS having already owned one previous system that was not web-enabled.

In January, they installed Dynamic Imaging's IntegradWeb PACS which is fully web-based, and it is now used both by the clinic's own in-house physicians and radiologists as well as their outside user base of physicians which is 1,000+ strong, and growing. All told, they currently log about 125,000 procedures a year.

"We have a very diverse referral base because we are freestanding," Griffith says. "Everything is outside of our walls. The bottom line with web-based PACS is that it doesn't matter whether you're logging in from home or from your office or wherever. If you're a radiologist looking at images on a diagnostic workstation, you also can get the same tool sets at home."

The ability to access the full tool set, including such advanced functions as multi-planar reformatting, 3D functionality, and ortho CAD templating, is a huge advantage from a user support perspective.

"If one of our radiologists gets a call from a referring physician who wants to look at a case," says Griffith, "or needs to navigate through the system and has a question, the radiologist doesn't have to think, 'well OK, what type of system are you looking on?' It's the same system the radiologist is looking on, so it makes it easy from that regard."

When a referring physician first logs into the system with the URL that Epic Imaging provides them, they are required to install a basic ActiveX viewer applet. So, though the applet itself is very robust, it is also "componentized" and allows a user to load the functionality from the server on an as-needed basis so as not to bog down your PC the first time you use it, Griffith says.

That's the nice thing about fully web-based systems. Once you are established as a user, it makes no difference what PC you are using because the data remain on the system's server, not on your PC.

"A physician's worklist is configurable and all of the changes are stored on the server, not on the client side PC. So, the settings travel with you if you use multiple machines," Griffith says.

Epic Imaging uses a storage area network (SAN) with clustered servers equipped with web server software to serve up the images very quickly. IntegradWeb uses JPEG 2000 which is a newer DICOM standard for storing images in a compressed format, Griffith says. He adds that as a result they are able to keep "all of our images online 100 percent of the time."

So who gets access to images? Like many healthcare organizations, Epic Imaging has a set process for setting up user accounts, either through a faxed form (in this case a HIPAA agreement) or email which gives the radiology department a chance to check the credentials of a physician to guarantee he or she should in fact have access to the PACS and network. Users are given how-to instructions and a username and password, which in this case expires every 45 days, though some facilities set expiration at 90 days.

Griffith says that although he can grant access "at the drop of a bucket," different levels of access are set depending on the situation. For example, specialists who might be dealing with a number of patients get access to the entire database; primary-care physicians are often only allowed access on a patient-by-patient basis. Access also can be organized by groups of physicians. Perhaps most vitally, emergency temporary access can be granted instantly.

Rockwood Clinic
Spokane, Wash.

Imaging centers that adopt powerful web-based systems can attract physicians who are hungry to have access to the flexible image viewing they offer. Rockwood Clinic is the largest outpatient facility in the area with specialty and family physicians totaling 140, as well as an ever-increasing outside user base of referring physicians. Annually, the clinic's radiology department performs 80,000 to 90,000 procedures.

Rockwood first installed DR Systems Dominator RIS/PACS two years ago, and JoAnn Tarlton, director of radiology, says that the system has been a huge success. Using a tool called Web Ambassador, referring physicians can quickly download the application and get up and running in very short order viewing images remotely over the web.

Through Web Ambassador, a patient who is referred to a physician in another city can go into the office and the physician can call up the clinic, get approved for temporary 24-hour access, download the application from a provided URL, and be looking at the images with the patient almost instantly, Tarlton says. "That's the type of access that they have to the system," she adds.

And it's not just images that physicians can look at. Through the Web Ambassador, a physician can actually listen to a voice clip of the radiologist's conclusions by clicking on a microphone icon that is part of the interface, within a minute of it being completed. This voice clip is available long before the actual transcription is completed, thus boosting the speed of care.

Rockwood Clinic is being very aggressive with these tools as a means of marketing their facility to potential customers. Tarlton says they plan to offer a new functionality called "Automatic Receive" which will be part of DR Systems' latest version of Web Ambassador which is expected to roll out soon.

"The Web Ambassador product automatically notifies a physician when he or she has received images," says Tarlton, "depending on how the doctor has it set up, as to what types of exams he or she wants to receive, what parts of the exam to receive, and it will load it right onto the PC. They will be able to view these images and not have to wait for the images to load. It doesn't take up any of your precious time."

Rockwood Clinic's long-term goal is to make their facility completely wireless and provide physicians with hand-held tablet devices.

"What doctors will do eventually is take the tablet into the area where they are seeing the patient and be able to communicate everything to the patient right there with all the lab results, radiology results and everything," Tarlton says. "So that's our eventual goal as a clinic. This product is helping us get there with radiology."

Big Hospital networks get BIGGER

Regions Hospital
St. Paul, Minn.

For large hospitals, the first challenge of image access with PACS can be to grant access to internal clinicians across the entire enterprise. The big concern, up front, is not referring physicians or referring institutions. That comes later.

For Regions Hospital, the move to web-based PACS was a gradual one that also marked the evolving capabilities of the PACS as time went by. Regions Hospital is a 350-bed facility with a Level 1 Trauma Center which is owned by the Health Partners network that includes 30 clinics and is affiliated with the University of Minnesota Medical School.

Back in 1997, Regions Hospital was associated with a group called St. Paul Radiology through which the hospital contracted its radiologists. At the time, St. Paul Radiology was shifting to PACS and wanted Regions Hospital to do the same, which they did, installing eMed Technologies PACS in November of that year, recalls PACS Administrator Paul Norsten.

Norsten was not a PACS administrator at that time and only worked part time with the PACS (eventually his work became full time which eventually led to creating a dedicated PACS team). The facility still used film but also used a few workstations as an add-on that provided limited distribution within the hospital and virtually none to the clinics.

"Once we decided we were going to [web-based PACS], we started evaluating our film usage costs, chemical costs, off-site storage costs for our films, productivity for radiologists and technologists, all of the standard things you hear talked about in the PACS world," says Norsten.

By 2001, things began to change as the radiology department installed the eMed .net Enterprise, a web-based image distribution software which can be used within an enterprise or by referring physicians for secure access. Physicians and clinics within the network were then able to access images via the hospital's intranet.

"[eMed.net Enterprise] seemed like a logical solution when it came along because it allowed us to expand out without having to add a bunch more hardware," said Norsten. "Also, because of networking concerns in the early years, our IT department was wary about letting us blast all of these images across their network. We had to do a lot of cable stringing of our own. We built our own radiology network, basically in the early years. That's now all since long changed in that the IT department has realized we're not going to break the network."

To assist with the web viewing, Regions bought "beefier" Dell PCs with large screen monitors with considerable RAM (ideally 2 GB). Today they have 30 such radiology-specific machines throughout the hospital. This became the solution they now use within the hospital operating rooms, though in this instance there are typically wall-mounted dual or quad monitors, says Norsten.

Between 2001 and 2004, there was some "fine tuning" that needed to be done to the PACS product itself regarding short-term storage limitations, he says. Additionally, the PACS team requested that some adjustments be made to the user interface of .net Enterprise to make it more user-friendly. eMed was responsive to the comments, and some from other customers, and made adjustments to the products which reflect in the current system.

This year, the radiology department upgraded to eMed Matrix, the company's latest PACS platform and workstation.

"In January, we made that connection to the outside world known," says Norsten. "Now we've put a link through our hospital's website" and physicians can be anywhere in the world and still access the images.

All of the hospitals' exam rooms contain desktop computers with an icon on the desktop for easy access to the enterprise-wide system, as do the clinics. For example, a patient visiting the orthopedic clinic can have x-rays quickly done and by the time they return to the room with the physician, the images are on the PC monitor waiting for them. Reports are available along side the images within a 24-hour period, Norsten says.

Once the hospital's radiology department opened its internet-based image viewing, the user base jumped considerably and now numbers about 2,000. The PACS administration team which Norsten runs manages the user enrollment process.

There are some user base headaches, especially for an organization like Regions Hospital due to their association with the University of Minnesota Medical School. Put simply, a partly transient user base made up of medical students or interns can be a real hassle.  

Norsten says that to compensate they run a script that shows if there is no activity on an account for 90 days. At that time, they try to contact the user. If the PACS team cannot get a hold of the user, they are taken out of the system.

The jump in users is also because of the hospital's Level 1 Trauma Center, which requires that certain protocols be followed, such as always having a neurosurgeon and orthopedic surgeon on call in addition to a number of other specialists which are available 24/7.

"Most [surgeons and specialty personnel] want to see their images from home before they come in, so if they get a consult they can pop on at home and decide if they need to come in right now or if it can be later. The decisions can be based on the information gathered from the images, says Norsten.

"Moving to filmless is a revolutionary change that impacts every level of the radiology department, as well as all of the clinics, and to a certain degree the entire hospital," Norsten says.

Overall, the shift to web-based PACS is an enabler because it increases speed and convenience, so the general benefits of a filmless environment begin to multiply.

Carolinas Healthcare System
Charlotte, N.C.

Carolinas Healthcare System (CHS) is one of the largest of such public healthcare systems in the nation. Of its hospitals, nursing homes, physician practices, home health agencies, radiation therapy facilities, and other facilities, the system is comprised of more than 4,249 licensed beds and approximately 25,000 employees.

Shifting to web-based PACS for such a large organization is no small undertaking. Doing so requires the buy-in of all the principal decision-makers, including the referring physicians.

 "We took the enterprise out to the referring physicians. We implemented [PACS] with a test server about four or five years ago," says Derek Sells, PACS administrator at CHS Carolinas Medical Center in Charlotte. "We ran that for a year in an enterprise fashion, just as an extra to the film. This was a way to get it out there and get the referring physician buy-in, if you will. That was a key component of this PACS - to get the referring physician buy-in makes the whole movement to full PACS easier for senior admin to sell."

The test was a success. In July 2003, CHS installed Stentor iSite PACS which now connects seven CHS hospitals as well as two imaging centers with two more coming online later this year. In addition, a project is underway to connect 11 urgent-care practices by year's end, all of which will be connected through the PACS, Sells says.

"We've got roughly 6,000 to 10,000 PCs throughout the whole enterprise," says Sells "The PACS can be accessed via both intranet and internet. Users only have to download a small applet the first time they log in and then they will have access to images. No client software needs to be installed."

All of the remote connections are through either CITRIX (Physician Portal), Neotaris SSL, or point-to-point VPN, depending on an end-user's needs and available options, according to Sells.

Once the enterprise was geared for full web-based PACS, adding new facilities became easier and hence growth skyrocketed.

"Growth has been amazing. It's almost been difficult to keep up with all of the growth," said Sells. "We can just roll it out and take the [CHS] sites digital. For example, we're doing a CPN clinic this week and they're going from film and putting a CR in and a workstation. Through only a T1 connection, we're able to make them digital. The result is better patient care."

CHS currently has 3,000 registered users as part of the web-based system - 1,000 of which were added just last year, Sells says.

With such speedy expansion, training and support are essential. Any credentialed physician who signs up and is granted access is offered training, though the application is easy enough to use that even if formal training is never completed most of the issues that pop up can be dealt with over the phone, says Sells.

At Carolinas Medical Center, the PACS team is available 24/7 with each member of the team taking week-long shifts. Though they work within the radiology department,  they do work closely with the Information Systems department. Calls come first to Information Systems, with any that are not easy to resolve then routed to the PACS team member on call.

Your Own Private PACS

The Nuclear Medicine Department at University of Miami/Jackson Memorial Hospital is in the enviable position of having their own PACS and supporting tools. It's an example of how the benefits of these systems can be seen on a huge scale with thousands of users, or for vastly increasing a single department's efficiency.

Earlier this year, the department installed ThinkingSystem's ThinkingPACS which includes ThinkingWeb, a thin-client based web product that provides full workstation functionality via the web which, along with viewing tools for conventional CT and MR, it provides special tools for nuclear medicine processing and quantitative analysis, and PET-CT fusion over the web.

The Nuclear Medicine Department plan is to have any studies that a referring physician might want to access delivered by the enterprise-wide IDX ImageCast PACS the university is installing, says Mike Georgiou, PhD, research assistant professor, director of Basic Science Operations in Nuclear Medicine. The department is in the process of converting data to the IDX system, with any future images and supporting data sent to the enterprise system for access by referring physicians.

Obviously, this is kind of a different approach. Probably not that many departments get to have their own private PACS to be either used internally by physicians in their office or from home.

But, if you think of the time it takes to maintain a user base, time it would take away from the work in nuclear medicine that the department needs to be doing, it makes a lot of sense. You also don't have to worry about referring physicians altering the data stored in the system.

"We will send our data to the IDX system so that referring physicians can look at the data," Georgiou says. "But as far as we are concerned, we are taking care of our own thing."

It is the ThinkingWeb capabilities in nuclear medicine that really sold them, Georgiou says. "[ThinkingWeb] has specialty programs that we use in nuclear medicine that makes the data readable and reviewable" that is very useful for us," he says. "For example, we use the ThinkingWeb with our new PET/CT scanner. It has a capability of taking the PET data and taking the CT data in an overlaid fashion."

Thus, the Thinking Systems products have become a very powerful, flexible tool for department physicians for use from within their offices, from home, reading rooms or anywhere really using a PC.