More Than Remote Success

Now that technology concerns for many have basically run their course for picture archiving and communications systems (PACS), the focus has turned to creating value. As radiologists expand their volume of work and others seek subspecialty expertise through teleradiology, interest grows in maintaining a personal relationship with all members of a facility's electronic community, incorporating quality assurance measures and ensuring consistency and reliability throughout the system.

The Cleveland Clinic's environment encompasses satellite sites from Iowa to New Jersey. The system does 50,000 to 60,000 exams per year and includes eight family healthcare centers and approximately 20 freestanding imaging centers. Some sites are separate business entities with their own needs and solutions for image acquisition. The philosophy at Cleveland Clinic is what is good for the hospital is good for the clinics and other locations.

"Whether it's an MR or CT from an imaging center, [everything] should come to me in the same kind of manner with the same kind of information that I would expect it could come from one of the hospitals or one of the other locations that I dealt with," says David Piraino, M.D., a musculoskeletal radiologist and head of computers in radiology. "It's not an exception. It's the rule."

The approach at Cleveland Clinic dictates the integration of images into a practice and the incorporation of all scheduling and ordering information as well. "You not only have to have your PAC system there, but you also have to have your radiology information system (RIS), your whole information technology infrastructure, at your freestanding imaging centers just like you would have it in your hospital."

Cleveland Clinic uses a Siemens Medical Solutions PACS and an IDX Systems Corp. RIS. The system's server component is UNIX-based. The viewing component is either PC- or UNIX-based.

The freestanding clinics are doing mostly CT, MR and ultrasound and very little plain film. Most of the freestanding imaging centers Cleveland Clinic is associated with have not put in x-ray. The associated sites that have it are mostly imaging centers that are in the same building as a moderate-sized group practice of radiologists. General radiography is for the most part in the Clinic's family health centers, which usually contain between 10 and 30 doctors with offices there.

Piraino says that every year additional imaging centers join the system. The technology continues to meet the e-radiology group's needs. Of the thousands of exams handled each year, most  come from freestanding imaging centers.

The integration of both the RIS and PACS has been an important process in the success of the undertaking.

"Our business model said that we would not take on any business that didn't use both of those systems," Piraino says. "We thought that we couldn't provide the type of service that we needed to [without that integration]. The amount of integration [and shared information, including images, patient demographics and history, RIS reports, and the reason for the examination] between the two systems has increased over the five-year period. So they function more as a single system now than they did at the beginning."

With a widely distributed environment such as this one comes inherent special challenges. Having imaging centers across a large geographic region, the Clinic recognized the importance of maintaining a personal relationship across the imaging centers among radiologists, technologists, referring physicians, cardiologists and orthopedists. "It's important that you deal with the quality of that whole process from scheduling to image acquisition to transmission, interpretations to distribution of the report," Piraino says. "I think that's one of the most difficult things, and the information technology provides you the tool to help you to do that."

The Cleveland Clinic faced its own special business challenge in that its physicians are a group practice comprising the Cleveland Clinic Foundation; that is, no separate practice groups exist. It is all basically one large entity handling more than a million exams per year.

"The difficulty that we have had when we do freestanding imaging centers that are not what I would call local, is we try to involve local radiologists in the process and just the business issue of two kinds of different cultures - one is a private practice culture and one is a large group practice culture - integrating those and having common goals such as care of the patient, providing high-quality service, reducing the likelihood of medical errors and using common information systems to do that has probably been something specific to us that other groups might not have to do," Piraino says.

Looking at the various sites as one group that does 1.3 million exams per year, about 1 million are digital. The freestanding imaging centers, depending upon their wishes, may distribute the images to referring physicians by film, CD or via the Internet. Because some of the freestanding imaging centers are separate business entities, the choice of media is up to them.

"We on the interpretation side and on the storage side never see any film from them at all, but they may decide because their referring physician base wants film, doesn't want film, wants it on CDs or wants it in another method, so each kind of freestanding imaging center makes those decisions that best fit their business," Piraino says.

The system uses lossless compression to optimize the bandwidth availability. "We didn't have to go to any further compression to get the speed we needed presently," Piraino says.


HIPAA mandates regarding patient confidentiality have imposed the expected additional burdens, increasing the cost of doing business to ensure compliance. "It has made it a little more difficult in a heterogeneous environment where you may be dealing with essentially 20 to 30 different medical businesses, and just maintaining the appropriate HIPAA practices has not been a big issue but somewhat of an issue," Piraino says.

The HIPAA directives have changed the business environment and underscore the importance of adaptability. "HIPAA is one example of something that appears and that you might not have been able to plan for, changing reimbursement models and changing technologies that you have to be flexible enough as these new challenges come on," Piraino says. "You need to expect them to happen that you're not in such a rigid technical environment, information technology environment or business environment that you can't deal with those changes."

For the future, Cleveland Clinic will continue to look at more efficient ways to transmit images, including more bandwidth-efficient methods and more closely coupling the textual-based information with the image information  "[For example], one of our initiatives is how we maintain this personal relationship between all parties in the electronic environment," Piraino says. "So we're looking at new technology, such as instant messaging and instant video conferencing, to make sure that everybody in the chain has a relationship with the other people in the chain."


Massachusetts General Hospital in Boston uses an Agfa IMPAX system to link 15 sites, including two remote hospitals, imaging centers in New York and Massachusetts, hospital ambulatory centers and the World Care Organization, a global provider of telemedicine services in approximately 25 different countries, including Saudi Arabia and Turkey.

"When we linked between Boston and Istanbul, Turkey, we specified to the people in Turkey what hardware to buy, which they bought on the local market, and then we sent all of the software that they needed to run the Amicas [Inc.] teleradiology system over the Internet," says James Thrall, M.D., chairman of the department of radiology. "So without an engineer or information technology person from the United States ever showing up in Istanbul, we were live with the teleradiology link."

In contrast, 10 years ago when Mass General first linked to Saudi Arabia, the hospital shipped five large crates of equipment and sent two engineers who spent three weeks configuring the equipment and establishing the link. "Today, it's a phone call, exchange of Internet addresses and a few minutes of tinkering to establish the connections," Thrall says.

The system contains a rather rich mix of components, but Thrall considers the Internet-standard modules to be key. The big transition the hospital made in PACS was to go from proprietary software to Internet-standard software. In hindsight, Thrall says they could have moved to open Internet standards sooner, but the investment in proprietary systems made it hard to let go. Now Mass General is fully committed to Internet standards and open systems. Between 50,000 to 55,000 cases per year come to MGH from different locations for interpretation.

Mass General uses wavelet compression in the transmission of images and was involved in obtaining the original FDA approval of wavelet compression for teleradiology and PACS. The hospital has been using the technology for more than 10 years and has found it to be a very satisfactory means of reducing the data transmission burden. The lossy compression typically runs 8:1 or 10:1 for CT and MRI and 20:1 for plain film.

The domestic practice is heavily weighted toward MRI, a favorite modality for freestanding imaging centers. "There is a recognition that for very sophisticated MRI studies, it is highly desirable to have a subspecialist radiologist so that in a smaller setting the hospital, clinic or imaging center may have access to [for example] a neuroradiologist," Thrall says. "So I think as you look around the country, you will see a lot of the freestanding imaging centers that have sought out a larger academic group practice or even a large private group practice to work with so that they have access to every subspecialty."

Domestically, Mass General's radiologists are typically only asked to look at the radiographic images, whatever the modality. Internationally, they are asked to provide a case management consultation that will include radiology, a review of the pathology and a review of the medical record. Following radiological interpretation and an analysis of pathology, a clinician selected on the nature of the case synthesizes all the information and sends back the diagnostic impressions and a recommendation for treatment.

With the many converging points, people have been concerned about the quality assurance for any telemedicine service. Who is responsible for the quality when you divide the responsibilities between two parties that are remote from each other? "One thing we feel very strongly about is working very closely with all of our clients, if you will, to include a quality assurance program in the services that we provide," Thrall says. "So we provide feedback on the quality and completeness of every study that we interpret."

One of the concerns of radiologists interpreting studies through teleradiology that originate elsewhere is the potential for incomplete protocols, missing data or poor-quality images. Thrall says that in every relationship they have with imaging centers or other hospitals that send Mass General cases for review, the hospital asks each radiologist to record any deviation from acceptable quality.

Although the technological challenges have been overcome, licensure concerns loom large. When the potential of telemedicine became apparent in the 1990s, many states legislated to make it more difficult to deliver services remotely.  "In some cases, these legislative initiatives were sponsored by state medical societies to protect their self-interests," Thrall says. "To me this is a sad turn of events because it puts a very difficult barrier in place. It actually is necessary to obtain a license in each state that telemedicine and teleradiology services are provided. This is simply impractical for most radiologists. [The result] is the patient is restricted in his or her access to medical opinion."

The solution may lie in eventual federal legislation. But Thrall doesn't see that in the near future because of what he describes as "fierce turf protectionism at the state level by doctors and their medical societies."


The technology team at 415-bed Bay Medical Center in Panama City, Fla., chose to employ a UNIX platform for its PACS because of its stability. At the very beginning of the project, the Center connected to Bay Med Diagnostic, which sends CT and ultrasound scans to the hospital for reading. The Center also linked its PACS to its outpatient center, one of its biggest links because MRI resides there, and to several other clinics. It plans to add another area hospital in the future. More than 1,000 exams per month go out from Bay Medical Center to other facilities.

The Center's PACS is DICOM compliant. When the project began, DICOM-compatible vs. DICOM-ready became a stumbling block in the PACS undertaking. In reviewing the approach to the PACS implementation, Imaging Supervisor for Radiology and PACS Administrator Suzanne Thomas says she would want a better assessment of existing equipment.

 "[The question asked by one vendor at the time] was [whether a piece of equipment] was compatible vs. [whether] existing software had already been purchased," Thomas says. "In our interventional suite, we had digital C-arm equipment, but we didn't have the software for it. So we had to put a patch, and those were the DICOM boxes or aspect boxes … [With those] when you send an image, you're limited. The physician is not really getting all the information, only what you sent him, [creating] problems with image manipulation …"

After the semantic snag over DICOM ready vs. DICOM compliant, the hospital now asks when it purchases equipment whether something is DICOM store, DICOM print (for redundancy) and has Worklist Manager to interface patient information with HIS/RIS. Thomas also checks what platform, i.e., UNIX as opposed to Windows, the software operates on to ensure compatibility with hardware.

The hospital's solution to its radiology needs was to incorporate the Image Qube,  web-based software that runs on a LINUX platform. Thomas describes it as a kind of mini-PACS. Bay Medical was the beta site for the Image Qube produced by Intuitive Imaging Informatics.

The Image Qube uses lossless compression. The software enabled housewide distribution without spending additional money for hardware, time-efficient teleradiology capability for radiologists on an on-call basis and the capability for radiologists to view images from their offices.

Prior to the implementation of the Image Qube, transmitting images could take an additional 30 to 45 minutes for techs to send. "With this, for example, if someone comes in for a CT scan, the techs will do the scan, send it to PACS and within three minutes or so it gets automatically transferred to the Image Qube, and the radiologist at home can query that particular patient in no time," Thomas says. "It's just a domino effect: better care, faster reporting … and a far more superior image."

The hospital chose to integrate PACS with its HIS/RIS at the end of the project, something Thomas would reverse. "Integrating that in the beginning would have saved a lot of duplication of patient information," Thomas says. Using Worklist Manager, a technologist prior to an exam now queries the system, ensuring correct demographic information.

Bay Medical's future goals include the use of voice recognition for radiologists, PACS expansion in the operating room and a move to digital radiography. Thomas's wish list also includes the purchase of a CD burner to encourage more adopters of PC-based viewing, expanded storage capacity and a move to a totally filmless environment.