RIS-PACS Rolls Over the Radiology Wheel

Daniel Kennedy, nuclear medicine and vascular interventional technologist, works on the ScImage PicomRIS and PicomEnterprise at Sapheneia Medical Center in Jackson, Miss.Integrated RIS-PACS almost sounds too good to be true. Can it really offer reduced costs, improved productivity, speedier report turn-around times, track patients and equipment, offer more detailed reports, and even help recruit physicians? Organizations that have implemented an integrated solution are experiencing all of this and more.

Sapheneia Medical Center in Jackson, Miss., a new facility that went operational in November 2006, was co-founded by Patrick Sewell, MD, a minimally invasive interventional radiologist. “We are building what we envisioned — the most technologically advanced ambulatory surgical center to date. Everything is the latest and greatest. We spared no expense on technology,” he says.

That vision led Sewell to the integrated PicomRIS and PicomEnterprise solution from ScImage. “What I was looking for didn’t exist. [ScImage] built the system for us with components they already had.” ScImage was still working on final tweaks prior to the November installation, but Sewell wasn’t nervous about going with a relatively untested system. As a pioneer in thermal ablation of cancerous tumors, he “likes the unknown when it comes to medical care,” he says. “We tend to go with edge-of-the-envelope technology.” He also was interested in working with ScImage to advance their solution. “I didn’t necessarily want perfection right away. I wanted to see the possibilities and be part of the creating.”

Track and review for improvements

Numerous data collection points mean that Sewell can better track and schedule patients. ScImage’s PicomRIS scheduling component allows for tracking of patient arrival times and wait times in each step of a visit, combined with medications, nursing notes and other details. To improve patient flow, “the key is retrospective review.” The scheduling component is “a way to get feedback that’s automated and easy to evaluate.” He can see where patients’ experiences can be improved, what caused a lag, and even whether additional employees are needed.

Patients aren’t the only factor Sewell is interested in tracking. ScImage’s solution also includes an inventory component — “critical for a start-up business and for private practices,” Sewell says. Misplacing a $500 catheter has a bigger impact on a smaller organization than it does on a large medical center. Preventing that and automated ordering capabilities are very valuable to Sepheneia Medical Center. Automated ordering “relieves the burden and removes human error,” Sewell says. 

Emphasize efficiency

The integrated Vision Series RIS and Vision Series PACS from  Amicas has helped Body Imaging Radiology, a group with two locations in Beaverton and Tigard, Ore., improve their billing, cut film printing, eliminate transcription costs and turn-around reports in minutes. Amicas worked with the organization to set up custom charging, says Scot Robinson, IT director. He also integrated speech recognition which saved thousands of dollars a month since he no longer needed one FTE and an outsource agency for transcription. Aside from those savings, Robinson says radiologists and referring physicians appreciate better workflow.

“Referring doctors get information much more quickly and can now access images over the internet. The radiologists particularly like the ability to use a worklist,” says Robinson. “They can pick studies off the worklist and sit and read.” Since they can start reading studies so quickly after acquisition, referring physicians can receive a preliminary report via fax or email in record time. The system allows for automatic sending of reports, so “there’s not even user intervention needed to get a report out of the RIS.”

Eliminating distractions for radiologists also has helped productivity for Outpatient Imaging Affiliates, an organization that partners with several facilities to manage outpatient imaging, headquartered in Nashville, Tenn., says Jeff Tumbleson, IT director. “Literally having everything at their fingertips they need to read the case when they sit down to read is a key component.”

The imaging reimbursement cuts from the Deficit Reduction Act (DRA) are requiring imaging centers to “become more efficient in everything we do for more exams and increasing throughput. In that environment, you can’t be hanging film and working with paper,” he says. An integrated solution allows users to have “a seamless workflow from scheduling through billing and take advantage of all of the nuances the system provides.” That helps recoup an investment in the system, Tumbleson says. Because he went with the Fusion RIS-PACS from Merge Healthcare, he says he doesn’t have a huge capital investment to pay off. “We didn’t spend millions, so it’s a lot easier to get to that breakeven point.”

Speeding throughput

Increasing throughput to manage the effects of the DRA is the strategy for Radiology & Imaging Specialists of Lakeland, Fla., says COO and CIO David Marichal. The organization has more than 20 radiologists, five imaging centers and affiliations with three other facilities. “That puts pressure on all of our staff,” he says. That pressure comes along with the desire not to increase staffing levels as the organization grows. “If you can grow incrementally without having to increase staffing needs, that’s the way to go, especially with reimbursement going down,” says Marichal. The organization is accomplishing that with the GE Centricity RIS and the former IDX Imagecast PACS (IDX is now owned by GE Healthcare).

Efficiency is important at medical centers as well, says Chris DeAngelo, RIS-PACS administrator at Alamance Regional Medical Center in Burlington, N.C. He started out looking for a PACS but after shopping around, realized the facility needed an integrated solution. He went with syngo Suite from Siemens Medical Solutions partly because he was so familiar with the syngo platform. Other vendors told DeAngelo they could make it work, but he wanted tight integration. “This system provides one location to make all modifications,” he points out.

“Initially, we were just looking for a way to store digital images,” says DeAngelo. That morphed into evaluating each department’s workflow, having discussions about how to improve, and “reinventing the way we do radiology imaging.” The dictation, images, and patient data all are embedded into the RIS. Each modality can work off of the RIS to create and update worklists so users don’t have to keep going into the RIS as they work. When a procedure is finished, the tracking and billing information automatically goes into the RIS. That eliminates several steps, says DeAngelo and has improved technologist proficiency. “I don’t believe we could have this efficiency without an integrated RIS-PACS,” he says.

The radiologists at Desert Valley Radiology, a three-location group of imaging centers in Phoenix, Ariz., have been reading at a greater volume thanks to the Unity RIS-PACS from DR Systems. Brian Wadley, MD, says the organization’s transcription costs have dropped in half and report turn-around time has gone from 24 to 36 hours down to just 2 to 3 hours since implementing the solution in January 2006. “Our volume is up by 40,000 cases a year without adding more radiologists,” he says. “All of those indicators are pretty significant. We haven’t run any hard numbers, but we’re happy with what we got for the money we spent. We couldn’t run our business without it.”

Wadley says the integrated RIS-PACS allows for scheduling of multiple exams at the same time. And, he has noticed a reduction in the number of problems with reports. There used to be multiple reports for the same procedure and reports that just had the body but no patient information or just patient data and missing text. All of those problems have been eliminated. Referring physicians have been pleasantly surprised that a study was already performed that same day. “They like being able to look at a study on the internet and pull up reports,” Wadley says. Plus, the system allows for referring providers to retrieve information themselves. That enables us to get to the studies and share the workload so that our turn-around time is very competitive.”

Ramp up reports

An integrated RIS-PACS lets radiologists include and refer to relevant information from medical records in their reports. “Even the diagnostic areas of radiology would be a lot more accurate in their interpretation if they had access to patient medical history,” says Sewell. Radiology reports have a lot of hedging, he says. “They often say that the patient could have this or it could be that.” However, if the radiologist knew by referring to the patient’s record that he or she already had an appendectomy, the report wouldn’t say that appendicitis is a possibility.

“The more information you have when you read the [images], the more accurate and useful your report becomes,” Sewell explains. “A generic report is accurate, but it doesn’t have a whole lot of beef.” More specific and detailed reports also reduce the need for back-and-forth phone calls about a patient’s condition. “If the radiologist already knows the patient had lymphoma, he could address that in his report,” says Sewell. “That saves time for the ordering physician.”

Wins for workflow

Workflow improvements have made the emergency department of Alamance Regional one of DeAngelo’s biggest fans. In the past, when an x-ray was ordered, it was performed and then returned to the ED where the physician reviewed it. He or she would make a preliminary diagnosis on paper and the patient was released. That evening, administrative staff made copies of all of the preliminary diagnoses. The first copy went to the radiologist to match up with the x-ray. The second copy was saved for when the report came in.

“We had two groups of people essentially doing the same thing, using lots of man hours and lots of paper,” he says. Now, with the use of interactive documents, a digital x-ray automatically appears on the worklist in the ED. The ED physician reviews the x-ray and electronically makes a preliminary diagnosis. The system displays that diagnosis and the radiologist can continue at his or her discretion. “If [the radiologist] sees a discrepancy, it just takes the click of one button to alert the ED. This way the patient is still in the ED and the issue can be resolved immediately,” DeAngelo explains. “We’ve gotten excellent feedback.”

The ED staff also can display images immediately. When appropriate, the physician can pull up priors. A web viewer has eliminated some printing of films. The ability to login remotely to view images is “a tremendous time-saver” for referring physicians, DeAngelo says. The hospital also has wireless carts throughout. That’s particularly helpful in the OR where surgeons can view images on CR readers rather than have someone print x-rays while a patient is on the table.

Streamline with one vendor

Working with just one vendor is another advantage of an integrated RIS-PACS. “We didn’t want two vendors pointing fingers at each other,” says Wadley. Plus, he didn’t have to pay two vendors to agree to work together. “The DR Systems product was really presented to us as a whole widget solution — from the front all the way to back end. We knew that it was all going to work together.”

Having just one vendor cuts down on problems as upgrades are released. When you have different vendors, everything breaks if one upgrades, says Wadley. We didn’t want to get into that cycle.” Wadley had used DR Systems equipment during his residency and noticed a “slow evolution of the same product. There was never a forklift upgrade.” He appreciated the company’s commitment to the product for the long haul. “It was going to continue to evolve and really add stability for us.”

Installing an integrated system is a big project, Wadley points out. You already have to manage numerous issues. “Dealing with one vendor is definitely easier. We’ve already had an upgrade to another version. Everything still works.” 

Crunch the competition

Integrated RIS-PACS has proven it can offer a competitive advantage. “It’s definitely a good marketing tool for bringing in new physicians,” says DeAngelo. The ability to offer images and reports immediately is attractive, he says. He has noticed that since implementation, the technologists have been spending more time with patients because they aren’t on the computer as much. “It’s going to overall help your turn-around time for providing patient care.”

Robinson has seen an enthusiastic response from some referring providers to the ability to access reports and images online. “They’re not diagnostic-quality images, but when you pair them with the reports, you get a way better understanding of what’s going on with the patient,” he says. Doctors also use the images to show patients what is happening.

From technologists to physicians, an integrated system “really frees up everybody to do what they want to do,” Robinson says. “Doctors just want to be able to be doctors, not chase down information.”

An integrated RIS-PACS has been good for Radiology & Imaging Specialists, says Marichal, since the group is in a region experiencing phenomenal growth. The three closest hospitals, two with more than 500 beds, do not have an integrated solution. “Our radiologists read for all three of them and they like our workflow the best,” he says. “They don’t have to chase information or be constantly interrupted. All of that is gone. They can get into the groove of uninterrupted workflow.”

Next up is delivering HL7 results to group practices that are converting to electronic records. “With our RIS, we can do that. It can interface with pretty much anything out there.” That offering will lock the organization in even tighter with their referring providers, Marichal says. “That’s another step in our competitive edge over anybody trying to come into this market.”

The organization has gone from 80,000 annual procedures performed by 21 radiologists four years ago to 150,000 procedures a year now — even without adding radiologists. Before the integrated RIS-PACS, that volume would have required an additional 6.5 radiologist FTEs per shift. Marichal says the group can perform the same amount of work with just 4.5 FTEs.

An easy decision to make

When Marichal took on his current position, the organization had three geographically close centers. “When I started, we were opening another center about 20 miles away and then bringing on a multispecialty practice 20 miles in another direction.” The only way to bring them all together was with an integrated RIS-PACS, Marichal says.

“To bring the two together so that the RIS is driving workflow and the PACS is an effective and powerful viewing tool and make them as seamless as possible makes the radiologists happy,” he says. That result had to be as effective for everybody along the chain. “From scheduling all the way to the billing office, there had to be a nice flow. That was what I was looking for. That’s what made my decision and it was an easy one to make.”

When will integrated RIS-PACS rule?
While users extol the many and wide-ranging virtues of an integrated RIS-PACS, more and more companies are working on getting in on the action. After attending RSNA 2006 and seeing what vendors have on tap, “everybody is headed in that direction,” says Jeff Tumbleson, IT director at Outpatient Imaging Affiliates, a Nashville, Tenn.-based organization that partners with several facilities to manage outpatient imaging. The organization uses the Fusion RIS-PACS from Merge Healthcare. “To not have a fully integrated solution will be the exception inside of this calendar year. Most [vendors] are targeting to have fully integrated solutions by RSNA 2007.” The companies that won’t meet that timeframe on their own will probably seek to offer an integrated solution via acquisition, he says.

The market includes a lot of legacy systems representing significant investment, Tumbleson says. Vendors are going to have to decide how to provide a path to upgrade and “make their offering light on the checkbook for the customer.” The installed base of large PACS will find it very difficult to migrate to anything, he says.

An integrated system is so much better than the two separately, that once people have it they will wonder what took so long, says Patrick Sewell, MD, a minimally invasive interventional radiologist and co-founder of Sapheneia Medical Center in Jackson, Miss. He believes the improvements will become obvious when there are several systems to choose from. Because so many vendors already are set up to be web-based, they will be able to accommodate an integrated offering more easily. “Technology in radiology changes fast,” Sewell says. He predicts RIS and PACS teams touting integrated systems at the RSNA 2007 meeting this fall.
Training tames the integrated beast
“The system is only as good as you know how to use it,” says Patrick Sewell, MD, co-founder of Sapheneia Medical Center in Jackson, Miss., of his integrated RIS-PACS. “You need to know the ins and outs to get all the good it has to offer.”

Sewell concentrated on training on his integrated RIS-PACS from ScImage from the get-go and still does. “The representatives from ScImage, in collaboration with our staff, continue to make changes to optimize workflow based on our specific wants and needs,” says Daniel Kennedy, nuclear medicine and vascular interventional technologist. “Everyone here at Sapheneia has been trained on the RIS-PACS components that are pertinent to their job.”

One way to manage the different components and keep everyone up-to-date on their features and capabilities is by assigning a technologist to oversee a section of the system. “This is used as a checks-and-balances system to assure that all of the information contained within a particular component is current and correct,” says Kennedy. The technologist also serves as a designated point person so that when there is a question or problem, the technologist can either take care of it or find out how to, says Sewell.

Chris DeAngelo, RIS-PACS administrator at Alamance Regional Medical Center in Burlington, N.C., trains users on the syngo Suite RIS-PACS from Siemens Medical Solutions.Some organizations have found that users only require minimal training before they are up and running. The Amicas system installed at Body Imaging Radiology in Oregon has been pretty intuitive, says IT Director Scot Robinson. “We had applications training for four days and we haven’t had any follow-up training.” New employees are mentored for their first couple of days.

 Users of the syngo Suite RIS-PACS at Alamance Regional Medical Center underwent group training for one to two hours at a time, says Chris DeAngelo, RIS-PACS administrator. Because the hospital also was going to install a new nuclear medicine camera, new CT scanner and CR and DR for the first time, those who would use the system were trained for months. The RIS went live before the PACS. “We had so much going on in the radiology department at that time,” says DeAngelo. “We didn’t want to overwhelm the staff.” Since the RIS was the biggest piece, DeAngelo made sure everyone was comfortable with that before moving on to the next phase.

When the PACS went live, the radiologists were individually trained. Films were printed during training, but “we found we could quickly turn off films because they became so comfortable so fast,” he says. Group training didn’t work well for referring physicians so they were scheduled for 30-minute training sessions. “It was quite simple for them,” DeAngelo reports.