Freestanding imaging centers are joining their “big brother” medical center counterparts en masse, realizing the benefits of deploying PACS. To some extent, multi-facility imaging systems have reaped even greater rewards because they can manage images across their several center enterprise, utilize their most precious resource radiologists to greater effectiveness and vastly improve report turnaround times that in turn enhances their relationship with referring physicians.

As the case studies in this article illustrate, imaging systems of all sizes have benefited greatly from PACS. They carefully analyzed their needs and workflow, set goals and studied the marketplace to determine the appropriate solution for their particular circumstance.
 
This month Health Imaging & IT spoke with experienced PACS users at seven imaging centers across North America who offer advice on how to do PACS right.


Advance Radiology Consultants | Trumbull, Conn.

This group has been providing radiology expertise for 100 years, and installed their first PACS in 1998. Duleep Wikramanayake, director of IT has 24 years of IT experience that he brought to bear in designing this PACS network with 99.99 percent uptime. He explains that of their eight imaging centers, half are full-service and they complete about 130,000 procedures a year with 17 radiologists. In 2002, they installed Intelerad IntelePACS software to serve as the backbone of their PACS, and he says that they are one of the most accountable companies he’s ever encountered.

“In many sites, we have DS3 [lines] and then we have two frame clouds. Our main site has an OC3 [line],” he says. In terms of storage, they have 14 Terabytes online and are upgrading to 20 TB, and those servers are mirrored. In this way, they always have three years of prior exams on spinning disks, so when their radiologists need to pull up something, it’s instantaneous.

“When you’re talking about data in radiology, it is now in terabytes (TB) rather than gigabytes (GB),” Wikramanayake says. If a server goes down (and that is inevitable because it’s hardware), the data recovery time on a 2 TB array could take approximately three to four weeks.
 
Wikramanayake relates that one time when one of their servers was down for 26 days, although his four member IT team was working like fury, the radiologists never knew there was a problem. Their maintenance window is between midnight and 4:00 a.m. and that is when Intelerad does any updates, which they install remotely. “It’s the only company I’ve ever known that pulls this off in such a nice fashion,” he concludes. They install upgrades, test them, and then they can pull it off if they need to without disrupting operation.

His advice to others considering PACS is to plan decades ahead for storage needs. Because migrating huge amounts of data is very time consuming and costly, IT professionals must plan accordingly and keep up with technology. He recommends planning for at least a 10-year window, and working to upgrade systems along the way.


Arcadia Radiology Medical Group | Arcadia, Calif.

Careful planning is essential to effective design of a PACS deployment, according to Alicia Vasquez, CRA, Arcadia’s practice administrator. In the midst of bringing the three hospitals and two imaging centers onto the same DR Systems PACS, they have found a significant cost savings, and a redistribution of the workload to increase their radiologists’ efficiency to be the primary benefits. They accomplish 40,000 multimodality imaging exams with nine physicians and have seen their film costs drop from $250,000 to about $27,000, with $17,000 due to screening mammography studies, which are performed on film-based systems.

As a California entity, they work within the constraints of managed care, which means they are challenged to provide quality exams and interpretation while working within fiscal constraints. Vasquez notes that adding PACS has allowed them to remain competitive.

Once several of their referring physicians learned about the PACS installation, they asked to have it installed in their homes. These physicians often face emergency situations in the middle of the night, and having a viewing station in their home allows them to make patient management decisions quickly. Additionally, this system has improved the throughput of the emergency departments in the hospitals, as the decision-making process is facilitated.

“Our patient satisfaction has increased dramatically,” Vasquez continues. One of their imaging centers is located in a medical complex near a hospital. “A patient can walk into our office, have a chest x-ray, and by the time he or she walks back to the physician’s office and gets in to see his or her doctor, the report is ready.”

One final bit of advice from Vasquez involves finding a radiologist champion who backs the PACS initiative and who can lead peers to accept the changes. Although there may be initial frustrations, eventually the benefits will far outweigh any headaches.


Burlington Ultrasound & Radiology | Burlington, Ontario, Canada

Besides a desire to improve efficiency and decrease expense, a top consideration for adopting PACS was Burlington’s desire to eliminate chemical film processing with all of the hazards and inconveniences that are part of film-based systems. According to Donna Duffy, Burlington’s clinic manager, this imaging center plus one satellite clinic completes between 160 and 200 studies per day that include mammography, ultrasound, bone densitometry and skeletal x-rays. They use film for their screening mammograms, but CR for their diagnostic mammographic studies as well as for general x-ray exams.

In February 2002, they selected RamSoft web-based PACS to help them eliminate wet processing and to be able to do remote reporting. The scalability of this system was one of the attractive features that helped them make their decision. Besides that, Duffy says that the RamSoft people were very skilled at taking away some of the mystery of PACS.

“RamSoft streamlined the implementation, and I would say that the transition from film to PACS was very easy,” says Duffy. With a web-based PACS, they have unlimited licensing opportunities with fees based on the volume of studies. They permit specialists to access images and have as many workstations within the department as they need for efficiency. But as with other centers, one of the unanticipated advantages was the recovery of space once film storage was no longer necessary.

They still have a library for storing mammography images because in Canada they are required to keep these studies for 10 years.

In terms of selecting a PACS vendor, Duffy advises centers to look at developing a partnership. Because so much of the work is done off site now, she says they had to get used to the fact that they might never see the person doing the work. She thinks of RamSoft as a long-term partner, and knows that they will need upgrades from time to time. “You must make sure it is an upgradeable platform and that you can commit for the long term.”


Diagnostic Radiology Consultants | Fort Oglethorp, Ga.

This eight-facility practice that includes a 300-bed hospital in a 25-mile radius has installed their Siemens syngo Imaging PACS, syngo Workflow RIS and syngo Voice integrated voice recognition system along with the NextGen electronic practice management solution. As James Busch, MD, interventional radiologist and director of specialties networks explains, before PACS their 11 radiologists interpreted 200,000 procedures each year, but now they have 10 radiologists performing the same number of studies.

“We went with Siemens because of their ability to support multiple entities and still maintain HIPAA compliance,” he explains. Of the eight imaging centers they cover, they own four of them. There is no issue with HIPAA compliance with those that they own, but a large multispecialty practice group owns two of them. While it is not problematic for the radiologists seeing the studies on this group’s patients, they cannot have those physicians see one another’s patients because they do not have a HIPAA agreement. Therefore, they wanted to maintain a separation for legal reasons, but have their radiologists be able to see the entire enterprise.

Busch attributes their dramatic improvement in report turnaround times to embedded voice recognition transcription capabilities. Their average time to report generation is less than an hour using voice recognition, which he believes, saves them five to six seconds per exam.  That becomes significant when considering the number of exams they perform. All of their radiologists (except one) edit their own reports.

They also wanted a scheduling and registration piece, because our polls told us that the ease of scheduling and ease of getting reports were the most important factors to their referring physicians. 

Busch considers that the strength of this system is the integration between the RIS, PACS and VR because it enables virtual reading rooms to keep a full day’s work in front of each radiologist. That spreads the work among all of their partners, and has enabled them to drop one FTE radiologist while maintaining the same number of imaging studies.

In late July, they installed Portal Radiologist that is a streamlined user interface that shows radiologists everything they need to see.  “Ninety percent of everything you need is there on the screen in front of you and the rest is one click away,” he says. “This is Siemens answer to designing a user interface that is for the radiologist.”


Oregon Medical Group | Eugene, Ore.

The integrated functionality that is enabled by a single vendor solution has greatly improved the efficiency in this practice, according to Dawn Klinglesmith, BS, RT(R)(CV), director of imaging services. With six clinics that provide diagnostic x-ray studies tied into their central imaging department, they perform about 50,000 studies per year with four radiologists. They serve more than 100 physicians from all practice specialties including pediatrics, family practice, orthopedics, GI, cardiology, allergy, surgery and hospitalists.

They went from “sneaker net” courier services to move films to the radiologists twice a day and a 24-hour turnaround time, to a vastly improved reading report generation scenario with their new Kodak PACS, RIS and CR deployment with many of their clinics connected via a dark fiber network. This multimodality imaging center offers interpretations on an “as done” basis.

“One of the things I loved about the fact that we installed CR, PACS and RIS with Kodak is that they had one project manager and we worked as a team to meet our goals and reach a successful implementation,” she says.  Having experienced less satisfactory installations in the past, she appreciated the customized solution that improved workflow for each independent center. “Everything flows from ordering, scheduling, and [image] acquisition to report dictation now. There are no delays in reading, transcription or onto billing.”

For their referring physicians, the web portal is easy to use. If they know how to put in a patient’s name, they can immediately navigate to accomplish the tasks that are required.


Radiology Ltd. | Tucson, Ariz.

The flexibility of customizable worklists is a key functionality to be considered when selecting a PACS solution, according to Ronald S. Cornett, RT(CT)(MR), director of imaging informatics at Radiology Ltd. With a system that includes 10 centers and 45 radiologists to read the 750,000 exams per year (of which 400,000 to 450,000 are digitally acquired), he notes that electronic management of the imaging chain has increased their efficiency by 30 to 35 percent.

“We are a radiologist-owned practice, and since the radiologist is the most expensive cog in the wheel, he or she must be productive and most efficient,” says Cornett. Deploying their Amicas PACS Vision series in 2003, they built their worklist around specific categories of imaging studies.

In their system, the radiologists do not read based on imaging site, but rather by their area of expertise. So there could be radiologists physically located miles apart who are reading studies from the same master list. For example, neuroradiologists might be reading CTs and MRIs from the neuroradiology worklist, but might not read a single study acquired in the center where they are physically located. With radiologists required to be onsite to monitor contrast injections, when they are not engaged in those procedures, they can read studies from their master list.

Another workflow issue involves images that require 3D reconstruction. Imaging studies marked “3D needed” move onto a specific worklist for those steps to be accomplished, and upon completion they are returned to the centralized work list with the notation that 3D has been achieved.

With 146 DICOM connections, accommodation was required for hanging protocols. Cornett explains that each group of radiologists made the decision about automatic presentation states. For example, all CT spines are hung the same way in a basic presentation format. Individual radiologists are able to change the configuration if they wish, but initially every study will be displayed in the same order. This approach has increased their overall efficiency once they became accustomed to the standardized patterns. 

Cornett notes that the technology required to make this all work is highly complex. They have worked for several years to develop their own desktop integrations. Their radiologists can click one button and have the hung images, prior exams, electronic medical record and PACS documents launched on their own GUI (graphical user interface).

Their storage functions are accomplished on a storage area network (SAN) environment that is mirrored 22 miles away, with the entire network sitting on a 100 MB fiber ring.


West Coast Radiology Center | Santa Ana, Calif.

“We started with a RIS as a foundation which allowed us to integrate all of the other components into the RIS. This is because workflow is everything, and the RIS handles the workflow,” says Tim Chavez, WCRC’s executive director. This multi-site center system offers every imaging modality and they made the decision in 2002 to go filmless and paperless for their 100,000 annual procedures. They now have the Merge eMed Fusion RIS and PACS and digital dictation that is embedded into the system. “In radiology, the workflow is the same every time from the initiating phone call to the report delivery.”

They have placed mirrored Fusion servers at different sites along with a mirrored RAID (redundant array of independent disks) to afford their strategy of redundancy.

He believes that embedded digital dictation has proven an important factor in this RIS-driven system. Radiologists sit at a workstation and initiate their session in RIS. The images come up, and the right monitor has all of the patient demographics and prior reports. They also can review prior images. When they open the accession number of the procedure, it allows them to dictate into that file. The transcribers are more efficient as a result because they are not waiting for a paper order.


Conclusion

The experts agree on a variety of points, including:

• Careful planning is essential
• Finding a vendor that can become a partner in your success is key, and
• PACS offers great advantages but must be integrated thoroughly with your other imaging and IT components to minimize headaches.

Couple this information with developing a robust network, and your imaging center will soar.