Web Enabled: Distributing Images to Referring Physicians

It's no secret that referring physicians drive the success of a PACS implementation. If they don't use PACS, the hospital will probably not meet its project goals. Successful hospitals balance technical and security challenges and demonstrate mastery of human relations and educational processes. The formula for securing buy-in among referring physicians boils down to:

  • Selecting the PACS
  • Providing fast and easy training for all users
  • Developing a HIPAA strategy
  • Planning for alternate image delivery methods


"Web-enabled PACS is absolutely the way to go," says Jeoff Will, physician liaison for Fairview Health System (Minneapolis). "I don't see system-wide PACS succeeding any other way."

With a web-enabled PACS, a small program is downloaded from a website, eliminating the need to individually load the client application. These hardware-independent solutions allow most users with access to Internet Explorer to view images.

Fairview Health System epitomizes the healthcare conglomerate. It includes seven hospitals, 41 primary-care clinics, 38 specialty clinics and 21 senior-care facilities. Fairview completes 500,000 imaging procedures annually and distributes images to 6,640 physicians.

The health system aimed for anytime/anywhere/any image distribution at the enterprise level with its IDX Imagecast PACS. "It's relatively easy to implement PACS in radiology," Will notes. "It's an entirely different animal to roll it out throughout the enterprise."

Currently, three Fairview hospitals have deployed PACS. Referring physicians within the system view images over an intranet. Physicians outside of the Fairview system primarily view images on CD, but Will aims to further improve access with a physician portal that will allow all physicians to access images over the internet. The SSL portal meets HIPAA requirements with password protection and encryption for each user. "We will continue to offer the CD option after the portal in implemented," Will says. "The whole goal is to improve - not hinder - access to images." (See chart)


Cedars-Sinai Medical Center (Los Angeles) is an 820-bed university-affiliated, not-for-profit medical center that performs 380,000-plus imaging procedures annually for a referral base of more than 2,000 physicians. When the medical center deployed its Kodak DirectView PACS four years ago, it identified image distribution to referring physicians as a major challenge. David E. Brown, manager of PACS/RIS at the S. Mark Taper Foundation Imaging Center at Cedars-Sinai, explains, "No one wanted to print film to distribute everywhere throughout the medical center once we were live on PACS. The solution was clear - a web server."

The medical center installed a Kodak DirectView Web Distribution System in conjunction with its Kodak DirectView PACS to provide image access to referring physicians within the hospital. Cedars interfaced the DirectView Web System to WebVS, an internally-developed web-based viewing system. WebVS enables access to Cedars' main clinical data repository and provides an integrated display of clinical data from over 20 information systems, including PACS.

"This is a solution for both employee and non-employee physicians," Brown explains. "They can view clinical data on WebVS and click on a link to access the DirectView Web System and look at images of the selected patient." WebVS supports security needs via confidentiality warnings, detailed logging of all accesses or attempted accesses to patient data and automatic daily surveillance reports.

Physicians can log on to WebVS from their office or home computer; however, only physicians connected with a secure VPN have access to PACS images. In the future, Cedars will turn on encryption on the DirectView Web System to allow for access to PACS images from anywhere on the Internet with proper authentication. (See chart)

Part of the reason behind Cedars-Sinai's success is Brown's willingness to maintain two generations of web servers to support all users. Newer web systems work well with state-of-the-art PCs, but do not always work well with older PCs. A first-generation web server interfaced to WebVS supports of older PCs with slower processors and less memory. Brown admits, "You can't tell referring doctors that they need to purchase a new PC to access images. It just doesn't carry over well."

This fall, Cedars-Sinai plans to upgrade to Kodak's System 5. The upgrade entails a single database for all users and will provide referring physicians with immediate access to key images, graphic overlays and electronic image notes generated by the radiology staff during the diagnostic interpretation of exams.


Gundersen Lutheran Health System (La Crosse, Wis.) is anchored by a 325-bed teaching hospital and one of the nation's largest multi-specialty group practices. It is associated with 30 regional clinics and hospitals and more than 375 physicians. The hospital accepts referrals from an additional 550 outside physicians.

One of the key hurdles in the image distribution equation is whether or not Gundersen Lutheran employs a physician. Employees tap into PACS images via the Fujifilm Synapse PACS viewing software, a seamless process for clinics connected by a T1 line. Clinics without a T1 line either installed the line or added a VPN and use high-speed internet to access images. The upshot is that images are easily distributable - if the physician is an employee, says Mark Nigogosyan, MD, PACS medical director.

If a physician is not an employee the hospital cannot allow him access to the entire image repository because HIPAA restricts access to needed information. Nigogosyan opines, "This is an example of HIPAA getting in the way of patient care."

Since referring physicians cannot electronically access images, Gundersen Lutheran offers them a CD or printed images. Most physicians accept CDs, but some request film. "You have to be sympathetic to the referring physicians," Nigogosyan explains. "The CD-to-film process should not take 10 steps. An orthopedic surgeon may not have a viewer in the OR where he needs images. If his office or hospital does not offer an easy way to print images, he needs a hard copy from Gundersen Lutheran."

It is unlikely that HIPAA will continue to block electronic distribution to non-employee physicians. Many vendors, including Fuji, built an audit trail into new software. An audit trail in conjunction with fairly basic security measures such as a user name and password (or biometrics for added security) can satisfy HIPAA.

Gundersen Lutheran is exploring another means of referring physician image distribution with competing institutions. Several months ago, the hospital started sending CDs when it transferred patients to other area hospitals. It recently established a direct electronic T1 connection with Winona (Minn.) Memorial Hospital, which allows the hospitals to push images to each other's PACS. The same model could be applied to non-employee referring physicians. "If a physician has a stand-alone viewer and is hooked up to Gundersen Lutheran with a VPN we could push images to his PC," says Nigogosyan.


The challenges of distributing images to referring physicians are not limited to large facilities. Take for example, The Imaging Center, a new state-of the-art, full-service independent imaging center, in Tupelo, Miss. The facility is filmless and paperless (except mammography) and performed 30,000 procedures for 40 referring physicians in its first year of business.

Although most referring physicians lack a strong Web presence or T1 connections, CEO Michael Currie, MD, opted for an Agfa Impax with Web 1000 Distribution System. "The ultimate goal is to help referring physicians look at images online," he says. "This provides faster distribution [than film or CD], and they are DICOM images, which gives physicians the ability to manipulate images to meet their needs."

The Imaging Center provides CDs to every patient imaged at the center and films approximately 80 percent of its studies. Currie's IT staff is gradually educating referring physicians about the ease and benefits of web distribution. He says web distribution has taken off in outlying rural areas where physical access to images is slower. Currie expects web distribution to become more popular among other referring physicians next year after the local hospital implements PACS.


Convincing referring physicians to view images on the web is a critical step toward successful web-enabled PACS implementation. The process is simple:

  • Involve & Engage
  • Provide Training
  • Identify Champions
  • Solicit Feedback

Brown of Cedars-Sinai emailed the entire attending group when the hospital deployed PACS and sent out mass faxes. He held classes for referring physicians, but admits he wasn't successful. What really worked was identifying a few champions and training incoming residents. At that point, web viewing spread through word of mouth.

Many hospitals offer one-on-one training sessions for referring physicians. "If we send film, I visit the referring physician with a laptop and CD to show them how it works," Will says. "I also explain the physician portal." He also assesses whether or not the physician's equipment can handle Internet access. According to Will, the following hardware should suffice: P4 processor, 2.4 gigahertz processor, 512 RAM, Internet explorer 6.0, Minimum OS of window 98, preferred Windows 2000 or XP.

"The personal visits to the physicians' offices provide a teaching opportunity and a relationship building tool to better meet the needs of the referring physicians," Will concludes.