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Imaging and the enterprise: "anytime anywhere" access to digital images means improved efficiency for caregivers and optimal healthcare decisions and treatment for patients. (PACS/Radiology)(Cover Story).

Three years ago, a take-off on a political slogan became the unofficial theme at a major radiology conference. The tongue-in-cheek theme, "It's the Enterprise, Stupid," captured the challenge confronting not only radiologists, but also the senior management of most healthcare institutions: how to meet the growing demand for fast, convenient access to diagnostic images, reports and prior exams throughout the healthcare enterprise. Simply put, referring physicians and radiologists want and need vital patient information on a real-time basis.

Diagnostic images, a core component of a patient's medical record, are assuming a more pivotal role in healthcare delivery. Increasingly, medical images are used in the prevention--not just the diagnosis--of medical conditions. A rising number of specialists utilize medical images as a pre-surgical tool, with an image viewer stationed in or near the operating room where diagnostic images, captured digitally, can offer information superior to that provided by static film images. As healthcare institutions nationwide work to develop comprehensive electronic medical records, the inclusion of diagnostic images, and particularly prior studies for comparative purposes, represents a robust addition.

An Enterprise Overview

What are the obstacles--and opportunities--to providing enterprise-wide access to images? Traditional film-based approaches have proven too radiology-centric and cannot scale sufficiently to keep pace as demand for quick access grows. Continued financial pressures on healthcare institutions mandate the minimization of both initial capital outlays for equipment and operating budgets.

The situation takes on added urgency given recent radiology trends. Many hospitals, integrated delivery networks and large academic hospitals are reporting 12 percent to 18 percent annual hikes in radiology volumes. Radiology procedures now rival and even surpass pharmaceuticals as the fastest growing healthcare expense. Availability of newer imaging modalities, an aging population and the overall consumerism movement in healthcare are driving the surge in the volume of image-based diagnostic procedures.

At the same time, the number of images-per-procedure (study) is also rising. A single patient study, containing 1,000 to 1,500 different images or slices, is becoming commonplace. While this level of detail improves the precision of the diagnosis, it also raises the workload burden on radiologists.

As a result, the search for solutions to manage diagnostic images has expanded beyond the radiology department to involve the enterprise's senior management team, including the CIO and CFO.

This multi-functional team approach is a marked departure from a few years ago, when the radiology department was viewed as a stand-alone entity in planning and management of its own IT needs. At that time, several factors contributed to the seeming remoteness of the radiology department. First, diagnostic images were served in proprietary environments, unfamiliar to the hospital IT staff. Second, radiology personnel are generally not hospital employees. Moreover, with most CIOs focused on Y2K compliance, network issues, terminal-to-PC conversions, and the growing complexity of their institution's help desk needs, radiology department chiefs simply turned to the familiar scanner (MRI, CT, etc.) or film vendors for their other systems needs.

Today, many CIOs are finding that familiarity and experience with diagnostic imaging systems is not only becoming a requisite from an organizational needs perspective, but that knowledge also represents a valuable attribute for their professional growth.

Digital Advantages

Five years ago, the first Web-based solutions were introduced for managing diagnostic-quality images. Using a standard Web browser, images could be made available within seconds across the enterprise and accessed on most legacy desktops. While distribution was the initial focus, today these systems also offer full Picture Archiving and Communications System (PACS) functionality, including radiology workstations, long-term archives, RIS/HIS interfaces and standards-based seamless integration with the electronic medical record.

The advantages of a digital environment are increased efficiency, cost savings and enhanced patient care. By eliminating or minimizing access to the physical film and inefficiencies associated with its printing, storage, retrieval and circulation, an enterprise-wide digital environment delivers advantages on all fronts.

In a film-based environment, more than 10 percent of patients' films are lost or misplaced, causing redundant scans and delayed care. A film-based environment generates expenses of $10 to $20 per study which can be reduced to $2 to $5 per study in an enterprise-wide digital environment. Additionally, the initial investment needed for a modern Web-based image management system is a fraction (often 20 percent) of the cost typically required for a film-based system.

Because the system is standards-based, there are no proprietary image formats or infrastructure requirements. A Web-based system can be easily scaled for clients based on their size, type of business and presence at multiple sites.

Finally, the ability to provide referring physicians with customization in how their images and reports are viewed and accessed is also becoming a mandate.

Benefits for patients include faster turnaround on their studies and enhanced health outcomes. In one recent real-life example, a patient was being treated for gangrene in a rural hospital. After his images were digitally captured, the patient's study was immediately forwarded electronically to an orthopedist specializing in the lower extremities at a major teaching hospital hundreds of miles away, who reviewed the study. The speed in that specialty read helped the patient avoid amputation, undergoing vascular surgery instead.

Starting Points

For those institutions that have already invested in a PACS and need enterprise-wide access, conversion to a digital imaging solution can be accomplished within a few days or weeks by adding a dedicated server, deploying a viewer in a few key departments such as the ER and ICU, and retrieving prior studies residing on the DICOM archive via a standard query/retrieve function.

For hospitals that haven't made a significant investment in PACS beyond implementation of a RIS, a phased implementation scenario enables facilities to move efficiently toward a filmless or less-film operation. By installing a dedicated server, a store of prior exams can be built. Adding a small number of diagnostic workstations enables a few key radiologists to begin softcopy readings while they evaluate required workflow changes. A viewer, deployed in the emergency room or ICU, can provide fast access to patient images while affording easy and quick measurement of the system's success.

Given these advantages, why aren't hospitals moving even more quickly to adopt Web-based diagnostic imaging solutions? It's estimated that only 8 percent of U.S. hospitals now have a digital image management system in place. But PACS consultants forecast that figure will jump 20 percent to 40 percent during the next two years. Several hurdles impact the adoption rate.

It's worthwhile to acknowledge several concerns that are either overblown in significance or can be easily addressed. For instance, physician reluctance to embrace new technologies is not a significant deterrent. Our experience in helping community hospitals and integrated delivery networks make the digital transition demonstrates that having an influential internal advocate, or "system evangelist," is key. This individual--whether from IT, radiology or another clinical area--should have broad leadership, and technical and operations know-how. This individual identifies and guides a few early adopters who quickly turn skeptical medical staff peers into loyal users.

The spread of universal desktop configurations and Internet standards has removed another deterrent, making these solutions easy to implement in most hospital environments. And while security remains a topmost priority, digital image management systems that incorporate user tracking, logging and other features satisfy most of these concerns.

Turf Concerns

Probably the most significant hurdle to adopting enterprise-wide imaging systems is the question-- whose system is it anyway, radiology's or IT's?

Historically, enterprise-wide systems such as healthcare information systems or electronic medical records have been selected via a committee representing all interested departments. However, once the decision was made, the daily caring and feeding of the system is the responsibility of the IT department. Hence, many of the selection and implementation criteria are set by IT; issues such as security, scalability, redundancy, integration, deployment, future upgrades, training, support and the overall operational cost are real issues. The traditional filmbased system vendors have not dealt with these issues on a large scale since their primary use has been by and within the radiology departments, their established strongholds.

The turf question in this case shows signs of diminishing as more "true" enterprise systems not only address the concerns of the IT department, but also provide the depth and breadth of functionality requested and required by radiologists. Early involvement of the IT department is recognized as a positive approach that can result in a better integrated and more comprehensive plan.

To some extent, radiologists might also fear role and turf erosion as more referring physicians, such as orthopedic specialists and neurologists utilizing a digital environment, can perform their own readings. However, the opportunities offered by a digital environment can offset this potential concern. The increase in case volumes has put radiologists in even higher demand. Radiology departments can grow market share by attracting business beyond their traditional geographic market boundaries, offering other facilities around-the-clock radiology coverage or access to specialty reads.

Convenience is another advantage for over-burdened radiologists. Radiology staff accessing images remotely from home PCs can easily provide 24/7 radiology coverage. There are diagnostic image management systems that even feature push technology, enabling robust image files to be waiting for the radiologist who is working remotely with limited bandwidth connections.

Marketing Semantics

Another hurdle to adoption stems from confusion about the marketing claims of different solution providers. Most traditional radiology equipment vendors promote a radiology-centric, not enterprise-wide, system. A truly "Web-based" solution offers speed in managing and distributing complex medical images, contrasted with "Web-enabled" systems that continue to utilize older technology with a bolted-on Web server front-end. While this approach achieves the convenience of using a Web browser, the workhorse of this system retains the older, non-scalable and proprietary client-server architecture.

Finally, there's inertia resulting from the fear that change brings complexity, disruption and hidden expense. For instance, the redundant costs of film during the transition to a digital environment, which typically spans one to two years, should be recognized. So should the investment needed to convert traditional non-digital functions such as X-ray equipment and report transcription to digital functions such as computed radiography or digital radiography and voice recognition report generation systems.

In working with healthcare facilities of all sizes and types, our company has found that a phased transition is best. Incremental adoption affords time to evaluate the needs of various clinicians, integrate with the IT infrastructure, establish a digital library of prior studies, upgrade older modalities and otherwise prove as you go. Many hospitals start with the ER or ICU departments, or establish a cluster of CT or ultrasound units tied to a single file server and archive, and expand from there.

Five Success Factors

A handful of factors, when carefully managed, yield the best return. The first is to commit to a digital environment infrastructure, including minimum requirements for network bandwidth, project staffing, modalities, and most importantly, redundancy. Start to capture digital studies in a standards and Web-based, as well as vendor-neutral or universal, format. The capture, storage and distribution of full fidelity images should be based on the DICOM, JPEG 2000 and Web standards with a fully redundant architecture.

Another factor involves a successful adoption, rollout and marketing of the system, beginning with internal customers and expanding externally. Since the images are already stored in an online repository ("forever priors"), successful institutions identify the early adopters, whether they're within the radiology department or in the referring physician community, who will create the most momentum within the enterprise.

The third factor is sizing the system's operational requirements including maintenance, technical support, upgrades, quality control, expansion and training. A standards-based system is far less complicated and costs less to support and operate.

The fourth factor entails customization and personalization. The required workflow and preferences for the type of image viewers will vary not only from hospital to hospital but also among the medical staff members within the same facility. The ability of the system to be utilized under different workflow conditions and viewing preferences contributes to the design of a practical and flexible enterprise-wide image management system.

Finally, the ability of the system to not only meet regulated guidelines such as HIPAA, but also seamlessly integrate with any current security infrastructure within the facility, will enhance the chances of a successful project.

Each of these areas should be addressed in planning the digital conversion, and any consultants or vendors brought in to assist should work closely with the enterprise's management to carefully plan the transition based on specific objectives.

In summary, an evaluation of systems for managing diagnostic images affords an opportunity to reduce capital and operating costs within a fast growing expense category, while building satisfaction across the medical staff. Length of patient stays can be decreased as physicians are able to make discharge decisions more quickly with better information at their fingertips.

Finally, the "anytime, anywhere" access afforded by Web-based systems eliminates geographic service boundaries, thereby increasing revenue and competitive advantage.

Digital Imaging Checklist

In evaluating different digital image management solutions, this checkIist may provide helpful criteria.

1. Is the system standards-based? Will it provide freedom from proprietary systems, lower the infrastructure burden, and ease later up grades?

2. Does it provide on-demand access to all prior studies, as opposed to a cumbersome "pre-fetch" process?

3. What is its speed and scale? What is the largest volume of installations currently in use?

4. How does the system integrate with the facility's existing infrastructure, including its desktops and electronic medical records?

5. How does it track users? Can it utilize a single set of security protocols, and avoid redundant log-in procedures and passwords, without compromising security?

6. Does it offer "push teleradiology" ability to accommodate remote reads via slow modems?

7. How useful are the tools provided for continuous monitoring of system performance?

8. What is the fully loaded system cost, including operational expenses? How much does it cost on a per-procedure basis? What is the cost if the system were deployed in stages (i.e., first add ICU and the orthopedics department and later add additional users)?

RELATED ARTICLE: The final mile to filmless. Courtney, Greg

How do you distribute high quality radiology images quickly across a medical network that encompasses four main campuses, 40 clinics and 1,300 beds, and generates 260,000 digital and hardcopy images a year? Kettering Medical Center Network (KMCN) of Kettering, OH, faced that question in early 2000.

For us, the answer was to transition away from film to a digital image distribution system over the course of a few years. We began the filmless quest by acquiring a traditional picture archive and communications system (PACS). It has served well in the radiology department, delivering and storing softcopy images and making them available to radiologists there. But it did not go the "final mile."

Radiologists had access to softcopy images, but referring physicians did not. Without an affordable enterprise-wide distribution method to deliver the images, our network of roughly 900 referring physicians, in specialties from cardiology to oncology, would continue to ask for film. We wanted to eliminate costly and cumbersome film, but needed an economical replacement method.

Kettering Medical Center, in conjunction with The Wallace-Kettering Neuroscience Institute and Wright-Patterson Air Force Base Hospital, selected as a solution Stentor's iSite Web server, which is fed directly from KMCN's PACS system and allows any of our affiliated physicians to access diagnostic quality digital images via an Internet browser using a standard desktop PC. This solution eliminates the need for costly PACS workstations by using off-the-shelf PCs, yet delivers the same image quality and tools needed to evaluate the study. It allows multiple users to simultaneously view the same image from multiple locations, enabling physicians to consult quickly on patient diagnosis.

Physician Benefits

Stentor's iSyntax technology utilizes mathematical representations called wavelets, iSyntax delivers only those pieces of the image needed for viewing and diagnosis, eliminating network congestion and enabling images to arrive at the PC within seconds, rather than having to endure a "pre-fetch" wait time for an image to be delivered and downloaded to a remote location.

The iSite software is downloaded to the physician's PC through the Web browser. The physician receives a unique user name and password to access the Web server. For added security, the entire system operates behind a firewall as part of a virtual private network.

More than 25 percent of our referring physicians already utilize this technology, with adoption and training continuing this year and next. Both Kettering Medical Center and Sycamore Hospital facilities have the ability to access digital images using PACS and iSite; Grandview and Southview Hospitals will come on board next year.

PACS workstations can be too costly to provide for referring physicians in remote locations. Giving physicians the ability to use a regular PC to access images is more economical and enables us to reach all of our doctors, not just the hospital where PACS is located.

Hamid Tabatabaie is president and chief executive officer of AMICAS Inc., Newton, MA. Contact him at hamid@amicas.

Greg Courtney is PACS administrator for Kettering Medical Center Network, Kettering, OH. Contact him at
COPYRIGHT 2001 Nelson Publishing
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2001 Gale, Cengage Learning. All rights reserved.

Article Details
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Author:Tabatabaie, Hamid
Publication:Health Management Technology
Geographic Code:1USA
Date:Nov 1, 2001
Previous Article:Behavioral health gets a jump on compliance. (HIPAA Watch).
Next Article:Saving money with PACS: two facilities join forces to share a cost-effective imaging system. (PACS/Radiology).

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