Whether teleradiology evolves organically or is an entrepreneurial venture, the hurdles are the same: how to make distant reading ethical and profitable. Just as PACS previously revolutionized the hospital environment, the technology is now transforming radiology practices of all types.

While there may be business model issues to be debated elsewhere, this article focuses on how radiology practices are using PACS to advance the profession. As is typical with emerging technologies, new solutions continue to appear. While more choices mean more options, there is also more due diligence before you buy.

To shed some light on the decision-making process, we discussed the role of PACS with five distinctly different teleradiology practices. Their stories reflect how PACS is enabling fundamental shifts in the profession while vastly improving patient care.

With one exception, the profiled practices have approached their PACS acquisition as a capital expense. In this group, accepting reassignment was uncommon —most charge a fee and maintain their own billing departments to work with patients, insurers, and hospitals.

The lone departure is The Radiology Group, Duluth, Ga. This practice has adopted what may become a new wave—PACS via an application service provider (ASP). In short, The Radiology Group pays a monthly licensing fee to its PACS provider for each physician in the practice who uses the PACS. The ASP then contracts with hospitals. Thus, hospitals and radiologists concentrate on their areas of expertise, and the ASP focuses on making the IT infrastructure work.

Regardless of which solution a group chose, all are experiencing remarkable success.

ProScan Imaging, Cincinnati

Business Model: Freestanding Imaging Group
Service Area: Worldwide
PACS Vendor: Intelerad Medical Systems, Montreal
PACS Selection Criteria: Solution Customized to ProScan’s Specifications
Goal for PACS: Create Efficiencies by Consolidating IT Solutions

“ProScan is the oldest teleradiology company in the country” says Craig Manahan, ProScan Imaging’s director of IT and security officer. “We began doing teleradiology before there was PACS.”

Over time, ProScan adopted numerous IT solutions as demand for teleradiology services grew among the company’s 28 imaging centers in the eastern United States. “We ended up with six different solutions, including one PACS,” Manahan says. “We were using systems from multiple vendors with a multitude of reading environments. None of them, including the PACS, was ideally suited to our workflow.”

By 2002, the operating expenses for maintaining disparate systems drove ProScan toward consolidation.

After 2 years of researching vendors large and small, ProScan implemented an Intelerad PACS in October 2005. Key to inking the deal: the vendor’s willingness to customize around ProScan’s well-developed processes.

“There are some special ways some of our customers want images read,” Manahan says. “Plus, our previous infrastructure allowed for each radiologist to choose a comfortable workflow, even though it might be different from others in our group. This was important for us to maintain.”

Another Intelerad benefit was the ability to offer image viewing to the referring physician while still maintaining security and Health Insurance Portability and Accountability Act (HIPAA) compliance, which is accomplished via a virtual private network (VPN) infrastructure.

VPNs are the least complicated and most cost-effective way to ensure robust encryption and other security protocols; however, they come with healthy overhead costs. “To implement a VPN, you must have a piece of equipment at either end,” Manahan explains. “So, when we set up a client, either they have their own device or, if they’re a smaller company, we send them a device. We’re constantly exploring alternatives to VPN, but there’s nothing on the horizon, near term.”

Another downside to PACS is the overall immaturity of the technology. “Today’s PACS are geared toward the hospital, rather than teleradiology,” Manahan says. “Every day, we work with our vendor on improvements.”

Integrated RIS/PACS also is high on the wish list. “In our business they’re very intertwined,” Manahan says. “Fortunately, a lot of vendors are moving in that direction.”

Still, ProScan’s PACS significantly impacted its bottom line. “To grow, we had to streamline,” Manahan says. “The Intelerad PACS definitely prepared us for the future.”

Now, ProScan reads for 300 facilities, worldwide. Its fellowship program, long an integral part of the practice, has trained more than 200 individuals. And ProScan recently launched a new company, World Care Clinical, to provide radiology services for pharmaceutical clinical trials.

With the PACS as its centerpiece, ProScan’s 10-person IT staff serves the tech needs of their freestanding centers, teleradiologists, and the new clinical trials venture, connected via wide-area network (WAN). “We’ve seen huge efficiency gains,” Manahan says. “Plus, it’s a more stable environment, so there’s far less downtime. All of this allows us to keep our radiologists doing what makes money, and that’s reading.”

Radlinx Group, Irving, Tex

Business Model: Entrepreneurial Teleradiology Practice
Service Area: Nationwide
PACS Vendor: BRIT Systems, Dallas
PACS Selection Criteria: Foundation of the Business
Goal for PACS: Make the Business Successful

Radlinx did not exist prior to PACS. As is well known, Radlinx was founded in 1998 to fill the overnight reading void. During the early years, Radlinx grew at a screaming 3,000% pace. Today, its central facility connects to 300 hospitals nationwide, via WAN, for emergency and overflow reads, day or night.

“Clearly, without PACS technology, we wouldn’t have a business,” says Radlinx CTO Brian Hall.

But practices looking to follow Radlinx’s lead might require more than just a PACS to meet customer needs. “The terminology ‘PACS’ is loosely used,” Hall says. “Systems that are just a method of sending images from point A to point B are really teleradiology systems, not PACS. PACS isn’t PACS until everything—patient records as well as images— is digitized and everyone can see it, from physicians to billing to insurance.”

In other words, the threshold for PACS is automating radiology processes regardless of source. “We collect from hospitals that all send from a different type of system,” Hall says. “Each collects, archives, and retrieves data differently. As a teleradiology provider, you have to know how to communicate with all those systems. There’s an array of formats to consider and decisions to be made when you deploy a PACS in an outsourced world that’s different from operating within a health care provider’s LAN [local area network].”

For Radlinx, this means a PACS from BRIT Systems acts as a cornerstone, with a number of other teleradiology systems in the mix to ensure compatibility with client systems.

Like ProScan, Radlinx selected its vendor because of its willingness to cooperatively partner and quickly adapt to Radlinx needs. “BRIT has been very fluid in making changes to accommodate us on a daily basis,” Hall says. “We have 20 to 30 BRIT support technicians at our disposal, and our key contact there is a senior engineer who has been with BRIT since the beginning. It’s a strong relationship, and you just don’t get that with the big guys.

“BRIT also allows us to develop our own interfaces and customization applications to interface with the PACS without stonewalling us,” he continues. “For example, eMed won’t provide us a password into its system. So, we use eMed’s teleradiology components, but they’re not our ‘mother ship.'”

Another BRIT plus is an appropriate operating system, ensuring uptime. “We have hundreds of studies coming in during an hour, so a Windows environment isn’t stable enough,” Hall says. “BRIT is never down, it’s a workhorse, because it runs on Linux and AIX.”

In addition to interfacing with other systems, a key feature of the BRIT PACS is “push” technology for continuously streaming images to remote readers. “As a doctor reads one study, 15 to 20 others are downloading, simultaneously, behind it onto the reader’s local hard drive,” says Hall.

Streaming images correctly requires complex autorouting, where BRIT reigns supreme, he says, adding, “Nobody else has the routing capability that BRIT has.”

Also like ProScan, Radlinx uses a VPN for security and HIPAA compliance. Additionally, Radlinx has closed a rarely considered backdoor. “To perform maintenance or upgrades, vendors often use the same log-in and password for every customer,” Hall says. “Instead, we need to be able to shut a person out of our system no matter who they are. So, we distribute user IDs and passwords to our vendors, and we change them periodically.”

On the reader’s end, Radlinx insists on a dedicated workstation to mitigate security breaches of all types. “We require our readers’ equipment to be completely segregated from computers used for anything else,” Hall says.

Up next for Radlinx is voice recognition, to streamline processes further. “The technology is there, but price points are still high,” he says.

Radlinx also is looking into the new JPEG2000 compression technology for improved image integrity. “There’s a lot of controversy about it right now,” Hall says. “We want a better understanding of the technology before we implement.”

teleRadia, Greater Puget Sound, Wash

Business Model: Traditional Professional Services Practice
Service Area: Pacific Northwest
PACS Vendor: AMICAS Inc, Boston
PACS Selection Criteria: PACS Functionality without Archiving
Goal for PACS: Improve Working Conditions, Business Growth

Perhaps the polar opposite of Radlinx, teleRadia evolved organically from the traditional professional services practice, Radia. The Pacific Northwest’s largest private radiology practice, Radia was formed by the merger of two regional players in 1997.

To efficiently provide nighttime readings for its nine hospitals in the greater Puget Sound area, Radia centralized its fledgling teleradiology infrastructure during the merger. While the system boosted productivity significantly over dialing in from home, the technology itself was point-to-point.

“But, by virtue of having a centralized IT system, we also taught ourselves to use teleradiology as a load-leveling mechanism during the day,” says Jeffrey Robinson, MD, musculoskeletal radiologist and teleRadia’s medical director.

In 2001, teleRadia further consolidated when it moved both its infrastructure and reading stations to a single off-site center. It continued to scale out its infrastructure for about a year until it neared its outer limits.

When teleRadia began considering PACS in 2002, its hospitals already had started migrating to PACS and preferred to retain control of archiving. “It took us a long time to get the PACS vendors to understand what we wanted,” Robinson says. Essentially, teleRadia was looking for a PACS without the “A.”

“But most systems are archive-driven, so the problem was finding one that worked,” Robinson says. In 2003, AMICAS came to the rescue. “They were willing to listen to us as well as offer us the flexibility in pricing structure that we needed.”

AMICAS also could meet teleRadia’s worklist management requirements. “At about the same time, we were establishing a second off-site reading center 20 miles from the first,” Robinson explains. “Another feature of the AMICAS PACS was that its worklist management system operated efficiently over a WAN.

“At the time, most PAC systems operated within an enterprise environment and assumed Gig-E, not a WAN,” he continues. “Transparency was one of our primary requirements, whether the radiologist was sitting in Seattle or Everett, it had to be transparent to our customers.”

Moving to off-site reading centers actually assisted with security and HIPAA compliance, Robinson says. “In a distributed system, where you’re reading from workstations at hospitals, people forget to log off. With our own centers and a VPN, we have controlled reading spaces that are secure.”

Although the initial capital expense for the PACS was made without any change in revenue, owning the system has paid dividends along the way. “Originally, we were willing to invest in PACS to make life civil for our radiologists,” Robinson says. “Then, we began getting contracts with other sites.”

Because it is booking more business, teleRadia is looking forward to upgrades in AMICAS’ results reporting functions. “We’re able to integrate cost-effectively with lots of other hardware due to DICOM,” Robinson says. “But to have a similarly efficient results reporting solution, you have to build HL7 interfaces, which are very expensive.”

Results reporting aside, AMICAS gets high marks. Now, teleRadia performs night reads for numerous hospitals outside its original service area, as well as some daytime reads for institutions for which it is not the primary radiology group. To handle demand, teleRadia is expanding at its two current locations and opening a third as well.

“Investing in the PACS not only addressed our own needs, but it also facilitated our growth,” Robinson says. “We’re very pleased.”

American Radiology Services, Dallas

Business Model: Academic and Private Practice Hybrid
Service Area: Dallas and Rock Springs, Wyo
PACS Vendor: AMICAS Inc, Boston
PACS Selection Criteria: Ease of Use; Cost-Effective
Goal for PACS: Take Academic Practice into the Community

As the professional radiology association for Baylor University Medical Center, American Radiology Services has always been on the leading edge of medicine. Yet, in 2001, they were still using couriers to reach outlying cancer centers.

Then, a young musculoskeletal fellow with an eye for technology, Anthony Toppins, MD, decided to find a better way. “We wanted to take our academic practice out into the community to give more patients the benefit of academic reads,” Toppins says. “Almost all 53 of our radiologists are fellowship-trained in subspecialties. Plus, we have a large residency program with about 40 residents and fellows on an ongoing basis.”

In addition to the antiquated courier service, radiologists were still driving around the metro area to cover daytime needs at Baylor’s sites. Toppins suspected it was time to invest in a PACS. “But our group doesn’t have much brick-and-mortar,” says Toppins, American Radiology’s CIO. “Initially, there was a lot of angst about spending so much money when the returns were unknown.”

While none of the practices reviewed in this article would discuss their PACS pricing in detail, Toppins described it as a mid-six-figures capital expenditure.

As investments go, it quickly paid off. “The first year our growth was in the 35% to 40% range,” says Toppins. “We were exceeding our ROI pro forma by 2 years, and it was all by word of mouth.”

Like teleRadia, Toppins settled on AMICAS. But with a new-wave radiologist driving the change rather than organic evolution, the key features and ultimate deployment differed markedly. To start, Toppins identified six key features:

  • Ease of distribution to remote sites. “We specifically wanted some thing Web-based,” Toppins says. “A remote user simply brings up their browser and the PACS installs itself.”
  • Distributed reading model. “Real-time worklists that permit multiple physicians to read them, without intervention by support personnel to route studies, is a significant departure from legacy systems,” says Toppins.
  • Easy to use. “Our practice runs the spectrum from young physicians, with plenty of computer skills, to veteran radiologists with less computer savvy,” says Toppins. “We wanted them all to be comfortable with our solution.”
  • Low maintenance. “We needed something that would run itself because we didn’t even have an IT staff, just a radiologist with an interest in PACS,” Toppins grins. “Nor do we have floor space for a washing-machine sized computer array. Our entire ‘IT center’ is the size of a large walk-in closet. The AMICAS runs on a 4U rack-mounted server.”
  • Responsive, personalized support. “Due to our hospital experience with various PACS vendors, we wanted one that responded to our needs,” Toppins says. “It didn’t matter whether they were a large company or small.”
  • Affordable cost. “We’re risk-averse, so we needed an economical solution,” Toppins says.

With regard to HIPAA, Toppins notes that all current PACS are HIPAA-compliant. “Much of HIPAA is left to interpretation,” he says. “What matters is that you can show you’ve implemented, and followed, proper procedures if a problem arises.”

For security, the practice encrypts image transmissions and they are sent via secure-sockets-layer (SSL) technology, similar to transactions on a bank Web site. When dictating reports, a VPN channel is used.

To differentiate American Radiology from its competitors, Toppins deployed PowerScribe to turbo-charge turnaround. “It’s all voice recognition,” Toppins says. “There’s no staff typing, faxing, mailing, or filing reports. From the time a study hits our server to when a client has a signed report is measured in terms of minutes,” he says. “Regardless, it’s 2 hours or less.”

American Radiology also is using its PACS to offer partners completely new job descriptions. “For example, we retained the expertise of a senior radiologist who moved back to Vancouver to begin building his retirement home,” Toppins says. “With DSL and a reasonable PC, he’s been very productive for us.”

The same goes for the unique expertise of a partner who is in her child-rearing years. “She lives over 3 hours away, in Austin, and reads completely from home,” Toppins says. “Before our PACS, this model wasn’t even an option.”

The Radiology Group, Duluth, Ga

Business Model: Start-up Academic
Service Area: Georgia, Alabama, Louisiana
Reading Group PACS Vendor: NeuroStar Solutions, Atlanta
PACS Selection Criteria: Outsource IT to an ASP
Goal for PACS: Deliver Academic Services to Rural Areas

Taking its cues from all of the established teleradiology models, The Radiology Group could be called the new third way. “Our founder was trained at Wake Forest, where 30% of his reads were on patients from rural areas where there was a misdiagnosis or a bad read,” says CFO Arun Jethani. “He founded our practice in 2002 with the specific mission of bringing academic care to rural areas.”

Indeed, since forming, the group has focused on subspecialist recruitment, hospital contracts, and locating a technology partner to make it all work. Since formally launching in April 2005, the practice has grown to service 20 hospitals in Georgia, Alabama, Louisiana, as well as four clinics.

The group currently consists of about a dozen radiologists, selected to ensure that no patient receives a general read. “Over time, we plan to grow into additional markets, such as Colorado or Montana, when licensing, credentialing, and insurance issues get ironed out,” Jethani says.

To fulfill its mission, the group decided against building an IT center, outsourcing it instead to an equally new breed of ASP. “NeuroStar provides IT support for the hospitals and for us,” Jethani says. “We focus on the best physicians and the best care.

“Because our hospitals have chosen different PACS vendors, we need our IT to be PACS agnostic with robust workflow, reading, and reporting processes,” Jethani continues. “We signed up with NeuroStar to have a Web-based system so we can read from our hospitals, our offices, or our home offices, and NeuroStar’s job is meeting our service level agreements [SLAs].”

The group also keeps the economics simple. The hospital charges the technical fee, and we charge the radiology [professional] fee,” Jethani says. “A year from now, we hope to have billing integrated, but doing our own billing keeps it clean.”

As stated previously, the group pays a monthly licensing fee to NeuroStar for each physician in its practice who uses the system. “About half of our sites now contract with NeuroStar,” Jethani admits. “The others are on separate systems, so we log into those individual systems, but our goal is bringing it down to one system.”

In selecting NeuroStar, the practice demanded more than just a standardized interface into each client’s PACS. To start, RIS is already integrated. “Plus, we wanted to add other leading edge tools,” Jethani says. “We’ve already built a sort of ACT! [contact management system] for radiologists to ensure that studies aren’t missed.”

Like American Radiology, the group uses voice recognition to prepare reports, but with a twist. “We’ve developed more than 200 templates to save time but increase quality,” Jethani says. “Using the transcription model, when radiologists get busy, they can give out one-liners, such as ‘MRI of the knee.’ and a template pops up that makes them look at each piece.”

So far, results from the templates are threefold. “Reports are comprehensive and consistent, which is an improvement for the referring physician and patients,” Jethani says. “And it’s fast. We deliver 93% of our nonemergency reads in less than 3 hours and 100% in less than 5.”

For anyone who has experienced life at a rural hospital, this model is light years ahead of current care standards.

While the group is in its infancy, its model is on the radar screen. “A year ago, no one was using our model,” Jethani says. “Now I have lots of competition as I call on new prospects.”

But with the need so great, the group is far from deterred. “We’re creating additional hubs in New York City and Miami,” Jethani says. “We want to be where our physicians want to live because the technology allows us to provide the highest levels of care to nearly anywhere.”

Anne Rawland Gabriel is a contributing writer for Axis Imaging News. For more information, contact