Investing in PACS and related technology can stabilize and strengthen your practice in uncertain times.

OK, what do you need a chair for? You need it to sit on—to provide support. If you want, for example, to sit at your workstation and get some work done, you’ve got to sit down on a good, solid chair. Otherwise, your entire foundation is pretty shaky.

I liken the lessons our practice has learned about PACS, its related technology, and the nontechnical aspects of the PACS purchase, implementation, and use to the four legs of a chair.

Here’s what each of those four legs looks like: a good local IT vendor that understands your needs, a PACS vendor that’s both agile and flexible, a robust network, and buy-in from your radiology group on the value of investing in a PACS system. The truth is, PACS isn’t an inexpensive proposition. But it certainly is an investment in your practice—one that will continue to pay dividends over time.

Radiology of Huntsville, where I’m a practicing radiologist, is located in Alabama. Our practice comprises approximately 30 radiologists who are committed to improving the health care of our patients by delivering state-of-the-art imaging. Our radiologists value what our patients and referring physicians value: accurate interpretations with rapid turnaround.

“Redefining the standards of excellence in the radiology profession” is a tall order. But I think our practice does accomplish this goal. Our smart investments in technology are just one part of what helps us accomplish this—but those investments have been vital to our success and vital to the well-being of the patients we serve.

Before I get ahead of myself, let me tell you about my experience thus far with Radiology of Huntsville. When I joined our group in 2004, we covered several independent facilities that were not affiliated with the two primary hospitals for which we provide services. I’m sure that our practice wasn’t running much differently than others at the time. We read from hard-copy films. What that meant to us as radiologists was that we had two options: either we had to drive from one facility to another to perform interpretations, or the films themselves had to be transported to where we were.

Reading from film is like having a yoke around your neck: It’s slow and expensive, comparisons are difficult, and films don’t move easily or rapidly from one place to another. Reading from film also created delays in turnaround time. At this point, we pursued what could best be described as a mini-PACS system.

Unfortunately, within a very short period of time, our network was bogged down and it became clear that this system was meant more for a local area network within the confines of the four walls of a hospital or imaging center. Once you got outside of those walls and tried to use a secure T1 line or other connectivity, the system fell apart and became virtually unusable.

So, with all of that as background, what are the keys to delivering excellent patient care in the most efficient way possible? To get there, let’s return to my analogy about the four legs of the chair.

A Good Local IT Vendor

This is absolutely critical. When you’re shopping around for an IT vendor, don’t even consider one that doesn’t serve clients in the health care space. That might appear to be a no-brainer—given HIPAA regulations—but I’ve heard of stranger things.

We’ve got just the right IT consultant (FINAO Solutions of Huntsville, Ala)—one that completely understands our business. They completely get what a physician needs from a PACS system. And their team helps make all of our lives easier, mostly because they understand “what’s going on underneath the hood.” For our practice, that means our local IT vendor has a solid understanding of the intricacies of software versus hardware versus networking.

Our practice can’t afford to have someone who understands only some of the systems we need to operate our practice—we need someone who can help, regardless of the type of challenge.

Related to this, we’ve also learned that it is essential to have a PACS administrator who has an intrinsic curiosity about radiology and technology. A PACS administrator who has a fairly flexible understanding of their job description is great as well. When you’re interviewing a candidate for this position, I’d suggest looking for a “jack-of-all-trades” personality. That is, someone who wants to understand—in a holistic way—how a solution works and how interdependencies between users and different components of the solution interact.

In addition, it’s critical that your support staff understands technology and the intrinsic efficiencies and inefficiencies of technology that impact the end user: the radiologist.

An Agile, Flexible PACS Vendor

Here’s the deal: In general, PACS vendors just don’t want to deal with a disparate reading environment. So long as you stay within the four walls of a hospital, everything hums along well enough. You sit at your workstation and provide interpretations, and the results are communicated to referring physicians so they can provide diagnoses for their patients.

However, if you step outside of those four walls, that’s when you run into problems. If you’re looking for a PACS that allows you to read remotely—and efficiently—then you have to find a PACS vendor that’s going to want to work with you to understand your practice’s unique needs.

Take our practice, for example. We don’t have a RIS, which can be a huge problem when you’re using a PACS system. A problem because if you don’t have the RIS sending the order into the PACS, then the PACS system doesn’t know what to do with it.

This is one example of where understanding a solution holistically comes into play. It isn’t just whether your PACS will accept an exam without an order from a RIS.

To understand some of the important issues involved, you have to consider the following:

  • Are you able to work with your preferred dictation or voice recognition system without an order?
  • How do you get results back into PACS without a RIS?
  • How do you distribute results to referring physicians?

Coming up with smart answers to these questions requires a partner that can help you think about all of this in advance—a partner that has the flexibility to come up with a solution that meets your needs. We found that partner in AMICAS (Boston).

Cost-effective Remote Reading

Again, most PACS vendors simply don’t want to deal with a distributed reading environment. The ideal solution should be one that allows you to provide optimal patient care without constraints, such as network speed or radiologist location.

We searched for a solution that would allow us to staff hospitals and imaging centers with fractional radiologist requirements. For example, let’s say that one hospital does more studies than a single radiologist can read but fewer than two would typically read. Or a site has many procedures every day that would prevent the radiologist from reading on-site on a daily basis due to interruptions.

Given that this was our reality, we had to ask ourselves: How could we efficiently staff this type of site and ensure excellent patient care—without sacrificing radiologist efficiency?

The historical answer has been that you’d either need two radiologists on-site or have a radiologist commute to the site to handle the additional workload. But both of these options are economically inefficient. Having two radiologists on-site means that one of them isn’t going to be busy for half of the time. Having a second radiologist drive to the site means that they have “downtime” while driving around, and there could be ebbs and flows in the volume at the site that could impact patient care.

A more efficient staffing model is to have a single radiologist on-site who can be supplemented with a virtual team that’s available for overflow reading. With this scenario, it is important to consider the challenge of network latency between locations. So, you’ll need to find a solution that works well in a low-bandwidth environment.

This is precisely what we’ve done at Radiology of Huntsville. We have a unified worklist for a substantial portion of our practice that allows us to balance workload across facilities. This gives us the opportunity to take on contracts with fractional radiologist requirements in a manner that’s good for the patient and makes sense for us economically.

PACS: An Investment in the Future

Over the years, I’ve noticed that many practices are hesitant to make an investment in technology. I suspect there are many reasons for this, most of which fall into one of two buckets: political and economic.

The traditional model is that PACS is provided by the hospital or imaging center. While this may be workable in many instances, some facilities may not provide a solution that’s feasible for the needs of the radiologist. This may be due to many factors. Sometimes it’s not economically feasible to provide a better solution, sometimes what a radiologist needs isn’t understood, and sometimes the decision was made years before the facility needed a new group to provide services.

The key to success is to work as a team with your customers to provide the best care for your patients and referring physicians. Give and take is critical on both sides of the equation.

Darrin Johnson, MD

The second, and more obvious, challenge is an economic one. Many radiology practices measure their own success by their radiologists’ take-home pay. The fact is, making an investment in technology creates short-term pressure on take-home pay. Despite the fact that the long-term payoff is hopefully substantial, it’s difficult to get many practices to make these investments.

Having a strong leader with a vision for the future of your practice is the best way to address these challenges. There are always mechanisms to address short-term economic issues. A political issue, such as providing services at unaffiliated hospitals, is an important one, but one that can be addressed with technologies that allow your practice to create a unified worklist across broad geographies.

Back to the Chair

Let’s return to that chair analogy. By their very nature, radiology practices are complicated businesses. These practices have intense IT needs, yet their principals are often hesitant to adopt and drive technology that has an end goal of improving patient care while driving efficiency.

Clearly, Radiology of Huntsville has been a success story. Our investments in technology have helped stabilize our practice in an uncertain time—perhaps like the support a chair provides. Certainty and stability are both very good things.

Darrin Johnson, MD, joined Radiology of Huntsville in 2004 after completing a fellowship in nuclear medicine at Vanderbilt University. He is a member of the Radiological Society of North America, Society of Nuclear Medicine, American College of Radiology, American Medical Association, and other professional organizations. He has written several publications and made presentations on radiology topics.