Jim Cramer, MS, is vice president and chief information officer for Scottsdale Healthcare (SHC). In that role he has been instrumental in taking the SHC hospitals’ information systems from the paper to the digital age. He estimates the hospitals can complete all phases of an internal EMR (electronic medical record) for their patients within 5 years, well ahead of a target for a national EMR by 2014.

SHC began life in 1962 as a single, community-owned, nonprofit hospital in Scottsdale, Ariz. Scottsdale, an upscale satellite city of about 220,000 in the Phoenix metropolitan area, is known for golf courses, art galleries, tourists, and people of means. Million-dollar homes are par for the course in Scottsdale, which has been called the Beverly Hills of the Desert. When money talks, services respond, including health care.

By 1984, SHC had outgrown its original hospital and it opened a second. It has now broken ground on a third, which is due to open this fall. Scottsdale Healthcare Osborn, the original hospital, is a 337-bed, full-service hospital that includes an emergency department and a trauma center. Scottsdale Healthcare Shea is a 405-bed, full-service hospital whose emergency department is a level II trauma center. All the patient rooms at Shea are private. Shea’s radiology department features all modalities, including PET/CT. In November, if all goes according to schedule, SHC will open its Thompson Peak hospital, a 184-bed facility that will open with 64 beds as a paper-lite facility. Altogether, SHC now has a staff of about 6,000, and about 2,000 physicians practice there.

CIO Jim Cramer joined SHC in 1991. He had come to information technology and health care in a roundabout fashion, having trained in industrial engineering and business administration. For years prior to joining SHC, Cramer, by his account, had been a “road warrior,” traveling between cities as a project manager for major accounting firms that were busily creating information systems. Some of the implementations on which Cramer worked involved health care, and he eventually took that IT niche as his own.

Several years after Cramer joined SHC, the hospitals had begun the first steps toward an EMR by establishing a repository of computerized data that included laboratory results, radiology reports, and transcribed medical reports. By 2000, Cramer had helped lay the groundwork for SHC’s installation of an enterprise picture archiving and communications system (PACS) to serve both Osborn and Shea using the same database. Three years ago, SHC added an enterprise-wide physician portal that allows referring doctors, with the proper security clearance, to monitor their patients by providing laboratory results, medication profiles, transcribed reports, and radiological images.

The efforts undertaken by SHC to build an EMR leave it ahead of a lot of community hospitals. SHC has been willing to spend for information technology where other health care entities will not or can not. According to the Healthcare Information and Management Systems Society’s 2005 Annual Report of the US Hospital IT Market, hospitals nationally expend 3% or less of their operating budgets on IT and continue to under-invest in technology.

While Cramer will not reveal proprietary funding information, he says SHC has been liberal in its IT outlays.

“When we did the last plan update for 2006 through 2010, there were about $40 million in IT capital initiatives. That included licensing for Thompson Peak as well as disaster recovery and a business continuity initiative,” he says.

Today, Cramer divides his responsibility between the hospital’s health information management unit, which he says handles transcription, coding, medical records, chart review, and release of information among its functions, and the information services unit, which runs a computer room/help desk, oversees network communication, and handles support and integration for all computerized programs, including the PACS and RIS (radiology information system), and the storage and transmission of data, including electronically stored images. Cramer also has special information project managers who report to the information services unit. Altogether, he says, he oversees a staff of about 75.

At the top of the list of Cramer’s current projects is the installation of a cardiovascular (CV) PACS that will allow cardiologists at SHC to read and store echocardiographic and cardiac catheterization laboratory images. The images will be read on special CV workstations and will be available to referrers and specialists through the hospital’s physician portal.

So Near Yet So Far

The creation of a complete EMR is a daunting task, made no less so by the 2014 deadline for national implementation targeted by President Bush.

Cramer says SHC hopes to have its internal EMR completed by 2010. Integrating one hospital’s EMR into a national database, however, is a problem that nobody yet knows how to solve, much less when it will be solved. Some companies are taking steps in that direction.

“When we did the last plan update for 2006 through 2010, there were about $40 million in IT capital initiatives.”
—Jim Cramer, MS
Scottsdale Healthcare

Interfacing one digital system to another can be daunting enough. Cramer says that as SHC has begun putting together its CVPACS, for instance, it has had to work long and hard with its vendor to marry that vendor’s echocardiograph imaging system with its previously stand-alone imaging system for cardiac catheterization, and then to make that combined product compatible with the radiology PACS from the same vendor.

“The vendor’s solution leverages the radiology PACS architecture,” Cramer says. “You partition the SAN (storage area network) for CV and for radiology so they are segregated.”

The image sets need to be segregated, he says, to keep the CV image space allocated and configured effectively. But on the hospitals’ web viewing tool and on its physician portal, both sets of images, from the radiology PACS and the CVPACS, need to display so referrers and subspecialists can get to them.

“The cardiovascular PACS has actually been more challenging than the radiology PACS,” Cramer says. “Bringing the [vendor’s legacy] systems together into a single solution while leveraging the existing radiology imaging architecture hasn’t progressed as quickly as we had hoped. We’re still working with the vendor and that product is evolving. As they have attempted to add new systems to the radiology PACS, there have been some migration issues.”

Migrating data from an existing system to a new system is a classical interfacing nightmare that can leave IS technicians pulling their hair out.

Jim Whitfill, MD, is CIO for Scottsdale Medical Imaging, Ltd (SMIL), a radiology group with 40 physicians who interpret for SHC and also for 11 clinics that SMIL operates in and around Scottsdale.

Whitfill is like Cramer in that he veered into health care IT from a previously chosen career path. In Whitfill’s case, he completed residency as an internist with a fellowship in medical informatics and found IT to his liking. He is married to a SMIL radiologist, but he does not himself practice clinically.

Whitfill says interfacing systems used by different providers is the key to building a shared EMR.

“The interface challenge is the critical challenge of the next year,” he says.

He estimates that among Scottsdale’s referring physician population, only 5% to 10% have the ability to create EMRs for their patients. The rest are relying at least partially on paper-based record keeping. But that is changing fast, Whitfill adds.

Jim Whitfill, MD, of Scottsdale Medical Imaging Ltd; and Jim Cramer, MS, of Scottsdale Healthcare
“It required a lot of trust and openness on both sides to make sure both parties felt the costs were fair and equitable. We have been fortunate that our relationship has always been built on cooperation.”
—Jim Whitfill, MD
Scottsdale Medical Imaging Ltd

SHC, he says, has initiated a series of EMR education sessions to discuss its strategy and guide its medical staff as those doctors design their own EMR systems.

“We’re moving from the early adopters to the mainstream phase,” Whitfill says. “This will be the year to go to 30% signing [vendor] contracts and starting implementation.”

Both Cramer and Whitfill note that changes in the Stark self-referral laws will allow hospitals to donate up to 85% of software and IT services to doctors with whom they have relationships without incurring kickback violations. Still, says Cramer, “the window of opportunity is effective through 2013. We are looking at the different options as to how we should approach this.”

He says Arizona also has launched a statewide initiative to build an EMR capability. Currently, the focus is on a 5-year plan to develop “interoperability tools to connect physicians, providers, and payors,” he adds.

Interfacing is not just a technical matter of integrating software, it also involves people talking to and learning from one another so that the systems can be used.

The Human Aspect

Victoria Myers is SHC’s PACS project manager. She is a radiological technologist and ultrasound expert who has followed her own altered career path through radiology management into information services. She says the people aspect of adopting systems can be the hardest part of the project.

“I would say the technical hurdles are the same no matter who the vendor,” she says. “The most difficult portion of implementation is truly the interface with the people. You have to get the people comfortable with the new technology. Having access is the biggest benefit, but also the biggest obstacle with implementation enterprise-wide.”

When SHC introduced its physician portal, Myers was charged with implementing the PACS portion of that. It was an important step because it was through the portal that surgeons, for instance, would be getting images on monitors set up in all 50 operating room suites at the two hospitals and two hospital-owned outpatient surgery centers.

“I would say the technical hurdles are the same no matter who the vendor. Having access is the biggest benefit, but also the biggest obstacle with implementation enterprise-wide.”
—Victoria Myers
Scottsdale Healthcare

“All the surgical nurses needed to know how to access the PACS, because the surgeons must be hands free. As we went live, every surgical nurse, special care nurse, respiratory therapist, and all the radiology staff were trained on PACS,” says Myers, adding that the PACS team attended every scheduled medical staff meeting. “I don’t think we could be accused of undercommunicating the project. There was a lot of one-on-one training through a just-in-time training program where physicians could contact a single point of call—me—to either assist them or schedule time with a PACS trainer.”

The rollout of PACS and then the physician portal went beyond what SHC was doing alone. SMIL also was involved. In fact, SMIL was a key partner.

The effort of SMIL and SHC to develop an imaging repository that was both secure to each entity and yet sharable offers an example, in fact, of the technical hurdles that must be conquered to enable imaging as a core piece of an EMR. Furthermore, the cooperation and adaptation between SHC and the radiology group are exemplary of the kind of effort that will have to take place on a much broader scale in order to create a generalized EMR.

SMIL’s Whitfill says that about half the radiology group’s time is spent interpreting studies for SHC. He says SMIL physicians interpret about a half-million studies per year, half of them for SHC. The radiologists who read for SHC do not read for other area hospitals, despite many requests to do so, Whitfill adds. “Our radiologists are very interested in making sure that when a radiologist is in the institution, [they are] providing the best patient care possible.”

When SMIL initiated its digital IT effort, it first installed a high-speed network capable of transferring DICOM (Digital Imaging and Communications in Medicine) images from scanners to workstations throughout its clinics, then it added a RIS, a billing system, and finally a full-blown PACS. To get near paperless, which it is now, it has added digital dictation and document digitizing.

Before SMIL developed its PACS, SHC installed a PACS on its side of the aisle. SMIL eventually chose the same vendor that SHC used. Both sides wanted their PACS units to be able to move information between them, but they did not want a shared PACS, Whitfill says. “Scottsdale Healthcare is a different corporate entity.”

Adds SHC’s Cramer, “It was a mutual decision to keep the systems separate. We have different master patient indexes for one thing.”

Jim Whitfill, MD, of Scottsdale Medical Imaging Ltd; and Victoria Myers and Jim Cramer, MS, of Scottsdale Healthcare

So what SHC and SMIL did was cross-install each other’s PACS workstations at the hospitals and in some of SMIL’s clinics. There are, says Whitfill, SMIL workstations in the reading rooms at both hospitals, and there are SHC workstations at two of SMIL’s outpatient sites. Each workstation accesses only its associated PACS, but radiologists can easily move from one PACS monitor to the other. That way the radiologist who needs to check patients’ prior images from a SMIL clinic when that same patient comes to the hospital, or vice versa, can move from one PACS workstation to the other without the need for a manual intervention to align patient data for both PACS systems.

The other step SHC and SMIL took was to feed the images from the SMIL PACS onto the SHC physician portal, so that subspecialists or referrers could check priors from both sources. The images from both PACS also can be accessed via web browsers.

The radiologist in a hospital reading room can go to the SMIL browser via the web and check priors, but for complex, cross-sectional images, it is better to use the SMIL workstation in the hospital, says Whitfill, “where they have all the tools to compare that exam.

“The hospital network and the SMIL network do touch. They can pass data between them. For example, from the MR console at the hospital, one can push to the MR console at SMIL, and vice versa,” Whitfill says. “Where openness needs to occur for patient care, we’ve worked to allow that to happen—and at the same time we’ve protected network security, so it’s not a wide-open gate.”

SMIL clients are cleared to access all relevant SMIL images, but unless they are also SHC clients with SHC clearance, they cannot get to the images on the SHC PACS, Whitfill says. But the hospital through its physician portal does offer a hyperlink to the SMIL PACS, so that medical staff with clearance can get to the relevant SMIL images.

“You can’t connect to us and get SHC, but if you connect to SHC, you can get us,” Whitfill says.

Sharing Beyond PACS

Financing the cross-installation of the PACS workstations was pretty much a matter of each side paying for its own equipment, Whitfill says.

“It required a lot of trust and openness on both sides to make sure both parties felt the costs were fair and equitable. We have been fortunate that our relationship has always been built on cooperation. We have been able to find wins for both organizations,” he adds.

So much have the radiology group and the health system come to trust one another that their cooperation on enabling an EMR has gone beyond PACS. SMIL also helped SHC roll out its physician portal, for instance.

SHC Vendor Resources

Physician Portal: McKesson
Radiology PACS: GE Centricity
Cardiology PACS: GE Centricity
RIS: McKesson 11.0
3D Vendors: Vital Images Vitrea, GE AW Suite
Results Communications: None
Archive: EMC Centera

“They had thousands of physicians who needed to be trained,” Whitfill says. “We also wanted to train physicians to use our [web viewer] system, which uses the same format. We took our trainers and ran at full speed. We let Scottsdale Healthcare know who we’d trained so they could cross those names off their list.”

SMIL and SHC also have worked to coordinate PACS software upgrades on each system so that the same versions are in use at both sites. “We haven’t always been perfect, but we’ve tried to keep them in sync,” Whitfill says.

Additionally, because its radiologists control SMIL, the group has the flexibility to try new technologies and then share results with SHC. SMIL is now evaluating an orthopedic imaging template product, as well as a 3D imaging viewer different than the one the hospitals use.

“We can work with our radiologists to determine clinical benefits and then go back and say to the hospital here is a proven technology in our environment,” Whitfill says.

From the EMR standpoint, SMIL is now trying out a vendor that transmits medical chart data and clinical results to SMIL’s referring physicians who have developed a digital capacity in their own offices.

SMIL Vendor Resources

Physician Portal: None
Radiology PACS: GE Centricity
Cardiology PACS: None
RIS: GE Centricity RIS-IC
3D Vendors: GE Advantage Windows Workstation and AW Suite, TeraRecon AquariusNet, Vital Images Vitrea workstation
Results Communications: ChartConnect, GE ConnectR

“We have worked to develop a single interface with [the vendor] and then they go out and do interfaces with the physicians. We’ve got about 50 referrers set up that way,” Whitfill says.

He says SHC is looking at the same vendor to possibly connect referrers to Health Level 7 (HL7) data that is not now available through the physician portal.

“Today, there is not an HL7 result interface between our system and the hospitals’,” Whitfill says, “although the PACS web viewer does have the diagnostic reports on it, so clinicians and staff can access the data without needing the results interface.”

Myers says cooperation between the hospitals and SMIL has been vital to EMR building thus far. “We know their IT department and their technical support people very well. It’s been an opportunity to share lessons learned.”

Recently, SMIL and SHC launched a PACS user group that meets bimonthly. Vendors and regional participants share information on such topics as monitor calibration and database management, Myers says. “SMIL was even more instrumental in coordinating the first meeting than we were.”

Getting Close

While there is plenty to do within SHC to achieve a complete EMR, the light is at least visible at the end of the tunnel.

“Today, we’re about halfway there,” says CIO Cramer. SHC has images on its portal. The portal also contains a patient’s laboratory results, nursing notes, and clinical documentation as well as prescribed medication, Cramer adds. Still to come is an EMAR (electronic medical administration record) that documents medications as they are administered.

Another step still to come, Cramer adds, is the CPOE (computerized provider order entry) that electronically tracks orders from physicians and other providers, including orders to the pharmacy. Finally, added to that, he says, will be electronic physician progress notes.

“We say by 2010 all those will be electronic,” Cramer says. “By 2010, we’ll be totally electronic with our EMR.”

IT people know that for the foreseeable future they will be busy. As momentum builds from the local level to the state and national levels, health care providers may have to decide between allocating funds to local IT demands and broader EMR goals.

Victoria Myers compares the process to clinical triage.

“I think it now becomes a kind of triage of what is needed to provide a complete EMR versus what is an upgrade,” she says. “We just had funding to change out our long-term archives. End of life with computers happens very quickly. We are in a unique environment that requires triage as to where the dollars will get spent.”

On the other hand, she says, as SHC has gone from paper to digital records and images, the demand for more technological capability has accelerated.

“It doesn’t take people long to see the benefits of having an EMR,” Myers says. “Now that they’re used to the technology, they can’t imagine being without it. It has saved doctors hours and hours, and that equates to improved efficiencies in patient care, so it has been easily supported in that way.”

SHC and SMIL have seen the EMR future, and they’re committed.

But as Cramer notes, “If there’s to be an EMR for everybody by 2014, there’s a lot of work to be done to get there.”

George Wiley is a contributing writer for  Axis Imaging News. For more information, contact .