Each time Partners HealthCare acquired a new hospital while on its way to becoming one of the nation’s larger integrated delivery systems, the Massachusetts-based organization gained something more than it bargained for — another information-management scheme to add to the growing collection of proprietary and commercial systems needing to somehow be integrated within the larger framework of the full enterprise.

“Often overlooked in any merger process is the information system infrastructure and how it will allow the various member institutions to exchange data with one another,” says Ramin Khorasani, MD, director of the Information Management Division of the Department of Radiology at Brigham and Women’s Hospital in Boston, one of the two founding institutions in Partners HealthCare, which launched in 1994. “The most obvious solution is to rip out the infrastructure in each acquired entity and replace it with a new one that is common to all. That, of course, is an expensive and time-consuming proposition. But what we realized in radiology is that there is no reason to go to all the trouble and expense of putting in a new network when there is already one out there called the Internet waiting to be utilized.”

Drawing on that insight, Khorasani’s group has set about the task of developing a web-based informatics solution for all services provided by the Brigham and Women’s radiology department, with far-reaching implications for the entire Partners HealthCare family of hospitals.

“Within the next 12 to 24 months, everything we do in radiology here is either going to be deployed on or run from the web,” Khorasani says. “This will be fully integrated with Partners HealthCare’s informatics network architecture. By utilizing the web in this fashion, Partners HealthCare can continue to grow and we, as a radiology services provider to the enterprise, can still achieve integration without having to enforce the type of hardware that sits in a particular office in each institution or the way they interact with the main campus.”


Brigham and Women’s is a 702-bed academic hospital formed from the 1975 merger of three Harvard-affiliated Boston hospitals: The Peter Bent Brigham Hospital (founded in 1913), the Robert Breck Brigham Hospital (founded in 1914), and the Boston Hospital for Women (itself a merger of the Boston Lying-in Hospital founded in 1832 and the Free Hospital for Women founded in 1875). Brigham and Women’s for the past 6 consecutive years has been ranked among the nation’s top 10 hospitals by US News and World Report.

Not surprisingly, Brigham and Women’s department of radiology is quite dynamic. Each year, staff spread among 17 radiology specialty and clinical services programs perform more than 350,000 inpatient and outpatient procedures at the hospital and elsewhere. The department was the first in the nation to utilize intraoperative MRI, which enabled the hospital’s neurosurgeons to conduct America’s first craniotomy. Every radiologist in the department is board certified, and 17 of them were listed in a recent edition of the directory Best Doctors in America.

Informatics is seen as foundationally critical to the fulfillment of the radiology department’s mission — so much so that Khorasani’s unit has devised, and is implementing, a comprehensive strategic plan for acquiring, deploying, utilizing, and servicing information technology.

“About 3 years ago, we saw that radiology was increasingly an information service business and the radiology department was the producer and manager of electronic information,” explains Steven E. Seltzer, MD, chairman. “It seemed logical that a department like ours should emphasize structurally and operationally the different aspects of being a producer and manager of information.”

Khorasani clarifies that the informatics strategic plan does not simply revolve around information systems. Rather, he says, it is a distributed information management program.

“What makes our effort somewhat unique,” he says, “is that it arises from the premise that the process of care in radiology does not begin when an examination is ordered but when the referring physician first begins to think about ordering that examination. The informatics infrastructure we are creating will stretch from the first point of contact with the referring physician when he or she wants to schedule a test, and it will extend to beyond the point where a bill is sent to the payor. We are looking at the processes we are using each step of the way to see how information technology can improve all of that and everything in between.”


The radiology informatics strategic plan describes approximately a half-dozen initiatives, starting with the already completed installation of a 100-megabit fast Ethernet switched network architecture (with a 1-gigabit core for the department’s already installed PACS) to provide broadband intranet access to the web.

“On this network we are deploying PCs, which are supported by the hospital’s information system platform,” Khorasani says. “Currently, these PCs are running Windows 95?. By the end of the conversion process, they will be latest-version PCs with either Windows NT? or Windows 2000?.”

For some years prior to this, the department utilized Macintosh computers exclusively. Then in 1997, Partners HealthCare decided to stop supporting Macintoshes.

“That meant we would be deprived of access to the rich, PC-based electronic network that Partners HealthCare was well on its way to developing,” Seltzer says. “We decided it was better to switch than fight. By the middle of this year, we will have completed our conversion to PCs, about 250 systems total. A few Macs will remain for instructional programs and publishing activities within the department’s education division.”

Khorasani says all of the PCs will be supporting a custom-designed web browser. This will give users access to the radiology information system and the hospital information system, plus imbedded speech-recognition programs for generating reports.

The second component of the informatics strategic plan calls for conversion of the department’s image-acquisition devices from analog to digital, and completing the deployment of primary interpretation workstations throughout the department.

“We are going to be reducing film and all associated handling costs as much as possible, and permit virtually every area of radiology to move into a soft-copy, print-on-demand environment,” says Jeffrey S. Oxendine, MBA, MPH, Executive Director of the Department of Radiology and the department’s Information Management Division. “We believe it will be a while yet before modalities like digital mammography and digital fluoroscopy systems are truly cost-effective. Accordingly, we are pacing our rate of conversion to coincide with anticipated advances in those technologies so we will be able to capitalize on them when the time is right.”

Currently, this initiative is about 75% complete. The goal is to be 100% complete by the end of 2000, Seltzer says.

Another big item in the strategic plan is web-based distribution of images and reports. This, Seltzer says, will not be achieved until the web browser is made available to all referring physicians throughout the enterprise.

“As of this juncture, less than 50% of the 5,000 referring physicians in the system have our browser,” Seltzer notes. “Fortunately, Partners HealthCare is in the middle of a major initiative of its own to put electronic information connections in the hands of those doctors, so we plan to piggyback on top of that deployment and provide our browser as part of the package. That probably will not be completed until sometime in mid-2001.”

Another project listed within the pages of the strategic plan entails the formation of partnerships with industry to help develop hardware and software solutions.

“We have a tradition in our department of academic-industrial cooperation, whether for innovation, field testing, or evaluation of the value of new technology,” Seltzer says. “We have talked with all of the major players in PACS and information management about our vision. We think it would be a win-win situation for vendors who share our vision of what radiology can become to partner with us.”

By taking a web-based approach, the radiology department has given itself the means of drawing on partnerships with an array of vendors, since the informatics scheme is completely platform-independent.

“We built components of our system in modules,” Khorasani says. “If a vendor has a better scheduling module, for example, we can acquire it and put it right in thanks to our being on the web. The web gives us a totally different approach to building things. It has significantly advanced our modularization of these programs.”


The thinking behind the development of a strategic approach to informatics began to coalesce about 3 years ago at one of the radiology department’s occasional retreats for its management team.

“We use our retreats as a time to reevaluate our strategic plan for all aspects of the department, not just our use of information systems,” Seltzer explains. “Often, the thing that drives our setting of priorities and allocation of resources as a department is this practice at our retreats of going back and asking ourselves the basic question of what business we are really in. For many years, the answer was always the same: we are in professional and technical services, trying to add value for our customers by creating the best images possible and reliably interpreting them as quickly as possible.

“But, at our retreat in 1997, the answer was different. There had been a shift of opinion. Some of our team believed — and persuasively argued — that our business was not only professional and technical services but, increasingly, information management.”

The vision for informatics that emerged from this new awareness was sweeping, Seltzer indicates. Essentially, he and his colleagues wanted to empower referring physicians from every corner of Partners HealthCare to be able to use a PC at his or her office, home, hotel, or wherever to interact with the radiology department across every type of function.

“From their own PCs, referring physicians would first select what imaging test was best for their patients,” he says. “Our information systems would give them advice about which tests would be most appropriate in difficult cases. While still online with us, these referring physicians would be able to schedule the test they selected. They would not need to make a separate phone call to us, be placed on hold, or end up in voice mail. They would be able to quickly enter their order, electronically, and move on to other things they needed to be doing.”

Seltzer says this intuitive scheduling component, now nearing completion, will also help reduce inappropriate testing and overutilizations.

“If a referring physician tries to schedule a chest x-ray, for example, the system will alert him or her if that particular test was performed just recently,” he explains. “It will give the referring physician the opportunity to cancel the test he or she is attempting to schedule and instead allow the most recent such test to stand. It will also indicate to referring physicians whether the test they want to order is the most appropriate one for the diagnosis. If there is a better choice, the system will present it and the physician can then make a selection.”

“This expansion of the radiologist’s traditional role in medical management — helping nonradiologists in the selection of the appropriate tests — will become a core mission of our department to increase the value of the radiologist in patient care,” Khorasani adds.

The department also envisioned an informatics infrastructure that would make information captured from referring physicians and patients flow more seamlessly through the system in such a way that its accuracy could be better ensured.

“With more accurate data in the network, it will be easier to comply with state and federal regulatory requirements, and it will also result in improved billing and collection performance,” Oxendine says. “When the physician orders an examination, the system displays a series of prompts for entering suspected diagnosis, indications, ICD-9 [International Classiciation of Diseases-9th revision] codes, and other pertinent details we need to capture up front in order to do perform a better-quality examination and get paid for it.”

Accuracy of the data is enhanced by quality-control filters, Oxendine notes. For example, a quality control relay device developed by Brigham and Women’s and one of its vendor partners lets a technologist compare information from the radiology information system and from the imaging modalities to verify that they are from and about the same patient — this is done prior to the data entering the PACS for reading by a consulting radiologist, archiving, and distribution, Oxendine says.

Implementation of the informatics strategic plan is fraught with challenges, not all of them of a purely technical nature. As Oxendine attests, many involve management issues. One is funding, having to justify the investment and compete for limited capital available within the system.

“The department has been able to obtain much of its financial support by emphasizing the enterprise-wide benefits in terms of improved quality and accessibility of service, greater business efficiencies, heightened cohesiveness and integration among the various business units of the health system, and cost savings,” Oxendine says. “But also, we were fortunate in having both our hospital’s and health care system’s management teams committed to developing and exploiting the value of information technology. When we explained our vision and strategic plan to them, they were willing to provide the additional human resources and capital we needed to go forward.”

The task of reconciling vision and reality requires some tempering of expectations. “Information technology now touches every area of the practice and delivery of radiology,” Oxendine notes. “Therefore, everyone has his or her own ideas as to what shape a new system like the one we are implementing should take. Expectations can be very high and sometimes become quite unrealistic in the process. We have to be careful to avoid promising more than we can deliver.”

Rich Smith is a contributing writer for Decisions in Axis Imaging News.