If you’re playing the TV game show Who Wants to Be a Millionaire?, only one answer can solve the question. In real life, though, one answer can be the winning response for many questions.

That’s just the case with applying solutions enterprise-wide. A range of organizational and practice issues-among them justifying modality investment, recruiting and retaining IT staff, and creating both patient and staff-friendly infrastructure-might find a common answer in multi-department or enterprise-wide solutions. Such solutions can take the form of PACS, PACS/RIS/HIS, or even creative use of modalities like PET/CT.

Imaging centers and hospitals clearly have distinct and different IT circumstances, at least in degree, including solutions already in place, practice and institutional requirements, and capital resources to apply to IT solutions. Both types of enterprises, though, are likely to seek the advantages of an enterprise-wide approach at some point-for both similar and different reasons.

Becoming One at The Ottawa Hospital

Through the 1998 merger of two teaching hospitals, one community hospital, and the medical-surgical programs of another community hospital, as well as several ancillary facilities, The Ottawa Hospital (TOH) was born. Now 6 years old, it is one of the largest facilities in Canada. The hospital’s statistics are impressive: 1,060 beds, 50,000 inpatients and 700,000 outpatients annually, more than 50,000 surgical procedures in 37 operating rooms, 450,000 diagnostic imaging procedures a year, and about 10,000 employees.

The newly cast hospital, however, faced predictable and daunting tasks: to create a vision that would carry the institution forward and have both patients and staff of the preexisting entities buy into it. A number of challenges were present in trying to bring people, services, and information together.

Not surprisingly, money was a particular issue driving the mergers, pushed in part by the province’s health services financing issues. Gino Picciano, COO and CIO at TOH, says only partly in jest that the “financial health of the hospital was quite terminal.”

Plus, 4 years after its start, the hospital was charged with finding $26 million (Canadian) in budget savings. In contrast to the largely private US system, in the Canadian health system, equipment acquisitions, such as MR and CT, must by approved by provincial authorities, often resulting in well-publicized limits on availability. Consequently, concerns about productivity driven by clinical and financial factors were present as well.

How could the hospital successfully function as one unified and smoothly operating clinical operation if, among other worries, each preexisting institution had used completely independent and distinct IT platforms? “We couldn’t be more different from an IT platform viewpoint,” Picciano says. “All of our hardware and applications-everything was completely different.” The hospital had to make a decision: either continue to perpetuate independent systems or build a corporation with enterprise-wide systems.

TOH chose the latter, believing that the price tag and protracted timetable of such a large-scale project would be worthwhile. The upside would be alignment, both internally and in the community, of the new culture and identity of TOH.

Clinical issues also drove the decision. Multiple campuses meant that patients might come to any one of several; therefore, information-health records, images, reports-needed to be transmitted quickly throughout the enterprise. This situation created what Picciano terms “a quality gap.” He notes that as much as 30% of the time, for example, patients’ films were not available to physicians on a timely basis.

“When you are delivering only two out of three times, you don’t build a lot of confidence in the system,” Picciano says. It was time to get a PACS process going.

Eliminating film and going exclusively to digital in MR, CT, angiography, and ultrasound was the strategy. That included not sending film to external physicians, who can request a CD instead. The goal was to reduce film costs by 40%, as not all of TOH’s imaging modalities were digital.

Also, the hospital designed the process to streamline workflow, thereby increasing productivity. Since Canada’s healthcare system limits approvals for equipment, “getting more patients through is the only means to try to increase our productivity,” Picciano says. Getting clinician acceptance also was especially critical after the merger and was a major objective of any enterprise-wide deployment undertaken.

One criterion in selecting vendors was to be able to work in partnership. “TOH is very much a self-sufficient shop; we outsource very little [IT],” Picciano notes. “Our philosophy is to own the system, so we wanted to use our internal experts to develop it in terms of its implementation and its embedding in the institution.” Michelle Leafloor, a senior systems analyst at TOH, echoes that theory: “We wanted a partnership that would be consultative on workflow and productivity issues, but we wanted to design those ourselves.”

The hospital chose the Horizon Medical Imaging solution by McKesson (San Francisco). According to McKesson, the company’s “software-only approach” provided TOH with options to install its own modalities.

The prevailing opinion at TOH is that the challenge of any IT solution implementation is the “philosophy of ownership”-the clinicians own it and have to feel it is partly theirs. The hospital spent a significant effort during the investigative phase bringing users heavily into the process, defining their needs, and ensuring that the solution would become the users’ solution.

By many measures, TOH has met its goals. “The acceptance level is beyond our expectation,” Picciano says. “I haven’t heard a single complaint.” Noting that maximal ease of use was a priority, he explains that physicians log into the clinical repository and with one click can go into the PACS and review images. Images can be seen on PACS viewers at more than 120 locations; an additional 7,000 users and 5,000 workstations can access the PACS or reports. Plus, radiologists and referring physicians with hospital privileges have remote access.

The hospital also met its objective of reducing film use, saving $800,000 (Canadian) annually and avoiding $200,000 in film costs that would have resulted from increased imaging productivity. The extra volume created by newer multi-slice modalities would have made film use even more impractical, Picciano notes.

The system’s features have been well received. Willie Miller, MD, chief of TOH’s neuroradiology section, says that the system has been very stable, is user friendly, and quite intuitive. Rebecca Peterson, MD, chief of diagnostic imaging at TOH, concurs, adding, “This has absolutely revolutionized our department, brought it from the 1950s to the year 2000.”

Brien Benoit, MD, of the department of neurosurgery at TOH, was very involved in the planning and implementation process, including the decision to move up the deadline for placing PACS workstations in all operating rooms. Asked if the change has been good, Benoit sums it up in a way that any COO would love to hear: “This system has greatly, greatly improved my quality of life.”

Growing Practices and Scanners

When Radiology Associates of Tarrant County (Fort Worth, Tex) planned to open a new outpatient-imaging center in South Arlington, Tex, facility planners knew that part of the process would mandate acquiring at least one new scanner. The radiology group, which consists of about 60 radiologists, provides services to seven hospitals and five imaging centers, according to radiologist Paul Shyn, MD.

The biograph BGO duo-a BGO PET crystal and with dual-slice CT technology from Siemens Medical Solutions (Malvern, Pa) that the facility had purchased in 2002 for the Fort Worth practice-had proven its merit. In a fixed installation at the practice’s major outpatient center, the scanner is used almost exclusively for oncology and handles a full caseload.

Expectations were that the new South Arlington center would serve only a modest caseload initially but would see a large variety of indications-everything “from working up abdominal pain to sinusitis to headaches, suspicious pulmonary nodules, scans of the spine, and so on,” Shyn says-all of which would require diagnostic CT scans plus oncology cases requiring the PET/CT.

The imaging quality and attenuation correction of the PET/CT made it attractive. Being able to use a PET/CT for diagnostic CT in addition to its combined imaging role was seen as an advantage, with the alternative being a dedicated stand-alone CT. Economically, it just made sense.

Additionally, a powerful, heavy-duty X-ray tube in the CT system was ideal for, among other things, allowing a number of scans to be performed without waiting for the tube to cool down. The center was expected to see the whole gamut of imaging, Shyn explains, so the flexibility and productivity afforded by the tube was important.

“Say you have a walk-in and want to do a CT scan before you do your next PET/CT. You don’t want to wait for the tube to cool down,” he says. “You can scan every 10 minutes without running into a cooling problem with the 16-slice CT.”

With an eye on imaging quality and the added benefit of a multi-slice scanner, a new biograph 16-slice LSO crystal PET/CT (also from Siemens) was placed in the new center. So far, the practice is pleased with its decision, Shyn says. “We were very interested in the idea of using the scanner for both diagnostic CT and PET, and that has turned out to be a very good decision,” he explains.

The PET volumes at the South Arlington practice are about three or four patients per day, and diagnostic CT scans average about five to seven per day. “This turns out to be an adequate volume for that scanner,” Shyn says, “It would have been less than ideal if we had a dedicated PET/CT and separate CT purchase.”

Integrated Solutions

It is commonplace for imaging centers and hospitals to use a collection of different vendors’ products. An entire industry has grown to meet the need of creating connectivity between products. Additionally, companies are bringing forth products that offer integrated solutions by literally reengineering their products.

For several years, the Centricity line from GE Healthcare (Waukesha, Wis) has been one of the market leaders for both radiology and cardiology PACS. The company used that position as a springboard for creating enterprise-wide, multi-department IT systems that were introduced as part of the Centricity line at the end of 2003.

The problem GE Healthcare sought to solve through its Centricity RIS/PACS is undoubtedly familiar to many hospital administrators: Each GE Healthcare PACS initially was partnered with a separate, distinct information system. “The challenge” says Peter McClennen, global general manager of imaging and information systems at GE Healthcare, “was [that the information systems] were disparate systems, and [consequently] required separate management, separate administration. They also had very little connectivity.”

The company set out to integrate the two systems to create a single one that, through a single infrastructure, serves “the constituents of radiology, cardiology, and the enterprise,” McClennen says. Now the patient has a single, electronic imaging record that is available anywhere via any PC that is connected to the hospital. Further, Centricity RIS/PACS doesn’t just integrate the images of cardiology and radiology, McClennen explains; it also integrates reports and, for example, the ECGs performed.

McClennen identified three constituencies that GE Healthcare is serving through its enterprise-wide approach: the patient and referring physician, the clinicians in radiology and cardiology, and the administration and IT departments. Better clinical results because of more informed decision-making are arguably reason enough to move to an enterprise solution. And the bottom-line argument is supported as well with a single system; it reduces costs because the duplication of databases, servers, and computer systems requiring management are eliminated.

From GE Healthcare’s vantage point, McClennen says, the enterprise solution has an additional advantage. Many other enterprise solutions currently available are done through partnerships. “With GE, it’s one single technology that we completely own and develop,” he says. As for where the enterprise approach might go in the future, he says, “We are looking to pull more enterprise-level information into the system-information from the lab, pathology, medication management, and other care areas that improve the overall imaging care process.”

It’s no mystery, then, why imaging centers would pursue an enterprise-wide system. According to Stuart Long, VP of sales-PACS at AMICAS (Boston), a solution that goes all the way-from the point of scheduling patients, managing their report data, linking to the billing system, managing images, and disseminating the reports and images in real time-is almost essential anymore, especially to the referring physician.

Frequently, Long notes, imaging center owners want to buy a PACS from their RIS vendor or vice versa. For one, imaging centers typically don’t have the IT infrastructure that a hospital has. Therefore, it is a uniquely different environment with a significantly different level of challenge to deploy these systems. The ability to go to a single vendor, a veritable one-stop shop for everything, is critical.

Part of what is driving automation in the imaging centers, Long notes, is that the modalities are producing enormous amounts of data. It becomes too costly in terms of film, space, and time to visualize and manage the volume of film that would be required. For workflow reasons, as well as maintaining clinical accuracy and efficiency, technology has gone from an attractive improvement to necessity.

Through its merger with VitalWorks (Ridgefield, Conn), AMICAS has been able to combine its Web-based PACS with both RIS and billing solutions offered by VitalWorks, resulting in an end-to-end, radiology image and information management system with the added advantage of being available from a single vendor. The individual products-PACS, RIS, and billing-are respectively Vision Series Web-based PACS (AMICAS); RadConnect RIS (VitalWorks), and Practice Manager Radiology (VitalWorks). Long says that the company’s PACS/RIS/ billing solution is able to provide information dissemination in real time. “It’s almost like a multimedia medical record, complete with information, images, and records. Roll that all together in real time,” he says.

Enterprise-wide solutions come in different flavors and solve a variety of problems. Embarking on selecting and deploying an enterprise-wide solution might yield as winning a result as that of The Ottawa Hospital. “It has fundamentally changed the way people provide care here, and it really is a major success story,” says TOH’s Picciano. “We are most proud because this story is not at the fringe; it is a fundamental change in how the process of care has changed in this institution.”

Ellen Zagorin is a contributing writer for Medical Imaging.