A Teleradiology Technology Journey

By Eric Gillespie, RT(R)(CT)CIIP

Teleradiology has been a central part of Radia Inc’s business for more than a decade. Radia is a leading provider of professional services in diagnostic imaging, interventional radiology, and vascular surgery in multiple hospital-based and freestanding clinic locations throughout Washington State.

In 2000, Radia launched a service to offer night services to its partner sites. With a radiologist at a central location during the night, emergency room cases could be turned around at a faster pace without having to call a radiologist to the partner site. ER physicians and x-ray technologists also had easier access to a radiologist for phone consultations. The practice eliminated worries about waking up a radiologist in the middle of the night.

After the initial foray into providing this centralized service to partner sites, Radia extended the service offering to facilities beyond its existing hospital partners. This became Radia’s teleradiology ser-vice and was branded as teleRadia. An increasing number of facilities in the state of Washington started coming on board, and soon teleRadia was offering 24-hour service to numerous partner and nonpartner sites.

During the daytime, partner sites sent subspecialty exams for reading by teleRadia’s subspecialist musculoskeletal and neurological radiologists. Additionally, partner sites experiencing high volumes sent overflow to teleRadia. In the early evening, nonpartner sites sent ER and stat inpatient/outpatient exams.

The significant increase in volume started taking a toll on teleRadia’s operations. The existing PACS system became unstable. Near-daily restarts became the norm. Challenges arose, especially at night when IT staff members were paged and traveled to the site of the affected PACS server(s) for manual restarting.

Additional challenges arose in the radiologists’ ability to keep up with incoming paperwork. Workflow involved:

  • exam orders and prior reports were sent by fax
  • radiologists reviewed the images
  • radiologists dialed into the facility’s dictation system to complete dictation
  • for ER patients, the radiologist would write a preliminary report and fax it to the emergency room.

Amid this, the phone would ring with calls from physicians wanting to discuss findings or working with technologists on exam protocols. Up until this time, all of the work was a manual process.

Addressing Early Issues

In 2003, as the practice’s radiologists sought to expand teleRadia, glaring issues needed to be addressed. “Imaging assistant” roles were created and filled to help offset the time radiologists spent with paperwork and the telephone. These “extender” professionals were responsible for answering incoming phone calls, gathering/prioritizing exam orders and prior reports, and faxing preliminary reports to referring facilities. Soon, teleRadia realized it could no longer afford the inefficiencies of bottlenecks caused by its manual faxing. A fax server was implemented.

Perhaps most significant was Radia’s need to address lost radiologist productivity due to PACS instability and downtime. A team was assembled to evaluate and identify the practice’s road map for PACS replacement. With a key focus on stability, flexibility, and storage, an RFP was issued to five PACS vendors.

Only one system, Amicas Vision PACS (now offered as part of Merge Healthcare), met all of Radia’s requirements. Of significant value was the PACS’ ability to process system orders without an HL7 broker. The Amicas (Merge) PACS accepted incoming exams and assigned them to specific radiologist worklists. The system also allowed for custom development of worklists by radiologist and scenario. With the Amicas (Merge) software solution, Radia was able to purchase its own hardware. This allowed Radia to spec out 5 months’ worth of storage, a huge improvement over the previous system, which handled less than 10 days of storage.

The system proved itself as stable. In 2004, teleRadia imported 89,000 exams. For 2005, imported exams shot up to 139,000, while 2006 was just under 200,000 exams. Gone were the days of daily server restarts. Radiologists now had the stability to do their work without worry about interruption.

A Bump in the Road

By the end of 2006, despite major strides, frustration started to increase among radiologists. At this time, tele-Radia used two PACS systems; the Amicas (Merge) system for everything but one large partner site. Radiologists were required to switch between two worklists when pulling up exams. Additionally, each teleRadia reading room had at least five dictation machines. Because specific machines were aligned for specific work types, the radiologists had to remember to align dictation machine selection and provide individual personal PIN numbers for each system. The possibility always existed that dictation might be done on the wrong system. When this occurred, Radia’s transcriptionists handled the “fix” on the back end.

Once again, Radia came to the table looking for help to address this teleradiology-specific need. Administrators met with several vendors at RSNA, but no single vendor could address both PACS worklist issues and transcription challenges. In late 2006, Radia hired an in-house developer to brainstorm approaches to overcome these challenges.

The first solution was to have an independent application create a “unified” worklist for the radiologist. In this environment, radiologists needed to access only one location to find and read all exams assigned to them. In working toward this, another solution evolved. The developer not only created the unified worklist but also figured out how to launch the appropriate viewer based on the type of exam being read. Once again, Amicas (Merge) proved its flexibility and time-saving efficiency by providing an environment in which, with a single click, the right viewer launched when the case opened. The system did the work.

Solving the Dictation Issue

Radia continued its struggles with multiple dictation machines. Well into 2007, all sites were still on telephony dictation systems. Essentially, the radiologist dialed into a system, entered a personal PIN number, and dictated into a microphone. On the other end, transcriptionists would listen and transcribe the report. This model was replaced with an environment that moved everything the radiologist did (with the exception of voice dictation) to the server side. A new application was developed. Now, the system knows which radiologist is dictating, dials the partner’s dictation system, enters the PIN number, plays back the voice file, and then hangs up.

By bringing on in-house development staff and working closely with vendors, Radia has improved its teleradiology offering by addressing both PACS and dictation limitations. Today, the practice estimates that radiologists are 20% to 30% more efficient due to these technology and process improvements. This is a significant accomplishment and critically important in today’s environment where reimbursement cutbacks seem to be looming around every corner.

Eric Gillespie, RT(R)(CT)CIIP, is Imaging Informatics Supervisor at Radia Inc, PS. He has 20 years of experience in the radiology field, which includes an AA as a radiologic technologist with certificates in CT and Certified Imaging Informatics Professional.