Many freestanding imaging centers have sought of late to fortify their information management capabilities by bringing aboard a radiology information system (RIS) as a key component of that effort. However, what such centers soon learn is that the RIS needs of their enterprises are significantly different from those of hospital radiology departments. In a hospital setting, key information management functions such as billing, accounting, purchasing, and insurance verification are performed by the hospital information system (HIS), not the RIS. When the operator of a freestanding imaging center considers its information management needs, however, those traditional HIS functions are frequently among them.
To address their greater needs, some operators of freestanding imaging centers are implementing their own creative solutions to RIS requirements. Consider, as a case in point, the experience of Los Angeles-based RadNet, which owns and manages 40 imaging centers across California, a mixture of start-ups and acquisitions. These centers are organized into nearly a dozen separate groups that need to interact electronically with company headquarters.
“Unfortunately, each group has been added to our enterprise in possession of its own information systems, and it almost seems like no two groups have had the same systems, which has made it very problematic for these groups to engage in easy exchanges of information,” says Micheal Hopkins, director of management information systems. “When you grow by acquisition, as we have, you don’t always have any control over the types of information technology and modalities that await incorporation into the enterprise.”
Several of the groups have at this juncture converted to technology that is compatible with RadNet’s existing information management systems, Hopkins assures. In a few instances, the conversion technology has been plug-and-play. Yet, in the main, RadNet has found it necessary to rely on what it calls a brokered approach to scaling the barriers to workable information exchanges.
“We have developed a single, generalized interface that allows us to broker information between our main computer and the various components out among the groups, such as their billing systems,” Hopkins says. “By brokering, I mean that we intercept data uploaded from the centers and then reformat it to what our main computer expects. We found this to be a simple and relatively inexpensive solution in our situation.
“Another option would have been to write a separate interface for each of the other systems, but that would have been a very expensive and cumbersome approach.”
In the course of evaluating RIS solutions, Hopkins had opportunities to examine many hardware-and-software configurations available on the market. “A problem I noticed was that RIS solutions freestanding clinics can acquire are too often in reality hospital-based systems that have been modified somewhat for the outpatient market,” he says.
One key weakness Hopkins observed was an inability of systems to recognize when they are in the service of enterprises that operate multiple centers under different names. “These RISs seemed confused by multiple centers that don’t all have a single name and logo,” he says. “It’s not unusual in a large enterprise to find that each center will need, for example, to produce a study or report printed with the name and logo of that individual center. Many RISs can’t accommodate that need. Nor can they split up billing output based on location.”
Hopkins says that, for RadNet and companies like it, the ideal RIS system is one able to schedule patients across modalities; collect demographic and insurance information; create an electronic medical record on each patient and track it from site to site; make transcription functions more efficient; and perform mammography tracking (if the center provides mammograms).
Beyond that, he posits that nice-to-have-but-nonessential software features might include:
- An input feature that would allow HL-7(Health Language 7) data to be populated into the RIS from either a hospital system or an HMO so that the center can rapidly preregister patients.
- Integration of the RIS with accounting and purchasing systems. “This would be ideal in an enterprise where a single business unit or division is responsible for the purchasing by all centers,” Hopkins suggests. “Having integration with the accounting systems in all the centers would allow the purchasing division to better anticipate purchase needs across the enterprise.”
Hopkins discloses that RadNet’s decision-makers required little convincing to embrace the RIS solution now in place.
“Our upper management believes wholeheartedly that good, inventive information technology improves the bottom line,” he says. “In fact, sometimes they are so enthusiastic about information technology that I have to ask them to slow down and not push the envelope quite so hard until at least we have had a chance to assess the viability of a promising information technology.”
STORAGE AREA NETWORK APPROACH
It was immediately apparent to Paul Merino that a hospital radiology department RIS would be inappropriate for a small, single-location enterprise like that of Teaneck Radiology Center in Teaneck, NJ.
“When I used to consult at a hospital, the radiology department’s objectives with RIS were to track a number of procedures, procedure codes, films, and reports: RIS was, in essence, a way to track workflow through the department,” says Merino, Teaneck’s manager of information technology. “But, here at Teaneck, we don’t need to track our workflow to the extent a hospital radiology department does. Instead, with modalities including MRI, CT, x-ray, ultrasound, nuclear medicine, and bone densitometry, what we need is a RIS to track cash flow and tell us whether we are profitable. We need to understand how the money is coming in from our reimbursement mix. Take capitated contracts, for example. It’s hard to understand without sophisticated software whether contracts are profitable, how our patients have been impacting our contracts on a quarterly or monthly basis, and which of our referring physicians are sending profitable patients and which are not.”
Like Hopkins of RadNet, Teaneck’s Merino found most of the RIS offerings available on the market to be inappropriate or inadequate.
“The weakness of most RIS solutions for freestanding imaging centers is that the systems are built around a core program that may have been written several years earlier onto which various newer modules have been added,” he contends. “The problem is that these add-ons usually are not linked well to the core program, so you get all kinds of errors and system throughput slowdowns. However, it is not all bad news. The good news is that more and more companies are jumping on the bandwagon of open architecture. In fact, there’s been a tremendous revolution in favor of open architecture in the past 2 years, and it’s had a tremendous effect on hardware and software concepts. Just look at software, for instance. The software of today is really a suite of modules that all link together well and allow a more common database throughout the enterprise. Because it’s all unified, any user of the system, be it a doctor, technologist, billing person, or transcriptionist, can look at a patient’s files and see the patient’s medical information, reports, images, bills, anything.”
Currently, Merino is surveying the available technologies that will allow for creation of a unified network on which RIS-type functions will be able to reside side by side with image scanning, archiving, and distribution.
“What we are going to do is develop a storage area network [SAN],” Merino reveals. “In a SAN environment, every bit of computerized information is conveniently available on a desktop or laptop computer, whether the information is a report, an image, or an electronic medical record. Now, we are not talking about PACS (picture archiving and communications system). This is not a PACS. However, the SAN can handle all the images, no matter what the size. I can move these images around to any PC workstation as long as I have one program that can unify all this information. We’ll be able to take all our medical information, CT data, MR data, and so forth as it streams out of the modalities and digitize it using DICOM (Digital Imaging and Communications in Medicine standard), then put it on the SAN and allow any authorized person in the Teaneck enterprise with a PC to access it.
“The beauty of SAN is it will allow us to put all of our information systems into an open-architecture, TCP/IP (Transmission Control Protocol/Internet Protocol) network, and give every person in the enterprise a computer to access it. I like TCP/IP, also known as 10-100 MHz Ethernet, because it is fast, cheap, and ubiquitous. And moving DICOM images around fast and inexpensively is finally becoming a reality. It is not yet perfected, but we see most vendors are now implementing DICOM properly, so it can be used as an open architecture for plug-and-play. Over the next 24 months, we’ll be implementing this as part of an information management strategy that will carry us through for, hopefully, the next 10 years.”
Teaneck is using a vendor that is a major marketer of SANs, which have mainly been employed by the banking industry.
“Unfortunately, at this juncture, there is not any one vendor that can provide for a small player like us the single system that will allow us to accomplish this total integration,” Merino laments. “It would be a different story if we were a giant enterprise. But since we don’t have multimillions of dollars for the systems at the high end of the scale, we have to wait for the price-performance ratio to improve at the middle of the market.
“Still, I’m convinced that SANs are going to make a radical impact on freestanding imaging center businesses in the next few years.”
A DATA WAREHOUSE APPROACH
For its RIS solution, InSight Health Services Corp in Newport Beach, Calif, has been developing an electronic data warehouse so that different makes and models of information systems spread across the enterprise can, from management’s perspective, function as a single system.
InSight, which reported pro forma revenues of $135 million in fiscal 1998, is one of the nation’s largest providers of high-technology diagnostic imaging and imaging-guided therapy services. The company owns more than 60 imaging centers (some of which are hospital-based) and nearly as many mobile MRI networks.
Services are provided by almost 1,100 employees to more than 35,000 patients across 30 states. Much information is generated on a daily basis.
“We needed a RIS solution able to address a large number of centers and to deal with each one both as an individual site and as a roll-up to the enterprise,” says Patricia Blank, chief information officer. “Across the enterprise we have no less than seven different RIS systems. We don’t think it’s crucial for all of them to talk directly to one another, but they all need to communicate with our home office and be understood. Our solution is to electronically construct a data warehouse.
“The data warehouse will be the source of all reports we generate. The warehouse will standardize the dictionary for each one of the seven systems so that we will have apples-to-apples data exchanges, regardless of the type of software residing at any particular center.”
Blank describes a data warehouse as a method of taking key fields of information and exporting them from the application’s database into a larger, centralized database. The data can be exported from any legacy system, be it financial, payroll, human relations, or general ledger, she says.
“As you have each one of these data fields available to you, you are able to utilize information from other systems to obtain higher-level reporting that would not be incumbent within an RIS,” adds MaryKatherine Kuner, director of training and documentation.
Concerning choice of platform, InSight wanted a Windows-based system for its client-server environment, Kuner says. The ultimate endgame for InSight, however, is a structure that is compliant with American National Standard Institute (ANSI) specifications, so that the company can utilize any ANSI-compliant data base engine.
Then, there was the matter of software. Blank identified three capabilities the software must possess. Most important is the ability to fully support an insurance claim through the processes of preparation and submission, and it must usher these activities to completion in the shortest time possible. “If my system accommodates getting a claim out the door within 24 hours, I’m going to have eliminated one major obstacle and can enjoy a rapid cash cycle time,” she says.
Next in importance is the ability to measure the productivity of assets, such as MR and CT machines. Similarly, the software must be able to measure the productivity of each freestanding imaging center’s direct labor. “I need to optimize the environment so I am getting the maximum throughput from both the equipment and the staff,” she says. “Accordingly, my RIS must be able to monitor time status and assess whatever dead time I have in both assets and labor.”
Third, the software must support the needs of referring physicians. In the current environment, that means preparing and delivering reports to the referring physicians in the most timely manner possible. “Most of our referring physicians like us to fax a report, and our system is able to do that,” Blank says. “Any value-add that I can do for the referring physicians maintains my base of incoming patients. It’s great that I’ve got good throughput, but if I don’t have enough patients, the advantage of good throughput makes no difference.”
Shopping for a suitable package of hardware and software led Blank and her colleagues to conclude that InSight might be better off developing a proprietary system.
“There are not a lot of systems out there able to effectively support multiple-site enterprises, those with 10 or more locations,” Blank says. “Most hospital-oriented RIS systems address the needs of the hospital, which have to do with a lot of inpatient and emergency department services, plus some outpatient services. The objective of such systems is generally to get a report back to a chart and to get a patient out of bed quicker. They also deal with a very limited number of sites and a very limited amount of equipment. Usually, hospital-based systems do not accommodate enterprises with more than four or five sites.
“So, generally, hospital RIS is dealing only with scheduling one, maybe two entities. But when you’re an enterprise versus a single entity, you need a system capable of allowing you to centralize certain functions, such as scheduling, transcription, and insurance verification.”
Insight’s solution remains a work-in-progress, although it is very nearly complete, Kuner reports.
“We believe our system is already helping us achieve our overarching objectives, which are to increase our market share and decrease operating costs,” Kuner says. “It’s helping us optimize the performance and productivity of all of our users, and that includes at each imaging center everyone from the receptionist and secretaries to the technologists, transcriptionists, and radiologists.”
Rich Smith is a contributing writer for Decisions in Axis Imaging News.