Radiology practices that invest in digital information and image management solutions often undercut the effectiveness of those systems by neglecting to support them with a well-constructed data communications network overseen by personnel specially trained in the bits, bytes, and bauds of information technology (IT).
“It takes good IT in order to realize the maximum return on investment from your PACS and radiology information system (RIS) implementations,” says Joe Falvey, chief administrative officer of Radiology Associates of New Hartford in Utica, NY. “With PACS and RIS, the goal is to be able to as efficiently and inexpensively as possible send images and text to other locationsthose you own as well as those where your referral sources are based. That goal can be met only if you first make the commitment to the IT component.
“The problem is, though, that IT has too many rapidly changing facets for a radiology practice to be able to stay abreast and understand how to take advantage of the latest technology without help from people who live and breathe that field. If you don’t have IT people among your resources, be they in-house employees or outsourced consultants, you’re setting yourself up for failure, you’re dooming your implementations of PACS and RIS before you even get them off the ground.”
IT SUPPORT IS NOT CHEAP
Many practices around the country have come to the same conclusion and taken the necessary steps to develop IT support systems and structures. Doing so, however, is not cheap.
Howard B. Kessler, MD, reports that his own practicePennsylvania Radiology Group just outside Philadelphiaspends close to $100,000 a year on salaries for one full-time in-house IT director and two assistants, with another $25,000 to $30,000 paid out annually for network equipment. His is an enterprise with a substantial amount of network traffic. It has 24 radiologists and multiple MRI centers across the state; together with the handful of Philadelphia hospitals it staffs, those facilities perform about 375,000 radiology procedures annually on top of additional tens of thousands of studies submitted electronically from far outside the area by imaging sources wanting a first or second opinion (beyond that, the practice also operates a billing service and financial consultancy called Reimbursement Solutions LLC, another big generator of traffic along the network). How this practice’s IT expenditures compare to national norms is difficult to say, since the norms are hard to gauge.
“Spending today on IT is all over the charts, with no common thread to it,” says Jon Copeland, chief information officer of Inland Imaging in Spokane, Wash, who also consults with practices small and large from coast to coast.
Nonetheless, Copeland predicts that IT outlays among radiology practices will rise appreciably in the years ahead. He attributes the expected climb to the continuing proliferation of PACS and RIS.
“Radiologists are discovering that PACS and RIS can make them 10, 20, and 30% more efficient,” Copeland says. “Numbers like that are leading more and more practices to see PACS and RIS as strategic, must-have investments. They’re going to need IT support in larger and larger amounts to keep pace with the IT infrastructure growth that PACS and RIS bring about.”
Inland Imaging’s 44 radiologists handle 200,000 outpatient and 250,000 inpatient procedures annually at its four freestanding imaging centers and through the 14 hospitals at which it provides contracted coverage. Modalities include CT, MRI, ultrasound, nuclear, CR, DR, x-ray, fluoroscopy, PET, and PET-CT. Copeland was brought aboard 8 years ago to develop the IT organization within the practice, but by that point IT was already an entrenched aspect of operationsand daily building in importance.
“Even back then, the group recognized the danger that IT, if not handled and developed properly, could become a growth-limiting factor for the practice,” says Copeland. “They did not want that to be the case.”
“The CEO Steve Duvoisin wanted IT handled by someone who’d wake up every morning thinking about nothing but IT,” says Copeland.
OUTSOURCED, AT FIRST
Meanwhile, Pennsylvania Radiology Group’s decision to set up an IT operation was spurred by somewhat similar circumstances. Launched 5 years ago with 10 radiologists and contracts from two hospitals, the practice needed IT in order to support distribution of reports and billings. Then, in early 2000, Pennsylvania Radiology Group began picking up MRI reading contracts from geographically distant customers. The practice needed the ability to pull those images into a central server, and then route them to various workstations and terminals within Pennsylvania Radiology Group.
Says Kessler, the group’s president, “It was a spoke-and-wheel configuration, using T1 lines. Not the most efficient arrangementInternet broadband had not yet come into its own. But back then, it was the best we could manage as people whose only exposure to the world of IT was as PC users.”
After a while, this setup became untenable as online file volume and sizes swelled. So the group retained the services of an IT consulting company to implement a solution. Things were looking up once again, but eventually it became clear to Kessler and his practice partners that the costs of outside expertise in this area were getting out of hand.
“We were paying the consulting firm $200 an hour and the amount of work we were sending their way kept growing right along with the volume of studies we were moving over the network,” says Kessler, recalling the exasperation he felt at the time. “We looked at a couple of options to bring down those costs, and the best one was to make IT an internal function.”
The high cost of outsourcing likewise drove Radiology Associates to bring IT in-house. Radiology Associates is a group of 16 radiologists conducting imaging services at three practice-owned imaging centers and providing coverage at four area hospitals. Total volume reaches about 275,000 imaging procedures a year, with MRI and CT generating the largest share of that load. Radiology Associates made the decision to go electronic nearly 4 years ago, but only recently took the first actual steps with the installation of a new practice management/radiology information system. Radiology Associates is now in the process of adding a PACS.
“The acquisition of our practice management-radiology information system and the search for PACS quickly opened our eyes to a huge weaknessour lack of IT knowledge,” confesses Falvey. “We had nobody in our organization with the strengths needed for such an undertaking, even though we’re all into computers. We needed IT support in order to be able to implement the network and to be able to derive the greatest possible efficiency from the systems we were installing.”
During the time Radiology Associates was planning its conversion to filmless, it worked with an outside IT service company that had been started by a PhD put out of work when the local Air Force base shut down. The group enjoyed an excellent relationship with that IT firm and found its services extremely helpful at that critical juncture. However, the farther along Radiology Associates moved toward RIS and PACS, the more expensive the relationship became.
“The last monthly bill they sent was so huge that, if I’d have annualized it, it would have paid the salaries of three or four in-house IT engineers,” Falvey marvels.
That is when Radiology Associates concluded the time had come to bring the IT operation under the practice’s own roof; no more outsourcing. Falvey says thought was given to pulling a radiology technologist from the clinical pool and reassigning him as an IT specialist. That idea was nixed once it became plain there would be immense difficulties involved in finding and training a replacement, given that radiology technologists were in short supply.
So Radiology Associate hired a full-fledged IT person. From whence did he come? He came from the very company that had been providing the outsourced IT services.
GOOD HELP HARD TO FIND
|Chaz Kaslouski (left) and Darian Hill (center) provide information technology for Pennsylvania Radiology Group, led by Howard B. Kessler, MD.|
Recruitment is an ongoing concern for Inland Imaging as well, which now has a radiology IT team of 20. The practice finds IT employment candidates through a mix of local classified advertising and use of national executive-search agencies. The hunting can at times be slow going: the group recently spent 7 months sifting through resumes and conducting interviews to fill a single slot for a programmer with HL-7 experience in hospital information system and outpatient informatics.
“We wanted someone with a solid technical understanding of the complexities of these interfaces,” says Copeland. “There’s a new type of IT person emerging in radiology who combines the expertise of a network engineer, a biomedical engineer, and an interface-integration engineer. This person understands DICOM, HL-7, and networking. Unfortunately, this type of person is still something of a rarity.”
Because of that, Inland is attempting to produce its own blended experts by cross-training network and biomedical engineers.
That is basically the same strategy embraced by Pennsylvania Radiology Group. In anticipation of converting to its web-based network solution, Pennsylvania Radiology Group set about the task of recruiting an individual to build and oversee an in-house IT department, one of the main functions of which would be to monitor network traffic and take steps to keep things flowing at peak speeds. Pennsylvania Radiology Group found such a person already on its payroll, among the film-hanging technicians at one of its imaging centers.
“It turned out he had a computer science degree from college,” says Kessler.
The background in computer science gave the technician a good foundation, but more training was needed. So Pennsylvania Radiology Group sent him back to school for formal IT schooling. Two years later, he graduated and stepped right into the position awaiting him with Pennsylvania Radiology Group as director of IT.
Occasionally, IT employment candidates who look great on paper just cannot cut it inside a practice. Avoiding such a pick requires asking the right questions during the interview process and, as Inland does, putting the job applicant to a hands-on practical test.
“With one recent candidate, we gave him a problem to solve,” says Copeland. “It was not a problem that we knew the answer to, by the way. It was an actual problem that we as an enterprise needed to solve; we wanted to see how the candidate would go about dealing with it. After spending about 4 hours working on it, he came up with a workable solution.” He also was immediately hired.
“If you’ve got a talented IT person, never let him get away,” Copeland admonishes.
When Copeland himself first arrived at Inland, step one was to install more robust networks connecting the facilities where Inland had an electronic presence.
“Initially, there were dedicated T1, point-to-point circuits between imaging centers,” he recalls. “Meanwhile, the rural hospitals we were providing coverage to had dial-up connections. We took all of it into a frame-relay topology. All of the rural sites were upgraded to at least T1 connections. We shored up the capacity between the imaging centers to dual and even triple T1s.”
“Today, all our facilities are linked by 100-megabyte Ethernet WAN connections. We have approximately 7,000 referring physicians, nurses, technologists, and other health care providers in Spokane and as far away as Seattle to the west and across the Idaho border to the east who are able as a result to make use of our remote image and diagnostic report viewing capability.”
Copeland’s most important contribution in all this was to spearhead a financial analysis of the IT requirements to put flesh on a high-level action plan he had developed.
“Every couple of weeks at our operating committee meetings, I’d give an IT update,” he says. “I’d also take IT recommendations to meetings of the executive board.”
Because IT can be like a foreign language to radiologists, Copeland cultivated sufficient IT knowledge in a handful of the practice’s physicians who then acted as evangelists to spread the word among the others there. This was vital because, to win the budgetary dollars necessary to carry out the IT plan, Copeland needed as much physician support as he could muster.
“The evangelists’ mission was to explain to the other radiologists what IT could do for them and how it would make their lives better,” Copeland says.
When all is said and done, experiences like Copeland’s, Kessler’s and Falvey’s point to the paramount value of making the IT function an integral part of practice management. Or, as Kessler puts it, “We have a critical need to be able to move images and information. In an electronic environment, you move images, not people. But without IT support, you’re back to moving people, not images.”
IT PERSONNEL: NO IDLE HANDS ON DECK
Worried that once you hire your first IT person you will sooner or later have trouble finding things for him to doand thus justify his continued presence on the payroll?
Radiology Associates of New Hartford confronted that very fear and is developing plans to ensure the IT specialist they recruited will always have plenty of work on his plate.
“One idea we’ve come up with is to sell IT support services to primary care and other specialty practices that want to get connected to the Internet and establish their own data-exchange networks,” says the Utica, NY, group’s chief administrative officer, Joe Falvey. “If we could each month attract even a few such practices and convince them to utilize our service, I’m reasonably certain our IT person would be kept very busy for a long time to come with that one task alone.”
Over at Inland Imaging in Spokane, the IT team now consists of 20 RIS/PACS specialists, and all are kept busy from sunup to sundownand beyond. For starters, they man daily from 7 am to 7 pm a help desk for users of Inland’s PACS and RIS services (after 7 pm, members of the team carry pagers and are on emergency call).
“Whoever is at the desk is expected to pick up the phone by the fifth ringand we do,” says CIO Jon Copeland. “Service is the name of the game.”
Typical of calls are requests from users who have forgotten passwords or are having trouble locating a particular patient’s records.
“We’re dealing in a multi-RIS environment, so patient identification issues between hospitals and outpatient centers have to be dealt with,” Copeland explains. “That’s something vitally important for IT to do.”
In addition to help-desk duties, Inland’s IT force continually monitors network integrity and performance. Moreover, the team has to stay abreast of innovation that might be suitable for adoption and integration within the Inland enterprise.
“We’re currently evaluating voice recognition, which would be one such example,” says Copeland. “And we recently began implementing a document-imaging solution to move us toward a paperless environment.”
Also, a select few team members serve in the capacity of product developers who step up to the plate when needed add-ons for installed systems cannot be procured commercially, because they do not exist or are too expensive.
“For instance, we couldn’t find a physician scheduling system that met our needs, so we built one of our own,” says Copeland. “And we’re right now building an OB ultrasound fetal growth charting system that will be tied into our RIS.”
The team also provides training to new users of PACS or RIS.
“We try to coax film-using physicians to start viewing images electronically,” Copeland says. “Any time a physician asks for film, we happily send it overalong with one of our marketing-savvy IT people who then offers to show the requesting physician how easy and efficient it is to access images in digital form. If the physician wants to switch over from film, he has to buy his own PC and network connection, but we’ll provide the necessary training. It’s a worthwhile investment for us, because then we don’t have to pay the cost of distributing film.”
Rich Smith is a contributing writer for Decisions in Axis Imaging News.