Radiology informatics team at the Cleveland Clinic Foundation includes (from left) Louis Lannum; Robert Cecil, PhD; David Piraino, MD; Jim Massey; and Michael Recht, MD.

Connectivity issues bedevil virtually every radiology enterprise that seeks to create a filmless imaging environment. The Cleveland Clinic Foundation (CCF) Division of Radiology, which serves a network of five community regional hospitals and eight family health centers in northeastern Ohio, is no exception.

But the matter of enabling PACS (picture archiving and communications system), RIS (radiolgy information system), HIS (hospital information systems), digital image acquisition devices, and other systems deployed around the enterprise to fluently and reliably talk to one another ceased to be quite so daunting a problem for the 80-year-old institution after it hit upon the idea of delegating to its technology vendors the primary responsibility for crafting connectivity solutions.

“Our vendors are incentivized to see to it that connectivity is achieved and achieved well,” says Robert Cecil, PhD, network director in CCF’s Division of Radiology. “We tell our vendors up front that we do not pay them unless and until the connections are made and working. And we don’t specify for them a connectivity protocol. Instead we take the position of not caring how they connect the pieces, just as long as the connections are made and they work.

“In fact, when vendors come to us and tell us, for instance, that they’re DICOM compliant and offer us their specifications to prove it, we politely inform them that we are not buying a specification. Rather, we tell them we are buying images on our users’ desktops, to be available where and when they want them.”


That may seem a rather harsh stance to take-until one considers what it has enabled CCF to accomplish.

Notably, CCF provides electronic delivery of radiology services to all its facilities on and off its main campus in the city of Cleveland, as well as to dozens of independent small hospitals and imaging centers scattered across the United States. Yet it does so in a way that actually improves radiologist productivity.

“Traditional teleradiology services provide reads to client institutions in whatever manner is preferred by that client, which requires the interpreting radiologist to treat that service in a manner different from that of his usual day-to-day in-house work,” explains Michael Recht, MD, section head of CCF’s e-radiology service. “As a result, the interpreting radiologist is not truly productive because he must switch gears, back and forth, between in-house work and external teleradiology work, often involving different equipment. That is very disruptive to the radiologist’s work flow. It prevents him from providing a uniform level of service.”

CCF’s approach has been to equip what it refers to as its e-radiology customers with technology identical to that which exists inside the CCF Division of Radiology, Recht says. The only elements that are not standardized in this manner are the customers’ image acquisition devices-clients use whatever they have on hand for that purpose.

“We’ve modeled our e-radiology service somewhat along the lines of an Internet applications service provider,” Recht says. “We supply the hardware and software the client imaging center needs in order for us to make it an actual node on our integrated RIS and PACS network. In this way, the client schedules its patients within our own system, then transmits the images to us using our own PACS. Those images come to our RIS-PACS integrated workstation the same way our own internal cases come in. We read the images and dictate the reports. Because the client center is using our RIS, it has immediate access to the reports.”

This, Recht says, is a boon to the CCF radiologists assigned to performing the interpretations. “As a radiologist, when I’m sitting at my workstation, it no longer matters to me whether the images are coming from the room next door or an imaging center out in Idaho,” he offers. “I simply take each case as it comes, from wherever it comes, one right after the next. Consequently, we do not have to structure our service such that we are doing all CCF cases from 9 am to 5 pm, then from 5 pm on, we will go over to a separate monitor and do the Idaho cases.”

Key to connectivity

From left, David Piraino, MD, and Louis Lannum, view a digital study at one of 30 diagnostic workstations deplyed among five hospitals and five family health centers within the Cleveland Clinic Foundation Network.

Recht points out that most of the client hospitals and imaging centers signing up for CCF’s e-radiology service own neither a PACS nor a RIS. However, that is advantageous, he says, because CCF much prefers to provide the necessary hardware and software components itself. Of course, a few clients already possess either PACS or RIS or have both.

“These clients don’t have to discard those systems; they can continue to use them for their own in-house purposes, if they so desire,” he clarifies. “But they can’t use them in conjunction with our service, since to do so would take us back to square one on the connectivity issue.”

Something else CCF requires: clients have to accept from CCF sufficiently high-speed telecommunications lines so it can monitor imaging studies in real time.

“We don’t monitor every patient’s examination in real time,” Recht says. “But if there is a study involving clinical or physiological issues that are out of the ordinary, we can be looking at the images while the patient is on the table. We can add contrast if we need to, we can do different imaging planes, we can converse with the physicians. Whatever we need to do, it will be done at that time-meaning the patient won’t have to come back later.”

Supplying to clients the requisite e-radiology equipment and network paraphernalia looks like it would be a fairly expensive proposition for CCF, but it is not, Recht assures.

“There are economies of scale at work here,” he says. “First, we’ve built our infrastructure in such a way to allow us to affordably provide connections to a growing roster of clients. Second, this approach is inexpensive not only because we have a large and growing number of clients to which we can provide standardized, PC-based equipment, but also because this approach allows us to do the service in a way that maximizes our internal operational efficiencies.”


And efficient CCF is. Before introducing its electronic infrastructure service about 4 years ago, the Division of Radiology was generating a total of about 400,000 images per annum. The most recent figures suggest volume has risen to around 700,000 images.

“Because of the increase in service demands, we have expanded our service hours and decreased turnaround time,” Cecil says. “We used to go 8 hours a day, 5 days a week. Now, our coverage is 24 hours a day, 7 days a week. Although we have increased our professional staff, the increase is far less than it would have been without the use of the electronic infrastructure.”

The explanation, he contends, is that CCF’s radiologists are working smarter, not necessarily harder, thanks to a powerful, comprehensive degree of integration between the Radiology Division’s PACS and RIS.

“Because of the way we have integrated PACS and RIS, our radiologists now have access to on-screen images and demographics with one click,” Cecil says. “This eliminates the need to make multiple clicks on multiple CRTs [computer remote terminals] and multiple computers to gain desired information. The radiologist clicks on the name of the patient and he automatically gets at his desktop the current signs, symptoms, reason for the current examination, the images, and the prior report. With a second click, he can interface with either a digital dictation system or a voice recognition system.”

As with connectivity, CCF convinced its vendors to shoulder the bulk of the burden in solving the technologic puzzle of how to make PACS and RIS work hand-in-glove. In this instance, the vendors found it necessary to develop their own mutual team for the express purpose of implementing data and image gateways, refining interface engines, and more.

The effort paid off. David W. Piraino, MD, section head of radiology computing, says the RIS-PACS integration includes a feature that automatically puts a diagnostic image back on the screen if it has not been read within a specified time.

“We also have been able to automate a significant portion of the demographic download to the scanners,” he adds. “And we now have made about 90% of the important medical information available electronically at the diagnostic workstation.”

Moreover, the integration extends to CCF’s hospital information system, furthering radiology’s efficiencies.

“Our RIS can query the HIS for demographics, scheduling data, order information, and results,” Piraino says.

The decision to integrate PACS and RIS traces back to the Division of Radiology’s efforts a decade ago to establish a filmless environment, Piraino suggests.

“CCF at the time wanted to go filmless only in radiology,” he says. “The idea was to perfect the process in this one division before attempting enterprise-wide image distribution.”

Today, the Division of Radiology is entirely electronic for digital modalities There remain about 80 division-operated radiographic rooms across CCF that continue to generate hard copy images, Piraino estimates.

“Our goal is to become a true virtual radiology department,” Piraino says. “Our radiologists, no matter where they happen to be in the enterprise at any moment in time, will be able to readily access all the text and image information they need to do their job.”

The PACS, which the division acquired in the course of this conversion to a filmless environment, boasts a short-term disc archive of 200 gigabytes. Tape-measured in multiple terabytes-is used for long-term image storage. Linked to the PACS are 30 diagnostic workstations deployed among five CCF hospitals and five family health centers. Additionally, there are 250 PC-based workstations inside and outside radiology for image distribution.

The network infrastructure employed to support this digital environment by institution, Piraino reveals.

“Typically, the infrastructure will feature a switched 100-base T network with an ATM backbone and gigabit Ethernet,” he says. “We also employ a SONET (Synchronous Optical Network) ring to connect several of the larger hospitals, while the smaller hospitals and the family health centers are connected by T-1 lines. Our e-radiology customers are connected either by T-1 lines, frame relay, ISDN [integrated services digital network] or-and this is new-virtual private networks over the Internet. For on-call radiology to our CCF referring physicians’ homes, connections are made through ISDN.”

Recht mentions that bandwidth likewise varies by site.

“It ranges from a low of 128 kbps up to 1.5 mbps, depending on study volume and the available image acquisition devices,” he says. “Sites with MR and CT receive more bandwidth than do those that lack those devices.”


Although CCF has managed to tame its connectivity concerns, the larger matter of building and maintaining a filmless environment is not devoid of challenges.

For starters, it is not easy overseeing equipment installations, upgrades, and day-to-day care within an enterprise that covers more than 100 square miles of Buckeye territory.

“A lot of the work can be done from this central office, but sometimes it is necessary to travel to the locations in order to be hands-on,” says Louis Lannum, manager of radiology informatics.

Then there is the ever-daunting task of keeping pace with technologic change.

“We have to continually update our technologies to stay cutting edge, but we can’t make a single change without first knowing exactly how that will impact the infrastructure already in place,” says Lannum. “For example, if we add a new CT, we need to know whether the current network structure will accommodate the distribution of the images the way we want.”

Answers, Lannum indicates, usually are derived through the workings of a partnership among the Division of Radiology, CCF’s information technology department, and the equipment vendors. James E. Massey, CPA, director of business operations in the Division of Radiology, says it is not possible to understate the importance of the partnerships CCF enjoys with its vendors.

“The greater the acceleration of the pace of technologic change, the greater the need for strong partnerships with our vendors,” he pleads. “One of the benefits of such relationships is that we can count on early warning of new developments. We may not be privy to our vendors’ strategic plans 5 years down the road, but when they come out with something new, we will know about it far enough in advance that we can make plans of our own to integrate it with the least associated disruption. This way, we are not constantly in a position of trying to play catch up. And in this environment, we cannot afford to be behind the curve.”

Those relationships also make it easier for CCF to carry out an obsolescence-avoidance strategy by wresting software-only licenses from vendors.

“By obtaining software-only licenses to the extent possible, we don’t become tied into hardware that will soon become obsolete,” says Cecil. “We can take our software, upgrade it at a cost of perhaps 20% of the off-the-shelf price, and then migrate it to the next hardware platform that comes down the pike. It is a very economical and practical way to go.”

Another challenge lies in keeping PACS and RIS-mission-critical systems both-online and available at all times.

“We have built multiple redundant paths in our networks so that if the connection between here and one of the family health centers goes down, the connection itself and the data and images moving along it at that instant will not be lost-they will be immediately picked up by one of the redundant paths,” Piraino says. “We also have multiple redundancies to our diagnostic workstations and archive.”

To further the cause of keeping mission-critical systems up and running, CCF is in the process of putting in place a command center from which it can monitor the moment-by-moment functioning of its PACS and RIS.

“Right now, we can put out fires only after the fact, after users come to me and tell me something is broken,” Lannum says. “With this new operations center, we will be able to watch the traffic on the networks, watch what is transpiring on all the viewing stations, make sure that images are being passed correctly, that things are being done right. I will be able to become much more proactive toward keeping the systems up and running.

“Also, I’ll be able to alert the various users when trouble seems to be at an early stage of development. This will afford them ample time to initiate contingency plans that can avert problems and bottlenecks if we have to shut something down to fix it.”

Although the strategic effort to develop and widely deploy an electronic environment is paying off for CCF, securing the capital to continue the work is not a slam-dunk, Massey says. The radiology department must still compete for funding against other needs.

“The selling point,” he says, “is the efficiencies we’ve received, the increases in productivity, the ability to provide wide geographic coverage. We’re doing some amazing things here.”

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