|Eric Nied, CIO, left, and Daniel Stricof, MD, CEO, Radiology Ltd, Tucson, Ariz.
When Eric Nied, CIO, came to Radiology Ltd, Tucson, Ariz, in 1997, he joined a high-volume practice that did not have a network in place to transmit its imaging studies. Nied’s first task was to find a picture archiving and communications system (PACS) that would streamline the practice, and he quickly decided on a commercially available system to meet Radiology Ltd’s needs. Since the PACS was implemented, the practice has been able to employ digital storage and display technology to raise clinical operations to new levels of service excellence. Radiology Ltd has not stopped, however, in its quest for gains in technologist productivity.
Already known in the area for its rapid turnaround time for examination interpretations, Radiology Ltd added to that speed in 2001, when it incorporated Web technology in its PACS. Now, the practice is looking into software-only solutions to cope with changes in its PACS provider and to continue revolutionizing the way that Radiology Ltd does business.
Radiology Ltd’s shift to the latest in PACS technology suits its leading-edge position in the marketplace. The practice is the only one in the Tucson area offering full-fledged interventional neuroradiology, as well as all diagnostic imaging options, from ultrasound to positron-emission tomography (PET) scanning. Radiology Ltd has more than 260 employees; this figure includes 40 radiologists, eight of whom are neuroradiologists. The practice encompasses six imaging centers in the metropolitan Tucson area, serves four area hospitals, and receives referrals from more than 900 area physicians. Currently, Radiology Ltd does more than 500,000 examinations per year.
Bringing Radiology Ltd’s communications technology up to a level suitable for its procedural volume was only the first undertaking by Nied, who is the practice’s director of PACS technology. Since he joined the practice, Nied has built an extensive network and hired three other individuals to assist him with the technological aspects of the practice. His initial choice of a PACS vendor was based on the practice’s prior relationship with that vendor for teleradiology. The PACS technology incorporates software to address the demands of various types of users, including their feature-set requirements and computer-skill levels, and encompasses primary diagnostic, secondary review, and tertiary review stations.
“All studies are sent to an archive, and then selected studies are forwarded to servers, where the radiologists can examine records in their workplace,” Nied says. “Most of our radiologists got a grasp of the system and were able to use it relatively easily, although it is not as neuroradiology-friendly as we would like. All told, there was a learning curve of about 2 months.” Another reason for choosing the PACS was its full compatibility with the Digital Imaging and Communications in Medicine (DICOM) 3.0 standard, which allowed easy customization and promised upgrading capability in order to meet what would undoubtedly be the advancing needs of a busy practice. Radiology Ltd’s current PACS technology relies on a combination of redundant array of inexpensive disks (RAID) and digital linear tape (DLT) for long-term and short-term storage.
While this was an excellent initial solution, Nied says that Radiology Ltd recently encountered a snag in its choice of technology. After another entity bought the PACS company, Radiology Ltd was left with an unsupported teleradiology system. Radiology Ltd still has this teleradiology system, but it is in the process of being phased out and discontinued. That fact, combined with the intrinsic problems of proprietary hardware and the staff’s desires for broader access to imaging studies, led Nied to his most recent task: finding a Web-based solution.
Pursuing Web-Based Distribution
“The Web integration was implemented in May 2001 for two reasons,” Nied says. “We needed to replace our current teleradiology system and we wanted to offer referring physicians in the community a way to look at their images and reports readily.” After meeting with many of the major vendors of such systems, Radiology Ltd made the decision to purchase its current technology from Newton, Mass-based AMICAS, Inc. Daniel Stricof, MD, CEO of Radiology Ltd and a neuroradiologist in the department of radiology at Tucson Medical Center, calls AMICAS “the only vendor that could meet the criteria to solve all of our problems. Among all the vendors that we have worked with over the past 12 years, AMICAS has been exceptionally responsive in terms of software development to meet our needs,” Stricof says, noting that Radiology Ltd has worked with two different radiology information system vendors, two different PACS vendors, and two different teleradiology companies over the years. “They are, to my knowledge, the first and only vendor to put out a Web-based product with automated push capabilities over the Web, and, so far, their support has been unparalleled.”
The May 2001 agreement between AMICAS and Radiology Ltd is one of the largest implementations of its kind in the southwestern United States. Under the agreement, Radiology Ltd will use AMICAS 3.0 server software, AMICAS/eFilm Diagnostic Workstation? software, and Personal AMICAS in its six imaging centers and in the homes of all 40 of its radiologists. The company also will be able to take advantage of remote-reading functionality in its radiology services to four Tucson-area hospitals, including the Tucson Medical Center, which is the city’s largest.
?”The product that truly won Radiology Ltd over was the Personal AMICAS system,” Stricof says. Personal AMICAS enables radiologists or other physicians to receive full-fidelity diagnostic images securely via their home or office computers, even over slow lines. AMICAS is fully Web and DICOM compatible, with an archive that complies with the Joint Photographic Experts Group 2000 (JPEG-2000) standard and one-click, instantaneous access to patient images and studies, eliminating the need for pre-fetch. The company has filed patents for this technology, Forever PriorsTM. “We are a very high-volume practice, especially after hours, because we serve four busy emergency departments,” Stricof says. “Our on-call radiologists basically demanded a teleradiology solution in which the radiology technologist could push the images directly to the radiologists’ computers at home.”
?Web-based teleradiology systems have traditionally required the radiologists or referring physicians to pull images to their computers through search and retrieval mechanisms followed by transmission; this is an inefficient and time-consuming method. Push functionality allows physicians to concentrate on viewing and interpreting examinations, rather than having to worry about locating and retrieving them. “AMICAS viewers work on any computer running Windows? software and Microsoft? Internet Explorer?, or Netscape Communicator? and our physicians have, at home, a variety of computers,” Stricof says. Radiology Ltd’s servers were purchased from Dell on the recommendation of AMICAS, and Stricof says that they have worked flawlessly.
Nied says that another positive aspect of the Web technology was a very clean transition within the practice. “The integration of the Web technology into the existing system was not difficult at all, although it did involve quite a bit of time spent planning ahead,” Nied says. “There was a good schedule, so there was no downtime involved. As far as work flow goes, at one of Radiology Ltd’s sites, patient volume has increased so much over the past 2 years that we would never have been able to print studies as quickly as we are moving now with the Web-based system.”
Stricof says, “We are doing more with our AMICAS system than we currently are with our full-fledged PACS because of the way we are using teleradiology. Together, we came up with Web-based image distribution for our teleradiology, which also gives our referring physicians access to the system. Already, we can see the convenience in the use of such a system practice wide. If a referring physician asks us to review a prior case, many radiologists will turn to the AMICAS Web system more often than our PACS system because it is quicker and more convenient. That was a surprise. We also are just as likely to use AMICAS as the full-fledged PACS for consultations among ourselves.”
Radiology Ltd had already been sending all outpatient CT and MRI studies to its current PACS, but, since May, all outpatient CT and MRI scans have also been automatically sent to the AMICAS system, as have all inpatient emergency studies, call reports (including on-call ultrasound), and plain-film examinations. Radiology Ltd’s PET scanner is equipped with diagnostic workstations that allow remote viewing, and it is not integrated into the PACS or Web system currently.
Previously, Radiology Ltd’s teleradiology system relied on direct point-to-point communication using either a standard modem or an integrated services digital network, but by switching to a Web-based solution, Stricof says that the practice now is able to take advantage of the variety of broadband communications services available in the Tucson area. “This includes digital subscriber lines, satellite services, wireless services, and T1 lines, while still allowing for standard modem communication,” he says. “The use of broadband communications has vastly improved our turnaround time for providing interpretations for emergency departments and other on-call cases. Instead of the average case taking 20 or more minutes to be received by the interpreting radiologist, it now takes less than a minute. Often, the referring physician has already received the results of imaging before the patient returns to the emergency department,” he adds. “Meanwhile, our radiologists are able to view these images from the comfort of their own homes. Needless to say, that is a tremendous benefit for the radiologists on call.”
Future Software Solutions
With the success of the Web-based system and the aging of Radiology Ltd’s PACS hardware, the practice has naturally begun casting about for other options for replacing its current PACS. The best option may be a software-only or Web-based solution, which would circumvent problems with proprietary hardware and give the practice more control over its costs. “In the very near future, we are going to evaluate different PACS solutions. Currently, I very much like a software-based solution,” Stricof says. “The problem with buying proprietary hardware is that we have ended up feeling that we paid too much for equipment that becomes obsolete and is not readily upgraded. For example, with the teleradiology computer system that we are in the midst of replacing fully with AMICAS, there are proprietary digital video-capture boards. Should they stop functioning, no one can sell us replacements,” he continues. “If we had not begun the transition to the AMICAS Web-based system, we would be in trouble, as there was no satisfactory backup system. We would not be able to do teleradiology. That would have been a disaster for our practice. With a software-based solution, we will not have the limitations inherent in being critically dependent upon one vendor’s proprietary hardware.”
One concern with that option would be a scenario wherein neither the software vendor nor the various hardware vendors would accept responsibility for glitches in the system, but Stricof says that such a problem is hardly new. Radiology Ltd has already encountered it, even when purchasing prior systems with proprietary hardware. “At certain times in the recent past, we wasted a tremendous amount of our staff time and technological support time proving to vendors that the problem was not with the hardware, but with their software, or vice versa-even when the vendor was the source of both the hardware and the software,” Stricof says. “To date, we have not found a single vendor that we felt could provide the best network, all the hardware, and all the software that we need for our practice. Therefore, when a glitch occurs, it is virtually guaranteed that the vendors will assume that the problem must be within whatever part of the system they have not sold and do not need to support. We have, therefore, found it mandatory to have our own in-house support team to troubleshoot our system.” Radiology Ltd already has six people on staff who form the in-house information-technology team led by Nied. “Any practice of reasonable size needs local support. We are more secure knowing that our own employees are directly responsive to us and are going to understand our crucial need to keep our network running,” Stricof says.
The anticipated switch to a new PACS technology would also give Radiology Ltd the chance to change its storage options. “We have been happy to date with DLT long-term storage, but as we look forward to upgrading, I would anticipate the likely use of more RAID, as it has recently become less expensive to use. There seem to be many exciting hard-drive storage options in the marketplace that are giving DLT significant competition for long-term storage,” Stricof says. “If we are going to start all over again, I would strongly consider what are essentially infinitely expandable multiple-array RAID storage.”
The opportunity to enhance all aspects of the system is driving Nied and Stricof to examine Radiology Ltd’s options closely, and they will reevaluate its full PACS within a year or so. They stress that they have made no final decisions in the matter. “This will be the first year that we will be looking at PACS based on Web technology, and we are looking at options from all the major players in this field,” Stricof says. “We are willing to look at any company that is willing to have us look at it,” Nied adds. “Most of the changes that we see from various vendors are in the realm of not having to buy proprietary hardware and just having them provide software,” Stricof says. “That, potentially, could save our practice quite a bit of money over time.”
Saving money is a potential benefit, but Radiology Ltd’s first priority is to find a long-term PACS solution that provides immediate benefits to the practice, and that poses no insurmountable challenges to its own radiologists. “One of our highest priorities, as we look to the near future, is improving the physicians’ workstation interface,” Nied says. “Particularly for interpreting neuroradiological studies, the demand for a more user-friendly and convenient interface has been exceptionally strong. For us to switch PACS products without making the system more acceptable to our own radiologists would be like shooting ourselves in the foot.”
Elizabeth Finch is a contributing writer for Decisions in Axis Imaging News.