New York is a big city, and one north Manhattan/Bronx subnetwork in its public health system is sizable enough that its PACS (picture archiving and communications system) installation took a year to implement and cost multimillions of dollars. It is still a work in progress, although the major elements of the system are in place and functioning. According to Roberta Camille Locko, MD, director of radiology, Harlem Hospital Center, all imaging with the exception of mammography is now processed digitally and read on monitors. Film savings in the first several months the PACS was in operation amounted to a half-million dollars, Locko adds.
Locko, who is board certified in radiology and nuclear medicine, is Network Director of Radiology for the Generations+/Northern Manhattan Health Network. The Network operates three acute care hospitals and three diagnostic and treatment centers with multiple outlets in Harlem, northern Manhattan and the southwest section of the Bronx just across the narrow Harlem River. Collectively, the Network employs about 33 radiologists who process about 300,000 studies annually. The hospitals between them contain 1,465 beds, and the hospitals and treatment centers handle roughly 4,200 ambulatory patient visits per day.
The Generations+/Northern Manhattan Health Network is one of the five networks that comprise the huge New York City Health and Hospitals Corporation (HHC), a public corporation organized in 1970 to oversee the city’s public health system. Locko, who works out of the Harlem Hospital Center, one of the three acute care hospitals in Generations+/Northern Manhattan Health Network, came to the Harlem facility in 1986 and was named Director of Radiology there in 1993. She still has that title in addition to her Network directorship.
The HHC Board of Directors approved Generations+/Northern Manhattan Health Network putting out an RFP (request for proposal) to find a vendor. When the vendor was chosen, Locko and her colleagues got right to work getting the PACS installed. “We started in January 2000, and by the end of December we had implemented the PACS throughout the entire Network,” Locko says. Looking back, she calls it “an exciting venture for us.” It required close coordination between administrators, vendor management, and the radiological clinical staff. “Our CIO and the project manager were outstanding,” Locko says. “It was, in a way a symphony.”
|Roberta Camille Locko, MD, director of radiology, Harlem Hospital Center, and network director of radiology, Generations+/Northern Manhattan Health Network, NY.|
It was a symphony that required upgrading the network’s communications infrastructure. It meant installing diagnostic workstations at all the sites, adding computed radiography (CR) to go digital with plain film, interfacing and upgrading an existing RIS (radiology information system) and a HIS (hospital information system), and installing and integrating a voice recognition (VR) component for diagnostic reports. As Locko summarizes the project, it also meant that hundreds of clinicians and technologists had to be trained (see related story, page 20), and that the Generations+/Northern Manhattan Health Network PACS had the capability to be linked with other, independent PACS that were being installed at HHC’s other networks. It meant that web browsers had to be installed to give referring doctors access to images and reports, and it meant that stored images had to be disaster-duplicated at HHC headquarters.
Little more than a year after its installation, the PACS is still being modified and expanded. According to Locko, a groundbreaking agreement will allow residents from the Harlem/Lincoln Integrated Residency Program/Columbia University affiliate to complete diagnostic reports at Columbia and New York Presbyterian Hospital. PACS workstations have been installed at Columbia/New York Presbyterian Hospital. Columbia University is an affiliate with Harlem Hospital.
“Because of the PACS, images from the Network will be visible, with all the security compliance at workstations at Columbia. The Columbia faculty are being credentialed at Generations+/Northern Manhattan Health Network to dictate cases at Columbia with the residents, which is really quite a feat,” Locko says. It is a feat made possible by the PACS installation and extensive collaboration by the Network administration, especially Senior Vice President Jose Sanchez, and Columbia Chairman of Radiology Philip O. Alderson, MD.
According to Locko, when images come from the modalities at Generations+/Northern Manhattan Health Network, they flow to a work list from which they can be called up for reading. Locko says it is the flexibility of the work-list software that lets cases be read essentially by the on-site radiologists at each facility, but when time or specialization is a factor, also by doctors off-site but within the PACS network. “The work lists can be generated in a very dynamic way,” Locko says, “and they get distributed based on modality and now, with some new software, based on body part. Residents are able to read cases at night and make a preliminary report, which is automatically seen at the point of referral. The geographic boundaries have been eliminated. There are no geographic boundaries.”
|Locko says it is the flexibility of the work-list software that lets cases be read essentially by the on-site radiologists at each facility, but when time or specialization is a factor, also by doctors off-site but within the PACS network.|
As it was breaking in the PACS, says Locko, one hospital at a time went filmless, and that was done in stages by modality, with CT and MR first and then the CR conversions. “We went live in stages, and then we just stopped filming. It wasn’t long before we were completely filmless,” says Locko. All images are being retained in short-term and long-term storage, but Locko says that HHC maintained the storage requirement of 7 years. The Generations+/Northern Manhattan Health Network sites are connected on a WAN (wide area network) that hard wires the sites via communication cable. There is also a web browser that lets referring doctors see images, but no diagnostic reading is done on the web.
Locko says it is important to make choices as any PACS installation progresses. For instance, one choice Generations+/Northern Manhattan Health Network made was to use an identifying suffix for each hospital. “We had to know the point of origin when moving the studies across locations,” she says. Locko and her colleagues brought in a physicist to look at reading room configurations and even evaluate furniture choices. “An idea would come up, and we would have meetings right there in the PACS room,” she says. “As we thought of things, we would implement them right then and there. You can’t wait to do it.”
There are always hurdles to overcome, and nothing is perfect, says Locko. For instance, the diagnosticians are not thrilled with having to edit the written displays of their dictations into the VR system. They do cooperate, however.
Summing up the experience, Locko says, “The PACS was an opportunity to optimize resources in an urban environment where there’s high volume, high need, and a radiologist shortage. Having it has improved our clinical quality, eliminated film loss, optimized staff productivity, and created an environment where we can be future oriented. We’re basically on the cutting edge. It’s awesome what we’ve been able to accomplish.”
|Ralph Stubenrauch (left), operations supervisor, and Don Cross, administrative director, Robinwood Diagnostic Imaging Services, Hagerstown, Md.|
Not every institution installing a PACS can afford the millions spent by Generations+ in New York. In fact, cost is always a fundamental concern. That was more than the case at Robinwood Diagnostic Imaging Services (RDIS) in Hagerstown, Md. When RDIS started looking for a PACS in 1997, says Administrative Director Don Cross, it isolated three variables as key to any installation: availability, ease of use, and affordability. RDIS found lots of systems that met the first criterion, one or two that met the second, but none that met the final one of cost. “Our budget was a mere fraction of what most systems cost,” Cross recalls. “RDIS being freestanding, we did not have the huge pool of IS (information system) specialists required to support a huge PACS. After years of looking, we had just about come to the conclusion that we couldn’t afford a PACS.”
Then, at an industry meeting, Cross saw a diagnostic workstation designed by RDIS’s eventual PACS vendor. The system was PC driven and relied on CD-ROM jukeboxes for image storage, an economical mode. Cross flew to Long Island to see the system in operation at a beta site. “With its PACS, a radiologist had just got a phone call asking for a consult on an old comparative study. For us, that process would take about a day to accomplish. He was able to bring that old study up and complete the transaction in about 3 minutes. That was a big selling point for me,” Cross recalls. He will not say what it cost RDIS to put in its PACS. The system, sufficient to support all of the RDIS digital modalities, was purchased outright, with an accompanying service contract. Cross says the bill was “about 20% of what it would have cost us to buy from one of the big players.”
|“A radiologist had just got a phone call asking for a consult on an old comparative study. For us, that would mean about a day to accomplish. He was able to bring that old study up and complete the transaction in about 3 minutes. That was a big selling point for me.” -Don Cross.|
Because RDIS’s corporate and professional situation is complex, many approvals had to be gathered for the PACS installation. And in something of a coup for convenience, Washington County Hospital, RDIS’s predominant facility for the exchange of comparison films, independently purchased an identical PACS system, so that the two institutions can interface and transmit images back and forth.
Hagerstown sits near the base of Maryland’s panhandle, a narrow strip of
land wedged between Pennsylvania and West Virginia. Thus, RDIS serves clients in a tristate area. Washington County, of which Hagerstown is
the county seat, numbers about 150,000 population. Washington County Health System Inc is the parent company of Washington County Hospital, a 309-bed acute care nonprofit facility. Washington County Health System is also the parent of Antietam Health Services Inc. Antietam is the for-profit arm of the parent. It operates several outpatient facilities, but mainly it operates Robinwood Medical Center, a 375,000-sq-ft outpatient center about four miles from the hospital. RDIS is housed at the Robinwood site, and its radiologists also cover the hospital. RDIS itself is a co-owned joint venture between Antietam and Associated Radiologists, the 10-man Hagerstown radiology group that reads for Robinwood and the hospital. Cross estimates that RDIS reads about 80,000 studies per year. All this detail is necessary to explain why the RDIS PACS had to be flexible and how it had to meet the demands of multiple ownership interests. The purchasing entity was RDIS. The PACS was installed in February 1999. Once Washington County Hospital saw how RDIS’s eventual PACS would work, it bought one of its own from the same vendor, and the two systems were installed at the same time. RDIS’s RIS and transcription system are also interfaced to the PACS.
Cross says that 100% of RDIS’s digital image output is now read filmless and that the distribution of film has been reduced by 80% or better. General radiology is still filmed, but conversion to CR or DR is a goal. Ralph Stubenrauch is imaging operations supervisor for RDIS. He explains how the PACS works. “The images from, say, CT go to what’s called a catapult, which is like the technologist’s QC workstation. The images can be manipulated and sorted on the catapult. From there, they are put on the main server, and then they go to two dominator workstations where the radiologists can read them.” Initially, the images are stored online on a server. From there, they go to DVD jukeboxes for permanent storage and reference. The PACS initially used CD-ROMs but the DVDs can hold up to six times the data. The older CDs and the new DVDs are “daisy-chained together” so that the archive is seamless, Cross says. Adds Stubenrauch, “We have a month’s worth of data online, but soon we will quadruple the size of our PACS server hard drive, which will allow for several months online. The jukebox archived material takes a minute at the most to restore online.”
The hospital and RDIS are linked through a fiber connection, which provides almost instantaneous access to each facility’s PACS database. The Robinwood Center is linked to RDIS through a LAN (local area network). The lines in the LAN were largely in place before the PACS installation and just needed reconfiguration, Cross says. RDIS already uses a redundant server to let in-house referrers see images on PCs. RDIS is working on a web site that will give secured access to referrers from all of the communities that RDIS serves. RDIS is also about to add diagnostic workstations at a new women’s imaging center it is building at the Robinwood site and at an outpatient clinic being built in north Hagerstown.
Cross says that return on investment through factors like film savings was never a motive in putting in the PACS. The cost of film was going down anyway, he adds. The real savings have come in productivity increases. “We’ve saved some money on film, but more than that, CT volume has increased by 40% and ultrasound by 25% since we put in this PACS, and our additions to the radiologist and technical staffs have been nominal. The big savings has been the ability to do more with less.” The PACS is also a big selling tool with recruitment, he adds.
Cross says RDIS had no control over what kind of PACS Washington County Hospital would install, but he adds that the hospital’s decision to install an identical system has “had a huge impact.” For day-to-day and after-hour and emergency department reads, the hospital can pull the images up instantly, even when RDIS has closed for the night. “If the hospital had not done the same system, it would have been very difficult for us,” he says. “We’d still be sending film.”
Cross says reading electronically has now become “commonplace,” and attributes this success to a team effort on the part of all RDIS staff prior to and during installation. The system is so reliable, he reports, that the server has not crashed once since it was installed in 1999. How would he sum it all up? Cross puts it simply, “Zero regrets.”
The Everett Clinic
In yet another variation on building a PACS, The Everett Clinic (TEC) has made the decision to distribute electronic images to referring clinicians first, before adding diagnostic radiologist workstations, a RIS, and PACS archive. This concentration on the picture communication component is partly a financially driven decision and partly a strategic one. TEC is a multi-specialty clinic with about 200 physicians and surgeons in Everett, Wash, which is about 25 miles north of Seattle. It has its own radiology department and completes about 120,000 imaging examinations per year. TEC serves Everett, Seattle, and the surrounding Snohomish County just north of Seattle. Donald Peters, MD, a diagnostic radiologist who has been at TEC for about 20 years, was instrumental in bringing TEC to the electronic imaging table.
“We looked at PACS for several years, and it looked like something only a well-to-do large hospital or university could afford,” Peters says. Like RDIS did in Maryland, however, TEC found a PACS solution that provided entree into electronic image management. Peters calls TEC’s effort “the outside-in approach” because it begins by providing electronic image access to the referring clinicians outside the radiology department using the enterprise LAN and WAN. The idea is to begin by having referring clinicians learn to use PCs for the electronic review of studies. Once they become comfortable and confident with using image distribution system and software, then theoretically there will be no major clinical barriers to eliminating film and implementing a full PACS with archive.
“The problem with many previous implementations,” says Peters, “is that they would implement the full PACS, including what they thought was a reasonable distribution product, and then the clinicians didn’t like it or wouldn’t use it. It then was not possible to eliminate film and realize the associated cost savings they were counting on to defray much of the PACS cost.”
|Donaold Peters, MD, The Evertt clinic, Everett, Wash|
TEC still has a long way to go to get a fully operational PACS. To perform diagnostic soft copy interpretation, it will have to purchase PACS workstations, install a RIS, and reconfigure its existing clinical information system to interface with the other pieces. Most important, it will have to add an electronic archive. For now, its electronic images are temporarily stored on its server, but that holds only 6 months of images, Peters says.
Peters believes that beginning with clinicians as the first users will pay off clinically, operationally, and financially. “Outside-in is really the way to go,” he says. “If you put the system in the other way around, it’s a leap of faith that film can be eliminated. By first documenting that your most frequent and image-intensive clinical users are comfortable with the system and software, you address significant people and political changes before you have made a major investment and commitment for a full system with a specific vendor. Concurrent to the adoption of enterprise distribution to clinicians, any required RIS upgrade or RIS purchase with work-flow redesign can be ongoing inside the radiology department.”
George Wiley is a contributing writer for Decisions in Axis Imaging News.