PACS is helping community hospitals grow their radiology services, cope with a shortage of radiologists, and keep competitive.

KLAS report released during RSNA revealed crowded competition in the community hospital PACS market. Large enterprise IT firms and smaller imaging services businesses alike are focusing their efforts on the demand coming from these small hospitals, who these days can select their choice system from a wide spectrum of vendors.

“PACS implementation at large independent hospitals and IDNs have reached a saturation point, leaving little opportunity for significant vendor deployments in that market segment,” said report author Ben Brown, who also serves as KLAS research director. “Large and small vendors are now looking to smaller community hospitals to grow their PACS market share. Based on that shift, it is no surprise that over the last 2 years, 64% of new community hospital purchases have occurred in hospitals with under 100 beds.”

But along with the desire to go digital is the presence of a tight IT budget, leaving many community hospitals to contemplate: Should I choose the more affordable solution with limited features, or should I pick the more comprehensive system with the heftier price tag?

Iredell Memorial Hospital, Statesville, NC

Timothy Jones, ARRT(N), CNMT, ARDMS, director of radiology at Iredell Memorial Hospital, faced these crossroads when the hospital decided to convert to a filmless environment in 2005.

Describing the problems the radiology department encountered prior to its PACS implementation, Jones said there were issues of film retrieval from the film file room and delays matching comparison and prior studies. Films weren’t located where they should have been, and the department lacked a tracking system that allowed staffers to find the missing studies.

In addition to a solution that would better manage patient casework in a more efficient fashion, Jones said he looked to purchase a solution that expanded radiology beyond the walls of x-ray. The system also needed to be convenient for referring physicians to use and easily navigable from separate locations. “We looked for a system that stored everything without the use of proprietary tags, so when it is time to transition to another system, we hopefully will not face the challenges that a lot of PACS users have when there are proprietary tags on the images,” Jones said.

The department didn’t have the money to spend a million dollars on a PACS, so Jones and PACS coordinator Myron Coulson, CIIP, searched for a solution that would be relatively easy to manage from an IT perspective. Seven months were spent on system evaluations, taking the time to speak with the various vendors, researching systems, and getting quotes.

The department ultimately chose to install the FusionPACS and eFilm solutions from Merge Healthcare. Before going live, the hospital took its time to undergo system testing, devoting several months to look at workflow issues.

“I think it’s false economics to try to rush a system installation and not allow proper resources or time to test,” Jones said. “We had several months when we went through system testing and looked at workflow issues, to see where things didn’t work, where things bottlenecked, what just didn’t fit for us. We did that in a parallel, nonlive environment to our film-based solution so when it actually came time to transition to PACS, it went very well.”

With anytime-anywhere access, Iredell physicians can instantly and simultaneously access images and reports in the hospital or in their office, via a secure Web server. The PACS can be configured to automatically acquire all prior images, which are placed inside a patient’s virtual folder. Solving the issue of lost records, images are permanently stored at the hospital on redundant storage area network (SAN) devices. These SANs are located in different buildings on campus, and third copies of the images are put on tape and taken off-site for disaster recovery storage.

Because the department spent the extra money to develop the infrastructure to allow for redundancy in networking, services, and storage, it has experienced zero unscheduled downtime, Jones reports.

Tips On Purchasing PACS

Thinking of investing in a PACS? Here is some advice from Timothy Jones, ARRT(N), CNMT, ARDMS, director of radiology at Iredell Memorial Hospital.

  1. Identify first the challenges you face and what you’re hoping to accomplish with the PACS. Talk to all the vendors, even the ones you think you can’t afford, because you get ideas from all of them about different workflow solutions.
  2. Make sure that when you are selecting systems, you don’t rely just on someone to bring a system in and show it in your conference room. Spend the time and money to go to a facility with your desirable system configuration and evaluate that system in its environment. Talk to people who use it and see what they like and don’t like.
  3. Lay out to the administration what you need and make sure you clearly communicate what you would get from it. Also outline to administration the potential disadvantages that you would have if you elect not to purchase any optional features that, as a department manager, you feel would be beneficial to your facility.
  4. The success of a system is also critically dependent upon the education of users by someone who understands both IT and radiology workflow. These two steps are critical in finding a good PACS administrator. Find somebody who is passionate about IT and understands the necessity to be able to communicate with individuals of all knowledge levels.
  5. As a community hospital, don’t hesitate to spend the money to ensure that you have a high availability system. When it fails, nobody’s happy.

“It’s pennywise and pound foolish to try to build your infrastructure in the least expensive way possible,” Jones said. “Our system has never been unavailable due to unscheduled downtime. We were allocated money to spend on network redundancy and upgrading the existing infrastructure to a gigabit backbone. It cost us more money up front, but the benefits are tremendous.”

A huge benefit for Iredell has been the growth of its radiology services. Since the department installed its PACS, it is able to manage studies that have large datasets. The hospital has added a 64-slice CT scanner and technologies for advanced MR imaging and PET/CT. “Those advanced technologies simply can’t exist in a film-based world. As community hospitals look to move toward the more advanced technologies, you have to have the IT infrastructure and the PACS to support it,” Jones said.

Most notably, at the end of its fiscal year, the hospital saw an 18% growth in volume without the need to add a new radiologist or technologist—a feat that Jones said is not possible in a film-based environment.

“It’s impacted our productivity and allowed our people to focus on what we do best, which is patient care and not managing film, processing film, and all those things that had to be done in a manual world,” Jones said. “We’ve been able to grow without adding staff, all the while becoming more efficient. Those soft dollars have been very cost beneficial for us.”

In a continual effort to improve workflow, the radiology department has recently implemented voice recognition and a critical results notification system. The latest two systems enhance the current systems and put the department one step closer to becoming paperless and fully digital.

Chinese Hospital, San Francisco

When asked to name some of the challenges in using a noncomputerized system, Roger Eng, MD, chief of radiology at Chinese Hospital, didn’t know where to start.

Upon arriving at the San Francisco community hospital in 2003, Eng entered an antiquated environment in need of a major IT overhaul. Locating films was a cumbersome task. Each physician had been assigned an individual cubbyhole, and in preparation for patient checkups, the corresponding jacket was placed into the slot. Therefore, when films went missing, staffers had to browse through all 25 cubbyholes. Post-it notes containing day-to-day instructions and last-minute changes littered the front desk area. Transcription was outsourced, and personnel commonly lost track of reports—sometimes they would return with mistakes. The actual film, the heart of the department, was separated into two locations, with 1 year’s worth of active cases on-site and the rest 40 miles away. Requesting prior studies led to major delays.

“The number of adverse outliers to the workflow was tremendous, and we had four or five mini-crises each day,” Eng said.

The hospital’s heritage shows that, from its very inception, “it had to do more with less,” as Eng puts it. Truly owned by the community, Chinese Hospital was founded in 1925 amid a climate of anti-Chinese sentiment in America, including San Francisco. The city quarantined its Chinatown neighborhood during the bubonic plague outbreak, refusing to treat its Asian immigrant population. As a result, the Chinese community, forced to provide for its own welfare, rallied together to establish the historic health facility. It is a testament to the community’s support that it is still one of the remaining six hospitals in a city that used to have 26, Eng said.

Yet, because the community, rather than a large health network, backs the facility, upgrading the IT system was a sizeable cost. At the same time, for a 54-bed hospital with the volume equivalence of a 150-bed hospital, the facility had reached its breaking point. Eng recalled long lines of patients streaming out into the hallway, yelling about waiting for imaging exams. Waiting times for mammography were 2.5 months; for ultrasound, 2 months; and for CT, 6 weeks. “We had to do a dramatic transformation,” Eng said.

Managers of the department, representatives from the medical executive committee, and various constituents joined a team effort to develop a blueprint. Looking at the project from a solution standpoint, they determined that they needed a technology that could handle high volumes, limited space, and the functionality for primary reading for anyone at anytime. After all, the radiology group was spread out over a 90-mile radius, with some physicians working on-site and others nighthawk. Also tired of housing the merry-go-round of multiple vendors, Eng and others wanted to streamline the department and purchase a system that could easily integrate with RIS and voice recognition.

In spring of 2006, Chinese Hospital went live with the Carestream PACS solution from Carestream, Rochester, NY. The company also installed three CR units in multiple rooms during that time, and a year later, the hospital went live with the company’s RIS, featuring an integrated Philips voice recognition module.

Reid Breckwoldt, MD, of Iredell Memorial Hospital relies on FusionPACS and eFilm solutions from Merge Healthcare.

Eng said the biggest benefit of the Carestream PACS is that it essentially liberates the department by allowing radiologists to access exams from anywhere and not forcing them to commute to the hospital. Because it is software-based, reading tools and features follow the users, who are not tied to a particular workstation. If one radiologist can help a fellow colleague with an extra 20 questions, they could just log onto the system from home and perform their edits there. This ability is especially helpful during the current shortage of radiologists, Eng said, adding that it allows him to find the right person for the job, where proximity to the hospital is not a factor.

The PACS solution has also dramatically reduced the inconvenient delays patients experienced while waiting for exams. Eng knows this because of an electronic board that lists the names of scheduled patients and indicates how long they have been waiting through color codes: 15 minutes or less is green; 15 to 30, yellow; more than 30, red; and early arrival is white. In the beginning, Eng would walk by the station and see all red. These days, he rarely sees any red at all.

“Unless you are in the middle of South Dakota, where you’re the only hospital for 100 miles, I don’t know how you cannot transition into an all-digital environment,” Eng said. “The competition has already done it, and it will be a disadvantage for you, in terms of attracting patients, to practice flat reimbursement.”

Elaine Sanchez is a associate editor for Axis Imaging News. For more information, contact .