Brian M. Barbeito, MBA, MSHA, heads a radiology group that deals primarily with hospitals, but his Memphis-based company, Mid-South Imaging & Therapeutics, also covers numerous outside-read businesses, which offer outpatient imaging services. Getting the right images to the right radiologists has not been easy, but technology has helped. Rob Sumter, PhD, COO and CIO at the Tennessee-based Regional Medical Center at Memphis, also has explored the technical and economic models for image sharing.
Both agree that demand for image sharing capabilities will only increase, but what works best in which settings? What will the future hold?
For its inaugural issue,
Executive IT Insight sat down with the two executives to discuss their perspectives on viable models for image sharing and distribution.
Executive IT Insight: How do processes differ between a radiology practice, a hospital, and a multispecialty group?
Barbeito: The biggest difference is scale. There is a difference between what you have to provide in an outpatient setting versus a hospital setting. Most of the outside-read business is single modality, such as one CT scanner or one MR scanner.
The hospital setting is going to be multi-modality—everything under the sun, from mammography to interventional radiology to CT and MR. In the outpatient setting, it is, in many cases, specific toward one type of imaging—cardiac, musculoskeletal, or neurological.
We read at a number of hospitals in the Baptist Memorial Health Care system, and it’s critical to be sure the right study goes to the right radiologist—and we must do that no matter what the setting. If you have a specialty image taken in hospital A, and the subspecialist is in hospital B 10 miles away, image sharing is very important. The ability to pull those images up and get them to the right radiologist can present networking challenges.
We are a radiology group, but if we are working with hospitals and multispecialty organizations that have different PACS solutions, we will use those systems. Our RIS is very flexible, and we have arrangements with many hospitals and multispecialty facilities that require this flexibility.
Sumter: A radiology practice group is likely to invest greatly in teleradiology, which helps them to read images of single modality quickly and to get them finished. When you send an image to our radiologists in the practice group, they don’t give a preliminary report; they simply give a final report.
In the hospital, where they are supporting trauma patients, the doctors' turnaround times for final reports are not as fast, due to the multiple modalities. To increase the speed of the clinical decision making process, many times a preliminary report is provided within minutes, with the final report coming hours later.
eITi: What is your economic model for image sharing/distribution?
Barbeito: We have been operating under a business model that is predominately hospital-based, but we also cover what we call outside-read businesses, which are traditionally outpatient imaging services, most often at physician offices—whether they be neurosurgeons, orthopedic surgeons, pulmonologists, or internal medicine physicians. They may have a CT scanner, MRI, ultrasound, or an x-ray unit.
Ten to 15 years ago, the physicians who incorporated imaging into their practices wanted Mid-South to provide interpretations for them because of our clinical quality. We are a subspecialized group, so if it was a neurological study, they knew a neuroradiologist would look at it. The same [is true] for a musculoskeletal read or for a cardiac read.
We discovered that a lot of these practices did not have an efficient method for image distribution, and they realized they did not need a full-blown PACS and all that IT equipment. They did not want to take on the responsibility of archiving the images. From that standpoint, there was a demand for these types of technological components, and we met that need with our tech solutions.
If a practice purchased and incorporated a CT scanner, we could link to their modality. There was a need for image distribution, and a RIS for patient histories. We met that need. We were able to have one radiologist in our corporate office, or to put a radiologist into their clinic.
We were much more efficient in our delivery model, and that allowed us to better manage our resources. Instead of having four different radiologists at four different facilities, one facility could have a radiologist on-site, while the other three facilities did not find that to be as important. We maximized our physicians’ productivity and our subspecialization. That efficiency translated into more revenue and lower expenses, along with better care, because, in the end, the image was interpreted by the best-qualified radiologist.
Sumter: Our model is changing to allow us to better service community hospitals and to incorporate outpatient imaging service centers. As a regional trauma center, we want to become a provider of PACS and imaging systems for many, if not all, of the community hospitals within the region. We want a model that spares the community hospitals the cost of investing in a PACS and RIS, because it’s costly for them to purchase and maintain.
We are one of the only hospitals in Memphis that has radiologists on-site 24/7, 365 days a year. They have some downtime in which they can be a resource to community hospitals, and we project that we could support up to five community hospitals.
eITi: Can you share a specific image sharing challenge that you overcame?
Barbeito: Some of the facilities we worked with had a PACS solution, but they did not have a RIS. By offering both a PACS and a RIS that was flexible, we could meet their needs in any way necessary. We could offer both solutions: a PACS platform and a RIS for, among other things, dictating and report distribution. That could be a challenge, and that’s why a flexible RIS and IT options were so important.
Sumter: We had to overcome image sharing quality challenges at one of our local hospitals, where we have the neonates. We have to transmit those images to our specialists, who look at them and make decisions. The system at the local hospital was not as compatible as we would have liked, so we removed their old viewing stations so they could see the images with much better quality. The viewing stations they had were 10 years old, which had a significant impact on the quality of the image.
eITi: How do electronic medical record (EMR) mandates fit into the technical aspects of image sharing?
Barbeito: We actually have an EMR system for our interventional services, which are more clinical than diagnostic. I would venture to say that radiology has been using an EMR for years through PACS and RIS. It may not be recognized in the same way, but the PACS and RIS are an EMR for radiology and it has been incorporated and utilized for years. I hope they can see that we have been ahead of the curve and recognize this when determining meaningful use.
Sumter: The EMR mandates usually lead back to meaningful use, and I support meaningful use mandates, which I believe move us toward what I call the “fourth wave technology revolution” in our society. Meaningful use helps put us in a productivity and quality mode as we report data. It means we must get better, and that somewhere someone is looking at the reported data.
In a hospital without EMRs, you can’t do data mining to determine what has gone on with a patient without digging through a lot of paper, and that takes time. In the information technology age, technology is a part of our workflow and our lives. Without it, we can’t advance the society. Technology and EMRs will improve quality because we can get to data faster and convert that data into information, which results in changes that improve patient care.
eITi: What challenges will the future bring with regard to image sharing?
Barbeito: One of the big areas we are addressing is radiation exposure for patients. It’s hard to monitor. If a patient goes to hospital A and receives 10 CTs in a short time, and then goes to hospital B, that hospital may not have access to, or knowledge of, those 10 scans. They may do another, and then you are continually radiating that patient. Many communities have implemented systems to identify emergency department frequent fliers, but I would hope that gets extended to radiology.
It’s a challenge because you are sharing medical records across facilities. We want to make that efficient among our current outside-read facilities that use our PACS systems, because we can easily see where patients have had studies performed. We want to make it easier to look at the imaging history for better patient care.
Sumter: We plan to use the same vendor, Carestream Health, for our PACS and RIS. We are also are going to be looking at the Carestream product for our cardiology sector. Why do we want the same vendor? In a word, it’s integration. If I am planning to support the community hospitals, I don’t have time to take multiple systems and put them together.
If I am going to take care of other people’s images, I need to make sure that I have a quality system through and through. Having one system that is excellent helps me to integrate, and it means I don’t have to worry about making a lot of changes.
If I want to upgrade my RIS or PACS, I know the upgrades will be accepted throughout the system. If I have three different systems and I upgrade one, I must contact the other two vendors and make changes.
We also are putting in a new bed management system, and implementing an innovative inpatient appointment system. We want to move away from the hospital model to the hotel model. We want to make sure we utilize patients’ time wisely.
For inpatients, we plan to schedule appointments while they are here. For example, the appointment will say that the physician will visit at 10 a.m., or that the patient is scheduled for a CT at 9:00 a.m. We will actually tap into the physician's schedule to make sure that he or she meets with the patient at the scheduled time.
We will spread it out so that the physician has enough time to spend with patients. We will do the same thing for ancillary services. If that patient has to go for radiology (in a non-stat situation), nurses and family members will understand the time frame.
eITi: What advancements do you think, or hope, the next 20 years will bring?
Barbeito: With any technology, you eventually have the law of diminishing returns. How much better is the 128-slice CT compared with the 64-slice? I don’t know. I think we will continue to advance, but probably not at the same levels as in the past 20 years. We will, however, see tremendous innovation in the interventional area, especially as it relates to oncological treatment. Targeted treatments will become the norm.
We will continue to see the ability to take those digital images and send them to iPads and mobile devices—even more mobile than we are today. That is a positive, because it’s critical to get the right radiologist to look at the right study. If that radiologist is at a continuing education conference and they have an iPad, and they can pull up the image and do a dictation and interpretation, that will be valuable. We are somewhat limited by wired networks, and we will overcome that in time. Imaging files are huge, so transferring that image across a wireless network is not always easy.
Sumter: I believe that in the next 20 years imaging will advance much faster, and that its quality will improve. If physicians want to increase the image, zoom in, and tell the computer to zoom in, or tell the computer to zoom in, they will have that capability. It’s all about seeing those images with great quality to be able to make sound medical decisions.
I believe the technology has reached a point where the time between breakthroughs is getting shorter. It’s only a matter of whether the public is ready. When I say public, I include FDA approval in that equation. They must accept the technology, improve on it, and move forward.
Greg Thompson is a contributing writer for Executive IT Insight.