Rex Healthcare: Taking the Logical Next Step in Image Exchange

As someone who has found himself—more than once—in a mad dash to catch the day’s last FedEx® pickup so that an out-of-town physician could have a patient’s images stat, Tom Hasley sees the wisdom of a cloud-based solution to image delivery. Hasley is systems support manager, ambulatory services, for Rex Healthcare (Raleigh, North Carolina), and he oversees image delivery for the system’s 400-bed hospital and four ambulatory sites, which conduct about 175,000 diagnostic-imaging procedures per year. In addition to meeting the health-care needs of its patients (including the occasional patient who transfers to a luminary site), Rex Healthcare is provider to the Carolina Mudcats, a local baseball farm team for the Cleveland Indians. When a player is injured, the team’s orthopedic surgeon does not want to wait 24 hours to receive a CD. In March 2011, Rex Healthcare launched a cloud-based image-sharing solution and began the arduous process of weaning patients, referrers, and radiology providers off the bedeviling CDs and VPNs that require so much support and so many resources. The next step is the transition to a new cloud-based provider with sharing that is tightly integrated with Synapse PACS from FUJIFILM Medical Systems USA (Stamford, Connecticut), the institution’s longtime PACS provider; this will enable radiologists who wish to share an image with a referrer to do so within the Synapse user interface. Several years, ago, Rex Healthcare began the transition to digital image exchange in the same way that many other institutions did—by setting up VPNs with its radiology provider, Raleigh Radiology Associates; several other heavy image requesters; and a competing hospital in town. “The initial VPN was for surgeons in the operating room who needed images quickly,” Hasley says. “The CD was forgotten, the films weren’t sent in time, or they didn’t have the films from exams that were performed elsewhere in the facility, so we came up with a VPN solution for an orthopedic practice. The VPN solution was extended to many of the offices with which Rex Healthcare had a high degree of CD and film exchange, in an attempt to lessen that burden.” Hasley has been tracking monthly film and CD requests since September 2009, and film requests have dropped from 32% to between 18% and 25% in September and October of this year. On the other hand, monthly CD requests have risen from 63% to between 75% and 82% in the most recent months. Five FTEs staff the image service center, where the printing of film, the burning of CDs, and the transfer and import of any images are handled. Within the VPN model, the service-center staff takes the image into Rex Healthcare’s test PACS and opens the image, where the medical-record numbers and patient IDs are validated. If the patient has been registered in the Rex Healthcare system, then the patient number is changed to match the Rex Healthcare patient number, so that the image would immediately be associated with the patient’s existing data in the Rex Healthcare system. “We import them into our system and can activate a deletion rule so that, after 30 days, they would be deleted from our system,” Hasley explains. “There is even more staging that needs to be done with a CD.” In an Ideal World When cloud sharing of images came onto the Rex Healthcare radar, Hasley saw the opportunity to begin to eliminate the cumbersome CDs and VPNs by getting the two local hospitals and their radiology practices onto the same cloud-based image-sharing system. Representatives from all major imaging stakeholders were assembled to hear a presentation by a cloud vendor, but the system described was deemed too pricey. Rex Healthcare went, instead, with a different provider, and the other stakeholders are currently sitting on the fence, preferring the VPN method of image exchange for the bulk of their needs. “It is so much easier to do one of these solutions,” Hasley says. “With cloud storage, you do not necessarily have to import those images into your system. Radiologists can view the images to see what they want to use, and if they want to use an image as part of the diagnosis, we can import that image.” Both the current system and the new system (Agilisys, DatCard Systems, Irvine, California), which is tightly integrated with the Fujifilm Synapse PACS, work on a subscription system using national provider identifiers. When a physician’s office calls to request an image, if it is enrolled in the image-sharing system, the service-center staff initiates a Web request to the image-sharing provider through its RIS. The image-sharing vendor’s software is loaded on a server in a room next to the image service center. Images are encrypted on their way both to the vendor’s cloud and to the requester. If a patient calls for images, the service-center staff checks to see whether the referring physician is at one of the sites that accepts images electronically. From a security perspective, Hasley’s primary concern is to make sure that the transaction was logged and to review who accesses the images. Way of the Future Currently, the radiologist is not involved in the transaction, but with the transition to the new system, radiologists will be able to stream images directly from within Synapse. “With the Agilisys product, the radiologist could share those images with the referring physician right from the PACS workstation, in an integrated method,” Hasley says. “There may be some opportunities for more collaboration, with the upcoming product.” Rex Healthcare is currently underwriting the cost of image sharing as a service to patients and referrers. “Right now we are paying a flat fee for a certain number of studies per month, and we haven’t hit that threshold yet,” Hasley says. “Is it cheaper than a CD? Probably not, but for convenience, if a patient calls and says, ‘I am going to Raleigh Orthopaedic Clinic; I need my images,’ all we have to do is say, ‘We can send your images electronically to Raleigh Orthopaedic Clinic, so you don’t have to come in and get films or CDs.” For Hasley, cloud-based image sharing is the logical next step in the digital transformation of radiology. Current users of the service are satisfied with the solution, but demand is not overwhelming. The preferred method of image exchange for three of the system’s superusers—Raleigh Radiology Associates, Wake Radiology (Raleigh), and Raleigh Orthopaedic Clinic—remains the VPN. To date, however, 70 referring physicians have enrolled in the program, and the number of cloud-based image shares appears to be gradually trending upward. Hasley attributes physician acceptance of the program to the efforts of Derrick Avery, imaging-center coordinator, who worked closely with the vendor on program setup and promoted the service to referring physicians through an email with hyperlinks to instructions for enrollment. “We are slowly growing that piece,” Hasley says. “It was a big stretch to move everyone off film and onto CD, and now it is a bit of a stretch to move them off the CD and into electronic transmission.” Citing the RSNA Image Share Network, Hasley envisions a future in which patients will be able to upload their studies to a vault in the cloud. “We are not trying to lead the way,” he adds, “but we don’t want to fall behind.”Cheryl Proval is vice president, publishing, imagingBiz, Tustin, California, and editor of Radinformatics.com.