Transforming the PACS Vendor Relationship
Radiologists at Yale University figuratively equate their PACS with a toolbox and themselves with artisans, from whose hands now spring forth remarkably useful pictures: namely, manipulated and reconstructed digital images of what lies beneath the epidermis.
Over time, the PACS acquired by Yale in 2003 required, in the department of diagnostic radiology’s estimation, an expanded tool assortment to meet the department’s evolving needs. The radiologists asked their PACS vendor to accommodate them. 
Robert Cooke At the time, the requested extras were nonexistent, but what transpired next would give the department tremendous encouragement. Some at Yale and within the ranks of the vendor (FUJIFILM Medical Systems USA, Stamford, Conn) began talking, wondering whether it might be possible to fashion a partnered process through which the additional PACS capabilities desired by the radiologists could be developed, refined, and formally introduced. One thing led to another, and before long, a formalized Yale-FUJIFILM collaboration was born, out of which have already arisen several valuable enhancements to FUJIFILM’s Synapse PACS product. More are in the pipeline. T. Rob Goodman, MD, Yale’s vice chair of radiology, says, “The significant thing here is that we are not involved with our vendor in the customary way, wherein user feedback is informally passed along from the sales staff to the product-design team. In our situation, we are almost serving as a vendor to the vendor.”
T. Rob Goodman, MD Robert Cooke, FUJIFILM’s vice president, network business management, says, “Academic medical centers have a unique challenge to balance their research mission against their health care mission. They are also facing many of the same challenges more typical radiology environments are facing due to changes in reimbursement, radiology shortages, increased volumes, and even outpatient for-profit imaging. After a successful implementation of Synapse in the Yale environment, it became clear there was more we could do to enhance our relationship and our products.” Adding Value By way of illustration, Goodman describes a few ideas that his group has passed along and then seen brought to life. “We provided Fuji our thoughts about Synapse’s multiplanar-reconstruction (MPR) package,” he says. “We told them we liked the fact that it comes integrated with PACS, rather than being available only as stand-alone postprocessing workstation, but our wish was that this package include the ability to measure objects on the MPRs. FUJIFILM is working on this right now. The solution being developed looks promising.” Also in development at FUJIFILM, in response to input from Yale, is a smart worklist. “At the moment, imaging studies come up in the order they were performed by the technologist, but a smart worklist would allow studies to be prioritized automatically by Synapse based on acuity, patient location, or other parameters we might choose,” Goodman says. Meanwhile, FUJIFILM recently previewed, for the Yale radiologists, a proposed redesign of the Synapse graphical user interface. “Fuji clarified that this was just a work in progress and was eager for our feedback regarding not just where icons were placed on the screen, but also the choice of display colors, text fonts, and sizes.” Attention to seemingly trivial details is appreciated, Goodman adds. “The initial iteration we were shown of the Synapse display screen highlighted, with italics, the identifying information for whatever study was currently selected,” he says. “While helpful in distinguishing that study from others on the displayed list, the italicization worked against us by making it harder to read for purposes of typing in accession numbers, which is something we must do with a fair amount of regularity. When we shared our concern with Fuji, they were quickly responsive. The result was an easier-to-work-with font style the next time the work in progress was shown to us.” A Busy Organization Indeed, while many of the suggestions from Yale for improving PACS may seem inconsequential, they will facilitate radiologists’ comfort and efficiency. Those are vitally important because productivity is the name of the game for Yale’s 40-doctor radiology group, which provides imaging services to 944-bed Yale–New Haven Hospital, Connecticut’s largest tertiary referral center (staffed by 2,500 attending physicians and handling 503,000 emergency and outpatient visits and 50,000 inpatient cases per year). The radiology department performs nearly 390,000 studies per year using a full range of modalities. Some of the studies are generated in the group’s sizable interventional radiology suite. All are read on roughly 40 PACS workstations deployed in nearly 10 reading rooms around the campus and at two satellite facilities not far away. So far, more than 4,000 clinicians in (and affiliated with) the hospital have been granted PACS privileges. The PACS is used, as well, to support an in-house teleradiology service through which some inpatient studies are read by former Yale faculty members now scattered across the country. These radiologists’ services are not used on a routine basis, but only as warranted by volume, or for their highly specialized reading skills. “Without question, PACS has delivered huge benefits,” Goodman says. “From the standpoint of patient care alone, one of the biggest of these benefits is the significant improvement in turnaround time to furnishing reports. Also, because PACS ensures that we always have previous films available, the quality of our reports is improved.” Goodman says he likes PACS not just for those reasons, but also for the way that it abets greater interactions with clinicians. “One of the erroneous assumptions about PACS is that it isolates radiology, turning the department into a deep, dark hole in which radiologists toil without ever once emerging. What actually happens is PACS creates an environment that promotes dialogue between radiologists and clinicians.” Formal Structure The collaborative arrangement between Yale and FUJIFILM is no casual endeavor. It is serious business, spelled out in a document covering rights and responsibilities, confidentiality, and other pertinent matters. “A collaboration at the level of what we and Fuji have established is not something the parties can treat lightly,” Goodman says. “It needs a formal framework and a legally binding contract in order for it to achieve what is intended.” Details of the Yale-FUJIFILM agreement were hammered out at the highest levels of the two organizations. Essentially, what the agreement does is ensure that Yale will enjoy ever-increasing satisfaction from its PACS investment, while FUJIFILM is promised a better understanding of the specific and unique needs of the wide range of radiologists, residents, and specialists at academic medical centers—an understanding that translates into a superior product for the market. Further, the terms of the agreement oblige Yale to undertake certain product-development tasks as requested by FUJIFILM. Yale fulfills that obligation by assigning a radiologist to work with the company as a consultant. “The consultant’s responsibility is to brainstorm with Fuji, funnel to them his (and our department’s) ideas about the product being developed, and help keep the overall project moving forward,” Goodman says. Some of the interaction between the consultant and team FUJIFILM is handled by phone. The balance occurs in face-to-face encounters. Wherever exchanges occur, “This ensures that Yale has direct, hands-on involvement in the creation of tools for PACS,” Goodman says. Coming Together Beyond allocating individual consultants, the agreement between Yale and FUJIFILM provides occasions for organization-to-organization encounters. These occur in the form of steering-committee meetings, using a concept that was mutually discussed and brainstormed by both parties. It is at these gatherings that plans are made for the projects the collaborators wish to tackle next. “The steering committee is a venue for our, and their, senior management to share ideas, understand and communicate challenges, and explore opportunities,” Cooke says, noting that meetings typically brim with robust discussions of new project possibilities and impassioned give-and-take regarding in-progress works. “The creation of a steering committee to map out strategic directions was a best-practice idea that is enhancing our partnership and is a model that we can look at following with other organizations,” he adds. Members of the committee are recruited from the best and brightest at each organization. Seats on FUJIFILM’s side of the table are taken by engineering, program-management, marketing, and sales personnel. Yale’s contingent is one consisting mainly of radiologists, but it also includes a senior hospital administrator. Ten individuals serve on the committee; they include the CEO of FUJIFILM and the chair of the radiology department at Yale. Goodman says, “Their participation signals that Fuji and Yale both take this group and its mission very seriously,” he says. Committee meetings are held at least once per quarter. The location alternates between Yale’s campus in New Haven, Conn, and FUJIFILM’s US headquarters in Stamford, about 45 minutes away. “The fact that we have these meetings on our campus and at Fuji’s flagship office is, I think, yet another representation of the shared nature—the shared workloads—of this collaborative relationship,” Goodman says. The relationship works particularly well because of the partners’ geographic proximity. “If Fuji were headquartered thousands of miles away, I’m not sure the relationship would be quite so cohesive as it is, with us being situated so close to one another,” he adds. Interactions between Yale and FUJIFILM consultants and steering-committee participants are uniformly cordial and nurturing, even if, at times, one side may not concur with the thinking of the other. Goodman says, “There is a great deal of mutual respect among the parties, which is something that must be present if a collaboration of this type is to succeed.” Goodman derives a sense of satisfaction from knowing that the contributions of Yale, in concert with those of FUJIFILM, will result in more valuable PACS technology for institutions worldwide. “We have, in this, an excellent mechanism for managing a key aspect of our relationship with our vendor,” he says. “Our vendor listens to us and now is able truly to understand our wants and needs. Best of all, the vendor is committed to acting upon what we communicate. For the radiologists here, that’s a great feeling.” Likewise, the collaboration has given FUJIFILM valuable insight into the academic medical center that will continue to feed product and relationship development. “We understand this environment and the needs of radiology’s diverse constituents better through our relationship with Yale,” Cooke says, “thus improving our overall delivery to the market as a whole.”
Robert Cooke At the time, the requested extras were nonexistent, but what transpired next would give the department tremendous encouragement. Some at Yale and within the ranks of the vendor (FUJIFILM Medical Systems USA, Stamford, Conn) began talking, wondering whether it might be possible to fashion a partnered process through which the additional PACS capabilities desired by the radiologists could be developed, refined, and formally introduced. One thing led to another, and before long, a formalized Yale-FUJIFILM collaboration was born, out of which have already arisen several valuable enhancements to FUJIFILM’s Synapse PACS product. More are in the pipeline. T. Rob Goodman, MD, Yale’s vice chair of radiology, says, “The significant thing here is that we are not involved with our vendor in the customary way, wherein user feedback is informally passed along from the sales staff to the product-design team. In our situation, we are almost serving as a vendor to the vendor.”
T. Rob Goodman, MD Robert Cooke, FUJIFILM’s vice president, network business management, says, “Academic medical centers have a unique challenge to balance their research mission against their health care mission. They are also facing many of the same challenges more typical radiology environments are facing due to changes in reimbursement, radiology shortages, increased volumes, and even outpatient for-profit imaging. After a successful implementation of Synapse in the Yale environment, it became clear there was more we could do to enhance our relationship and our products.” Adding Value By way of illustration, Goodman describes a few ideas that his group has passed along and then seen brought to life. “We provided Fuji our thoughts about Synapse’s multiplanar-reconstruction (MPR) package,” he says. “We told them we liked the fact that it comes integrated with PACS, rather than being available only as stand-alone postprocessing workstation, but our wish was that this package include the ability to measure objects on the MPRs. FUJIFILM is working on this right now. The solution being developed looks promising.” Also in development at FUJIFILM, in response to input from Yale, is a smart worklist. “At the moment, imaging studies come up in the order they were performed by the technologist, but a smart worklist would allow studies to be prioritized automatically by Synapse based on acuity, patient location, or other parameters we might choose,” Goodman says. Meanwhile, FUJIFILM recently previewed, for the Yale radiologists, a proposed redesign of the Synapse graphical user interface. “Fuji clarified that this was just a work in progress and was eager for our feedback regarding not just where icons were placed on the screen, but also the choice of display colors, text fonts, and sizes.” Attention to seemingly trivial details is appreciated, Goodman adds. “The initial iteration we were shown of the Synapse display screen highlighted, with italics, the identifying information for whatever study was currently selected,” he says. “While helpful in distinguishing that study from others on the displayed list, the italicization worked against us by making it harder to read for purposes of typing in accession numbers, which is something we must do with a fair amount of regularity. When we shared our concern with Fuji, they were quickly responsive. The result was an easier-to-work-with font style the next time the work in progress was shown to us.” A Busy Organization Indeed, while many of the suggestions from Yale for improving PACS may seem inconsequential, they will facilitate radiologists’ comfort and efficiency. Those are vitally important because productivity is the name of the game for Yale’s 40-doctor radiology group, which provides imaging services to 944-bed Yale–New Haven Hospital, Connecticut’s largest tertiary referral center (staffed by 2,500 attending physicians and handling 503,000 emergency and outpatient visits and 50,000 inpatient cases per year). The radiology department performs nearly 390,000 studies per year using a full range of modalities. Some of the studies are generated in the group’s sizable interventional radiology suite. All are read on roughly 40 PACS workstations deployed in nearly 10 reading rooms around the campus and at two satellite facilities not far away. So far, more than 4,000 clinicians in (and affiliated with) the hospital have been granted PACS privileges. The PACS is used, as well, to support an in-house teleradiology service through which some inpatient studies are read by former Yale faculty members now scattered across the country. These radiologists’ services are not used on a routine basis, but only as warranted by volume, or for their highly specialized reading skills. “Without question, PACS has delivered huge benefits,” Goodman says. “From the standpoint of patient care alone, one of the biggest of these benefits is the significant improvement in turnaround time to furnishing reports. Also, because PACS ensures that we always have previous films available, the quality of our reports is improved.” Goodman says he likes PACS not just for those reasons, but also for the way that it abets greater interactions with clinicians. “One of the erroneous assumptions about PACS is that it isolates radiology, turning the department into a deep, dark hole in which radiologists toil without ever once emerging. What actually happens is PACS creates an environment that promotes dialogue between radiologists and clinicians.” Formal Structure The collaborative arrangement between Yale and FUJIFILM is no casual endeavor. It is serious business, spelled out in a document covering rights and responsibilities, confidentiality, and other pertinent matters. “A collaboration at the level of what we and Fuji have established is not something the parties can treat lightly,” Goodman says. “It needs a formal framework and a legally binding contract in order for it to achieve what is intended.” Details of the Yale-FUJIFILM agreement were hammered out at the highest levels of the two organizations. Essentially, what the agreement does is ensure that Yale will enjoy ever-increasing satisfaction from its PACS investment, while FUJIFILM is promised a better understanding of the specific and unique needs of the wide range of radiologists, residents, and specialists at academic medical centers—an understanding that translates into a superior product for the market. Further, the terms of the agreement oblige Yale to undertake certain product-development tasks as requested by FUJIFILM. Yale fulfills that obligation by assigning a radiologist to work with the company as a consultant. “The consultant’s responsibility is to brainstorm with Fuji, funnel to them his (and our department’s) ideas about the product being developed, and help keep the overall project moving forward,” Goodman says. Some of the interaction between the consultant and team FUJIFILM is handled by phone. The balance occurs in face-to-face encounters. Wherever exchanges occur, “This ensures that Yale has direct, hands-on involvement in the creation of tools for PACS,” Goodman says. Coming Together Beyond allocating individual consultants, the agreement between Yale and FUJIFILM provides occasions for organization-to-organization encounters. These occur in the form of steering-committee meetings, using a concept that was mutually discussed and brainstormed by both parties. It is at these gatherings that plans are made for the projects the collaborators wish to tackle next. “The steering committee is a venue for our, and their, senior management to share ideas, understand and communicate challenges, and explore opportunities,” Cooke says, noting that meetings typically brim with robust discussions of new project possibilities and impassioned give-and-take regarding in-progress works. “The creation of a steering committee to map out strategic directions was a best-practice idea that is enhancing our partnership and is a model that we can look at following with other organizations,” he adds. Members of the committee are recruited from the best and brightest at each organization. Seats on FUJIFILM’s side of the table are taken by engineering, program-management, marketing, and sales personnel. Yale’s contingent is one consisting mainly of radiologists, but it also includes a senior hospital administrator. Ten individuals serve on the committee; they include the CEO of FUJIFILM and the chair of the radiology department at Yale. Goodman says, “Their participation signals that Fuji and Yale both take this group and its mission very seriously,” he says. Committee meetings are held at least once per quarter. The location alternates between Yale’s campus in New Haven, Conn, and FUJIFILM’s US headquarters in Stamford, about 45 minutes away. “The fact that we have these meetings on our campus and at Fuji’s flagship office is, I think, yet another representation of the shared nature—the shared workloads—of this collaborative relationship,” Goodman says. The relationship works particularly well because of the partners’ geographic proximity. “If Fuji were headquartered thousands of miles away, I’m not sure the relationship would be quite so cohesive as it is, with us being situated so close to one another,” he adds. Interactions between Yale and FUJIFILM consultants and steering-committee participants are uniformly cordial and nurturing, even if, at times, one side may not concur with the thinking of the other. Goodman says, “There is a great deal of mutual respect among the parties, which is something that must be present if a collaboration of this type is to succeed.” Goodman derives a sense of satisfaction from knowing that the contributions of Yale, in concert with those of FUJIFILM, will result in more valuable PACS technology for institutions worldwide. “We have, in this, an excellent mechanism for managing a key aspect of our relationship with our vendor,” he says. “Our vendor listens to us and now is able truly to understand our wants and needs. Best of all, the vendor is committed to acting upon what we communicate. For the radiologists here, that’s a great feeling.” Likewise, the collaboration has given FUJIFILM valuable insight into the academic medical center that will continue to feed product and relationship development. “We understand this environment and the needs of radiology’s diverse constituents better through our relationship with Yale,” Cooke says, “thus improving our overall delivery to the market as a whole.”