Palm Beach Radiology Institute: Digital Out of the Box

At Palm Beach Radiology Institute, operated by Palm Beach Radiology and Imaging Associates (PBRIA), there is no film, there never has been film, and no one expects ever to see film. When the outpatient imaging center opened a year ago, it was already an all-digital environment, built from the ground up to accommodate a digital infrastructure and a paperless workflow. The patient accesses the digital file from the RIS and verifies the information by signing a signature pad; the RIS routes the ordered exam to the modality; the patient is escorted to the exam room, where the images are acquired and sent to the PACS; when the study appears on the worklist, the radiologist interprets it and dictates the report, which is saved to the RIS; a remote transcriptionist transcribes in real time into the RIS; and within half an hour of the images hitting the PACS, reports are automatically faxed or emailed to the referrer from the RIS.

“I would estimate it is 30% to 40% more efficient than a nondigital environment.” —Scott Studdard, IT manager, Palm Beach Radiology Institute, North Palm Beach, Fla

The multimodality center occupies 4,000 square feet in a North Palm Beach medical center, sandwiched between a rehabilitation center and an orthopedics practice. Its wood floors, granite countertops, crown moldings, and natural lighting belie its medical purpose. Three patient-prep rooms feed patients into six exam rooms, one for each modality: X-ray (computed radiography), digital mammography, 1.5T MRI, 16-slice CT, ultrasound, and bone densitometry. All modalities are positioned around two central reading rooms, where two radiologists practice near–real-time interpretation. A staff of roughly 14 serves the imaging needs of 40 to 75 patients per day. When Scott Studdard was contracted by PBRIA as IT manager six months before the center opened, in the summer of 2007, he was charged with shepherding all modalities and information systems into an efficient and productive whole. Because PBRIA was all-digital from the outset, Studdard says that it is difficult to calculate the cost efficiencies of the filmless and paperless workflow. There are no film-world benchmarks for comparison. The real savings come from increased productivity, and Studdard says that Palm Beach Radiology Institute is ahead of schedule in recouping its total investment of about $4.2 million. Studdard is quick to point out that a tightly integrated RIS/PACS—the result of a partnership between FUJIFILM, Stamford, Conn, and Empiric Systems LLC, Morrisville, NC—is a key to the center’s operational and clinical efficiency. Last year, Empiric Systems signed a reseller partnership with FUJIFILM that allows it to provide a combined RIS/PACS to hospitals and imaging centers like PBRIA. The solution combines both applications under a single sign-on process and provides a single graphical interface for the radiologist and the clinician. Blazing Clinical Efficiency Two radiologists, who own the center with two associates, perform interpretations. The primary reading room has a full-blown Fuji Synapse workstation with three-head five-megapixel monitors, a computer-aided diagnosis station, and a third Synapse workstation for all outside images. A second, smaller reading room with a single workstation and three-head five-megapixel monitors comes into play when both radiologists are on-site, but also provides a measure of security in case one workstation fails. Though most reading is done on-site, the PACS does have the ability, using the Synapse SSL server, to push overflow images to an outside workstation to be read by part-time radiologists. PBRIA goes to great lengths to move reports to referrers faster than its competitors can—another advantage of being completely digital, Studdard says. Once acquired, the images show up on the worklist and are read within 15 minutes by the radiologists, who dictate their interpretations into the RIS. Patient information has already been entered into the RIS by the patient at check-in and by the scheduler. A remote transcriptionist logs into the RIS and transcribes the dictation into the RIS. The report is automatically faxed from the RIS to the referrer. The goal is for the radiologist to have completed the interpretation within 15 minutes of the exam reaching the PACS, giving the transcriptionist 10 minutes to complete it so that the referrer has the report half an hour after the imaging was done. “We’ve got a quick turnaround on the reading and a quicker turnaround getting the report on the Web and available,” Studdard says. Referring physicians also can log into the PBRIA physician portal with a user name and password, where they will see information on their patients who have been referred, past patients for whom reports are available, and patients who are about to be scanned. Images also can be viewed over the Synapse SSL server, secured with a VeriSign SSL key. Its robust RIS/PACS capacity enables PBRIA to offer teleradiology services, seen as an opportunity to grow. PBRIA currently reads for four smaller imaging outlets, Studdard says. “They send the images to our PACS and use our RIS,” he explains. “We provide them back a faxed report and a digital report that they can forward. The faxed reports go out automatically from the RIS, which also posts the report online. If the fax gets missed, they can print the same information off of our physician portal or save it as a PDF.” Attuned to Service This access to reports and images is typical of what all referring physicians get from PBRIA, according to Studdard. “We have a Web-based log-in portal for the physicians to access, and in our RIS, they see all the cases they sent and all that are scheduled,” Studdard explains. “They can click on the reports and actually pull up the images and compare them to the reports. It’s good for those doctors whose patients require further treatment, and it’s all done on the fly.” As part of its service, PBRIA also offers its teleradiology clients access to its RIS for their patient data, including information for billing and tracking expenses, Studdard says. “They have the ability to go in and run their reports, month’s end to month’s end, and see how many patients they’ve sent to us,” he explains. “We are in the business of being strategic partners with our teleradiology clients,” he says. “We offer them great radiologists to do their reading and access to our Web-based RIS.” In Studdard’s view, it’s a good deal for PBRIA’s clients: A RIS would cost the client $100,000 to $200,000, and PBRIA provides it gratis. RIS access for teleradiology clients also provides further workflow efficiencies. “If they are putting the patients into the RIS, then that is information we don’t have to add,” Studdard explains. “They are scanning them, and entering the information into our RIS so that we can interpret the studies. The system does have the ability to do online ordering, but we are not there yet.” The RIS/PACS offers additional opportunities not yet tapped to streamline operations further. While PBRIA generates daily billing reports from the RIS, it still uses a billing service, uploading a billing export file daily from the RIS to the billing company. At some point, he adds, this will end. At that point, all PBRIA billing will be done through the RIS, including electronic claims, remittance, and sending statements. Storing All The Data PBRIA stores its own images long term on the PACS using FUJIFILM’s spinning disk array, which has a four-terabyte capacity, Studdard says. “We estimate that will be three years of capacity at the current rate.” The RIS data are stored on a separate server with a 1.5 terabyte capacity, enough for five or six years. A third teleradiology server from FUJIFILM is used for short-term storage of teleradiology images, which are automatically deleted after 30 days. Daily, the RIS and PACS data are transmitted to an off-site storage center, which PBRIA uses for backup. “I audit the backup every few months and make sure that it is actually working,” Studdard says. At the moment, he says, the center is focused on system upgrades. “The Fuji Synapse has just been upgraded to 3.2, and we’re getting ready to upgrade the Empiric RIS from 4.0 to 5.0, which is mostly a functionality change.” The center is also installing a 45-kW diesel generator for power backup, Studdard says; this is a key measure on the East Coast of Florida, where summer storms often cause blackouts. The Painless Installation In the case of PBRIA, the joint RIS/PACS offering made going digital out of the box easy, or at least easier than it might have been if the facility had been trying to interface disparate technology. “We set up all of the modalities at the same time,” Studdard says. “All the technology and the servers came in at the same time, and then we tested.” First, Studdard ran raw data tests on the IT side to make sure that everything worked. “They were simple network tests, DICOM echoes, and things of that nature,” he says. “From the modalities, we did basic tests with phantoms.” To ensure that patient processing went smoothly, PBRIA spent a couple of weeks doing free imaging for family, friends, and even some vendor reps, Studdard says. “We checked them in at the front desk and put them through the workflow. We worked out 75% of the bugs right there, and the rest, we did in real time.” The bugs were never significant, Studdard says. Sometimes patients failed to understand the electronic sign-up process and had to be helped. The staff had to be trained. Then, there were small network glitches, or bad cables that had to be replaced. “Overall, it was pretty smooth and seamless,” he says. “Patients were surprised at how quickly they could go through the check-in/check-out process. Fuji and Empiric made everything painless. It wasn’t a challenge, once we got everything rolling.” Above and Beyond Debbie Hammond is director of operations at PBRIA. She says that being digital from the beginning was looked at as a competitive advantage for the center but, she adds, the center’s philosophy of personal service to patients and referrers is key to its success. “We go above and beyond the typical imaging center,” she says. Having radiologists on-site enables the center to perform breast biopsies, as well as CT-guided and ultrasound-guided thyroid and other biopsies. “Our patient care is more hands-on than at most centers,” she adds. “The doctors are hands-on with every patient who walks through the door.” Service is key, Hammond says, because PBRIA does have competition. Several hospitals and imaging centers are within a few miles. “My marketer goes out [to call on potential clients], but once the referrers and patients come here, they don’t want to go anywhere else.” That, says Hammond, is because of the friendly staff, as well as the efficiency with which patients can be imaged and referrers receive results. Summer is the off season in Florida, even for imaging centers. Once the snowbirds come back, Hammond says, PBRIA will probably add at least an hour to its morning schedule—opening at 6:30 instead of 7:30—to accommodate the anticipated increase. It has already added staff to do so, she says. “It’s helped tremendously to be paperless,” Hammond concludes.