Grow Your Multisite Business With a Single Sign-on Solution

Six months ago, Jesse Salen, vice president of sales and technology for Online Radiology Medical Group (ORMG), Riverside, Calif, found himself in a situation familiar to many radiology practices: upgrade ORMG’s RIS/PACS platform or face dissolution. ORMG had been in operation for nearly a decade, but the practice’s single-database PACS wasn’t sufficient to meet its needs. With an increasing number of radiologists reading from home, a single sign-on solution had gone from being a fantasy to a necessity. “It’s not like we’re in a controlled environment, like a hospital,” Salen says. “We have no control over what our customers send us. In order to operate efficiently, we have to be able to adapt to whatever the customers need.” Add to that the complicated infrastructure created by a staff of more than 30 radiologists, and you’ve got a daunting problem. It’s an issue faced increasingly by practices that want to expand their businesses in the era after implementation of the Deficit Reduction Act. How can you support efficient, distributed reading over a wide geographic spread? The Dark Ages ORMG began ten years ago, with a merger of three Inland Empire radiology practices that wanted to provide better patient service and to get more clout with payors. The staff of the resulting practice, Renaissance Radiology, decided to designate specific radiologists to handle night call. “They set up a little office in the basement of Riverside County Hospital,” Salen says, “where they would take nighttime calls for the whole group.” When a deal is good, word gets around, and other radiology groups in the area were soon requesting that Renaissance’s night shift cover their nighttime readings as well. “We had multiple workstations set up, different viewing stations, and all kinds of crazy networking equipment,” Salen recalls. “The hospital got concerned because we were drawing way too much power. Eventually, they kind of kicked us out.” Now formally incorporated as an independent business, ORMG moved its operations to a data center in Riverside and implemented a PACS. “The advantage to that system was that you could log on from anywhere, and that was important because, as we grew, we needed more than four doctors,” Salen says. “It started with them sleeping in a chair in the office between calls, but soon they were up all night, so we set them up to work from home.” When the vendor couldn’t make the kinds of changes to its PACS that ORMG required, the company switched to a single-database solution from a smaller San Francisco-based vendor. “They were great as far as being flexible and adding all kinds of images, but they don’t scale well,” Salen says. It wasn’t long before ORMG was facing every practice’s worst nightmare: so much volume that its current RIS/PACS platform was a threat, not a boon, to the business. “If we didn’t implement a new PACS, we were going to break,” Salen says. It’s in the Architecture Salen and team turned to GE Healthcare Dynamic Imaging Solutions for a more scalable PACS solution, the Centricity PACS-IW (formerly IntegradWeb PACS). “[IW’s] architecture allows us to scale,” Salen says. “As we grow, we can add more and more servers, and it runs off an SQL server database from Microsoft, so we can now handle the volume.” The results have been everything Salen hoped for, and more. “Since we switched four months ago, we’ve probably increased our volume by about 25%, as far as images,” he says. “As far as workflow’s concerned, the system hasn’t even shown a sign of slowing down.” Another key factor in ORMG’s decision was its RIS, which for some time had been a highly customized solution developed in conjunction with ThinAir Data Corp, Los Angeles, at a time when the RIS was less common. “That relationship had been around since 1992,” Salen recalls. “ThinAir’s RIS code was designed for us.” Like the new PACS, ThinAir’s TeleRIS product has the architecture and functionality that ORMG needs to remain efficient. “At the time we got onboard with ThinAir, any RIS that was being developed was for a hospital environment,” Salen says. “ThinAir custom programmed this product for us, and it developed over time. There hasn’t been any time that we haven’t had around fifteen outstanding change requests with them.” One of ThinAir’s most crucial functions is the custom assignment engine, which enables ORMG’s doctors, who read in more than 20 states, to receive automatically assigned worklists. “Not all the radiologists are able to read for all the states,” Salen says, “or some don’t read MRs and some do. Each of the facilities wants its reports faxed back in a different way. Then, you don’t want to get behind with anyone in the emergency department because you’re reading 10 cases for an outpatient facility. ThinAir automatically assigns cases to doctors based on how busy they are and what kind of study it is. When a case sits too long in one doctor’s queue, it’ll turn red and show up at the top of everyone’s list.” Additional ThinAir features include full integration with Dragon voice-recognition software from Nuance, Burlington, Mass; several different options for report transmittal, including fax and HL7; and customized templates for customers who request them. In an environment like ORMG’s, a single sign-on solution is imperative in maintaining unimpeded workflow. “Because of all the complexities in that workflow engine, there’s no way to duplicate it within the PACS,” Salen says. “With our previous PACS, what we would do was have the ThinAir worklist up, and then we’d have the [PACS] worklist up, and the doctors would have to go into [PACS] and find the case. You can see how that would leave room for error.” Now, with the new solution, there’s a direct interface between RIS and PACS. “When the doctor clicks on the study in ThinAir, it launches in the PACS,” Salen says. “When the report is generated in ThinAir, it goes into the PACS, so if you ever need to review the case for a quality-assurance issue, it’s right there. As we get busier and busier, having that integration is crucially important.” Costs and Benefits In the end, Salen and team implemented the new PACS out of necessity, and return on investment (ROI) was a secondary issue. “If we were down for a month, we would’ve lost enough money and customers to justify buying the PACS,” he says. “If you attribute dollars to the PACS, we won’t achieve positive ROI for at least three years.” It wasn’t an economic decision, Salen says; it was about efficiency, and in that sense, the Centricity IW PACS is already paying for itself. “Our volume has grown by about 25%, and I couldn’t put a cap on our capacity,” he says. “Our imaging-volume growth in March alone was 50%. We’ve had plenty of added revenue that we wouldn’t have had without the new PACS, and we can process images faster.” One ongoing issue is inability to process compressed JPEG images; although these types of images represent only 5% of ORMG’s volume, “I’d say 80% to 90% of my headaches have come from those customers,” Salen says. The complexity of the integration also leads to occasional problems with image transmittal. “What I hear, on a daily basis, is that someone is trying to send us images and can’t,” he says. “There are still times when studies will show up in Centricity that don’t show up in ThinAir, and we’re working with the vendors to fix those.” For the most part, though, the team at ORMG is thrilled at the new efficiencies offered by the single sign-on solution. “This was the selling point for our radiologists—the single sign-on and single worklist,” Salen says. “Anytime you’re going to switch PACS, they hate it, because they have to learn a new interface. The integration was what sold it.” Next Stop: Expansion Freshly revitalized by a scalable, fully integrated PACS platform, ORMG is ready to focus on its newest business endeavor: mammography. “There’s a lot of backlog now in mammography reviewing, and we’re hoping we can help with that,” Salen says. “More and more procedures are being done, and we haven’t seen any other groups doing it because it requires special monitors and special training. We hope this program will be a big benefit to clinics that can’t handle their volume.” Beyond the mammography program, ORMG hopes to be up and running with coronary CT angiography by the end of 2008. “We want to set up subspecialty programs in the future,” Salen says. “Wherever there’s a need for a group to help, we want to be there.” With an unlimited capacity for volume and integrated worklists to maximize efficiency, ORMG just might meet that goal. “Everything you do with technology is designed to let the radiologists do their jobs,” Salen says. “We’re taking away all the frustrating parts of their work and making them even more efficient.”