Leveraging PACS for Growth
When Rob Smith walked into a rural Kentucky emergency department on a Saturday afternoon in the summer of 2011, he knew nothing of the distributed-reading contract put in place just a week before. This fortuitous timing led to prompt care for his aching wrist—a direct result of services from Radiology Imaging Consultants, Harvey, Illinois.
Without Radiology Imaging Consultants’ help, Smith’s plain-film wrist radiograph would have languished on the PACS virtual shelf until Monday morning. As part of the hospital’s new workflow, Jay A. Bronner, MD, MBA, saw the image on his monitor in Chicago while the patient was in the emergency department, and he recognized a dislocation of the carpal bones.
Bronner, a 26-year veteran radiologist and CEO of Radiology Imaging Consultants for the past decade, heads Radiology Imaging Consultants’ group practice of 75 associates and partners. He called the emergency-department physician to discuss the case just 10 minutes after receiving the image. The emergency-department physician was extremely skilled, but the patient’s injury was not an easy one to catch.
“I told the emergency-department attending physician that I thought it was a perilunate dislocation—a type of injury that required immediate care,” Bronner says. “It’s much better if this type of injury is reduced in short order, as opposed to waiting days to fix it. The physician and patient were pleased, and the patient was sent, that afternoon, to a university facility, where he saw an orthopedist.”
At first glance, the emergency-department wrist radiograph contained little drama, but another pair of eyes uncovered another layer of the mystery. “Nothing about that emergency physician was deficient in any way, but perilunate dislocation is not something you see very often,” Bronner says. “I had not seen it in five years.”
Bronner’s analysis from afar is one benefit of distributed reading, particularly when it comes to faster turnaround times and better access to care in rural areas. Spreading its reach from the southern suburbs of Chicago, Radiology Imaging Consultants now serves 16 hospitals in a region that includes Illinois, Kentucky, and Indiana.
Radiology Imaging Consultants is part of a growing cadre of group practices that are able to distribute in-person talent from headquarters to various points. Advanced Radiology Services, Grand Rapids, Michigan, boasts what might be the largest physician-owned distributed-reading group practice in the country, with 120 radiologists fanning out to many hospitals. 
Advanced Radiology Services does not own competing imaging centers, choosing instead to plant its flag at host facilities—an arrangement that pleases all parties. Steven Waslawski, MD, president of the group’s Grand Rapids division (one of four divisions), relies on a solid PACS, but is keen never to lose sight of the personal touch. “We are not a virtual service where there is a lack of physical presence and boots on the ground,” Waslawski, a 21-year radiology practitioner, explains. “We forge partnerships, and we don’t want to compete on a virtual playing field. We feel we can deliver greater value by maintaining and strengthening our on-site presence.”
Effective engagement with medical leaders, as well as the performance of common interventional procedures, requires on-site radiologists. Despite all manner of technology, many hospitals are loath to give up that vital communication and expertise.
If referring physicians doing business with Medford Radiological Group in Oregon have any trouble maintaining that personal connection with radiologists, a call center fosters crucial communication. Roseanne McLaren, CEO of Medford Radiological Group, says, “Physicians are put through to wherever the radiologist is working, and it’s a convenient way to access our physicians. This is a way to connect referring providers to radiologists, if the radiologists are not available in the hospital to speak in person. The central call center is open from 8 am to midnight, Monday through Friday, and physicians can call directly to get a radiologist. We extended the hours because providers liked the service.”
Justifying a PACS
There will always be small facilities where critical volume makes it difficult to justify a 24/7 on-site presence. In these cases, coverage five days a week—or even one day a week, for small facilities—might be appropriate.
When radiologists can’t be on-site, an excellent Web-based PACS that works seamlessly with a RIS can avoid a lot of headaches. Given the choice, many radiology groups would prefer one effective PACS, from a single vendor, that stretches across all hospital partners. Michael Troychak, MD, says, “That would be an understatement; however, we have two different major PACS in our practice. One of them is from an important customer/client that is part of a large hospital system, and we are obligated to use its PACS.”
As president of Medford Radiological Group, Troychak regularly confronts incompatible PACS, which is a familiar situation for much of the industry. Despite challenges stemming from differing viewing platforms, both Web-based systems at Medford Radiological Group ultimately work well together, offering patients and clinicians outstanding turnaround times. 
Despite covering a service area that is 200 miles in diameter and that has 23 facilities, Medford Radiological Group’s PACS is able to compare multiple prior studies, which are automatically integrated from different databases. “We currently have discrepant dictation systems, but we are midway through the process of transitioning to a single voice-recognition solution, one site at a time,” Troychak says. “We are aiming for a single-workstation solution. One PACS and one RIS is the goal, with one voice-recognition system. As we implement that, it gives us the capability of moving away from a site-specific setup to a transparent system, where radiologists can be anywhere in our practice.”
Medford Radiological Group radiologists will ultimately be able to view a master worklist that can be accessed according to the preference of the referring physician. “Distributed reading is moving more toward subspecialization and is not site dependent,” Troychak says. “The RIS we have chosen as the interface for our voice-recognition system is from the same vendor as the PACS. It allows us to organize studies by organ system and urgency, not just chronologically or by site. The RIS launches voice recognition and the PACS, based on the needs of the practice.”
Medford Radiological Group’s distributed-reading model will increasingly rely on voice recognition to foster prompt final reports, which are fast replacing the old practice of preliminary interpretations. “Historically, with transcription, you put out a preliminary report,” Troychak says. “Now, we are making the preliminary report unnecessary because instead of sending to transcription, we self-edit our dictation with voice recognition. That final report is coming up to us in real time on a monitor, as we dictate. We send out that final report immediately.”
Bronner adds, “Our model is that we read in real time while patients are still in the emergency department. This allows the emergency-department physician to make confident, timely decisions that improve the quality of care for the patients. Our turnaround times, for our facilities, are 20 minutes for emergency cases and 40 to 60 minutes for all the other cases, including outpatient exams.”
When Radiology Imaging Consultants initially decided to go to in-house final interpretations, it did not even have a PACS. “We did not need it because we always had somebody in-house at our client facilities,” Bronner says. “We continued in that mode until about two years ago, when we started to consider facilities that could not justify an overnight in-house radiologist, due to geography or case volume. It was then that we decided to invest in a PACS.”
Of the 16 facilities served by Radiology Imaging Consultants, 12 do not have a radiologist on-site 24 hours a day. Radiology Imaging Consultants plans to add client facilities, but only some of them will have radiologists on-site around the clock. The distributed-reading model ensures that final interpretations will continue without skipping a beat. “We will use our PACS in some facilities and not in others,” Bronner says. “We will use our distributed PACS in situations where we do not have someone on-site 24 hours a day. Clients are individual in their willingness to build the interface with our system. If they are reluctant to interface with us, we will try to work around that.”
Those who wish to interface are likely to do so, in the future, based on the dictates of electronic medical records (EMRs). Government enticements—and penalties—will probably motivate facilities to act, whether they are ready or not.
“There is an ongoing evolution of information systems within the hospital as many hospitals migrate to EMRs,” Bronner says. “Many of our clients and potential clients have big, coordinated projects on the table right now and are open to that, but it requires prioritization of their precious IT resources. We have many clients that we believe genuinely recognize some of the added value that our workflow and systems provide because they can get enhanced access to subspecialty interpretation while clinical decisions are being made for their patients—day or night.”
Purchases and Politics
As practices get larger and cover ever more territory—and reimbursement continues to drop—the need to invest in IT (including PACS) continues to grow. It comes down to efficiency, and it comes at a price. When Gary H. Dent, MD, president of South Georgia Radiology Associates in Baxley, went shopping for a new PACS to bolster his distributed-reading capability, he encountered many promises—and even more options. At the top of his list were easy image transfers and seamless interfacing with disparate PACS in client hospitals.
As he sought to expand a client base that already included nine different Georgia locations and 140,000 exams per year, Dent wanted to avoid a large on-site hardware footprint, if at all possible. “If you must have a designated server, it can cause technical issues that can slow you down and lead to increased overhead, from an IT standpoint,” Dent says. “If it is a hospital, you must also ask them for server space. If you can tell them you are going to bring in a little computer smaller than a laptop, just in a corner in the server room with Internet access, you are good to go, and it is no problem.” 
Dent’s server actually sits in Tennessee, away from his Georgia base, and he pays a company to handle networking issues (in addition to paying a per-study fee). “Our night interpretations are handled by one radiologist, every single night,” Dent says. “We are literally scattered across the state, and we do as much boots-on-the-ground radiology as we can. We do not congregate in one bunker.”
Another expensive challenge for Dent and his colleagues is interoperability with hospital PACS because many institutions have different systems. Customization is necessary for virtually every implementation, and successful integration is never a cookie-cutter process. “You never know how long it is going to take until you start,” Dent says. “There are always interfaces that must be written, and there is tremendous variability. We take that variability and get it to conform to a model of real-time, 24-hour interpretation.”
It’s a huge challenge, but Dent’s IT team of four has never been stymied. Two of the four take care of all implementations, and outsourcing is also done, when necessary. “Even with all the resources, PACS integration has allowed us to bring distributed-reading services to new facilities, and it’s been a valuable tool,” Dent says. “The PACS is worth the investment, if you have the support and knowledge to implement it.”
Actually making the investment is a large (and usually expensive) decision. When Waslawski began the vendor-selection process, he was not surprised to find that everyone had an opinion.
“It is not a simple matter to convince a group of physicians to invest in something that has historically been provided for by our facility partners,” Waslawski says. “It is a significant political effort to deliver added value, both to our facility partners and to our practice, that groups should not underestimate. In the end, we needed to embrace these technologies, rather than fight them. We were not going to continue to be the preferred provider if we were not going to adopt distributed reading.”
During an exhaustive vendor-selection process, Waslawski marveled that features and functions changed from week to week, and even day to day, as software designers came up with new efficiencies. “Technology is changing even during the selection process,” he says. “Some vendors did not have products that were ready, and some had products that were more mature. They all had different attributes, in terms of size, stability, and likelihood that they would still be there tomorrow. There is no perfect vendor or platform. We selected one with a proven platform that could grow into a long-term partnership and continue to develop the technology and applications.”
A multivendor approach might have brought features that no single vendor could provide, but Waslawski and his associates at Advanced Radiology Services believed that the solid relationship was most important. In essence, manufacturer and radiology group worked together to smooth over any bumps.
The Advanced Radiology Services IT department eventually doubled in size to accommodate the 24/7 model. At this point, about 10% of client facilities use the new system, but 25% will probably be on board in the next six months. From there, the percentage will only grow, as features continue to be perfected. 
“Worklists are filtered by subspecialty,” Waslawski says. “Our goal is not to remove our on-site presence, but actually to enhance our on-site presence. For us, distributed reading is not a virtual service line. We are able to supplement our on-site radiologists to maintain and improve service that we could not achieve before. Most of our work is (and will still be) done on the premises, even though we can fill in from any site.”
Filling in during busy times is an important feature that Dent’s clients also appreciate. Stat designations on the worklist foster turnaround times of less than 15 minutes, day or night. “The stat case comes up as a priority, and we immediately see it on the list,” Dent says. “We immediately go to that page, and then we go back to our location-based workload.”
For any new contract, Dent’s group downloads two years of prior exams, all while retaining the ability to query and retrieve from disparate PACS. “If there is something over two years old, we ask the technologist to inform us about that,” he says. “If we must retrieve it, we have an assistant who does that. If there is a pulmonary nodule, and we know there is a chest radiograph from 2002, we get that. Anything less than two years old we automatically have available to us. That’s a minimum. Sometimes, we have three to four years of exams available.”
The Wish List
With the old lightbox all but a relic in radiology departments, physicians have grown used to the fruits of new technology. With each advance, refinements and new ideas quickly follow. In some cases, the technology is available, but just out of reach. Dent admits that efficiency will go up another notch when he is able to read PET/CT scans conveniently.
“If I get called about a PET/CT right now, and I am not at the workstation where I can read it, I have to tell my client that I will call back,” he says. “If the radiation oncologist is trying to plan treatment, that is not good. It delays workflow, and I don’t like that. Fortunately, the advent of PET/CT fusion sent directly into the user interface will soon improve our ability to serve the customer. We are doing a lot more PET studies—ten to 15 a week, which is pretty substantial for a rural area.”
With so many sites and interfaces involved, many radiologists—in the age of distributed reading—must deal with several passwords, user names, and database addresses. Troychak, for one, is not alone in his wish for a system that takes out another pesky step in the sign-in process.
“What we really could use is roaming profiles, and I’m sure the technology will get there with our current PACS and RIS providers,” he says. “You log on once and you are in; from there, you don’t want to do more that triggers passwords. Any computer you go to would operate in exactly the same manner as any other workstation. That would eliminate some frustration. That is something we are really looking forward to conquering with the cloud-computing model.” Greg Thompson is a contributing writer for Radiology Business Journal.
At first glance, the emergency-department wrist radiograph contained little drama, but another pair of eyes uncovered another layer of the mystery. “Nothing about that emergency physician was deficient in any way, but perilunate dislocation is not something you see very often,” Bronner says. “I had not seen it in five years.”
Bronner’s analysis from afar is one benefit of distributed reading, particularly when it comes to faster turnaround times and better access to care in rural areas. Spreading its reach from the southern suburbs of Chicago, Radiology Imaging Consultants now serves 16 hospitals in a region that includes Illinois, Kentucky, and Indiana.
Radiology Imaging Consultants is part of a growing cadre of group practices that are able to distribute in-person talent from headquarters to various points. Advanced Radiology Services, Grand Rapids, Michigan, boasts what might be the largest physician-owned distributed-reading group practice in the country, with 120 radiologists fanning out to many hospitals. Advanced Radiology Services does not own competing imaging centers, choosing instead to plant its flag at host facilities—an arrangement that pleases all parties. Steven Waslawski, MD, president of the group’s Grand Rapids division (one of four divisions), relies on a solid PACS, but is keen never to lose sight of the personal touch. “We are not a virtual service where there is a lack of physical presence and boots on the ground,” Waslawski, a 21-year radiology practitioner, explains. “We forge partnerships, and we don’t want to compete on a virtual playing field. We feel we can deliver greater value by maintaining and strengthening our on-site presence.”
Effective engagement with medical leaders, as well as the performance of common interventional procedures, requires on-site radiologists. Despite all manner of technology, many hospitals are loath to give up that vital communication and expertise.
If referring physicians doing business with Medford Radiological Group in Oregon have any trouble maintaining that personal connection with radiologists, a call center fosters crucial communication. Roseanne McLaren, CEO of Medford Radiological Group, says, “Physicians are put through to wherever the radiologist is working, and it’s a convenient way to access our physicians. This is a way to connect referring providers to radiologists, if the radiologists are not available in the hospital to speak in person. The central call center is open from 8 am to midnight, Monday through Friday, and physicians can call directly to get a radiologist. We extended the hours because providers liked the service.”
Justifying a PACS
There will always be small facilities where critical volume makes it difficult to justify a 24/7 on-site presence. In these cases, coverage five days a week—or even one day a week, for small facilities—might be appropriate.
When radiologists can’t be on-site, an excellent Web-based PACS that works seamlessly with a RIS can avoid a lot of headaches. Given the choice, many radiology groups would prefer one effective PACS, from a single vendor, that stretches across all hospital partners. Michael Troychak, MD, says, “That would be an understatement; however, we have two different major PACS in our practice. One of them is from an important customer/client that is part of a large hospital system, and we are obligated to use its PACS.”
As president of Medford Radiological Group, Troychak regularly confronts incompatible PACS, which is a familiar situation for much of the industry. Despite challenges stemming from differing viewing platforms, both Web-based systems at Medford Radiological Group ultimately work well together, offering patients and clinicians outstanding turnaround times. Despite covering a service area that is 200 miles in diameter and that has 23 facilities, Medford Radiological Group’s PACS is able to compare multiple prior studies, which are automatically integrated from different databases. “We currently have discrepant dictation systems, but we are midway through the process of transitioning to a single voice-recognition solution, one site at a time,” Troychak says. “We are aiming for a single-workstation solution. One PACS and one RIS is the goal, with one voice-recognition system. As we implement that, it gives us the capability of moving away from a site-specific setup to a transparent system, where radiologists can be anywhere in our practice.”
Medford Radiological Group radiologists will ultimately be able to view a master worklist that can be accessed according to the preference of the referring physician. “Distributed reading is moving more toward subspecialization and is not site dependent,” Troychak says. “The RIS we have chosen as the interface for our voice-recognition system is from the same vendor as the PACS. It allows us to organize studies by organ system and urgency, not just chronologically or by site. The RIS launches voice recognition and the PACS, based on the needs of the practice.”
Medford Radiological Group’s distributed-reading model will increasingly rely on voice recognition to foster prompt final reports, which are fast replacing the old practice of preliminary interpretations. “Historically, with transcription, you put out a preliminary report,” Troychak says. “Now, we are making the preliminary report unnecessary because instead of sending to transcription, we self-edit our dictation with voice recognition. That final report is coming up to us in real time on a monitor, as we dictate. We send out that final report immediately.”
Bronner adds, “Our model is that we read in real time while patients are still in the emergency department. This allows the emergency-department physician to make confident, timely decisions that improve the quality of care for the patients. Our turnaround times, for our facilities, are 20 minutes for emergency cases and 40 to 60 minutes for all the other cases, including outpatient exams.”
When Radiology Imaging Consultants initially decided to go to in-house final interpretations, it did not even have a PACS. “We did not need it because we always had somebody in-house at our client facilities,” Bronner says. “We continued in that mode until about two years ago, when we started to consider facilities that could not justify an overnight in-house radiologist, due to geography or case volume. It was then that we decided to invest in a PACS.”
Of the 16 facilities served by Radiology Imaging Consultants, 12 do not have a radiologist on-site 24 hours a day. Radiology Imaging Consultants plans to add client facilities, but only some of them will have radiologists on-site around the clock. The distributed-reading model ensures that final interpretations will continue without skipping a beat. “We will use our PACS in some facilities and not in others,” Bronner says. “We will use our distributed PACS in situations where we do not have someone on-site 24 hours a day. Clients are individual in their willingness to build the interface with our system. If they are reluctant to interface with us, we will try to work around that.”
Those who wish to interface are likely to do so, in the future, based on the dictates of electronic medical records (EMRs). Government enticements—and penalties—will probably motivate facilities to act, whether they are ready or not.
“There is an ongoing evolution of information systems within the hospital as many hospitals migrate to EMRs,” Bronner says. “Many of our clients and potential clients have big, coordinated projects on the table right now and are open to that, but it requires prioritization of their precious IT resources. We have many clients that we believe genuinely recognize some of the added value that our workflow and systems provide because they can get enhanced access to subspecialty interpretation while clinical decisions are being made for their patients—day or night.”
Purchases and Politics
As practices get larger and cover ever more territory—and reimbursement continues to drop—the need to invest in IT (including PACS) continues to grow. It comes down to efficiency, and it comes at a price. When Gary H. Dent, MD, president of South Georgia Radiology Associates in Baxley, went shopping for a new PACS to bolster his distributed-reading capability, he encountered many promises—and even more options. At the top of his list were easy image transfers and seamless interfacing with disparate PACS in client hospitals.
As he sought to expand a client base that already included nine different Georgia locations and 140,000 exams per year, Dent wanted to avoid a large on-site hardware footprint, if at all possible. “If you must have a designated server, it can cause technical issues that can slow you down and lead to increased overhead, from an IT standpoint,” Dent says. “If it is a hospital, you must also ask them for server space. If you can tell them you are going to bring in a little computer smaller than a laptop, just in a corner in the server room with Internet access, you are good to go, and it is no problem.” Dent’s server actually sits in Tennessee, away from his Georgia base, and he pays a company to handle networking issues (in addition to paying a per-study fee). “Our night interpretations are handled by one radiologist, every single night,” Dent says. “We are literally scattered across the state, and we do as much boots-on-the-ground radiology as we can. We do not congregate in one bunker.”
Another expensive challenge for Dent and his colleagues is interoperability with hospital PACS because many institutions have different systems. Customization is necessary for virtually every implementation, and successful integration is never a cookie-cutter process. “You never know how long it is going to take until you start,” Dent says. “There are always interfaces that must be written, and there is tremendous variability. We take that variability and get it to conform to a model of real-time, 24-hour interpretation.”
It’s a huge challenge, but Dent’s IT team of four has never been stymied. Two of the four take care of all implementations, and outsourcing is also done, when necessary. “Even with all the resources, PACS integration has allowed us to bring distributed-reading services to new facilities, and it’s been a valuable tool,” Dent says. “The PACS is worth the investment, if you have the support and knowledge to implement it.”
Actually making the investment is a large (and usually expensive) decision. When Waslawski began the vendor-selection process, he was not surprised to find that everyone had an opinion.
“It is not a simple matter to convince a group of physicians to invest in something that has historically been provided for by our facility partners,” Waslawski says. “It is a significant political effort to deliver added value, both to our facility partners and to our practice, that groups should not underestimate. In the end, we needed to embrace these technologies, rather than fight them. We were not going to continue to be the preferred provider if we were not going to adopt distributed reading.”
During an exhaustive vendor-selection process, Waslawski marveled that features and functions changed from week to week, and even day to day, as software designers came up with new efficiencies. “Technology is changing even during the selection process,” he says. “Some vendors did not have products that were ready, and some had products that were more mature. They all had different attributes, in terms of size, stability, and likelihood that they would still be there tomorrow. There is no perfect vendor or platform. We selected one with a proven platform that could grow into a long-term partnership and continue to develop the technology and applications.”
A multivendor approach might have brought features that no single vendor could provide, but Waslawski and his associates at Advanced Radiology Services believed that the solid relationship was most important. In essence, manufacturer and radiology group worked together to smooth over any bumps.
The Advanced Radiology Services IT department eventually doubled in size to accommodate the 24/7 model. At this point, about 10% of client facilities use the new system, but 25% will probably be on board in the next six months. From there, the percentage will only grow, as features continue to be perfected. “Worklists are filtered by subspecialty,” Waslawski says. “Our goal is not to remove our on-site presence, but actually to enhance our on-site presence. For us, distributed reading is not a virtual service line. We are able to supplement our on-site radiologists to maintain and improve service that we could not achieve before. Most of our work is (and will still be) done on the premises, even though we can fill in from any site.”
Filling in during busy times is an important feature that Dent’s clients also appreciate. Stat designations on the worklist foster turnaround times of less than 15 minutes, day or night. “The stat case comes up as a priority, and we immediately see it on the list,” Dent says. “We immediately go to that page, and then we go back to our location-based workload.”
For any new contract, Dent’s group downloads two years of prior exams, all while retaining the ability to query and retrieve from disparate PACS. “If there is something over two years old, we ask the technologist to inform us about that,” he says. “If we must retrieve it, we have an assistant who does that. If there is a pulmonary nodule, and we know there is a chest radiograph from 2002, we get that. Anything less than two years old we automatically have available to us. That’s a minimum. Sometimes, we have three to four years of exams available.”
The Wish List
With the old lightbox all but a relic in radiology departments, physicians have grown used to the fruits of new technology. With each advance, refinements and new ideas quickly follow. In some cases, the technology is available, but just out of reach. Dent admits that efficiency will go up another notch when he is able to read PET/CT scans conveniently.
“If I get called about a PET/CT right now, and I am not at the workstation where I can read it, I have to tell my client that I will call back,” he says. “If the radiation oncologist is trying to plan treatment, that is not good. It delays workflow, and I don’t like that. Fortunately, the advent of PET/CT fusion sent directly into the user interface will soon improve our ability to serve the customer. We are doing a lot more PET studies—ten to 15 a week, which is pretty substantial for a rural area.”
With so many sites and interfaces involved, many radiologists—in the age of distributed reading—must deal with several passwords, user names, and database addresses. Troychak, for one, is not alone in his wish for a system that takes out another pesky step in the sign-in process.
“What we really could use is roaming profiles, and I’m sure the technology will get there with our current PACS and RIS providers,” he says. “You log on once and you are in; from there, you don’t want to do more that triggers passwords. Any computer you go to would operate in exactly the same manner as any other workstation. That would eliminate some frustration. That is something we are really looking forward to conquering with the cloud-computing model.” Greg Thompson is a contributing writer for Radiology Business Journal.