From Here to Eternity: Extending the Franchise Through Distributed-reading Solutions
Few developments in radiology have been more productive (or disruptive) than the advent of PACS. To PACS, radiology owes its ability to increase productivity dramatically during the past 10 years, thereby conserving income levels at a time of diminishing reimbursement. To PACS, radiology also owes the very real threat of commoditization. 
Robert Pollard Nonetheless, the remarkable evolution of PACS technology is slowly but surely making its way back to old-school referrer interaction through distributed-reading solutions in a variety of settings. As prices drop and vendors leverage Web-based architecture, PACS has become a necessary tool for radiology practices seeking to expand service through the distributed-reading model, perhaps including on-site consultation with referring physicians. One example of a personal touch melded with technical savvy can be found at Advanced Medical Imaging Consultants (AMIC) PC, Fort Collins, Colorado. Raym Geis, MD, is part of this group, which covers 22 sites from Casper, Wyoming, to Sidney, Nebraska. AMIC’s 29 fellowship-trained radiologists offer full service for facilities with several hundred beds (and others that are much smaller). It’s a bit like traditional radiology, except that it is distributed over a wider area.
Eric Slimmer, CEO AMIC sends radiologists to contracted sites at least every other week, when biopsies or interventional procedures can be performed. Most studies are read remotely, and on any given day, AMIC has radiologists at up to seven different sites doing subspecialty interpretations. The distributed-reading workflow has improved through the years, and various sites are tweaking it as needed. “In the ideal world, we would be able to read from any type of workstation,” Geis, a veteran of many RSNA lecterns, explains. “We don’t have that situation yet. We read from basically three different PACS. One system is a fairly thin client, but I can’t just go to any computer, log on at an Internet site, have all the programs show up, and read from it. I must download things to that computer, and I must have an IT person come and set up a workstation.” Through interfaces, AMIC’s radiologists are able to read images for all but two of the company’s 22 clients from its own Web-based PACS. Radiologists covering all sites, therefore, must have access to three different workstations. For smaller health-care providers (such as practices and mobile imaging services) that might once have been reluctant to deal with the hassles of a distributed-reading business model, the technological barriers are not so formidable anymore. Robert Pollard, IT director at Decatur, Alabama-based Drs4Drs (www.drs4drs.com), is the technical guru behind a consortium that represents physicians and provides multiple services, including mobile ultrasound. Pollard uses a Web-client PACS to manage images from a central location so that radiologists can read the studies from standard workstations. Typically, image files are uploaded to a centralized PACS over a wireless microwave network at 5MB. “Radiologists from various locations in Georgia or Alabama log on over the Internet, and they read the studies and write the reports,” Pollard says. “We get the reports to the ordering physicians within a 48-hour turnaround time.” Pollard has two different ways to obtain prior studies. Since not all the studies are in the system, the first way is to go back and get documents, scan them, and import them. “We mark them as medium-level stat, which bolds the actual study on the worklist,” Pollard explains. “The radiologists can immediately see that it is a prior study, or that it has a prior study associated with it. They open it, and in the lower left frame they can see all of the standard documents from prior studies. If we already have a study in the system, we add another study for that patient. It is automatic; all the studies show up, and radiologists can go back and look at the prior studies anytime.” Beating Worklist WoesWith 30 years of IT experience, Pollard selected his PACS with an eye toward governing the company’s worklists, which are refreshed constantly. “You log into the PACS, and the worklist is isolated to your specific login,” Pollard says. “We can customize it to show studies originating from specific clinics, or use any criteria you want.”
Raym Geis, MD After the technologist completes the scan, the study and the supporting documentation are uploaded to the PACS by an employee at the central office. Only then does the study become visible to the company’s radiologists as unread. When the radiologists complete their dictation, the study is marked as read. Far more than in days past, PACS has become an affordable option for radiology groups and other health care providers. “It used to be a money pit,” Pollard says. “People would get in, but then manufacturers would ask you to add on more, and that inevitably ran up costs. It used to be six figures, and from my perspective, that is not really affordable.” Radiologists contracted to provide interpretations for Drs4Drs have no specialized workstations and need only standard computers and browsers. The PACS is Web based, and it includes an option for voice recognition, but Pollard currently has opted to use a transcription service instead. Radiologists email the audio files, and Pollard’s team gets the reports to the referring offices. In 2009, the organization interpreted 12,233 ultrasound procedures. The situation at Oklahoma City, Oklahoma-based Eagle Imaging Partners (www.eagleimagingok.com), a seven-radiologist practice, is a bit different, especially when it comes to workstations. Interpreting from 23 sites using nine PACS and ranging from Abilene, Texas, to Tulsa, Oklahoma, the radiologists at Eagle Imaging Partners provide subspecialty coverage and an on-site presence, and all interpretations are done from a standard workstation. Eric Slimmer, CEO at Eagle Imaging Partners, says, “All of our workstations at all of the centers are identical. When our physicians log in, they are able to access all the images that are on their worklist on that same multifunction workstation. We do not have other workstations lined up anymore, and we have been able to consolidate all of those under one worklist.” With sites scattered throughout Oklahoma and Texas, Eagle Imaging Partners locates its physicians in areas close to the hospitals and imaging centers that they serve, making it easier to provide the necessary on-site coverage. “All of our physicians are working on the same network, no matter where they are,” Slimmer explains. “The physician may go to one imaging center one day and one hospital another day, and those are 30 to 45 miles apart. The system and the workflow are the same at each location. All of our clients’ cases come into the same centralized worklist, and the physicians work off that worklist no matter where they are.” With seven physicians in the group, Eagle Imaging Partners contracts with a major teleradiology provider for after-hours coverage, as well as for the use of its technology and workflow expertise. “With its teleradiology software and after-hours coverage, and our on-site presence, we can go to rural facilities and provide 24/7, turnkey workflow that is seamless,” Slimmer says. “Our group takes care of all the daytime studies. We provide the rural United States with high-quality care, and we do that by using image distribution, coupled with our on-site presence and after-hours coverage.” Slimmer searched for, and ultimately found, a system that allowed physicians to filter worklists by subspecialty or privileges/credentials. “If the physician is not properly credentialed, he or she may not be able to see cases from a certain facility,” Slimmer says. “Our group uses the sort function of chronological order. The studies are on the worklist based on when the case arrived. All urgent cases go to the top of the list and are interpreted within 30 minutes. Each physician, when he or she logs into the worklist, will only have cases that he or she reads and is credentialed/privileged for, in order of urgency.” Eagle Imaging Partners eschews archiving images for the facilities that it serves, but the system does keep reports permanently. It usually preserves images for 30 to 60 days, depending on the facility. The Tables TurnIn fact, distributed reading has rendered PACS such a requisite tool, Geis says, that facilities that still do not have a PACS might do well simply to buy their own archives and use the interpreting practice’s PACS. “Institutions pay all this money for a PACS, and nobody uses it, because they use ours,” he says. “Instead of buying a PACS, they should buy their own archive, which is cheap. Save everything in standard format. If you become dissatisfied someday with your distributed-reading provider, you can simply go to another radiologist.” If a facility has its own PACS (or just an archive), AMIC will essentially serve as a backup for just that purpose, and the backup is actually the version from which Geis reads. In the future, he predicts, all images might be stored via cloud computing, allowing capacity to be purchased from third parties only as needed (and reducing capital expenditures). “Not only are you going to have the images archived in the cloud, but people are going to start providing a lot of the image-viewing software as a Web service,” Geis says. “AMIC sees its future not only as radiologists, but as a consolidator and provider of Web services for PACS, RIS, report generation, advanced image processing, the knowledge base, and outcomes data.” At Slimmer’s central facility, autorouting works hand in hand with a centralized worklist. “When they log in, all physicians will see the worklist that they are willing and credentialed to interpret,” he explains. “Those cases immediately begin caching to their systems, and they read from the top of the list. Once a radiologist selects a case, another radiologist cannot select that case. The same case could be on multiple radiologists’ worklists. As soon as it is selected, that image is captured and that radiologist interprets it off the worklist.” Centralized worklists and image-distribution systems, if implemented properly, can dramatically increase productivity. In Slimmer’s case, they have also lessened radiologists’ daily errors and interruptions because the radiologists are no longer working on three or four different systems. “The new system has also given us the ability to consult easily with other partners in the group, since we are all working on the same system,” Slimmer says. “Physicians can pick up the phone and have a look at the same images. The ability to work on the same system, with the same worklist, has really unified our group, even though we are spread out all over the state.” Geis agrees that the filtering mechanisms of sophisticated worklists can add efficiencies to today’s distributed-reading solutions. In addition to accounting for privileges/credentials and subspecialties, filters can be set up based on whether the radiologist is reading for an IDTF or whether the patient is a Medicare enrollee. “If you don’t have the worklist sophistication, you will end up doing things that you don’t get paid for,” Geis says. “Remember that the insurance companies are notorious about changing the rules, and as nearly as I can tell, their goal is not to pay us.” AMIC radiologists currently are unable to read all images from one workstation, and Geis contends that some of the big software manufacturers probably want it that way; that is, they are likely to prefer that radiologists stay on their proprietary systems. There are a number of small companies, he says, that are working on image-viewing software that could interact with disparate archives and multiple lists. The images might be on a large company’s PACS, but small companies are increasingly learning how to interface with all of those. “Half the places we read from have their own PACS; we can plug our system into theirs, and it works robustly,” Geis says. “We can get the information we need. Our smaller system plays well with others, and you have to have that nowadays.” The workstation that Geis uses at home is essentially the same as the one that he has at the hospital. It’s an off-the-shelf computer with inexpensive medical-grade monitors. He says, “When we first started, the monitors cost tens of thousands of dollars for medical grade.” Now, he reports, they can be bought inexpensively online. Beyond TeleradiologySlimmer notes that advocates of pure teleradiology, as opposed to distributed reading, might have been inclined to use teleradiology specifically to avoid having to work on-site. Instead, the Eagle Imaging Partners model involves forming a group that is actually spread out all over the state. This system allows the company to send physicians to different locations, but they still use the centralized worklist. Eagle Imaging Partners contracts with hospitals and provides the radiologists with the workstations that it requires the physicians to use. “Teleradiology certainly has its place, with huge benefits to the facilities for nights and overflow coverage, but it has its limitations,” Slimmer says. “That is exactly why we have structured our operations the way we have in partnering with a teleradiology company to accomplish both tasks. I think the on-site model will always have a place in radiology. The ability to provide on-site coverage changes the level of care that the facilities can give patients. I don’t think the on-site presence will ever be eliminated.” Some patient-care advocates might agree that relentless technological progress in radiology must be tempered with respect for the on-site physician. Pollard predicts that better distributed reading (through improved access and standardization) is one way to make this a reality. “There is no doubt that in the future, everything will be more easily transported and shared,” Pollard says. “Radiologists will be able to read anywhere they want, and more devices will integrate seamlessly with PACS as well.” Slimmer adds, “We will become more and more wireless, using mobile devices (which our physicians do not use right now) to give preliminary interpretations. Voice recognition will be mandatory, if it is not already, and it will improve. Wireless consultation with the referring physician, and the ability to look at the images and do a mobile consultation with the referring physician, will be right around the corner.” Distributed images will get better (as images always do), but what about reporting the circumstances around these images? A big problem, Geis reports, is that information about the imaging process is needed. “Historically, radiologists provided information about the images, and that is what we’ve been doing for 100 years,” he says. “For radiologists to continue to play an important role, we need to provide information about the whole imaging process. Not only do I interpret the images, but I can tell you about the patient’s radiation dose, assure you that we did the right study, and provide the data needed to follow up and determine how well I’m doing.” Geis continues, “Trying to collect relevant data is the big issue right now. I don’t think most of the big manufacturing companies get it. They have all of their best software engineers working on how to make a prettier 3D image. There is a need for that, but I want them to use their best software designers to tackle the problem of collecting the data.” Greg Thompson is a contributing writer for Radiology Business Journal.
Robert Pollard Nonetheless, the remarkable evolution of PACS technology is slowly but surely making its way back to old-school referrer interaction through distributed-reading solutions in a variety of settings. As prices drop and vendors leverage Web-based architecture, PACS has become a necessary tool for radiology practices seeking to expand service through the distributed-reading model, perhaps including on-site consultation with referring physicians. One example of a personal touch melded with technical savvy can be found at Advanced Medical Imaging Consultants (AMIC) PC, Fort Collins, Colorado. Raym Geis, MD, is part of this group, which covers 22 sites from Casper, Wyoming, to Sidney, Nebraska. AMIC’s 29 fellowship-trained radiologists offer full service for facilities with several hundred beds (and others that are much smaller). It’s a bit like traditional radiology, except that it is distributed over a wider area.
Eric Slimmer, CEO AMIC sends radiologists to contracted sites at least every other week, when biopsies or interventional procedures can be performed. Most studies are read remotely, and on any given day, AMIC has radiologists at up to seven different sites doing subspecialty interpretations. The distributed-reading workflow has improved through the years, and various sites are tweaking it as needed. “In the ideal world, we would be able to read from any type of workstation,” Geis, a veteran of many RSNA lecterns, explains. “We don’t have that situation yet. We read from basically three different PACS. One system is a fairly thin client, but I can’t just go to any computer, log on at an Internet site, have all the programs show up, and read from it. I must download things to that computer, and I must have an IT person come and set up a workstation.” Through interfaces, AMIC’s radiologists are able to read images for all but two of the company’s 22 clients from its own Web-based PACS. Radiologists covering all sites, therefore, must have access to three different workstations. For smaller health-care providers (such as practices and mobile imaging services) that might once have been reluctant to deal with the hassles of a distributed-reading business model, the technological barriers are not so formidable anymore. Robert Pollard, IT director at Decatur, Alabama-based Drs4Drs (www.drs4drs.com), is the technical guru behind a consortium that represents physicians and provides multiple services, including mobile ultrasound. Pollard uses a Web-client PACS to manage images from a central location so that radiologists can read the studies from standard workstations. Typically, image files are uploaded to a centralized PACS over a wireless microwave network at 5MB. “Radiologists from various locations in Georgia or Alabama log on over the Internet, and they read the studies and write the reports,” Pollard says. “We get the reports to the ordering physicians within a 48-hour turnaround time.” Pollard has two different ways to obtain prior studies. Since not all the studies are in the system, the first way is to go back and get documents, scan them, and import them. “We mark them as medium-level stat, which bolds the actual study on the worklist,” Pollard explains. “The radiologists can immediately see that it is a prior study, or that it has a prior study associated with it. They open it, and in the lower left frame they can see all of the standard documents from prior studies. If we already have a study in the system, we add another study for that patient. It is automatic; all the studies show up, and radiologists can go back and look at the prior studies anytime.” Beating Worklist WoesWith 30 years of IT experience, Pollard selected his PACS with an eye toward governing the company’s worklists, which are refreshed constantly. “You log into the PACS, and the worklist is isolated to your specific login,” Pollard says. “We can customize it to show studies originating from specific clinics, or use any criteria you want.”
Raym Geis, MD After the technologist completes the scan, the study and the supporting documentation are uploaded to the PACS by an employee at the central office. Only then does the study become visible to the company’s radiologists as unread. When the radiologists complete their dictation, the study is marked as read. Far more than in days past, PACS has become an affordable option for radiology groups and other health care providers. “It used to be a money pit,” Pollard says. “People would get in, but then manufacturers would ask you to add on more, and that inevitably ran up costs. It used to be six figures, and from my perspective, that is not really affordable.” Radiologists contracted to provide interpretations for Drs4Drs have no specialized workstations and need only standard computers and browsers. The PACS is Web based, and it includes an option for voice recognition, but Pollard currently has opted to use a transcription service instead. Radiologists email the audio files, and Pollard’s team gets the reports to the referring offices. In 2009, the organization interpreted 12,233 ultrasound procedures. The situation at Oklahoma City, Oklahoma-based Eagle Imaging Partners (www.eagleimagingok.com), a seven-radiologist practice, is a bit different, especially when it comes to workstations. Interpreting from 23 sites using nine PACS and ranging from Abilene, Texas, to Tulsa, Oklahoma, the radiologists at Eagle Imaging Partners provide subspecialty coverage and an on-site presence, and all interpretations are done from a standard workstation. Eric Slimmer, CEO at Eagle Imaging Partners, says, “All of our workstations at all of the centers are identical. When our physicians log in, they are able to access all the images that are on their worklist on that same multifunction workstation. We do not have other workstations lined up anymore, and we have been able to consolidate all of those under one worklist.” With sites scattered throughout Oklahoma and Texas, Eagle Imaging Partners locates its physicians in areas close to the hospitals and imaging centers that they serve, making it easier to provide the necessary on-site coverage. “All of our physicians are working on the same network, no matter where they are,” Slimmer explains. “The physician may go to one imaging center one day and one hospital another day, and those are 30 to 45 miles apart. The system and the workflow are the same at each location. All of our clients’ cases come into the same centralized worklist, and the physicians work off that worklist no matter where they are.” With seven physicians in the group, Eagle Imaging Partners contracts with a major teleradiology provider for after-hours coverage, as well as for the use of its technology and workflow expertise. “With its teleradiology software and after-hours coverage, and our on-site presence, we can go to rural facilities and provide 24/7, turnkey workflow that is seamless,” Slimmer says. “Our group takes care of all the daytime studies. We provide the rural United States with high-quality care, and we do that by using image distribution, coupled with our on-site presence and after-hours coverage.” Slimmer searched for, and ultimately found, a system that allowed physicians to filter worklists by subspecialty or privileges/credentials. “If the physician is not properly credentialed, he or she may not be able to see cases from a certain facility,” Slimmer says. “Our group uses the sort function of chronological order. The studies are on the worklist based on when the case arrived. All urgent cases go to the top of the list and are interpreted within 30 minutes. Each physician, when he or she logs into the worklist, will only have cases that he or she reads and is credentialed/privileged for, in order of urgency.” Eagle Imaging Partners eschews archiving images for the facilities that it serves, but the system does keep reports permanently. It usually preserves images for 30 to 60 days, depending on the facility. The Tables TurnIn fact, distributed reading has rendered PACS such a requisite tool, Geis says, that facilities that still do not have a PACS might do well simply to buy their own archives and use the interpreting practice’s PACS. “Institutions pay all this money for a PACS, and nobody uses it, because they use ours,” he says. “Instead of buying a PACS, they should buy their own archive, which is cheap. Save everything in standard format. If you become dissatisfied someday with your distributed-reading provider, you can simply go to another radiologist.” If a facility has its own PACS (or just an archive), AMIC will essentially serve as a backup for just that purpose, and the backup is actually the version from which Geis reads. In the future, he predicts, all images might be stored via cloud computing, allowing capacity to be purchased from third parties only as needed (and reducing capital expenditures). “Not only are you going to have the images archived in the cloud, but people are going to start providing a lot of the image-viewing software as a Web service,” Geis says. “AMIC sees its future not only as radiologists, but as a consolidator and provider of Web services for PACS, RIS, report generation, advanced image processing, the knowledge base, and outcomes data.” At Slimmer’s central facility, autorouting works hand in hand with a centralized worklist. “When they log in, all physicians will see the worklist that they are willing and credentialed to interpret,” he explains. “Those cases immediately begin caching to their systems, and they read from the top of the list. Once a radiologist selects a case, another radiologist cannot select that case. The same case could be on multiple radiologists’ worklists. As soon as it is selected, that image is captured and that radiologist interprets it off the worklist.” Centralized worklists and image-distribution systems, if implemented properly, can dramatically increase productivity. In Slimmer’s case, they have also lessened radiologists’ daily errors and interruptions because the radiologists are no longer working on three or four different systems. “The new system has also given us the ability to consult easily with other partners in the group, since we are all working on the same system,” Slimmer says. “Physicians can pick up the phone and have a look at the same images. The ability to work on the same system, with the same worklist, has really unified our group, even though we are spread out all over the state.” Geis agrees that the filtering mechanisms of sophisticated worklists can add efficiencies to today’s distributed-reading solutions. In addition to accounting for privileges/credentials and subspecialties, filters can be set up based on whether the radiologist is reading for an IDTF or whether the patient is a Medicare enrollee. “If you don’t have the worklist sophistication, you will end up doing things that you don’t get paid for,” Geis says. “Remember that the insurance companies are notorious about changing the rules, and as nearly as I can tell, their goal is not to pay us.” AMIC radiologists currently are unable to read all images from one workstation, and Geis contends that some of the big software manufacturers probably want it that way; that is, they are likely to prefer that radiologists stay on their proprietary systems. There are a number of small companies, he says, that are working on image-viewing software that could interact with disparate archives and multiple lists. The images might be on a large company’s PACS, but small companies are increasingly learning how to interface with all of those. “Half the places we read from have their own PACS; we can plug our system into theirs, and it works robustly,” Geis says. “We can get the information we need. Our smaller system plays well with others, and you have to have that nowadays.” The workstation that Geis uses at home is essentially the same as the one that he has at the hospital. It’s an off-the-shelf computer with inexpensive medical-grade monitors. He says, “When we first started, the monitors cost tens of thousands of dollars for medical grade.” Now, he reports, they can be bought inexpensively online. Beyond TeleradiologySlimmer notes that advocates of pure teleradiology, as opposed to distributed reading, might have been inclined to use teleradiology specifically to avoid having to work on-site. Instead, the Eagle Imaging Partners model involves forming a group that is actually spread out all over the state. This system allows the company to send physicians to different locations, but they still use the centralized worklist. Eagle Imaging Partners contracts with hospitals and provides the radiologists with the workstations that it requires the physicians to use. “Teleradiology certainly has its place, with huge benefits to the facilities for nights and overflow coverage, but it has its limitations,” Slimmer says. “That is exactly why we have structured our operations the way we have in partnering with a teleradiology company to accomplish both tasks. I think the on-site model will always have a place in radiology. The ability to provide on-site coverage changes the level of care that the facilities can give patients. I don’t think the on-site presence will ever be eliminated.” Some patient-care advocates might agree that relentless technological progress in radiology must be tempered with respect for the on-site physician. Pollard predicts that better distributed reading (through improved access and standardization) is one way to make this a reality. “There is no doubt that in the future, everything will be more easily transported and shared,” Pollard says. “Radiologists will be able to read anywhere they want, and more devices will integrate seamlessly with PACS as well.” Slimmer adds, “We will become more and more wireless, using mobile devices (which our physicians do not use right now) to give preliminary interpretations. Voice recognition will be mandatory, if it is not already, and it will improve. Wireless consultation with the referring physician, and the ability to look at the images and do a mobile consultation with the referring physician, will be right around the corner.” Distributed images will get better (as images always do), but what about reporting the circumstances around these images? A big problem, Geis reports, is that information about the imaging process is needed. “Historically, radiologists provided information about the images, and that is what we’ve been doing for 100 years,” he says. “For radiologists to continue to play an important role, we need to provide information about the whole imaging process. Not only do I interpret the images, but I can tell you about the patient’s radiation dose, assure you that we did the right study, and provide the data needed to follow up and determine how well I’m doing.” Geis continues, “Trying to collect relevant data is the big issue right now. I don’t think most of the big manufacturing companies get it. They have all of their best software engineers working on how to make a prettier 3D image. There is a need for that, but I want them to use their best software designers to tackle the problem of collecting the data.” Greg Thompson is a contributing writer for Radiology Business Journal.