Choosing Web-based PACS

The power and reach of the web is empowering the health imaging world — completing the loop from radiology to specialist and back to the referring physician and even the patient. Healthcare providers utilizing web-based PACS to distribute digital images enterprise-wide and remotely are further meeting the needs of their radiologists (literally). Clinicians and referring physicians are reaping the benefits, too. While these physicians can access patient images in a film-based environment, albeit cumbersome, the web offers timelier and more convenient access to electronic images from a PC located anywhere inside or outside the hospital.

Web-based PACS reengineers workflow and redefines the boundaries of medical care and treatment. Take for example, Inland Imaging. Based in Spokane, Wash., this medical imaging provider is comprised of 55 radiologists, five vascular surgeons and 350 employees who provide imaging services to 14 hospitals and clinics spread throughout Washington and northern Idaho.

Wanting to electronically store and distribute digitally-acquired, diagnostic images to radiologists, surgeons, and other physicians across 14 hospitals, and to provide secure access from physician offices and from home, the organization installed Phillips Medical Systems’ iSite Enterprise PACS (formerly Stentor iSite PACS). The PACS has virtually connected all the hospitals together.

“A patient can show up with a cracked spine at a hospital located 90 miles away in Pullman and the physicians there may be unsure whether they want to put the patient in a helicopter and fly him or her to Spokane for neurosurgery,” says Jon Copeland, CIO of Inland. “What they can do is call Spokane and ask the doctors there to take a look at the patient’s images since they are instantly available via PACS. The doctors also can call a neurosurgeon at home, who can log in from a home system using the web viewer to look at the spine and help make a judgment call. Without a shared, single image environment, this would be impossible.”

Leveraging the web

Capital Health System is another organization that chose web-based PACS. This 589-bed dual-campus, acute-care teaching hospital in Trenton, N.J., installed Dynamic Imaging’s IntegradWeb PACS that provides the organization with complete functionality and authorized accessibility to the PACS from PCs in various locations.

Why was web-based PACS “the” choice? “Films were being lost,” says Yaakov Applbaum, MD, Capital’s chairman of radiology. “My favorite stories were those of the trauma surgeons where hip films would be done in the trauma bay and the patient would be moved to CT. By the time the patient was at CT, the hip films were lost. Internally we needed PACS to survive. Once we decided to get a PACS, we wanted to be able to compete favorably with other institutions in the area and make it easier for referring physicians to see patient images. To facilitate that, we went with a web-based system that has 100 percent functionality outside the hospital equal to inside the hospital.”

“Anything that a radiologist can do on the PACS at the hospital, the radiologist can do remotely,” says Applbaum. “We wanted the physicians to be able to utilize the system within and outside the hospital without knowing the difference. Another thing we were looking for was simplicity of use. We did not want a system that required a CD to download software. We simply wanted the physician to be able to log into a website, and with a username and password, retrieve his or her patient information.”

Mercy Medical Center in Baltimore, Md., transitioned its radiology services onto a web-based environment after replacing their existing PACS with Amicas’ Vision Series web-based system. “For a long time I think that people viewed PACS as a tool for the radiologist or for their department,” says Jim Stalder, CIO of Mercy. “While that is certainly still the case, the folks who refer patients in for [medical imaging] exams also need more access to this information. Often times, depending on the specialty, the referring physician will want the film as well. It’s a burden for the patient, in addition to the doctor, to manage and carry around film.”

In addition to improving relations with its referral base, Mercy has experienced benefits in the emergency department due to some innate features of the web-based system. “Amicas has a real-time worklist,” explains John Goldback, Mercy’s system analyst. “When the ER doctor places an order for an imaging exam, a scheduled status shows up. As soon as the digital x-rays are acquired, they are sent to PACS. The system automatically updates its status to unread. As the doctor reads the image, its status changes to final. If a STAT read is needed in the ER, they can see the status change by color on the screen.”

Workflow has improved significantly with the web-based system due to the increased ease of access to information for all clinicians. “The ability to provide better, faster access to patient images is going to improve the quality of care that our patients receive,” says Stalder.


Better quality of care

“Every PACS has made workflow in a hospital better,” says Capital’s Applbaum. “What the web-based system facilitates is bringing in physicians outside the hospital, whether they are taking care of inpatients or outpatients, so they can stay right on top of their patients.

“In terms of better patient service [with web-based PACS], there is no comparison,” continues Applbaum. “If an orthopedist or pediatrician sends a child in for a [study], that doctor has access to the images within seconds of them being taken. If physicians are looking at chest x-rays of children and they see the pneumonia or they see a fracture, they are able to treat the patient that much more quickly and efficiently. Of course that has impact on patient care. It is completely a one way street in terms of increasing the quality of patient care.”

Inland’s Copeland says quality has made the PACS project all the more rewarding. “This has been probably the most rewarding project of my life because we are actually improving patient care so dramatically and getting hospitals to cooperate in ways that have been unheard of in the past,” he says. “Patients benefit enormously because they do not always [receive treatment at] the same place. The web viewer is what really has broken down the barriers because it is just so effective.”

Alton Memorial Hospital in southwestern Illinois implemented ScImage’s Enterprise PACS, PICOMEnterprise. Installing the system in phases, the project began with cardiac catheterization imaging, echocardiography reporting and EKG management for cardiology services. Next, all modalities in the hospital’s medical imaging department were integrated with the existing radiology information system, providing web image and information distribution and archiving. Finally, the facility moved to a nearly filmless and paperless digital operation and now provides electronic access to referring physicians.

In terms of benefits, Jack Wepler, Alton’s manager of medical imaging services, says there have been film savings but “that is not the feature of this,” he says. “The feature of this is getting the images onto the network for the physicians to see right after the patient is done being imaged.”

“If a patient goes to an orthopedist’s office, that doctor can connect to our PACS via a VPN client and actually see the images from our facility,” continues Wepler. “We have an orthopedic surgeon who accesses PICOM online when he is on call. He has already looked at the images before he sees the patient because he does it from home. From an emergency room department standpoint, as soon as an image is taken it can be looked at within seconds. You can’t beat that in an emergency situation.”


Images & reports

No matter which PACS implementation path is chosen, healthcare providers hit a cross-roads and decisions must be made on how efficiently and quickly reports are integrated with patient images. For some, this may boil down to implementing an advanced dictation system. For Cottage Health System and the Sansum-Santa Barbara Medical Foundation Clinic in California, it entailed the use of voice clip technology.

“Both enterprises have PACS and both of those PACS servers and networks are connected at high speed to each other,” says Michael Trambert, MD, lead radiologist for PACS reengineering at Cottage Health and at the Santa Barbara Medical Clinic. “We basically have four geographic reading rooms and we can read any study from either enterprise, since the radiologists work 100 percent paperless. The PACS also uses voice clips so we have immediate results available on the web for referring physicians as soon as the exam is read by the radiologist.”

Trambert emphasizes that is important for healthcare providers to analyze how quickly radiology reports accompany digitally acquired and saved images, especially in light of advanced web-based PACS technology. “However you want to do it, whether it is with a voice clip and or the actual text report via an integrated voice recognition system, in my opinion results must be provided with the images as soon as the radiologist reads the study. Not only do you need the radiology images out there, you need the results.”

Cottage Health and Santa Barbara Medical Clinic commenced web-based services in 1999, deploying DR Systems RIS/PACS. “It liberated the referring doctors who used to have to call or come down to the department for results, and/or have their front office request film and printed or faxed reports from the radiology front office,” explains Trambert. “We have conducted surveys of our referring doctors and some specialists are saving an hour a day from the image and results availability.”

How does it improve patient care? “At the Sansum Clinic, in addition to having two buildings two miles apart with 180 physicians, the SB Medical Clinic has five satellite facilities anywhere from a mile to 40 miles away,” says Trambert. “Those sites are connected and have CR readers. Patients will arrive at these urgent care centers, have a chest x-ray, and the radiologists will read that study within several minutes and the result — via voice clip — is instantaneously available to the remote practitioner, usually before the practitioner has even seen the patient.”


Advice from the trenches

When it comes to selecting and successfully implementing a web-based PACS, there is no one path on which to travel. But some who have made the trip have some tips to make the entire journey a little less arduous.

Capital’s Applbaum recommends testing web-based PACS in both onsite and offsite settings before it is deployed. “First, make sure the system works in the hospital,” he explains. “You have to do site visits. Sit down and see how intuitive the system is, how quickly the images come up, how easy it is to use different features and how easy it is to compare prior studies.”

Secondly, test the system remotely. “We did a bake off where we asked the vendors if a number of doctors could use the system from home for a period of two weeks,” says Applbaum. 

Trambert urges PACS buyers to get multiple parties involved since web-based is a complex purchase and a complex workflow reengineering project. “It’s not just putting images onto servers and networks and archiving. It involves numerous task workflow assessments, understanding and changing, reengineering and simplifying.”

Who should be involved? The CIO, a radiology administrator and a radiologist who “understand how computers work and how the radiology department functions…and how it can function better,” says Trambert. 

Inland’s Copeland stresses scalability. “Buy a product at the beginning that can scale to 300,000, 400,000, and 500,000 exams a year because you never know what is going to happen,” says Copeland. “Suddenly one multi-specialty clinic merges with another one. Or one imaging company merges with another one and the whole infrastructure collapses because it is not designed for large volumes and high complexities. Replacing a system costs a whole lot more than paying a little bit more upfront for a system you will not outgrow.”

And what should you ask potential vendors? “Can the system handle multiple organizations in a single database and can it scale to half a million exams a year with a guaranteed response time and uptime,” says Copeland.