PACS Customized & Configured for the Imaging Center and Small Hospital

The North American PACS market is growing at a good clip of about 11 percent a year through 2008 from a 2001 base of about $500 million, market analysis firm Frost & Sullivan projects. Much of that growth is occurring in small and medium-size hospitals and robust imaging centers that are ready to take advantage of a more mature market with more options. Smaller facilities have much to gain from installing PACS but their limited resources require thorough evaluation and careful investment. Making a wrong decision is clearly not an option. Here's how a variety of facilities have added PACS with great success.

Going completely paperless in a rural environment

Lea Regional Medical Center is a 250-bed full-service hos≠pital in rural Hobbs, N.M. A move to PACS began because the facility could not afford to lose its one and only radiologist. They'd gone through nine locum tenens radiologists over a year-and-a-half period and did not want to go through the process of searching for a new radiologist. The ability to read images remotely was essential to retaining their radiologist.

After deciding to implement a PACS, the facility began seeking the right vendor. They wanted to go completely paperless, says Larry Hannah, director of IT. "None of the off-the-shelf, large companies seemed to want to talk to us." Plus, their users were still generating paper. "In our journey, we found that small companies talked at our level," Hannah says. "They were willing to at least entertain the idea that there were features they could work on."

NovaPACS' Notes feature was the function that clinched Lea Regional's decision, says Christina Seed, director of medical imaging. It offers the radiologist the ability to pull up images on screen and write a note on screen. That answered that part of the paperless drive, she says. The technologist can type from five to 5,000 lines in a popup box and then send it to the radiologist so he doesn't have to search for the patient's history or wait for a piece of paper to make its way to him. That popup box can be made available to referring physicians as well.

Novarad also developed their own software—Nova≠scan—that allows the user to scan in any paper that previously would have been filed, essentially allowing for digital archiving of all associated forms and documents. With the elimination of film, practitioners were still pulling a film jacket for orders and forms. "That didn't make a lot of sense," says Seed. "With the ability to scan, we're only pulling film jackets so we can do comparison reads. If [the] Medical Records [department] needs a document retrieved, we can print up a scanned copy."

"The Novascan function that couples with their own software and the Notes function are the two things that really helped us get off the ground as far as being paperless," says Hannah. "Larger companies said they could do that but Novarad already had it in place and is refining it daily."

Lea Regional is one of 51 facilities owned by Triad Hospitals Inc. The organization is slowly moving their radiology departments into PACS, says Hannah. At the corporate level, no one had yet used a smaller vendor. "They were interested in seeing how well that worked," he says. "They let us do our own research and come up with our own answer and they supported our choice. They are looking at us to see how well this will work out and compare our costs with other facilities."

After their first few months of working with the system, Seed and Hannah remain impressed. "Since this is our first experience with the digital world and PACS, we have weekly, if not daily, communication with Novarad," says Hannah. They're continually listening and soliciting comments for new features, he adds. He's already seen some of his suggestions appear in the product. "The flexibility is there and the willingness to evolve the product in a timely manner. As we're learning what we need and what we want they're learning how to provide that for us and meet our needs."

Centralization in private practice

It's not only rural facilities limited to one radiologist that can benefit from centralization. St. Paul Radiology is a large, private group of more than 80 radiologists in Minnesota. The group has six of its own imaging centers and provides radiology services to more than 10 hospitals. Back in 1996, they decided to centralize the night call. With a PACS, rather than having five or six radiologists on call, they could have one or two radiologists in a central location utilizing their own network and PACS workstations. After a year of evaluating products and vendors, they installed the Merge eMed PACS in 1997.

Radiologists looked at all studies done from 10 p.m. to 7 a.m. in one centralized location. They quickly learned that that was a good way to work more efficiently, says Ross T. Sutton, MD, and so expanded into all parts of the practice. "Now, we read everything we can off our PACS diagnostic workstations."

Five years after implementing the system, the practice found they'd saved money due to the increased efficiency. That increased efficiency also reduced their need for more radiologists—their biggest expense. Another benefit was the ability to do more accurate interpretations. The PACS diagnostic workstations allow radiologists to enhance, change angles, measure more easily, and more.
 
Sutton says one of the most important aspects of the PACS is the vendor's open architecture. "Lots of companies will say they have an open architecture but actually still have proprietary servers," he says. Because St. Paul works with several competing hospital groups, they had the unique position of needing to interface with multiple modality vendors and multiple PACS vendors. "To do a good job, we need to interface with each of their servers and that has been a challenge."

Sutton also recommends selecting a PACS vendor that is committed to being a good business partner and is responsive to your facility's needs. Bear in mind that a product demonstration has little to do with your day-to-day work, he says. "You need to sit down at a diagnostic workstation for two to three hours and, if possible, have them do the demo at your own institution where they actually hook up into your system." Work the mouse and workstation yourself; don't let the trainer do it. "Try two or three different settings. Go through the normal steps of a day. You'll find the little bugs and quirks. Don't just rely on the demo with somebody else's hand on the mouse."

Smaller provider helps practice customize

Mary Sims is the administrator for Edward L. Brown, MD, and his business partner Craig T. Folse, MD, who formed the Brown-Folse Radiology Group in Rayville, La., to provide radiology coverage to 12 rural hospitals. She attended the PACS 2004 meeting in March 2004 "with no idea what a PACS was and what it entailed," but she knew the doctors wanted a system that could be configured to fit any of those rural hospitals' architecture.

The bigger companies said, 'like it or leave it,' she says. BRIT Systems, however, impressed Sims and the doctors because "we really liked their ability to conform to what we needed. We were really blown away with how well they were able to configure the system to fit our needs."

Before installing PACS, the doctors were reading films by traveling from site to site. One would read and one would travel to provide coverage. Transporting films back and forth meant that an imaging report might be available in 48 hours or up to a week. Now, 12 facilities are on the PACS and two mobile nursing home facilities digitize films onto the group's server. The radiologist can read images from any location. "This way, the film is taken and by the time the patient is dressed and back in the doctor's office, they have a report," says Sims.

This process has been a great service to rural hospitals that didn't have radiology coverage, especially in their emergency departments. "The physicians may or may not have experience in radiology," she explains, so they're treating from guesstimations. "This way they have a specialist's opinion. Just today, a patient's neck was broken and subluxed but until we read the exam, the patient wasn't even in a neck collar."

With PACS, the radiologists can look at films in the way they prefer. They can mark a film critical—highlighting the image so it "jumps out." Images are read as they come in unless they are marked as critical. An autofax feature attaches the radiologist's report to the order so it's right there for the next care provider.

Hurricane Katrina gave the practice the opportunity to test the BRIT PACS' disaster recovery. "When the power went down, we were down," says Sims. The radiologists were able to go on laptops and go onto servers directly and read their films without anything going to the main server. The small, rural facilities still got reports but they had to go back to typing reports. "It could have been a disaster," she says, "but BRIT never missed a beat. Everything kept running.

The server was not damaged and we moved it to Dallas to a secure facility with a lot of redundancy."

Implementing intuitive, easy access PACS

Kenneth Cohen, MD, co-director of radiology at Warren Hospital in Phillipsburg, N.J., has been using StarPACS from SmartPACS, now called INFINITT, for more than four years. He didn't really know what he was looking for when he began his search for a PACS, but opted for StarPACS because all images are kept on live memory. "From day one, I knew that everything would always be available to me with no limitations. Nobody had to have a jukebox or prefetching protocols," he says. "Everything is always available to me instantly, whether it be a study I took today or from a library four years ago. That really attracted me to them."

Cohen's initial impression was a system that was very intuitive and user-friendly and that has proven to be the case over the years. "It's extremely stable with much redundancy built into it. I didn't have fears of losing images."

The first modality Cohen hooked up to the PACS was CT. "It was so intuitive that we were able to start using it the first day we had it," he says. The facility even decided to stop printing films on day one. Shortly afterwards, they hooked other modalities up to the PACS. The system allowed radiologists to develop their comfort level over time. That included experimenting with different methods, says Cohen. "It's very easy to switch from one way of reading to another. There wasn't a difficult learning curve."

Cohen himself has noticed increased accuracy and efficiency in his own reading by being able to scroll through images and follow different structures from top to bottom. He can manipulate images to improve his readings.

The hospital uses the PACS for teleradiology and rolled it out to referring physicians who can sign on and view images from any location. Physicians in different locations can conference with each other as they discuss and view the images simultaneously. Physicians also can import images to the auditorium for conferences.