Investing to Improve Workflow

Efficient workflow is the Holy Grail of imaging today. To be a competitive player and grow the business, outpatient imaging centers are investing in advanced systems such as RIS-PACS, voice recognition, and digital x-ray and mammography systems to facilitate digital workflow. The investment, implementation and integration of these technologies into daily workflow increases efficiency in many forms. Operations tend to run a lot smoother, and radiologists are able to read more imaging studies from a variety of locales. Most imaging centers that have invested in IT report increased patient throughput and shortened report turn-around times. At the same time, improving workflow increases patient satisfaction and strengthens relationships with referring physicians.

Declining reimbursement is a significant challenge that imaging centers face today. According to Jon Copeland, CEO of Inland Imaging, the Deficit Reduction Act of 2005 is their No. 1 problem because reimbursement has dropped significantly since January. Increasing patient volume is one way to solve the conundrum. However, imaging centers can only achieve this goal by improving workflow, increasing patient throughput, and promising referring physicians rapid report turn-around time.

Headquartered in Spokane, Wash., Inland Imaging is comprised of outpatient diagnostic imaging facilities in the Northwestern United States. More than 60 radiologists affiliated with Inland provide imaging services to 20 hospitals and clinics across Eastern and Western Washington. Its outpatient imaging centers alone perform 265,000 imaging exams annually. “We have to admit, treat, discharge, and get the diagnostic results back all in the same day,” Copeland explains as the main difference between in-patient and outpatient healthcare.

As a result, an outpatient imaging center’s workflow has to be more streamlined and more specialized. “Systems have to be a lot more efficient and a lot more specialized specifically to one purpose,” says Copeland.

To reengineer workflow, Inland Imaging implemented GE Healthcare’s Imagecast RIS and Philips Medical Systems’ iSite PACS, centralized its scheduling and billing and created outbound HL7 interfaces to receive orders electronically from electronic medical record (EMR) systems. A core advantage of PACS is quick, any-time delivery of images to radiologists. Inland Imaging’ radiologists are sub-specialized, says Copeland, and specific exams can be electronically and seamlessly moved throughout the enterprise and delivered to the appropriate doctor to read, in priority by urgency. “This makes the radiologists more efficient and increases job satisfaction,” adds Copeland.

A filmless enterprise also means that films are not delivered around town to referring physicians. “Using the Philips iSite Web Viewer, referring physicians can log on and look at the exams online from their office or home computer,” he says. Improved physician satisfaction helps to ensure their loyalty and continued patient referrals. Inland Imaging has expanded rather quickly since investing in IT systems. “Eight years ago, we were a 12-person radiology group,” says Copeland. “Now we are a 65-person radiology group, and we have not outgrown our systems.”


Digital efficiencies

Diagnostic Imaging Services (DIS) in New Orleans runs three multimodality clinics, an open MRI facility and a dedicated Women’s Center. Nine radiologists cover the five facilities. DIS has experienced many workflow improvements and a surge in patient volume since installing Canon Medical Systems’ digital radiography technology that include the CXDI-22 Sensor Panels and CXDI-50G Portable Sensor Panels. The third clinic is due to upgrade to DR and be completely filmless by December 2007.

The key workflow advantages of having DR are numerous, says Michael St. Germain, director of imaging services. “First, speed and efficiencies are improved dramatically because of eliminating the manual wet processing of films, as well as reducing our repeat rates,” he explains. Prior to DR, it took technologists at DIS an average of two minutes per film to develop the x-ray using a multiloader and wet processing. With DR, images are acquired and appear on the computer screen in three to five seconds. “Our average imaging time for a seven view lumbar spine series went from 20 minutes to five minutes,” says St. Germain. “This improved efficiency allowed us to increase capacity during normal business hours.”

The two centers that utilize DR have seen a 25 percent increase in x-ray volume, St. Germain says. Hours were not augmented to accommodate the patient volume increase, nor were more technologists hired. “At our flagship imaging center, we went from four conventional x-ray rooms to three fully digital x-ray rooms, and were able to reduce the number of FTEs working in the diagnostic x-ray department from five to three,” cites St. Germain. “We are doing more exams with fewer employees because of the efficiency of the equipment.” In addition, report turn-around time has improved at DIS since images acquired from the DR systems are pushed directly to PACS. “Patient wait times were significantly reduced as a result of having a fully digital department. Exam times of all x-ray procedures were reduced by nearly 70 percent,” says St. Germain.


Adding digital mammography

DIS’s Women’s Center recently installed GE Healthcare’s Senographe 2000D full-field digital mammography system (FFDM). St. Germain says the workflow advantages of digital mammography are similar to that of digital x-ray. “By eliminating the wet processing of films, streamlining the time it takes to check mammography images, and reducing repeat rates because of instantaneous image capture, we were able to increase mammography volume by nearly 30 percent per day,” explains St. Germain. “Digital mammography allowed us to reduce the time it took to perform a diagnostic mammogram from 45 minutes to 20 minutes. Screening mammography procedures were reduced from 20 minutes to 10 minutes.”

However, a big challenge hindering the wide-spread utilization of FFDM systems is a lack of system interoperability. Workflow does improve with the utilization of digital mammography once users have jumped over a few integration hurdles. “Digital mammography is probably our most challenging area in workflow,” says Inland Imaging’s Copeland. “All of our imaging exams are read on PACS workstations except for digital mammography. We are encouraging our PACS vendors to work with our digital mammography vendor to integrate the two workstations. The reporting is also a little different. Even though our RIS has a mammography module, the reporting is still challenging.”

What are some core workflow advantages of using digital mammography in an outpatient setting? “The patients like it because it is a quicker service,” says Copeland. “We can do a CAD [computer-aided detection] read of every mammogram, so it is a better quality of interpretation. Also, the radiologists say there is more manipulation that can be done [to increase diagnostic accuracy] with the digital image, compared with film mammograms.”


The benefits of electronic workflow

Radiology & Imaging Specialists of Lakeland, Fla., is a leading radiology provider in Polk County. Currently, the group has more than 20 physicians and five established centers, and is affiliated with three local hospitals. On the outpatient side, RIS performs 150,000 exams annually. According to David Marichal, COO/CIO at Radiology & Imaging Specialists, outpatient volume has grown considerably since 2003.

In 2004, Radiology & Imaging Specialists implemented GE’s Centricity RIS-IC, Imagecast PACS and Centricity Group Management. The workflow benefit of having one vendor for three systems, in addition to a tightly integrated RIS-PACS, is one phone call for service and support, says Marichal. “Even with different applications, if we have a problem with one, and it’s affecting the other, there is no finger pointing,” he explains.

Marichal emphasizes the integration of the radiology information system with the practice management system. In the past, administrators would have to open different applications and windows to schedule a patient. “Now with the tightly integrated system, the schedulers can complete registration and input insurance information without having to open the practice management system,” says Marichal. “All the patient data are captured in the RIS and flow bi-directionally over to the practice management system via HL7.”

Another workflow tool is a paperless, RIS-driven worklist. “Across two counties spanning 40 miles, we have three radiologists reading for five imaging centers on a fiber optic network,” describes Marichal. “The only way we can do this is by making sure the work is distributed evenly. While the RIS-driven worklist delivers all the patient information and clinical history the doctor needs, it also allows the centers to divide and evenly distribute the workload amongst the radiologists. I can have one radiologist sitting in a specific location only reading modality-specific exams acquired at specific locations.”

With RIS-PACS, the practice has increased its imaging volume by 42 percent and added two locations, while reducing its radiologists from six to three and a half. However, IT staff has been added to support all of the systems and the geographically dispersed imaging centers. Another time-saving tool is web access to images for referring physicians, so they do not have to wait for films or CDs, says Marichal. “Electronic workflow is the reason we have grown as much as we have,” he explains. “It also has helped us be more efficient through the entire imaging chain: from scheduling to results.”


Seamless integration

Jim Busch, MD, is CEO of Specialty Networks LLC and a radiologist with Diagnostic Radiology Consultants (DRC), a private practice radiology group in Chattanooga, Tenn. A 10-radiologist practice, DRC reads approximately 200,000 cases annually for 11 practices scattered throughout Tennessee and Georgia. Specialty Networks is a stand-alone application service provider that supports the IT services for the practices for which DRC provides imaging interpretations.

“When I joined DRC three years ago, the practice had six imaging center locations, 11 radiologists, and we were all working about 10-hour days,” explains Busch. “There were three PACS, three transcription systems, multistate commutes and we were down to a 24-hour report turnaround time.” Wanting to improve efficiencies, Specialty Networks standardized the user interface utilized across the DRC enterprise, installing an integrated system from Siemens Medical Solutions that included RIS-PACS, digital dictation (syngo Voice) and an enterprise practice management system, NextGen Healthcare Information Systems.

The integrated, enterprise-wide system centralizes patient information and image interpretation acquired from multiple sites into one location for the DRC radiologists. Variations in workload now pose less of a workflow problem. Even though patient volume varies daily at each imaging facility, radiologists read off the RIS’s centralized worklist and work is steady. DRC is down one radiologist, but its imaging volume still increased 15 percent. Busch narrows the workflow improvements down to about a 27 percent workflow increase per each radiologist.

Riverwoods Advanced Diagnostic Imaging Center is a multimodality outpatient center in Provo, Utah, that utilizes NovaRad Corp.’s NovaRIS and NovaPACS. The two systems are tightly integrated. Wendell Gibby, MD, a neuroradiologist and president of Riverwoods, reads images acquired from the center, as well as exams acquired at a variety of locations via AlphaRad Corp., a virtual group of radiologists. AlphaRad provides healthcare facilities with a NovaPACS router that automatically routes images to a central facility and disperses them to the appropriately trained radiologist. In turn, the radiologists have software and connectivity capacities to read the images from anywhere they have an internet connection. Gibby says none of this would be possible without a tightly integrated RIS-PACS.

The RIS-PACS helps make personnel more efficient. “You do not want to have redundancies in your system,” says Gibby. “For example, you should not have to enter patient information two or three times. If you have integrated RIS-PACS, the data are gathered and kept electronically. They are not lost and are available for everybody in your system.”

An enterprise-based system also helps to manage your business, says Gibby. “By analyzing the [RIS] data, you can see at a glance where the load is on your schedule, and you can see that across your enterprise,” he explains. “You may have one MRI facility that is busier than the other. In that case, you can schedule more patients at the location that is less busy.”


Can you hear me now?

Riverwoods and AlphaRad Corp.’s radiologists started using Nuance’s Dragon NaturallySpeaking voice recognition system about a year ago. “In doing so, we have virtually eliminated all transcription costs, approximately $30,000 a year,” says Gibby. Transcription is done electronically by the radiologists and the information goes to the RIS, which makes it available on the intranet for the technologists to access. “At any given time, a technologist who is not busy can pick up his or her headphones and correct our reports,” says Gibby. “We have been able to use the technology to leverage personnel.

“It also has made the radiologists vastly more efficient,” he continues. “Our turn-around time on reports with our old system was 30 hours. Our report turn-around time now [with digital dictation] is less than four hours.” In addition to improving workflow, Gibby says the efficiencies gain them a market lever with referring physicians. “If a physician can send a patient to one of our imaging centers that will quickly respond to them and get the data back to them immediately, it will thus save the referring physician time,” he says. “This goes back to the essential issue of doing more with less.”

Inland Imaging radiologists are using MedQuist’s SpeechQ for Radiology voice recognition and speech reporting application. Since last May, Copeland says Inland Imaging has reduced its number of transcriptionists from 25 to eight. “Voice recognition has helped reduce our transcription costs and we also have improved our turn-around time — from the time it takes to dictate to the time we can deliver that report to the referring physicians,” says Copeland. Inland Imaging’s report turn-around time has been reduced from 54 hours to just a few hours. Same-day delivery of reports is an essential workflow improvement for outpatient imaging centers.


Boosting patient satisfaction

Despite the issues imaging centers must confront to be successful and growing businesses, new and improved technologies such as RIS-PACS, digital imaging and voice recognition help mitigate the challenges. Investing in these applications have many benefits for an outpatient imaging center, particularly improving workflow, increasing patient throughput and speeding up report turn-around time. But at the end of the day, both inpatient and outpatient healthcare settings say their No. 1 priority is to offer patients the best care possible.

Diagnostic Radiology Consultants’ ‘Specialty Network Imaging Alliance’ is an agreement that has been formed between DRC and each healthcare facility on the network so that images and patient reports can be shared and viewed by radiologists in various locations. “Radiologists can see the entire enterprise; however each one of the facilities can only see its own patient information.” This directly impacts patient care. A woman who undergoes a breast MRI and mammogram at one DRC healthcare center can have a breast biopsy performed on the same day at another affiliated location, and the radiologists can seamlessly and securely share her images and report results.

Diagnostic Imaging Services’ St. Germain says that having fully digital x-ray and mammography departments has allowed them to decrease the time it takes to perform an exam. “Because we specialize in outpatient imaging, it is important for us to perform imaging procedures in a timely manner,” says St. Germain. “Our patients have come to expect that. 

“If patients are happy with the services we provide, they tell their physicians, which we believe leads to increased referrals.”