The Logistics of PACS for the Practice
Now that radiology practices have discovered the benefits of PACS, they are investing in the IT support to leverage the technology for its maximum potential At one point during his enrollment in business school, Randy Hicks, MD, MBA was assigned a paper detailing how he might go about reorganizing his Flint, Mich, radiology group to make it a more efficient, prosperous practice. Very quickly, Hicks concluded that Regional Medical Imaging (RMI) needed to embrace a distributed model for reading so that the practice could provide subspecialty interpretation to multiple clients without having radiologists present at every RMI site. This, he envisioned, could best be accomplished by outfitting his practice with a PACS. Having to perform this academic exercise inspired Hicks to explore the possibility of actually acquiring such technology for RMI. Unfortunately, at the time (about 10 years ago), PACS was not a particularly practical investment at the practice level. These were systems intended for hospital applications, to judge by their price tags alone. Still, Hicks knew that one day PACS would migrate from the hospital to the practice. For his group of nine radiologists, that day arrived about three years ago. Things have not been the same since. “We have greatly benefited from having our own PACS, and so have the customers we serve,” he says. IT Support RMI is one of a growing number of radiology practices around the nation acquiring PACS. A driver of this, just as Hicks noted in his own situation, is the need to provide distributed image reading. There can be no question, though, that another equally important driver is the attractiveness of the costs associated with PACS acquisition and, especially, ownership: in a well-run, medium-sized practice, PACS typically accounts for a mere 1% to 3% of total practice expenses. IT-department costs make up a significant share of that outlay, according to James List, director of informatics and advanced applications support at Consulting Radiologists Ltd in Minneapolis. The organization of about 70 radiologists covers 30 hospitals in Minnesota and Wisconsin and provides services to 53 other clients (and those services include after-hours, weekend, and subspecialty reading). “In our group, we have a team of seven IT people who all contribute to support our PACS operations,” he says. There is, of course, a PACS administrator on this team, but Consulting Radiologists takes an interesting approach by designating eight FTEs to act as radiologist service specialists. Among their assigned duties is the chore of checking PACS images received from remote locations to make sure that all sequences have arrived safely and that the images and associated clinical data are accurate. “This way, when the radiologist selects that image for viewing, we have assurance that all information needed is, in fact, there,” List explains. “We are preventing the situation wherein the radiologist makes it halfway through the read and only then discovers there is a sequence missing. That sort of gaffe is a time waster. We want our radiologists to be as productive as possible, which is why PACS is here in the first place.” Other members of the IT team at Consulting Radiologists function as teleradiology coordinators. One of their tasks involves helping readers start their days by hitting the ground running. “In the early morning hours, the teleradiology coordinators prepopulate the PACS workstations,” List says. “This way, as soon as the radiologist logs into the workstation, the data are already resident locally. This spares the radiologist from having to experience any latency during data transfer. The radiologist is thus able to work at an optimal pace.” Teleradiology coordinators also free radiologists from having to attend to much of the daily minutiae that normally act as a drag on productivity. “For example,” List says, “if the radiologist needs to consult with the ordering physician, one of our coordinators makes the phone call and puts the two parties together. The radiologist does not spend minutes on hold while the ordering physician is located.” List credits a creative radiologist with developing an enterprise worklist that denotes who is reading which study. “One of our radiologists developed a homegrown product because he wanted to eliminate the dependence on faxing and didn’t want multiple radiologists querying the same data (a waste of bandwidth). We want radiologists who submit a query to know when someone else has already subscribed to it. This allows our radiologists to go quickly to an available unsubscribed study that they can start working on,” List says. Moving efficiently from study to study is essential at Consulting Radiologists: Images from approximately 450 separate scanners, from CR, DR, and CT to digital mammography, PET, 3T MRI, and ultrasound, funnel into the practice’s PACS, resulting in the workstation display of more than a million examinations per year. Consulting Radiologists began using PACS in 2007 with the purchase of a system. Swift Return on Investment Another expense element is the PACS itself. Alta Vista Radiology, a Paradise Valley, Ariz, coverage service that has 15 radiologists providing interpretations for 80 hospitals and 10 imaging centers, spent more than a few dollars on its PACS in 2006, but elected to pay for the purchase up front, with funds drawn in full from the practice’s treasury. “This was must-have technology for us, so an outright, no-financing purchase made the most sense in our scenario,” Alta Vista founder and principal Robert Ortega, MD, recalls. “We felt, with cash, that we would be able to procure a better deal and avoid having interest payments raise the total purchase price.” Other practices prefer acquiring PACS through financing, as did Consulting Radiologists. “Outright purchase can be disadvantageous,” List says, in justifying the decision to lease. “When a practice makes a large purchase and expenses it, the current shareholders bear the cost of that purchase. Conversely, leasing and other alternative financing arrangements allow the impact of the financial investment to be spread across time and across multiple shareholders.” Regardless of how one pays for PACS, the technology offers a potentially swift return on investment (ROI). “We broke even on our PACS in about a year because the consolidation of personnel and functions it permitted reduced our overhead and made us so much more efficient,” Hicks says. His practice is, in Michigan, a preeminent provider of breast diagnostics, with total imaging volumes of 100,000 to 150,000 studies annually from modalities that include CT, MRI, PET/CT, nuclear medicine, color Doppler ultrasound, bone densitometry, and radiography. “We were able, with PACS, to change the pay scale of our radiologists, compensating them based on their productivity instead of having them on salary. This change has resulted in our radiologists becoming more productive. They understand that they now have complete control over how much or how little they make. They also understand that PACS gives them the tools they need to make every minute count. For the practice as a whole, this change in compensation strategy means we can now better control our costs,” Hicks says. Profit-center Potential Many practices are accelerating PACS ROI by uncovering and developing opportunities to transform their systems from cost centers to profit centers. “The way medicine is being practiced is being changed by the digitization of radiology; as radiologists, this digitization has allowed us to get closer to our referring-physician customers,” Hicks says. “For example, we’re now in the offices of our referring physicians and linking them to us with [our PACS]. It allows them to tie their radiography equipment right to our PACS and send their images into our centers. It also allows, for example, a surgeon in the operating room to look at my images instantaneously and discuss them with me in real time.” Pete Higgins is the CIO for Radiology Affiliates Imaging in Hamilton Township, NJ. PACS was implemented for his group in 2004 following acquisition of a system. The technology today permits full-service coverage by the practice’s 17 (soon to be 20) radiologists at three hospitals, along with covering a shorter list of services at a women’s health center. Radiology Affiliates Imaging offers a subscription service that opens up the PACS to providers using digital imaging modalities who need a place to archive images. “We offer this via the Internet under a private label,” Higgins says. “If you would like to store your images on our PACS and avoid the expense or trouble of acquiring your own in-house storage solution, we will assign to you a PACS Web site that is yours alone and that your referring physicians can access. This is a Web site that we develop and are responsible for keeping secure. We offer this service because it helps us defray the cost of our own PACS development. As a result, we expect, at some point, to turn the corner on this, and PACS will become a profit center.” Naturally, there are certain logistical challenges associated with the provision of a service such as this. “Let us say that you are a small hospital and are inquiring about our services,” Higgins proposes. “One of the first things we will do is identify the modalities you have installed and develop a good sense of what your five-year plan is for acquiring additional modalities.” A leased line of the appropriate size is then added to the network. Higgins adds, “We will provide all the connectivity, integration, and project management required.” Later, he notes, Radiology Affiliates Imaging works with the client’s IT department to make sure there is sufficient wiring, disaster recovery, battery backup, emergency power, and (for the reading areas) sufficient heating/cooling and ventilation. He continues, “When your images arrive at our PACS, we will store them and give you a site code so that you can access them. Your images will be segmented and kept separate from those of our other customers. We also will provide all the on-site and off-site backups for retention. We will help you satisfy all HIPAA requirements and your state’s record-retention laws. In support of all this, we have grown from a simple, server-attached storage environment to, now, a storage array with a fiber-channel backload that provides three gigabytes of full-duplex bandwidth to service 45 drives simultaneously.” Consulting Radiologists likewise offers archiving to other providers, but approaches the service somewhat differently. “We start by installing for our clients, at their locations, one or more store-and-forward devices,” List says. “These are devices that serve as a destination for image data acquired within that hospital. The device serves as a local archive that can be easily queried. The device also aids our WAN application in that we can use it to compress data to send to one of our radiologists at any of our multiple locations across the country for after-hours or weekend reads.” List clarifies that the store-and-forward devices are undergirded by a 10-terabyte blade server farm with a replicated storage area network (SAN) array at a local data center in nearby St Paul. He adds, “We have a digital tape archive for our own use and as a disaster-recovery element for all of our application service provider clients. We also use software virtual private network connectivity over the Internet for many of them and monitor those connections by using a very cost-effective network tool called Jumpnode. If a connection fails, the tool will notify us of that event immediately and will help us quickly determine what went wrong.” Strategic Leveraging Clearly, PACS capabilities can be leveraged to offset costs. Some practices, however, believe that it is more useful to leverage PACS capabilities in order to meet bigger-picture objectives. Brian Hannon is director of IT for Salem Radiology, Salem, NH, a seven-radiologist practice that bills itself as a community based group (it covers a hospital, a privately owned MRI center, and one outpatient imaging center, all in the same locality). He says, “I love the concept of PACS, not as a revenue center, but as a strategic center. We use our PACS to bring in outside-read business, rather than to provide a storage service for other practices or institutions. We have probably a dozen sites—rehab hospitals, general practitioners, neurosurgeons, and orthopedists—that currently send into our PACS for reads.” Salem Radiology archives the studies for these clients for quality control purposes, but not as an application service provider. List foresees a day when even the smallest hospitals will be able to afford their own internal PACS. Until then, groups like his are only too happy to offer their PACS services. “We work with a number of 20-bed to 80-bed hospitals,” he says. “They are large enough to need PACS, but not large enough to be able to jump into it easily. There are many technical challenges that cloud a smaller institution’s understanding of what it needs and does not need in regard to, for instance, storage.” List continues, “Assume, as an illustration, that one of these small hospitals wishes to retain three or four years’ worth of images on spinning disks. A problem is that the cost of storage is continuing to fall. As such, it makes no sense for this institution to purchase, in year one, four years of storage if, by year two, it would be able to deploy those latter years at a cheaper price than what it paid for it in year one. Our service is especially attractive to the smaller hospital because we help its decision makers work through this and other issues.” An interesting issue that occasionally surfaces both for customers and PACS-owning practices is the effect that the technology can have on the thought processes surrounding new modality acquisitions and the adoption of new imaging techniques. To be blunt, PACS can dampen enthusiasm for bringing aboard imaging systems and processes. “This can happen because the planning that’s involved is often very complex,” Hannon says. “The complexity frightens off some people. They would rather not have to deal with it. This is unfortunate, because PACS technology should never be a barrier to taking advantage of new imaging modalities or techniques.” Hannon also reports seeing instances where PACS objectives take priority over the manner in which a modality is used. “A perfect example is 64-slice CT,” he says. “One hospital I’m acquainted with does not want to work with 0.0625-mm slices because they feel it uses up too much space on their PACS and slows things down too much. If you do not use the 0.0625-mm slice thickness, however, and you insist, instead, on using 0.25-mm slices, then you are not truly employing 64-slice CT. It is just eight-slice CT, made a little faster.” That hospital, according to Hannon, could recapture speed by increasing storage. “It would require little more than a scalable SAN solution,” he says. That is the beauty of PACS in the practice. A radiology group like Hannon’s could come alongside an imaging producer or user and offer real help of the sort that might not have been possible in the time before the migration of PACS from hospital to practice had commenced. Additional Reading - Role of the Practice CIO