Ask any health–IT executive for a synonym for change, and a probable response is merger/acquisition. The rapid pace of consolidation among physician practices, individual hospitals, hospital enterprises, and hospital-chain corporations has generated an unprecedented level of organizational, operational, and technological change. From a radiology perspective, what happens to the installed base of legacy imaging-informatics systems of merging entities? What are the strategies and decisions that have an impact on imaging informatics? From an operational perspective, the best and most enduring strategy, in Geisinger Health System’s experience, is to install the same RIS, PACS, and related software across an enterprise and to consolidate long-term archives. Over the long term, Geisinger Health System has found this to be as cost effective as (and potentially more cost effective than) keeping an acquired hospital’s legacy systems. In addition to its hospitals, Geisinger Health System has nearly 60 community-practice sites serving 44 Pennsylvania counties. In the past 2.5 years, the organization has added three Pennsylvania hospitals (Geisinger-Community Medical Center of Scranton, Geisinger-Shamokin Area Community Hospital in Coal Township, and Geisinger-Bloomsburg Hospital) through mergers/acquisitions. Geisinger Health System is awaiting approval from the Pennsylvania attorney general to add Lewistown Hospital through merger/acquisition. On September 9, Geisinger Health System and Holy Spirit Health System (Camp Hill, Pennsylvania) announced the signing of a letter of intent to explore ways that the health-care organizations can work together. Holy Spirit Health System includes the 315-bed Holy Spirit Hospital (Camp Hill). John A. Cardella, MD, associate CMO and systemwide chair of radiology, explains, “Our IT strategy is to absorb any new health-care facility that joins our health system by providing it with IT systems that it is not likely to be able to afford on its own. We replace all IT systems with what has been deployed at Geisinger Health System. This includes the RIS, PACS, speech-recognition/dictation systems, the archives, and the EHR—everything.” The capital investment and other resources allocated to implementing these changes are expensive, but the up-front financial outlay is more cost effective, in the long run, than allowing an acquired facility to continue to use the systems that it has in place. Cardella explains, “With disparate IT systems, a merged enterprise can turn out to be a Tower of Babel, so to speak.” He adds, “To deal with the challenges of integration and transparent interoperability of disparate legacy systems, it is necessary to invest a lot of time integrating systems, building interfaces, and writing custom code (to get disparate systems that are not designed to communicate with each other to do so). Even after investing that effort, the end-result IT environment will not be efficient. Human effort will be required to overcome the limitations of the cobbled-together systems.” He says that expediency (or financial constraints) at the time of an acquisition might be the rationale for keeping two or more different RIS and PACS in operation, but in the long term, the actual cost of doing so at many different operational levels tends to be much greater than the cost of replacing the systems and unifying the informatics environment at the time of the merger. Technical Aspects Mike Leighow, vice president of operations of Geisinger Health System’s radiology service line, says that the most challenging aspect of a conversion is migrating images from a legacy archive to the system’s PACS. Geisinger Health System contracts with an application service provider, so a fee is charged for each archived exam. Assigning medical-record numbers, consolidating the files of patients who might have used more than one identity, and other data-migration issues all are challenges that the radiology IT team expects to face. Geisinger Health System’s long-term archiving strategy is to add a VNA, although basing this archive in the cloud remains a challenge because it involves protected health information. At Geisinger Health System, a radiology-informatics oversight group carefully plans every known aspect of the conversion and implementation; the group consists of key leaders from the IT department, physicians and staff from the radiology department, and the radiology-informatics staff. The group sets the agenda and priorities, which tend to change somewhat as planning proceeds. “No matter how often we do this, the project is challenging, and it may take months to develop an integrated plan,” Leighow says. Training teams are sent to each site in advance, and on-site support is provided, around the clock, for as long as it’s needed after activation. Informally, this is called the big-bang go live, a term used at Geisinger Health System to describe the practice of making all information systems live at one time. Cardella attributes the success of each conversion to two factors. The chair of systemwide radiology and the vice president of the radiology service line are held accountable for the quality of the radiology practice and for the care that patients receive at the new sites, from both clinical and technical perspectives. They have accountability, and they are given a considerable amount of latitude in terms of committing resources; performing security analyses; making equipment-replacement decisions (for example, for diagnostic workstations); garnering resources; and prioritizing projects. Another important factor that Cardella says contributes to the organization’s successful conversion of new sites is the fact that most of them, to date, have had outdated legacy RIS and PACS. For this reason, most radiologists and technologists welcomed the change and the opportunity to use up-to-date systems. No acquisition has generated a layoff of IT staff; in fact, the number of IT personnel has increased. The geographic dispersion of Geisinger Health System’s facilities requires on-site radiology-informatics support teams, as well as a large team at the Danville headquarters. “The tight integration of our systems and the use of a single platform across the enterprise are responsible for improving the quality of care our patients receive. The patient, the technologist, the radiologist, and all clinicians have access to a lot of the same information. This foundation of IT uniformity enables our providers to serve our patients better—and more safely,” Cardella concludes. A Dual Approach Inland Imaging (Spokane, Washington) was formed in the 1930s and had grown to six members by 1985. The practice was up to 60 radiologists last year when it merged with Seattle Radiology, a 37-radiologist practice, to form Integra Imaging. Now 97 radiologists strong, the practice serves the entire state of Washington and adjacent regions of the Northwest. As an early adopter of PACS and imaging-informatics innovations, it spun off a technology-services company in June 2012 for health-care, utility, and business-service sectors across the United States. Jon Copeland served as Inland Imaging’s CIO from May 1996 through May 2006. During this time, he oversaw the implementation of the practice’s PACS at more than 40 different sites. What began with three small outpatient facilities that performed 50,000 radiology exams annually has grown into a business that now serves more than 100 clients and manages more than 2 million exams per year. When Inland Imaging acquires an outpatient facility or obtains a new professional-interpretation agreement with a facility or hospital, it installs the RIS and PACS that it uses. It is much better to have all entities using the same system, Copeland emphasizes. He says, “It is very expensive to operate and support multiple systems, and the radiologists are much less efficient if they need to work on multiple systems. The cost of maintaining more than one system is always going to be greater than that of maintaining only one, even if there is a large initial implementation cost.” He adds, “We’ve determined that some hospitals and radiology practices do not know how to evaluate the total cost of maintaining a PACS (or grossly underestimate the cost). They capitalize and depreciate the investment, but they may not factor in the cost of ongoing IT support, the annual maintenance agreement, the need to replace server hardware every four to five years, and the cost of off-site storage required by HIPAA and the Health Information Technology for Economic and Clinical Health, or HITECH, Act. They also may underestimate additional IT costs: all overhead allocations, all network and data-center costs, and all depreciations of equipment associated with this.” The practice’s hospital clients sign interoperability agreements, if they are not using the same PACS as Inland Imaging. The practice has gone one step further: It has created a de facto health information exchange for any hospital in the region to use, whether or not it is a client of Inland Imaging. A hospital that needs to send a study to another hospital can push the study from its PACS to a short-term PACS cache, where the image can be retrieved by the recipient hospital. Copeland says that this network service, which is free of charge to the hospitals, has had a major impact on improving patient care, particularly for trauma patients, and on reducing costs through a reduction in duplicate studies. With respect to archival storage, acquired entities tend to retain the storage solutions that they have, unless they specifically want to convert to Inland Imaging’s system. Relevant prior exams are shown in a patient’s electronic file, and if a radiologist wishes to review them, the process of transferring them to the PACS is very rapid. Living With Complexity Doing what makes sense for a local imaging center, especially when that also aligns with a corporate IT strategy, seems easy enough. It is dizzyingly complex, however, to achieve radiology-informatics harmony for CDI Management (Minneapolis, Minnesota). CDI Management oversees a coast-to-coast network of 110 imaging centers located in 22 states—including the facilities of CDI, as well as the mobile-imaging business of Insight Imaging (Lake Forest, California). As the two companies came together, in July 2012, CDI Management began discussions about moving the two national imaging providers to a common platform. It takes a large team to manage IT: about 90 people, according to Linda Bagley, CDI’s senior vice president of business process and technology. Out of the gate, Bagley and her colleagues evaluated the technological infrastructure of each company, the functionality of each product, and contractual agreements with vendors. They evaluated the market needs and factors at each location, as well as what the companies needed to do to provide support for patients and physicians. The process was complex and challenging, and it did not yield easy or obvious solutions. The analysis evaluated dozens of elements, the foundations of which (from a radiology perspective) were RIS, PACS, and speech-recognition/dictation systems. There were similarities and differences. Each company had customized its RIS. In fact, Insight Imaging was using an internally developed RIS. With the additional software that CDI had developed with its vendor, the RIS not only supported four or five PACS used by hospital clients, but also included sophisticated features designed to support meaningful-use attestation. Insight Imaging was using a legacy PACS (which was sunsetting) and a third-party vendor to provide archival storage. CDI’s PACS function incorporated a mix of older and newer systems, from the same vendor, that were used primarily for viewing—with image transfer, management, and storage provided by another vendor. CDI also had received images from various PACS of the hospitals and providers where it provided professional services. Both companies used the same speech-recognition/dictation vendor, but with different systems. “We wanted to retain our RIS-driven workflow, and we wanted to keep our ability to send images easily, across the country and between our markets. Those were our overriding goals,” Bagley says. The joint planning team evaluated commercially available RIS and PACS to determine whether better, more cost-effective options were available. They decided that CDI’s RIS should be retained and that Insight Imaging’s facilities should transition to it. It worked well, and it was meaningful-use certified. With respect to PACS, the most sophisticated product in use at CDI would be retained, as well as the vendor providing image-management, -transfer, and -storage services. CDI sites with older PACS versions would upgrade, and Insight Imaging sites would convert to this. The most comprehensive speech-recognition system was selected. Facilities that had the other system quickly switched. The complex conversion process began in January 2013, market by market. Priorities were determined based on market requirements, greatest need, and number of integrations required. “Our focus has been primarily on Insight Imaging facilities, this year,” Bagley explains. “By the end of the year, all facilities should be using the same RIS. About 70% of the facilities are now converted to the PACS, with their archives transferred, as well, from Insight Imaging’s third-party vendor provider to CDI’s vendor.” The project is huge. Making it happen are an IT operations team responsible for networks, security, and servers; a software-development application team that is performing the integration; a business-intelligence team; an installation team; a training team; a go-live team; and a PACS–administration team. “We’ve developed and are using a comprehensive, flexible template. There are, however, unique things for each market. We are doing an implementation each month, which starts with a conference call. Conversions take place over weekends. We are moving quickly, but we want to make sure that the process is smooth, thorough, and efficient,” Bagley says. In July, the company acquired two of the MRI Centers of New England (in Peabody and Woburn, Massachusetts) and moved them to its new centralized platform. A Slow Burn When Scottsdale Medical Imaging and Valley Radiologists decided to merge into a single business entity called Southwest Diagnostic Imaging Ltd (Scottsdale, Arizona), they did it as a merger-in-progress, from 2003 through 2011. Ultimately, they decided to consolidate their two RIS platforms, but keep the legacy PACS of each group intact. James Whitfill, MD, former CMIO, says that this was a pragmatic decision, made after a thorough analysis. When the merger was announced, a committee was formed to evaluate the technology that each practice was using and to prioritize what needed to be done. First on the list was the creation of a uniform platform for billing. “When you form a single tax ID, the requirement of consolidating billing takes precedence over everything else,” Whitfill notes. Infrastructure IT, email services, websites, intranets, instant messaging, and telephony also were consolidated, but later in the merger timeline. The RIS was the next priority. The committee evaluated what was available, in the commercial market, with the features and functionality of the two systems in use. Of benefit was the fact that both practices were using the same speech-recognition/dictation platform. One existing RIS was selected, and the other group converted. “One of the first things that the IT department did was develop the ability to see across the entire patient jacket. DICOM tools are used to pull or push studies between the two PACS, and that has worked pretty well,” Whitfill explains. “From an interoperability perspective, it is possible for a radiologist to obtain prior exams for review that have been stored in the remote archive.” This is not a perfect solution, but it is working well. Whitfill notes that the radiologists in each of the former practices liked their own PACS. Unifying the two PACS also did not rank high on the immediate-priority list. The IT–evaluation team created a matrix that scored the cost and complexity of merging a function, and it ranked the value that a consolidated system would have for users. The complexity of consolidation was also assigned a rank that estimated the staff resources needed and how laborious the project would be. It became easier to prioritize projects. One benefit of the merger was that each practice previously had operated a sophisticated data center, with backup power and backup air conditioning. As these centers were about 10 miles apart (and because there is little regional concern about potential destruction by hurricane, tornado, or earthquake), Southwest Diagnostic Imaging had ready-made disaster recovery facilities. Backup tapes from each PACS are taken to the other. Each facility is building the capacity to support the other, in case archives are destroyed at one site. Another benefit of the merger was the opportunity to evaluate its firewalls and security against intrusion from a new perspective. “The merger enabled us to take a fresh look at how well we were secured. Some vulnerabilities were identified, and these were corrected,” Whitfill reports. “Merging the IT teams was more challenging. When you have two departments come together, the process is challenging, but ultimately rewarding. It’s necessary to understand cultural issues and philosophies—and to create a new environment that works well for everyone.” Whitfill continues, “We were especially fortunate in having an imaging-informatics manager who had worked with both of the PACS in her career. Her experience and knowledge were respected, and this made the process a lot smoother.” With mergers/acquisitions continuing to play out across the health-care landscape, health-care IT professionals will be challenged to create an integrated whole. The solutions, however, are as varied as the organizations. Cynthia Keen is a contributing writer for Radiology Business Journal.