The United State of Imaging in Tacoma
Located on the Puget Sound about 35 miles south of Seattle, Washington, the community of Tacoma and surrounding Pierce County benefit from a number of innovations that are linking local radiology providers in an uncommon collaboration. Through IT and service agreements across two competing hospital systems and two separate radiology groups, all parties report improvements in multiple areas of patient care. It’s most notable that imaging-report turnaround times have dramatically improved in the emergency departments involved, where even small delays can mean the difference between life and death. Other quality indicators are being tracked and measured using specific metrics. At MultiCare Health System (Tacoma), which operates four hospitals and several clinics in the region, radiologists’ average interpretation-turnaround times for imaging exams from the emergency department went from more than an hour, three years ago, to about 20 minutes today. Franciscan Health System (Tacoma), which runs one of Tacoma’s two level II trauma hospitals, also has experienced reduced emergency-department turnaround times in recent years. For standard imaging exams that previously took an average of more than a day to complete, referring physicians often receive results in less than an hour at both hospital systems. These improvements were made possible through high-level software integration within the two health systems and through community-wide collaboration among the hospitals and the two competing radiology groups. The programs still exist within separate, distinct systems, but such collaboration aligns the disparate groups on the same platforms, allowing access to images—wherever they might be housed. Unified PACS In 2007, the two competing hospitals made a strategic decision to use the same PACS vendor. MultiCare Health System followed Franciscan Health System in buying and implementing a new system, along with mutually chosen voice-recognition software, in all but one of its four hospitals. The fourth hospital will be added to the system soon. Two radiology groups that serve the hospitals are 52-member TRA Medical Imaging (Tacoma), which contracts with both hospital systems and operates its own freestanding centers, and Medical Imaging Northwest (Tacoma), a 25-member group that contracts with hospital systems and medical offices, in addition to operating joint-venture outpatient imaging centers. Medical Imaging Northwest and TRA Medical Imaging both have their own PACS, provided by the same vendor that serves the hospitals. Medical Imaging Northwest also uses a middleware product that streamlines workflow by consolidating RIS data, PACS images, and dictation from disparate sites into one worklist. Use of the same PACS vendor makes a more seamless workflow possible among the various health-care providers in the community, according to Brian Knudsen, area supervisor in the IT department overseeing the PACS at Franciscan Health System. It also facilitates access to prior studies. “It was a pretty easy decision because our primary focus is on patient care,” Knudsen says. “Whether patients have been seen at a different organization or at ours, they are our neighbors. They are a part of our community, and we want them to be treated as quickly as possible.” Andre House, manager of diagnostic imaging services at Franciscan Health System, says, “It definitely streamlined patient care and made access to comparative studies on patients more optimal.” Sharing a PACS vendor also opened the door to greater collaboration between the hospitals. MultiCare Health System and Franciscan Health System alternate level II trauma response every 24 hours, and this switching has enjoyed greater coordination since they began using the same PACS vendor. The two health systems (along with TRA Medical Imaging) also share a Tacoma joint venture called the Carol Milgard Breast Center. Each party owns a third of the facility. The two radiology groups and both health systems also coordinate their software upgrades at the same time, saving resources for the hospitals and vendors because the PACS trainers might need to make a trip to Tacoma for only one round of upgrade training (instead of four). The organizations’ PACS administrators meet on a fairly regular basis and communicate almost daily about how they’ve solved problems or configured the system to be more effective. Knudsen says, “That collaboration is possible because we work from the same system.” Having a common PACS vendor also provides the four organizations with a certain amount of leverage (in negotiating prices and making special requests for software tweaks) that they might not enjoy as single customers, Knudsen says. Shared-management Agreement MultiCare Health System went a step further in October 2010, when it began the process of integrating its RIS and PACS with its electronic medical record. Jim Sapienza, FACHE, imaging division administrator at MultiCare Health System, says that the move gave radiologists greater access to patient information because the entire record was complete and accessible in one place. “Now, the physician can know all the details for that patient in the context of the entire health-care record,” Sapienza says. More important, an integrated system allowed IT specialists to zero in on key quality measures that might need improvement. With the RIS tightly integrated, administrators knew exactly when a technologist started an exam and when a radiologist accessed that exam in the PACS. Together, this new information represented a complete picture of the hospital’s imaging-service workflow. One of the deficiencies that administrators quickly noticed was emergency-department turnaround time, but there also were differences in the ways that certain procedures were performed by the two radiology groups. For instance, when the technologist deemed the exam to have begun, what type of contrast material was used, and the ways in which the exam was documented were often inconsistent. “Even where we were believed to have reliable data, you’re only as good as your input,” Sapienza says. In response, MultiCare Health System administrators and the two radiology groups negotiated a shared-management agreement that would define specific protocols for the way that an imaging exam should be performed. Dennis Carter, TRA Medical Imaging’s CEO, reports that over the past three years, the groups have worked to implement the guidelines (which cover everything from physician credentialing to stroke protocols) for both technologists and radiologists. The hospital system attached a small incentive—roughly $100,000 annually for each radiology group—to be paid if the groups met certain benchmarks. Both groups have met the benchmarks for the past two years. “What they specifically are trying to do is get two separate groups to agree on how to deliver service in one unified way,” Carter says. “This has been all about trying to get two groups in alignment in a contractual way and about giving them incentives.” Once the organizations reached agreement on what to measure, the question of an appropriate goal arose; it wasn’t easy to reach agreement among entities with separate groups of lawyers. It took more than a year, for instance, for the parties to reach agreement on what constituted the beginning and end of emergency-department turnaround time. After protracted discussion and formal negotiations, the parties reached agreement in 2009. “It’s about how we deliver good, consistent clinical care across all of the hospitals, even where there is a different radiology group,” Carter says. “Radiologists don’t necessarily practice the same way.” He adds that great progress has been made in agreeing upon appropriate measures, recording compliance with them, and reporting on them. Giving Quality a Number There are six indicators that the groups agreed to measure. First, neuroradiologists read all MRI and CT exams of the head and neck. This measure arose to ensure that subspecialty radiologists were reading at the highest level of their training. Second, critical results from CT and PET exams are reported by telephone to the ordering physician and documented in the final report. Third, there are zero infections from catheter cultures within seven days of imaging placement of a peripherally inserted central catheter. Fourth, cases randomly selected for peer review are completed within 30 days. Fifth, emergency-department turnaround times are recorded. Sixth, exposure time for fluoroscopy is documented in the final report. After two years of tracking and reporting the results, both radiology groups are meeting the benchmarks, with only slight deficiencies in one or two categories. For instance, the target goal of 90% completion within 24 hours was set for neuroradiologists or interventional radiologists reading MR angiograms and CT angiograms of the head and neck. In 2010, one group met this target just 36% of the time. Now, both are near the target. Both groups succeeded in surpassing the 90% benchmark for documenting critical results in the final report. For the past two years, neither group has had an infection linked to an imaging exam, and both groups met the 95% benchmark for peer review of cases within a month. Mike Dowd, MD, president of TRA Medical Imaging, says that improvements in emergency-department turnaround times occurred as soon as the groups started measuring elapsed times consistently. “Once we started measuring and showing turnaround times, people started focusing to make sure those exams were read in a timely fashion,” Dowd says. “Once you start to measure something, it tends to get better. It’s definitely helped to raise the bar in our community, in a variety of ways.” While emergency-department turnaround had been decreasing over the past several years, in 2011 alone, times for both groups dropped from around 30 minutes to 20 minutes. It was this dramatic improvement that caught the eye of hospital administrators. Dowd says that practices at MultiCare Health System have carried over to improvements at Franciscan Health System as well. “We like to provide the same level of service,” he says. “If we raise the bar at one hospital system, we want to do the same thing down the street.” Keith Arnzen, MBA, CEO of Medical Imaging Northwest, says that there’s no doubt that this program has helped improve the quality of care. “It really has given everybody a keener focus on what the priorities should be,” Arnzen says. “Together, everyone sits down, talks through issues, and looks for opportunities. We look at the metrics regularly to see how we’re doing.” Safety Enhancements The IT managers at MultiCare Health System have leveraged their improved access to data (provided by integration) to push quality efforts and to help meet established measures. Specifically, the system was programmed to alert a technologist that he or she is about to perform a repeat exam. An alert can also be made to appear when a radiologist is about to read the wrong image—or an exam that is outside his or her expertise. Scott Bennett, a medical imaging analyst at MultiCare Health System, says, “It will trigger an alert, and we can call and say, ‘It looks like you’re about to read this study.’ The radiologist will says, ‘How did you know I was about to read this?’ More important, we don’t have to deal with mistakes afterwards.” Bennett says that the hospital can identify cases where pulmonary embolisms occurred, but weren’t acted on in a timely manner. “Through computer-assisted analysis of those reports, we can affect care on patients in real time, rather than waiting until they are statistics,” Bennett says. “We’ve really taken advantage of the data to maximize our clinical care.” If turnaround times exceed the appropriate threshold, radiologists are alerted. “We’ve literally made life-or-death differences in patient care through the technology,” Bennett says, “but what’s key is not the technology itself: It’s the collaboration with the physicians. We’ve collaborated to provide them the data they can act on to improve the care of our patients. We’ve removed thousands of hours of manual reporting and turned them into tens of hours of meaningful reporting that people can use to make a difference.” This year, the groups are tracking the self-editing of reports. The goal is to eliminate transcription service, relying entirely on voice-recognition software and self-editing by radiologists to confirm the report. If the groups comply, it would save the hospital system money and improve the overall turnaround time for reports. Aggregating Prior Studies Medical Imaging Northwest also has pioneered the use of an application that gives its radiologists ready access to a far greater number of prior studies than they had access to formerly. Rather than relying on images being pushed or pulled, Medical Imaging Northwest’s radiologists have any prior studies performed within the MultiCare Health System at their fingertips. The system, which includes middleware and a server, acts as a conduit to access the health system via secure private network and stores images for up to 60 days. It also enables the practice to consolidate reading lists from multiple sites into one list. The advantage has meant the difference between pulling 40 to 60 prior exams (manually) per month and having 400 to 700 prior exams automatically routed by the PACS to the interpreting radiologists. “That was almost a tenfold improvement in information about a patient that we didn’t have before,” Bennett says. Arnzen says that the new method is extremely helpful. “It has been wonderful in allowing radiologists to see prior studies in an automated way. Before, we relied on imaging assistants to have the time to queue up those prior studies—and to try to decide which ones they should look for,” he says. What’s next for the health-care leaders in Tacoma? For the future, Sapienza says, MultiCare Health System is looking for a good cloud-based solution for sharing images. “We are challenging the major PACS vendors to give us a really good, workable cloud-based solution,” he says. “Once they do, the hospital system will no doubt be looking for another round of collaboration among competing interests.” TRA Medical Imaging is planning to push its technology envelope further with investments that will result in a more seamless interoperability among its own information systems as well as among those with which it interacts. “It appears to me that legacy PACS vendors are holding on too tightly to the old models and are asking way too much,” Carter says. Andrew Levine, MD, chair of Medical Imaging Northwest’s executive committee, believes that the advances in Tacoma represent where a lot of other regions will be going in the future. “You’re going to see these kinds of software products available because there’s going to be a requirement,” Levine says. “Most radiologists work with different systems. You’re going to need these integrators to provide better patient care.” David Rosenfeld is a contributing writer for Radiology Business Journal.