In 2005, immediately following Hurricane Katrina, New Orleans, La.-based Ochsner Health System—one of the largest independent academic health systems in the U.S. and the largest entity of its kind in Louisiana—set off on an acquisition path. By the end of that year, it had acquired three hospitals, with another four subsequently added to its roster and similar initiatives still a strong possibility. The healthcare provider also has, quite recently, forged strategic alliance agreements under whose terms it leases its PACS and EMR systems to two hospital partners; other alliances are on the drawing board.
Ochsner’s moves on the acquisition front underscore a growing trend among hospitals to acquire or consent to be acquired by other hospitals: In an article published in The Wall Street Journal in September, the year 2015 is characterized by healthcare research firm Irving Levin Associates, Norwalk, Conn., as “on-pace to notch the most U.S. hospital deals since 1999, with 71 announced through the end of August.” This, writes reporter Anna Wilde Mathews, “comes on top of an already torrid spate of deal-making,”—72 hospital acquisitions finalized in 2010 vs. 50 the previous year and 100 deals completed in 2014. Not surprisingly, these mergers have significant impact on imaging IT, not only within the hospitals themselves, but for the radiology practices that serve their imaging needs.
“It touches all the corners,” says Brian Deshotel, BSRT, MBA, CIIP, Ochsner’s radiology informatics director. The health system, which encompasses 10 owned or managed hospitals and 40 health centers, has a radiology IT infrastructure that encompasses 80 PACS workstations designated solely for radiologists’ use; more than 1.2 million imaging studies are performed at Ochsner facilities annually.
Hospitals on the buyer’s side of the bargaining table in the current consolidation environment find themselves grappling with a number of issues pertaining to imaging IT components and infrastructure. The question of whether to replace the existing PACS at the soon-to-be acquired institution, or follow another strategy, tops the list.
Ochsner’s standard approach here entails extending its PACS by adding the new site to its current PACS database, based on the rationale that all patient data and images should be available to every clinician in every location in order to optimize the caliber of patient care while conserving costs. Expanding the database—a vendor-neutral archive—in such a fashion is always less expensive than replacing a PACS entirely.
“At one time, we did maintain multiple databases for multiple facilities, as opposed to expanding our own database to accommodate the new site,” Deshotel states. “However, we also have a lot of patients who move from hospital to hospital, depending on a number of factors, and it was brought to our attention that we were repeating a lot of studies as a result. Eventually, we saw the need to make the change,” but again, without installing replacement PACS at acquired facilities.
Meanwhile, PACS replacement is the watchword for MaineHealth, Portland, which in the past few years has added five hospitals to its network and remains in acquisition mode. All five facilities have been standardized on the same PACS as that used at Maine Medical Center, MaineHealth’s flagship institution.
The strategy will remain the same going forward, as it is believed to support the most open and comprehensive information- and image-sharing among clinicians at separate facilities, explains James K. Butler, PMP, project manager, project management office, information services. Relevant priors, Butler asserts, are seen as priority for radiologists and critical to the best quality care.
Even when systems are standardized across hospitals, problems can and do surface when data are migrated from the acquired hospital’s PACS to that of its new owner. Butler cites the example of a situation that occurred when MaineHealth acquired Conway Hospital in Conway, N.H.
During the migration step, he and his team noticed that not all of the latter institution’s data had been accurately migrated to MaineHealth’s PACS. An investigation revealed that Conway Hospital had, during a technology upgrade several years prior, adopted a six-digit format for its medical record numbers (MRNs). However, MaineHealth utilizes an eight-digit format; the difference between the two formats was interfering with the migration process.
To resolve the trouble, Baker explains, MaineHealth’s IT teams were required to “code a solution” that would permit patient data to be ported to its destination regardless of MRN. “We were then able to successfully migrate all of the data and match it up with information in our PACS,” he notes.
Just as critical are issues surrounding network and storage capabilities, because these needs change and increase each time a new hospital joins the fold. While radiologists themselves consider access to relevant priors most important and are loathe to sacrifice it in the wake of a hospital acquisition, speed of access, too, is a priority for them. Accordingly, in addressing connectivity, Butler and his colleagues carefully assess the number of studies read at the location and the average size of all studies, as well as current study retrieval times and what those retrieval times should be once the merger is complete.
Under certain conditions, MaineHealth will install a separate network to support a new hospital site, but this is typically done on a short-term basis (a few months) only. After that, the new hospital is connected to MaineHealth’s enterprise network platform, which is adjusted to accommodate the accompanying heightened data transmission volume. Such an infrastructure—one that encompasses a single network and a single domain—supports optimal network stability, reliability, redundancy, and disaster recovery, all of which become ever more important as the number of facilities in the hospital system continues to expand.
Similarly, the protocol for altering Ochsner’s PACS database to incorporate data and images from newly acquired hospitals entails not only expanding the cache and available archive space (generally, by about two terabytes each time), but in addition, the ability of the network to handle increased traffic. Ochsner is currently in the process of transitioning to a virtualized server environment for its PACS and voice recognition applications; 80% of the PACS is expected to be operating in virtualized mode by the end of 2016.
In a virtualized environment, multiple applications can run on a single server, and single applications can utilize resources across the network. Applications can be dynamically shifted from one physical server to another as data/image transmission demands and resource availabilities change, without interrupting service.
“The network capabilities piece is big,” Deshotel observes. However, he notes, “virtualization also gives us the flexibility to create and install servers faster, as well as to better control power, network, and [hardware] cooling expenses” because there are fewer physical machines in the radiology IT infrastructure.
The scope of Ochsner’s disaster-recovery model has been broadened to a comparable extent. A large data storage facility in the Nashville, Tenn., area houses an “expanded” backup database, enabling backups to occur in real time. “When you have 15 facilities and conduct more than one million exams per year, you can’t afford to do it another way,” Deshotel emphasizes.
Oschner’s acquisition mode also has altered its financial model for radiology IT. No hospital is single-handedly responsible for PACS expenditures; rather, each institution pays a percentage of the total cost of maintaining the central PACS and vendor-neutral image archive. Percentages are based on individual hospitals’ total system usage volume. Sharing a hypothetical example, Deshotel says, a site at which one million imaging exams are conducted annually would pay 10% of the overall PACS tab; one at which 50,000 exams were conducted, 5% of that figure.
Although a single-seat software licensing structure remains in place for some systems (e.g., the mammography database), Ochsner now holds site licenses for most of its PACS installations. “It’s not difficult to negotiate with most vendors for site licenses where it makes sense, to keep costs down,” Deshotel asserts. One key to successful negotiations, he has discovered, is emphasizing to the vendor its status as the organization’s “vendor of choice” for its particular category.
Feeling the pain
Changes to a hospital’s radiology IT infrastructure in the face of acquisition impact entities other than hospitals themselves: Radiology practices with which these institutions contract for imaging-related services feel the pain as well.
When one hospital acquires or merges with another and changes its PACS, voice recognition solution and/or workflow, radiologists may find themselves forced to become accustomed to a different version of each type of system, explains Steve Duvoisin, CEO, Inland Imaging (a division of Integra Imaging), Spokane, Wash. In radiology practices that provide contracted imaging services to more than one hospital system, the headaches can worsen.
“Systems vary quite a bit, from the manner in which images are brought in, to the way reports are generated, and more,” Duvoisin states. “For each different system, there is a decrease in reading efficiency and sometimes even the quality of reports,” causing disruptions and, potentially, rendering it more difficult to sustain a high caliber of patient care. “It’s not that any single PACS is tremendously better than another; it’s just that radiologists have a harder time of it when they are reading from two or three of them.”
In two or three instances, Duvoisin says, Inland Imaging has managed around these problems and kept disruptions to a minimum by investing in and implementing what he deems a software “overlay” for hospitals’ PACS. This “overlay” enables Inland Imaging to provide teleradiology services to the hospitals in question, despite the fact that their radiology IT infrastructure includes PACS from a different vendor than the PACS in place at Inland itself.
“This approach required working closely with the hospital’s IT department so our PACS could access theirs,” Duvoisin continues. When the reading is finished and the reports are complete, the reports are “pushed back” to the hospital’s PACS.
Duvoisin adds that in his experience, hospital decision-makers are not averse to allowing the radiology practices with which they contract for teleradiology services to harness the overlay approach—provided they need not absorb the expense. The interface between systems also must be satisfactory to the hospital IT department.
In certain situations, hospitals can be persuaded to standardize all acquired institutions on the same PACS and voice recognition system—one that matches those used by their radiology practice. “Much of what can be worked out comes down to having at the practice a CIO or other high-level IT person in the radiology practice who can sit at the table with the [acquiring] hospital and explore solutions,” Duvoisin asserts.
Prasanth Prasanna, MD, of Diagnostic Imaging of Salem, Ore., corroborates Duvoisin’s comments about the snafus that stem from PACS incompatibilities. The practice’s scope of imaging services extends to two nearby hospitals—Silverton Hospital in Silverton and Samaritan Albany General Hospital in Albany—and an imaging center. Each of the three sites has a different PACS. Two sites utilize the same radiology reporting platform; the third, another platform.
“It’s a complicated; for example, right now we need to double-click four different icons to launch PACS,” Prasanna says. “And even if the third facility moves to the same reporting system as the other two, we could still have trouble if the versions aren’t the same. We are looking at ways to share HL-7 feeds to get around the issue, but still, there could be obstacles.”
Further complications could be on the horizon: In mid-December, the boards of directors of Silverton Health, which owns Silverton Hospital, and Portland, Ore.-based Legacy Health, signed definitive affiliation agreements under whose terms the latter will become the parent company. To minimize these complications, Diagnostic Imaging of Salem will “likely” replace its existing PACS with whichever PACS Legacy Health opts to employ. A migration to Legacy’s EMR system is probable as well—again, in a move to keep disruptions and complications as limited as possible.
For hospitals and radiology practices alike, minimizing the negative impact of acquisition cannot be, left to chance. Rather, there are set agendas and best practices to follow.
MaineHealth has used as a roadmap guidelines created by the Project Management Institute (PMI), a not-for-profit professional organization for the project, program and portfolio management profession. The guidelines stipulate using what Butler deems a “very structured” approach to managing projects, so that important steps involved in executing them are neither inadvertently overlooked nor intentionally omitted.
Under this umbrella, there is an initiation phase that entails meeting with stakeholder teams to review business requirements. This is followed by planning, building and testing or, as Butler puts it, “execution and monitoring and controlling the work.”
One major caveat: Execution does not begin until the plan is finalized and has been approved by all stakeholders. Moving ahead prematurely almost always results in revisions that expand the scope of the project even when it probably is not necessary, in turn increasing costs and sparking dissatisfaction among involved parties, Butler notes.
He adds that like any other project undertaken by MaineHealth, an acquisition initiative that touches radiology IT typically brings surprises, particularly in the planning phase. Leveraging the PMI guidelines, he says, allows these “gotchas” to come to light in sufficient time for them to be properly and proactively addressed.
“When we uncover a ‘gotcha’ up front because of the guidelines, we collect information and observations from all subject matter experts, then present it to executive leadership saying, ‘Here’s the challenge, here are three options and here are the potential by-products of choosing each one,’” Butler explains. “Executive leadership can then decide on a course of action.” Without the framework, he asserts, this would not be possible.
Moreover, MaineHealth has devised a radiology IT deployment strategy designed to make transitions to new systems resulting from acquisitions as painless as feasible. Accordingly, radiologists from hospitals that are about to be acquired by the healthcare system attend on-site hands-on training sessions to learn the ins and outs of its PACS and shadow Maine Medical Center’s clinicians as they utilize the system.
Wherever possible, radiologists also are invited to practice using the PACS on test workstations that have been scrubbed of data to simplify the process of test-driving the technology. Multiple MaineHealth IT team members, along with vendor representatives, come on site to offer assistance on the day the new PACS goes live.
“We make it a practice to anticipate risks at this stage of things, and to address them in a proactive manner,” Butler reports. For instance, at one of MaineHealth’s hospitals, the lead radiologist was scheduled to retire before the changeover from the old PACS to the new. Additional training coverage was provided, and extra assistance was arranged for an interval following the “go-live.”
For its part, prior to every hospital acquisition, Deshotel and his team host a kickoff meeting where stakeholders from the soon-to-be-acquired hospital and the Ochsner team can become better acquainted. This also enables the Oschner team to understand the roles of the new team members and where they fit in going forward.
“We look at their fears and, by sharing information, build trust and get buy-in,” Deshotel explains. “We evaluate procedures and policies to try to find a common ground or explain the ‘why’ behind the differences—everything from who is or will be permitted to delete images, to what is going to be different about the new system, and in between. It’s how to get people on our side. There’s no buy-in when you say, ‘Here is the new system. Suck it up.’”
Deshotel concedes that securing stakeholder buy-in can be a bit tricky when “everyone wants everything”; clinicians, he says, sometimes try to push the envelope when it comes to accessing older priors. “This is very important to them, but five to 10 years’ worth is a challenge,” he concedes. “So I go to the table with three years and agree to a designee for manual migration of older images as needed.”
Neither Deshotels nor Butler—or Duvoisin and Prasanna, for that matter—foresee a time when hospitals will veer off the mergers and acquisition course. The impact on acquired facilities—and on radiologists—is certain to become greater as radiology IT evolves. Entities that come to the table prepared to meet the challenges with both strategies and an open mind stand to weather and benefit from the storm.