radiology business journal february/march 2011

FOR LEADERS IN MEDICAL IMAGING SERVICES

February/March 2011

www.imagingBiz.com

Featured in this issue

radiology and the heart:Four Models of Collaboration | page 34

Piggyback PaCs: in hot PursuitOf enterprise image Management | page 40

Clinical decision support: the Journey Begins | page 50

Image Sharing:

The Cloud, the Roadmap, and the Business Models

Image Sharing:

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FOR LEADERS IN MEDICAL IMAGING SERVICES

February/March 2011

www.imagingBiz.com

Featured in this issue

radiology and the heart:Four Models of Collaboration | page 34

Piggyback PaCs: in hot PursuitOf enterprise image Management | page 40

Clinical decision support: the Journey Begins | page 50

Image Sharing:


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February/March 2011 | Volume 4, Number 1

4 Radiology BusiNess JouRNal | February/March 2011 | www.imagingbiz.com

cONTeNTS

FeaTureS

22 Image Sharing: The cloud, the roadmap, and the business Models By Julie Ritzer Ross These four projects are blazing a path into cyberspace for image sharing among health-care providers.

34 radiology and the heart By Cat Vasko In the collaborative models described here, education, service, and collegiality have ensured radiologists a seat at the cardiac-imaging table—sometimes, near its head.

40 Piggyback PacS: Pursuing enterprise Image Management By Kris Kyes Though technological, logistical, and political hurdles confront those seeking enterprise image management, the goal is worth pursuing and progress is being made.

50 clinical Decision Support: The Journey begins By George Wiley Minnesota and Washington take different paths in the journey to acceptance for clinical decision support.

22

34

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ital

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6 Radiology Business JouRnal | February/March 2011 | www.imagingbiz.com

CONTENTS FEbruary/MarCh 2011 | Volume 4, number 1

PubliShErCurtis Kauffman-Pickelle

[email protected]

EDiTOrCheryl Proval

[email protected]

arT DirECTOr Patrick R. Walling

[email protected]

TEChNiCal EDiTOrKris Kyes

aSSOCiaTE EDiTOrCat Vasko

[email protected]

CONTribuTiNg WriTErSRobert A. Bell, PhD;

Liz Quam; Julie Ritzer Ross;

George Wiley

SalES & MarkETiNg DirECTOrSharon Fitzgerald

[email protected]

PrODuCTiON COOrDiNaTOrJean Lavich

[email protected]

COrPOraTE OFFiCEimagingBiz

17291 Irvine Blvd., Suite 105, Tustin, CA 92780(714) 832-6400

www.imagingbiz.com

PrESiDENT/CEOCurtis Kauffman-Pickelle

VP, PubliShiNgCheryl Proval

VP, aDMiNiSTraTiONMary Kauffman

Radiology Business Journal is published bimonthly by imagingBiz, 17291 Irvine Blvd., Suite 105, Tustin, CA 92780. US Postage Paid at Lebanon Junction, KY 40150. February/March 2011, Vol 4, No 1 © 2011 im-agingBiz. All rights reserved. No part of this publica-tion may be reproduced in any form without written permission from the publisher. POSTMASTER: Send address changes to imagingBiz, 17291 Irvine Blvd., Suite 105, Tustin, CA 92780. While the publishers have made every effort to ensure the accuracy of the materials presented in Radiology Business Journal, they are not responsible for the correctness of the information and/or opinions expressed.

DEParTMENTS

8 adView ace in the hole By Cheryl Proval

10 The bottom line Where is the alignment behind Decision Support? By Liz Quam

12 Priors 12 health-care reform | Quo Vadis/Whither goest Thou? 16 Numeric | Providers to increase Purchases of Medical-imaging Technology in 2011 16 imaging informatics | health iT: Cornerstone of health-care reform 18 accreditation | Ten Questions to ask in Comparing Mri Physics Services By Robert A. Bell, PhD

58 advertiser index

60 Final read The radiology Mba By Curtis Kauffman-Pickelle

40

50

solutions to problems that have already been designed (and financed).

When a radiology department or practice goes shopping for an information system, a piece of technology, or an informatics appliance, it is possible to buy one that adheres to accepted standards. That is not so in any other department/specialty (please correct me if I’m wrong).

The role of health IT is so critical, at present, that it is driving (and will continue to drive) mergers and acquisitions in the health-care market. The IT experience and intellectual capital that radiology has acquired over the past 15 years, in its transition to a digital workflow, will prove invaluable to the profession and health care in general in the years to come.

ImagIng IT CompeTITIonOver the next few months, RBJ and SIIM

will cosponsor a competition to recognize the wealth of IT innovation in our specialty with “The Top Five Medical-imaging IT Projects of 2010.” We will look at projects in these categories: clinical, business intelligence/finance, communications, interoperability, and security.

A jury of six members of SIIM, representing a broad spectrum of practice settings, will judge the entries based on ingenuity, on meeting a need that is unmet by commercial solutions, on quality improvement, and on potential impact. Winners will be announced at the SIIM meeting in Washington, DC, on June 2–5, and will be featured in the June/July issue of RBJ. The deadline to enter is April 1, 2011.

The next time you pass your department or practice’s informatics champions, please encourage them to enter their latest medical-imaging IT project in the RBJ–SIIM “Top Five Medical-imaging IT Projects of 2010” competition at www.imagingbiz.com. A pat on the back, a big thank-you, or a lunch at the Ritz also would be in order.

Cheryl Proval, [email protected]

While the pols dicker about whose

health-care bill will save Medicare, a changing of the guard commences at the Office of the National Coordinator, and the

states take their concerns to the courts, one thing has become increasingly clear: Without health IT to turn the vast web of discrete clinical, administrative, and financial transactions that is health care in the United States into a interconnected whole, the challenge of improving the health of all US residents at lower cost will fail.

This is hardly a new idea. Rather, it is a truth recognized at the highest level of government, with a large incentive program—the Health Information Technology for Economic and Clinical Health Act—standing ready to reward nearly 90% of US physicians who invest in electronic health records for their patients with a $44,000 incentive payment. Whether it will be the biggest boondoggle in US health care or a decisive investment in the quest remains to be seen.

Either way, there is no question that money alone—whether $19 billion or $99 billion—cannot achieve this incredibly challenging objective. It will take an army of health IT professionals—hammering out standards, designing networks, building interfaces, and managing huge stores of data—to make this work. That is why I’d like to take this opportunity to issue a shout-out to all of the unsung heroes of health-care reform: health IT professionals (specifically, those in radiology), not just for how far they have brought us to date, but for where they will take us tomorrow.

Among these heroes, I count the PACS pioneers in academia, as well as the current generation of imaging informaticists working to improve clinical quality, the informatics professionals working in the hospitals, the hospital and practice CIOs and their staffs, and the radiology-informatics vendors. As a matter of fact, Radiology Business Journal has partnered with the Society for Imaging Informatics in Medicine (SIIM) to launch a competition to recognize five innovative IT

projects, but more on that later. Let’s talk about heroes first.

PACS pioneers and imaging informaticists: Have we said enough about the contributions that these physicians and physicists have made to health care through their efforts to make images pervasive and PACS ubiquitous? I think not. How many unreimbursed hours have been spent on DICOM boards and Integrating the Healthcare Enterprise (IHE) committees, or in planning PACS implementations?

What of their efforts in developing new media-appropriate reading styles to replace the old-fashioned stack mode? The discomfort caused by this tectonic change to radiologists’ practice patterns, in the transition from film to soft-copy reading, should not be underestimated, yet adoption of PACS is almost ubiquitous and film has nearly vanished from reading rooms.

Hospital and practice CIOs: These are key positions in every health-care organization today. Not only are hospital and practice CIOs responsible for keeping the clinical systems operational in a mission-critical environment, but they increasingly will be called on to orchestrate the interoperability of clinical, administrative, and financial information systems, in a growing number of settings, as care extends into communities across the United States and health-care providers are induced to accept risk. May the force be with you!

Imaging-informatics professionals: When you can’t get your computer to recognize your password or the CT study is loading too slowly, this is the person you call to fix the problem—sometimes, in the middle of the night. PACS administrators and other imaging-informatics professionals are the invisible seams in a seamless integration—the glue that holds the domain together. When the big, multimillion-dollar scanners arrive by train, plane, and crane, these are the people who bring the technology onto the network. It is not always painless.

Imaging-informatics vendors: While successful vendors survive because they have a business model that works, the vendors in radiology informatics deserve recognition for their adoption of standards and support of the IHE framework, even when that means undoing proprietary


Ace in the HoleWhen it comes to navigating the change ahead, radiology’s assets begin with its strong informatics backbone

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The lack of consensus (and vision) in the imaging community is readily apparent when the topic of clinical decision support is raised. Clinical

decision support allows for electronic documentation of the appropriateness of the imaging service ordered and provided, offering clinicians real-time guidance, rather than black-box rules.

Clinical decision support improves efficiency by eliminating the administrative burden experienced by the ordering clinician and the imaging provider under radiology benefit management (RBM) companies. While it is a win–win proposition for the providers and the payors, the ultimate winner is, of course, the patient, who receives assurance that the wisest course of treatment has been delivered, whether it is two weeks of aspirin, radiography, or an MRI exam with and without contrast.

There are decision-support naysayers within the imaging community who are concerned that clinical decision support will reduce the number of tests they perform. Certainly, these worries have some validity. The initial data from Minnesota, where clinical decision support is now widespread in the provider community, indicate that single-modality centers have seen a decrease in volume.

There is some indication that this is because clinical decision support has guided treating clinicians to order a test using a different modality, ultimately saving some patients the cost and time of inconclusive results from the first (inappropriate) exam.

Why isn’t our whole imaging industry focused on documenting that the right test is provided, at the right time, by the right provider? Our collective voice is weakened by the actions of a minority whose members resist change—and in the absence of consensus, the RBMs have flourished.

a ShorT hISToryWhen the DRA delivered radiology a

nearly fatal financial blow, some radiologists and their imaging-industry partners focused even more intensively on holding on to every patient that they could, while pointing fingers at medical specialists who are essentially doing the same thing: hanging on to every piece of health-care business that they can legally sequester.

In contrast, others in the industry absorbed the DRA and collectively sought viable alternatives to the perceived and/or real concerns of government and commercial payors. We want to avoid further devastating reimbursement cuts and more mother-may-I telephone calls to RBMs. We are collaboratively seeking to assure the purchasers of diagnostic imaging services—whether patients, employers, health insurers, or government—that they are receiving appropriate, value-added health-care services.

At Center for Diagnostic Imaging (CDI), Minneapolis, Minnesota, an initial, proactive step that we took, after the DRA, was to advocate for consistent standards for the technical portion of a diagnostic imaging test. The founder of CDI, Kenneth Heithoff, MD, chaired the UnitedHealthcare® medical advisory group, which resulted in UnitedHealthcare’s adoption of accreditation standards for imaging providers, a development that received a mixed reception in the outpatient imaging center community.

Thanks to the efforts of the ACR® and other members of the Access to Medical Imaging Coalition (AMIC), including the Association for Quality Imaging, the 2008 federal Medicare bill followed the lead of UnitedHealthcare in mandating accreditation standards for Medicare imaging providers.

This program offers reasonable assurance (where none existed previously) that the imaging provider will at least perform the test correctly. With the exception of the accreditation standards and clinical decision support, we haven’t been able to identify significant, viable methods to assure the patient, employer, or payor further that the diagnostic test being ordered is appropriate.

The eorderIng CoalITIonTherefore, adoption of clinical decision

support should be the imaging industry’s collective focus, until we have deployed clinical decision support nationwide and quieted the cacophony over the growth of diagnostic imaging. This is the goal of the eOrdering Coalition, a foresighted and energetic group of industry leaders/thinkers who, together, battled to kill President Obama’s 2009 call to hire an RBM for all of Medicare.

We made several visits to Congress to communicate that this would create cranky-physician syndrome nationwide (which politicians prefer to avoid, prior to an election); provide no added value to the health-care

service being provided; be administratively burdensome to providers—with our emphasis being on the burden to family physicians; and seriously muck up an already-cumbersome system because Medicare would have to add an appeals department to handle all the appeals filed when the RBM denied coverage (this seemed to generate the most attention in Washington).

Thanks again to the help of the AMIC and the ACR, we were successful in keeping RBMs out of the Patient Protection and Affordable Care Act. This, however, was only one skirmish in the imaging industry’s battle for survival. Much more needs to be done, including the integration of clinical decision support into the meaningful-use standards for health IT.

To that end, CDI was an early adopter of clinical decision support in our Minnesota market, where clinical decision support will soon be deployed throughout the state, including rural areas (one state down; 49 to go).

Based on data from our state’s three largest commercial insurers, utilization of diagnostic imaging services has been reduced, especially at single-modality centers, pleasing state officials who oversee our Medicaid program. Ordering clinicians are accepting the program, which is available as an embedded tool for computerized provider order entry for some hospital-based physicians and at the point of scheduling/service for other providers. Our state’s large-employer coalition is highly supportive.

Imaging providers, such as CDI, are vocal proponents because we have moved from the defensive to the offensive line: We have electronically documented the appropriateness of the services that we have provided.

While many other areas of the country are now in early decision-support deployment, there is much more that needs to be done. We must quiet the naysayers among us. We must find ways to erode the hold that RBMs have on some of our biggest insurers—which are not yet convinced that they should eliminate this internal profit center. Together, we in the imaging industry must continuously strive to find ways to assure our patients that they are receiving the best, most appropriate care from us every time they visit a radiology department or an outpatient imaging center.

Liz Quam is executive director, CDI Quality Institute, Center for Diagnostic Imaging, Minneapolis, Minnesota; [email protected].


The BoTTom Line

Where Is the Alignment Behind Decision Support?

By Liz Quam

RBMs have flourished as the medical-imaging community has failed to coalesce around clinical decision support

It is no easy task to hit a moving target, so the seven speakers who presented the refresher course, “How Payment Policy Will Impact Technology

Development in the 21st Century,” on November 30, 2010, at the annual meeting of the RSNA in Chicago, Illinois, diligently colored in the background of the canvas, offering insight into the anatomy of a CPT® code, a review of the successful campaign to get a code for CT angiography, and a postmortem on the recent attempt to get CT colonography reimbursement from Medicare.

When the talk turned to delivery models, Christopher G. Ullrich, MD, chair of the ACR utilization management committee and a neuroradiologist with Charlotte Radiology in North Carolina, had some real-world observations and thoughts on one of health-care reform’s key abstractions: accountable care

organizations (ACOs). He subtitled his talk, “Quo Vadis.”

Ullrich observes that all current CMS demonstration projects are using fee-for-service payment and relying on resource-utilization management to reduce costs. Payors are currently bearing the cost of radiology benefit management (RBM) programs (and ignoring providers’ compliance costs), he adds.

The programs serving as poster-child models of health-care reform—such as those at Geisinger Health System (Danville, Pennsylvania); Mayo Clinic (Rochester, Minnesota); and Marshfield Clinic in Wisconsin—are based on current levels of reimbursement and would be unsustainable at, for instance, 30% less than Medicare payment levels, as recently threatened. Because they are typically the largest employer in most communities, Ullrich says, hospitals

possess unequaled political clout in the health-care sector, as witnessed by a 3% to 4% pay increase since 2000, compared with physicians’ net loss.

“Continually paying less is not, in fact, a sustainable strategy,” Ullrich states. “Better methods of practice, efficiency, rightsizing, and a variety of other strategies are the only real ways to move forward in taking care of our patients.”

With radiology accounting for roughly 7% of health-care costs, the successful management of the utilization of radiology will be a requirement of any successful ACO. Drug costs, physician referral, and emergency-department utilization, however, are much higher on the priority list, Ullrich notes, even as radiology finances the change.

Making it up as we go High levels of uncertainty prevail as

health-care providers attempt to prepare for a rule that remains largely unwritten by the DHHS secretary. Ullrich identifies three scenarios for reimbursement that are being floated. One is hospital ACO

payments, per beneficiary, per month—essentially, capitated care,

which most organizations have

demonstrated that they do not know how to manage. They probably would suffer, should that be the path.

A second model is bundled payment for episodes of care, and the question is how radiology’s portion will be calculated. Currently, it’s fee-for-service payment with a portion withheld; if savings are substantial, radiology gets a share of the savings. “There are very few models, but this looks a lot like an HMO of 1998 to me,” Ullrich says. “I watched multiple multispecialty clinics go broke with


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this arrangement, trying to make it work.”

In a third model, the ACO negotiates f e e - f o r- s e r v i c e re imbursement with a payor. This is a scenario in

which radiology will be challenged to protect its relative share. “If the RBM isn’t used (perhaps that’s a factor), this is essentially what we do now: direct negotiations,” Ullrich notes. “Because there are no working models, radiology could possibly be in the forefront of creating the model.”

Ullrich urges radiologists to stay abreast of the demonstration projects sponsored by the Center for Medicare and Medicaid Innovation (CMMI), which made its first eight awards at the end of November 2010, rather than speculating on which models (most of which are currently in practice) will be used to deliver accountable care.

surViVal ModesWhether an ACO is managed by

a hospital or by a physician network is less important than this question, Ullrich says: “How will we survive in this brave new world? We can become more productive, participate in capitation or risk sharing, provide value-based services or management of utilization within an ACO, or become a hospital or clinic employee.” Ullrich is pleased to report that about 70% of the audience prefers the ACO option.

Medical homes are one of the ACO models being discussed to manage chronic disease, and Ullrich describes a project in North Carolina—and how radiology might prosper within this model. “Patients in a medical home are best cared for in an environment where they are consistently engaged by an adequately funded and well-organized and supported primary-care provider system,” he says.

“The biggest economic impact is in chronic-disease management—for diabetes, congestive heart failure, chronic obstructive pulmonary disease, and other

chronic diseases—and in the reduction of the use of emergency-department visits and other specialist referrals. Although you and I don’t think of this often, radiologists are the most frequently consulted specialists in all of medicine. We outweigh any other specialty by magnitudes of utilization, and we touch every portion of the patient-care system,” Ullrich notes.

Community Care of North Carolina (CCNC) in Raleigh has been operating for more than 10 years, Ullrich says, and currently consists of 15 nonprofit networks, operating in all 100 counties of North Carolina, from the poorest to the most prosperous. It involves 4,500 primary-care physicians in 1,350 homes, or provider sites. Designed as a Medicaid public–private partnership, it functions with local medical-management committees, safety-net agencies, and local hospitals to care for more than a million Medicaid beneficiaries.

Under a primary-care model, CCNC pays a per-member, per-month fee to the physician and the network, and a shared-savings payment (based on benchmark costs) is given to physicians and networks able to keep utilization below the benchmark. If the spending goal is exceeded, no additional payment occurs, but Ullrich points out that North Carolina Medicaid, not the provider, holds the basic risk.

“The physician and hospital participants are not insurers,” he says. “If they miss the goal, they do not get the golden carrot, but they don’t write a check out to Medicaid either. It is a quality, system-oriented effort that is invested in local communities and jobs. We are not shipping jobs to administrators in Nashville, Tennessee.”

Ullrich reports that over five years, CCNC saved North Carolina $950 million, compared with an unmanaged Medicaid population in the state, while the primary-care network has actually been paid more, on average, than Medicaid rates. Radiology is paid on a fee-for-service basis, for Medicaid patients, at 86% of Medicare payment levels; primary-care physicians are paid at 95% of Medicare levels in North Carolina.

There is no question in Ullrich’s mind that health care’s fiscal outlays are unsustainable. North Carolina has a $3.6 billion budget deficit for 2011 and a $19 billion total budget, so nothing, including Medicaid rates, is sacred.

During the past budget cycle, the state engaged an RBM, MedSolutions (Nashville), in return for a fixed budget for imaging and an estimated $100 million budget savings. An unintended consequence of that deal was that health-care providers in the state of North Carolina lost $400 million in reimbursement, or $3 in federal matching funds for every dollar that the state cut. “If you do not spend the money at the state level, the manna from Washington does not arrive,” Ullrich says.

In addition, the RBM raised providers’ compliance costs, increased denials, decreased procedural volumes, and diverted funds from local providers. IDTFs also are prohibited by the North Carolina Medicaid program from providing most Medicaid services, so the policy drove most of the patients into the more costly hospital setting. “This is an unsustainable provider business model for radiology, over the long term,” he believes.

The medical-home approach based on primary care and embodied by CCNC, on the other hand, controlled costs by raising quality, not by lowering payments. “It is a viable business model for local care for the entire community, while it manages your Medicaid population,” Ullrich says. “It already qualifies as an ACO. It received one of the first CMMI grants for a seven-county project in Western North Carolina that will combine Medicare, Medicaid, and Blue Cross Blue Shield patients. This project enrolls 5,000 patients in that model for a three-year demonstration.”

Ullrich concludes with an urgent call for all members of the radiology community to be engaged and to participate in the health-reform discussion in the local and organizational arenas. “The last thought I want to leave you with is this,” Ullrich says. “If you are not seated at the table, you will be on the menu.”

—Cheryl Proval

Christopher g. ullrich, Md

INTEGRATED

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i m a g i n g i n f o r m a t i c s

Health IT: Cornerstone of Health-care Reform

When, today, you go to see suites of hospitals and systems, they have got a grand strategy for what they want to execute in

the next 10 years. It’s not an exaggeration to say the whole thing depends on IT. Without IT, it’s not going to change. How different from past reform attempts this will be is due to the power and capability of IT,” James Field says.

Field is general manager of syndicated research and an executive director at The Advisory Board Company (Washington, DC), a research and consulting company that covers health care. He spoke on January 21 during a webinar hosted by the

Healthcare Information and Management Systems Society.

Whereas earlier attempts at health reform—including the early movement toward capitation and the effort by the Clinton administration to overhaul delivery—made little headway, Field says, this time, the situation is different. This time, health reform will take place.

It must, Field says, “because the nation is broke. We’re at the endgame, in terms of affordability. State governments are in dire straits, employers are broke, and there are 50 million noninsured. That’s why the system will change; the question is how it will change,” Field says.

For the most part, he adds, the health-reform focus has been on the forest—breadth of coverage, cost of financing, and impact on the federal deficit. The real impact of the Patient Protection and Affordable Care Act, however, is in the trees, where important, beneficial, and progressive steps have been taken to change the delivery of health care radically, Field says.

Value CreaTIonValue creation, throughout the health-

care enterprise and in the delivery system, will be the buzzword, going forward, Field says—and IT will be in the forefront. Fee-for-service and volume-

In a promising sign of economic recovery, hospital-based radiology decision makers intend to spend 10% more overall on medical-

imaging technology this year, according to a new report from KLAS (Orem, Utah). According to Diagnostic Imaging Purchases 2010: Spending Increases, Loyalty Is Tested, providers plan to meet or increase purchases in all modality categories except radiography/fluoroscopy, digital mammography, and CR. MRI is at the top of the wish list—with 61 of the 230 respondents reporting plans to acquire a unit in 2011—followed by CT, ultrasound, and DR. For more information about the report, contact KLAS at (800) 920-4109 or visit www.klasresearch.com.

n u m e r i c

Providers to Increase Purchases of Medical-imaging Technology in 2011

119

46

54

37

3234

48

54

61

13

21

4949

CR CT Digital Mammography DR MRI Radiography/fluoroscopy Ultrasound

Planning to purchase 2009

Planning to purchase 2010

Figure. Number of providers saying they planned to purchase equipment; image courtesy of KLAS (Orem, Utah).

Stages of risk

necessary building blocks

(partial)

Performance risk utilization risk Financial risk

Cost reduction Quality IT

Partnerships/acquisitions Physician alignment Primary care

Patient activation Chronic care Service-line blueprint

Time

Figure. Building the necessary foundation for taking/managing risk; image courtesy of The Advisory Board Company (Washington, DC).

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a c c r e d i t a t i o n

ten Questions to ask in Comparing MRI Physics Services By roBert a. Bell, phd

The looming deadline of January 1, 2012, is prompting many MRI scan providers to apply for accreditation. According to section

135 of the Medicare Improvements for Patients and Providers Act, as of this date, any provider of advanced imaging services billing under Medicare Part B must be accredited to receive payment. Choosing the cheapest service might jeopardize not only your accreditation, but also the health of your MRI system.

The annual MRI performance test required under the ACR® accreditation program is its annual physical, and the results provide not only a higher degree of confidence in the technical characteristics of your unit, but also function as an

based reimbursements will give way to bundled payments, episodic bundling, and shared savings, all organized as accountable care organizations (ACOs) and team-driven care entities put together around the concept of a medical home.

“To be honest,” Field says, “if you go into the corporate offices in the major systems, a lot of folks that run these large enterprises think the system will stop with global capitation. A lot of system folks think that will probably be the end state.”

eMpHasis on tHe patientPatients have always been central to

health care, but certain classes of patients will attract a more strongly patient-centered focus. This applies especially to the chronically ill, who are the 20% of patients who use 80% of the health-care dollar. The management of chronically ill patients will require efforts to curtail readmissions to hospitals, Field says. That will mean that hospitals will need to focus on care delivered both before and after acute care.

“Half the readmissions will not be paid for within a few years,” Field says. “If you have to reduce them by 50%, what are the implications? You’re going to have to go into postacute-care settings, you will have to track patients, and you will have to direct patients and collect data on patients. That, in itself, is a huge hurdle because the hospitals have got to extend themselves outside their walls into a different setting, and you’re going to have to have the data to track that.”

Furthermore, for hospitals to become more efficient and build evidence-based protocols, information on chronically ill patients will need to be placed in registries. These will have to be organized and tracked, and the data from them will need to be analyzed, Field emphasizes. As evidence-based care advances, decision-support tools will come more and more into use, and these will also need to be integrated into other information systems, Field says.

Beyond that, both chronically ill and healthy patients will be encouraged—perhaps required—to assume greater involvement in their own care, Field says. Personal health records must be integrated with the electronic medical records of the health-care enterprise. Patient-response systems, via email or some other digital mechanism, will need to be wired into the care network, Field adds. Actions such as taking medications might have

to be documented that way, Field suggests.

“Patients are going to be wired into the system in such a way that they can’t escape, and that way, they will become part of

the ACO, and the utilization of services will be controlled,” Field says. “It’s that whole network of interaction with the active patient that’s going to make this thing work, and it will be a completely different economy. One of the most fascinating pieces is how the patient engages the system through IT.”

tHe reign oF dataAll of the information systems on

the care/treatment side will need to be integrated on the payment side, where the overarching motif will be “doing less to patients,” Field says. Huge amounts of IT investment (and the enterprise knowledge necessary to make it all work) will call for the management talents and capital-raising capacities of hospitals and physician-group networks, pushing these entities further into the forefront, Field adds.

IT expertise will be needed to do more than construct and connect systems; the huge amounts of data that will be generated will give rise to a new class of data analysts, Field says. IT will no longer be a background

function, but will move to the foreground. CIOs will reign over fiefdoms of data. Analysis of the data will push the whole system forward on both the treatment and the financial sides. Vendors of analytical tools might become key players.

Field identifies five core competencies that will be required of IT: network interconnection, clinical knowledge management, patient activation, financial operations, and population risk management. Guess wrong in building and deploying an information network and an enterprise could be held back for years. He says that he tells hospital systems that if they stick to the basic block and tackle, they are not going to be wrong. Nonetheless, this is no time for IT to be complacent, Field advises.

“At some point, it will switch. The world will turn upside down, going from volume-based medicine to being rewarded for utilization management and shared savings,” Field says. “How do you take a big organization to that new world? We don’t know; it’s the art of management—but IT will empower the system to allow it to do that.”

Private payors and providers are scrambling to prepare for the coming changes, Field says. On the government side, where Medicare will set the payment paradigms of the future, he concludes, “The government train has left the station.”

—George Wiley

James Field


priors

important check on the quality of service that your vendor provides.

As you consider the physics services that you will need to support your accreditation process, these 10 questions can help you identify those with the competence and experience needed to facilitate the process (and to give you confidence that your system is performing well). They will also help you assess the true value of a quote by identifying support services that might or might not be included in the price.

First, are you qualified, under ACR requirements, to perform annual MRI testing? Generally, this will require board certification for medical physicists or an advanced degree and a minimum of three years of experience in testing MRI for those qualifying as MRI scientists. Not all medical physicists have experience with MRI. You can also ask if the tester serves as an ACR reviewer, which shows an extra level of experience. Ask for the tester’s ACR number, and if he or she does not have one, ask why not.

Second, how long does your testing take? To meet the criteria specified by the ACR for the annual exam, even the most efficient and competent MRI physics group will require at least two to four hours. If someone tells you that he or she can finish testing in less time, be very wary.

Third, do you conduct testing outside normal scanning hours? The typical MRI scanner generates about $750 to $1,000 per hour in technical revenue, and MRI testing takes hours. If the physics group requires part of your scanning day for testing, that can cost thousands of dollars in lost patient time. Remember to add such costs when you are comparing quoted fees for services.

Fourth, do you operate the MRI equipment without assistance? This question is very important. Those with limited experience cannot possibly offer you a competent test if they can’t run the MRI system. Would you trust your car to a mechanic who couldn’t drive it? Some argue that they can tell the technologist what exams to run, but why should you pay for a technologist to stay with the tester?

Others might say that they oversee testing by your vendor’s service personnel, but how independent can such testing possibly be? Be extremely skeptical if a group needs any assistance during testing. If you still decide to employ it,

require it to pay for the overtime cost of any assistance that it needs.

Fifth, how many MRI units from my vendor and of my model have you tested in the past 12 months? Just as you would in researching the background of a surgeon for an open-heart procedure, you want someone who has experience with your equipment. Require at least two previous tests, unless you have a very new or unusual MRI model. Don’t be afraid to ask where the previous tests were done.

Sixth, do your reports include all of the test criteria required by the ACR? Some groups try to save time and money by cutting corners. Ask for a copy of a representative report from the group. The ACR has established minimum test requirements in its published quality-control (QC) manual for MRI.1

Check to see whether the testing and the report include all specialty coils used clinically (the report must include the model and serial number for each coil, as well as the transmit gain information from the test); homogeneity testing on the magnet; and luminance testing on the system monitor. Note that the ACR will reject reports not meeting its requirements. If this happens to you, you must get the testing group to return, complete testing, and resubmit the report. This can delay your accreditation significantly.

Seventh, what fraction of MRI units pass your annual testing without any errors? Considering that you pay many thousands of dollars each year for a service contract, who is checking to see whether your vendor is doing a good job? If a physics group usually finds nothing wrong, it might not know how to look for problems that could exist.

With experience based on more than 1,700 MRI tests, I have found something wrong in about 85% of cases. This has saved sites thousands of dollars in monitors, coils, gradient amps, and other components that needed to be replaced, but were not identified as faulty through vendors’ QC activities. Even more important, image quality suffers when the instrument is not performing optimally. If your system is not working as well as possible, you want to know.

Eighth, do you provide QC training for our technologists as a part of your testing? The ACR requires sites to conduct weekly QC that must be checked annually by the physics group. Often, local technologists benefit from a short inservice session,

conducted by the tester, that includes setup of the QC phantom, acquisition and interpretation of the data, and a discussion of how to fill out the required weekly paperwork. Does the physics group charge extra for such training?

Ninth, what assistance with accreditation do you provide? As a part of the accreditation process, the ACR requires sites to submit five scans done on the ACR phantom. These are sent by the ACR to a reviewer for scoring. If the images do not pass a series of tests, the site is sent a notice of failure and must either appeal or resubmit new images (at an additional cost). A review prior to submission can help to identify problems that could result in failure and can save you time and money. Will the physics group conduct a review of your technical images, and does it charge extra for such service?

Tenth, what help do you provide if I fail the technical portion of accreditation? Should you fail, the letter from the ACR will identify the tests that did not meet its criteria. Your physics group should review your submitted images and let you know whether it agrees with the ACR findings. If not, it should help you draft your appeal (this must be done within two weeks of notification of failure).

Some groups offer a guarantee that you will pass accreditation. Be cautious of such claims, since they might constitute a direct conflict of interest. If the testing group has guaranteed passing, will it have a tendency to overlook possible problems?

When comparing the costs and capabilities of different MRI physics services, remember to consider any additional costs for ancillary support that you will need. In-house training for your technologists, a review of your technical images, and support if you need to appeal a failure can add hundreds of dollars, if not included in the basic testing package. Finding faulty equipment also can save thousands of dollars. Competent and experienced MRI physics support should be worth far more than you pay for it.

Robert A. Bell, PhD, is an independent MRI scientist based in Encinitas, California, and a senior reviewer for the ACR®; [email protected].

reference1. MRI Quality Control Manual. Reston, VA: ACR; 2004.

These four projects are blazing a path into cyberspace for image sharing among health-care providers

COVER | Image Sharing

Image sharing yields an impressive host of benefits. Patient care improves with timely physician access to images, and there are much-needed

efficiency gains when examinations repeated due to the inability to access prior images are eliminated. While specifications for image exchange have surfaced in the past decade, few projects have advanced outside the walls of a single health-care entity.

Proprietary solutions have proliferated, in the past year, in the form of software and technologies that leverage the Web (and cloud computing) to make image sharing possible among multiple hospitals, clinics, and imaging centers. Image-sharing projects, however, continue to be stymied by a raft of challenges on the business, legal, and clinical fronts; these include handling referrals, generating revenue, and grappling with patient-privacy issues.

Fox Chase Cancer CenterOne multifacility image-sharing

project—undertaken by Fox Chase Cancer Center in Philadelphia, Pennsylvania—was born of an initiative to streamline the referral process and bolster referral rates. Fox Chase Cancer Center has a staff of 140 physicians, maintains a referral base of approximately 35,000 medical practitioners, and works with a network of about 26 partner health-care institutions in Pennsylvania’s Delaware Valley, as well as in New Jersey.

Some 8,000 new cancer cases are added to its patient roster each year, with about 100,000 radiologic-oncology procedures performed annually.

Not long ago, hospital decision makers concluded that a health information exchange (HIE) implementation was needed to address the volume of images and documents being generated in conjunction with such a heavy patient load. Asked what specific pain points the HIE should address, an overwhelming number of physicians (both on staff and from partner institutions) cited a lack of optimal access to images and laboratory results. Brian Vecchiarelli, clinical systems manager, says, “They wanted a full-bore, interfacility image-sharing system” that would transcend the problems inherent in the use of other image-transport vehicles, such as CDs (see sidebar, page 29).

The Fox Chase HIE (FCHIE) allows the sharing of images among physicians at Fox Chase Cancer Center and its partner sites via password-protected Web portal and VPN. Rather than relying on remote, distributed image storage, as used in cloud-based configurations, FCHIE was designed so that images (and patient data) reside either in the hospital’s PACS or those of partner institutions.

It is constructed on a proprietary HIE services platform that uses, as enabling tools, interoperability profiles published by Integrating the Health Enterprise (IHE). These include, on the image-sharing front, the Cross-enterprise

Document Sharing for Imaging (XDS-I) integration profile (see sidebar, page 30). The DICOM standard constitutes another tool promoting image exchange employed by the hospital, in conjunction with the portal.

Vecchiarelli says that the image-sharing portal addresses Fox Chase Cancer Center’s referral challenges, in large measure, by making it much easier for referring physicians to supply images and data to the hospital (and also to retrieve them). “A transport mechanism of this type is essential to our remaining a partner of choice for our own partners,” he says.

Further leveraging the benefits of image exchange, the institution has constructed a clever business model for the HIE and, by extension, the portal. Under this aegis, partner institutions may—rather than merely using the portal to share images with Fox Chase Cancer Center—employ it to send images and associated data to the hospital for interpretation, on a fee-for-service basis. Two of the hospital’s partners have signed on for such services; marketing campaigns aimed at encouraging others partners to follow suit have been launched.

“Early on in the process of building the HIE, it became clear to us that the grant monies we were allotted to fund it would probably be inadequate to sustain it on a long-term basis,” Vecchiarelli states. Going forward, the fee-for-interpretation piece will be a cornerstone of the financial

22 RadIology BuSIneSS JouRnal | February/March 2011 | www.imagingbiz.com

By Julie Ritzer Ross


Image Sharing:Image Sharing:Image Sharing:

www.imagingbiz.com | February/March 2011 | RadIology BuSIneSS JouRnal 23


framework for additional image sharing, beyond the hospital’s walls.

Vecchiarelli adds that the solution’s key strength—“support for many, if not all, HIE standards”—will pave the way for one of Fox Chase Cancer Center’s next image- and information-sharing steps. He says, ”We want to make images and data available to patients through the portal.” Fox Chase Cancer Center sees that as a natural evolution in the continuum of care—and a move into the cloud is a strong possibility.

The University of Wisconsin Hospital and Clinics

Like Fox Chase Cancer Center, the University of Wisconsin Hospital and Clinics also has constructed a revenue-generating HIE platform with an image-sharing piece. Gary J. Wendt, MD, MBA, vice chair of informatics, professor of radiology, and enterprise director of medical imaging, describes this innovation as “an application service provider for PACS.” It is used by 14 client health-care organizations (hospitals and

clinics of varying sizes) as a repository for (and link to) images and digital reports.

“These sites themselves are separate entities; they have no common electronic medical record (EMR) and no physical equipment for image and data storage and exchange,” Wendt explains. “We maintain one PACS for all of them, and we maintain and manage the cloud,” which is built on a proprietary technology platform through which image (and data) sharing occur as a result of EMR integration.

The PACS is linked to 60 different systems across the 14 client sites; images and data sent to the cloud come from nearly 1,100 DICOM devices. IHE

integrated profile tools, notably XDS-I, are also part of the image-sharing tool kit.

Wendt says that this mode of image exchange goes far toward helping the University of Wisconsin Hospital and Clinics and its client sites improve the caliber of patient care, as well as cutting down on the number of imaging procedures that payors might later deem excessive or inappropriate (and not reimbursable). As he elaborates, “Immediate access to images (in the cloud) is especially critical for us because we are a level I trauma center and a primary stroke center. The ability to view images before a patient arrives—or even before we accept a transfer—as

Early on in the process of building the HIE, it became clear to us that the grant monies we were allotted to fund it would probably be inadequate to sustain it on a long-term basis.

—Brian Vecchiarelli, clinical systems manager, Fox Chase Cancer Center, Philadelphia, PA



well as the ability to avoid unnecessary transfers or decide on the necessary level (helicopter versus vehicle, for example) for an emergency transfer all have a positive impact on care.”

At any site, he continues, additional positive effects come from “avoiding unnecessary travel time, planning resources before patients arrive, and having the opportunity to grab images captured at one facility quickly during follow-up care at another facility. The more imaging that can be put into one bucket, and the more consistent the images across sites—not in 3D at one site and another format in the next one— the better.”

Leveraging the PHRMeanwhile, a move to place control

of images and related examination data squarely in patients’ hands has given rise to RSNA’s Medical Image Sharing Project. Funded by the National Institutes of Health’s National Institute of Biomedical

Imaging and Bioengineering to the tune of approximately $4.7 million, the two-year project centers on a standards-based workflow for populating personal health record (PHR) platforms with patients’ imaging data.

David S. Mendelson, MD, FACR, is chief of clinical informatics and director of radiology information systems at the Mount Sinai Medical Center, New York, New York, as well as principal investigator for the Medical Image Sharing Project.

When the proposal for the project came together in September 2009, he explains, “The prevailing thought was that giving patients control of their imaging histories (reports and images)—much in the same way they have a hand in other aspects of their lives, like online banking—would do away with a lot of the legal and privacy issues that come into play when institutions trade information and images, and these individuals are not directly involved.”

He continues, “We were also aware of

the disadvantages presented by existing image- and information-sharing solutions in that however elegant they are, they are also proprietary and, therefore, neither effective for exchange beyond the realm of local health-care entities nor particularly well priced.”

In addition to the Mount Sinai Medical Center, project participants include the Mayo Clinic, Rochester, Minnesota, and the health-care systems of the University of Maryland, the University of California–San Francisco, and the University of Chicago. About 300,000 patients are expected to interact with the exchange over the course of the project’s two-year time window, Mendelson estimates.

He explains that there are three components of the exchange: RSNA’s edge server, which acts as a conduit among the PACS/RIS of participating institutions and a vendor-neutral cloud archive or clearinghouse; the cloud technology platform itself, developed by a vendor; and individual, standards-compliant PHRs.

All images and related report data from the five participating medical centers flow, via edge server, through the cloud to the participating PHR platforms. Whenever physicians or other providers need to review a report or images, patients can go online and sign on to the appropriate PHR, then view these items on the fly or initiate a full DICOM data transfer into a local archive or another PACS.

Built on an IHE infrastructure, the cloud component includes an IHE registry, a repository, and IHE’s Patient Identifier Cross-reference Manager. The IHE XDS-I.b profile serves as the main transport mechanism between each imaging center and the edge server; the latter uses IHE XDS-I.b to access images from multiple PACS and reports from RIS, and it securely transports them to the clearinghouse. Patients employ one of three PHR mechanisms, Mendelson states.

To address security concerns inherent in any online transfer of information, patients are assigned secure multidigit RSNA ID numbers and a PIN that is hidden from RSNA, much as a the PIN of a bank-card holder is not visible to the bank. When patients access their PHRs,

The prevailing thought was that giving patients control of their imaging histories (reports and images)—much the same way they have a hand in other aspects of their lives, like online banking—would do away with a lot of the legal and privacy issues that come into

play when institutions trade information and images, and these individuals are not directly involved.

—David Mendelson, MD, FACR, chief of clinical informatics and director of radiology information systems,

Mount Sinai Medical Center, NY, NY

These sites themselves are separate entities; they have no common electron-ic medical record and no physical equip-ment for image and data storage and exchange. We maintain one PACS for all of them, and we maintain and manage the cloud.

—Gary J. Wendt, MD, MBA, vice chair of informatics and enterprise director of medical imaging,

University of Wisconsin Hospital and Clinics, Madison, WI


they must re-enter the RSNA ID and the PIN to allow images to be accessed by the cloud. This is an adjunct to any security provided by individual PHRs.

RSNA expects the first version of the project to go live in February 2011. Its funding extends through September 2011—two years after the wheels for the exchange were first set in motion—but Mendelson says that a long-term partnership with one of the vendors is likely. He notes that RSNA has no plans to own the image-sharing solution, citing a few different business models for operating it in the future.

For example, while one prominent PHR vendor currently offers PHR access and accounts at no charge, patients could eventually be required to pay for these services. Alternatively, providers might opt to fund the solution themselves or to build the cost of image exchange into their own fees.

Regardless of how the scenario unfolds, RSNA believes that the strength of the cloud-based solution lies in the fact that

it was built on nonproprietary standards that should hasten adoption down the road. A weakness exists, too. Mendelson observes, “Clearly, image exchange in the cloud is tailored to individuals who are accustomed to using the Internet. Millions—or more likely, tens of millions of people—fall into this category. Some, however, will need additional hand holding.”

The Canadian EffortIn a related vein, all hospitals and

clinics in Canada are engaging in image sharing as part of the implementation of a national EHR solution set to provide all Canadians with secure, interoperable lifetime records of their key health histories and care. Records will remain available electronically, anywhere and at any time, to authorized health-care providers and individuals, with the goal of facilitating the sharing of data across the continuum of care, health-care organizations, and geographic and other boundaries.

Mark Nenadovic, MHSc, serves as Canada Health Infoway’s group director for its iEHR, laboratory information systems, diagnostic imaging, and patient access to quality care programs. He notes that while the EHR solution incorporates an image-sharing component, in part, because diagnostic imaging results, including images themselves, are considered a key component of patients’ health histories, it is also intended as a remedy for myriad other ills.

Specifically, he says, 80% of Canadian health-care facilities are rural and have fewer than 250 beds. While such entities require PACS functionality in order to support the new solution, the bulk of PACS reside at large urban hospitals, and stand-alone PACS installation was not financially feasible for their smaller hospital and clinic counterparts.

Moreover, while these smaller facilities offer diagnostic imaging services, many do not have on-site radiologists; rather, specialty services and associated physicians work primarily in a handful of

Radisphere is a special group of professionals. We staff only the best Radiologists in their areas ofspecialization and hold them to a higher standard of medical and business practice. Our extensivesupport team delivers these decisive, specialized reports within committed turnaround times – thekind of service delivery that increases medical staff satisfaction and expands referral volume andrevenue. And yet Radisphere also lowers the costs you currently dedicate to managing radiology.Allow us to analyze your needs and design a solution where every study is read by the right

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MAKING EVERY IMAGING STUDY THE BEST IT CAN POSSIBLY BE.

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regional and tertiary health-care facilities in Canada’s urban areas. Traditionally, this has impeded timely access to radiologist coverage and specialist consultation, bringing to bear quality-of-care issues—and often resulting in expensive (and frequently unnecessary) patient transfers.

In addition, Nenadovic explains, the Canadian health-care system sees a considerable volume of interfacility patient referral and transfer, but without an image-sharing mechanism, physicians did not have ready access to diagnostic imaging records from other facilities, and an inordinate number of repeated diagnostic imaging procedures were being performed.

Of the $2.1 billion (Canadian) in federal funds allocated to Infoway since its inception, $365 million has been earmarked for diagnostic imaging. Image sharing under Infoway occurs through a network of 19 vendor-neutral diagnostic imaging repositories that consolidate imaging results and, in hub-and-

Radisphere is a special group of professionals. We staff only the best Radiologists in their areas ofspecialization and hold them to a higher standard of medical and business practice. Our extensivesupport team delivers these decisive, specialized reports within committed turnaround times – thekind of service delivery that increases medical staff satisfaction and expands referral volume andrevenue. And yet Radisphere also lowers the costs you currently dedicate to managing radiology.Allow us to analyze your needs and design a solution where every study is read by the right

Radiologist, raising the entire level of radiology for your facility.

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MAKING EVERY IMAGING STUDY THE BEST IT CAN POSSIBLY BE.

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However daunting the concept might appear, migration to image sharing via Web portal or the cloud is seemingly well

worth the effort, given the disadvantages of other options, such as paper printouts, film, and CDs. David S. Mendelson, MD, is chief of clinical informatics and director of radiology information systems at the Mount Sinai Medical Center, New York, New York. He admits that although film and paper printouts can sometimes serve as stopgap or one-time vehicles for sharing isolated conventional radiographs or sets of summary images, they are not sufficiently robust to address all imaging needs on a continuous basis (or on a large scale).

The bulky nature of film and printed images makes them difficult to transport. Moreover, producing film is time consuming, and there is no adjustment for window width and level. The benefits offered by CDs—portability, compactness, the ability to store multiple images from multiple

exams, and a low reproduction cost ($0.50 or less)—do not, for the most part, outweigh their disadvantages.

Mendelson says, “With CDs, be careful what you wish for, because you might get it. About 5% of the discs that we receive at the Mount Sinai Medical Center cannot be imported; similarly, the Mayo Clinic has reported a 0.6% unreadable-disc rate. There is also the rare instance of receiving a different disc than the one that was expected.”

Moreover, Mendelson points out, there is no getting away from the fact that although they are more easily moved around than film is, discs still need physical transportation. The wait for courier services and patients to deliver them interferes with efficient image sharing, especially if a physician needs to seek an opinion from a specialist outside the originating institution. “All in all, image sharing via other means is a preferable approach,” Mendelson believes.

—J.R. Ross

CDs: Migration Is Worth the Effort



spoke fashion, provide a shared PACS application for those facilities that do not have PACS in place.

“Essentially,” Nenadovic observes, “ours is a shared-utility model wherein small and rural hospitals can join larger, urban hospitals in the functionality that PACS provides, as well as the diagnostic imaging repositories’ archiving component. For example, 14 hospital sites in and around London, Ontario, are sharing one instance of a PACS solution maintained by the regional shared services group at the London Health Sciences Centre.” Nenadovic adds that Infoway’s standards collaborative has approved IHE’s XDS-I (and several related integration profiles) for use in

allowing image sharing among the 19 image repositories. Several jurisdictions and their vendors are engaged in projects to comply with the integration standard.

Almost all of Canada’s public hospitals are now filmless, Nenadovic says, with the exception of some smaller, remote locations in the Midwestern portion of the country. Provinces with private-sector imaging clinics are now working toward including their images in the archives.

On the clinician side, Infoway’s image-sharing component is leading to timely consultations, improved workflow and efficiency, and optimal access to images and reports; on the patient side, it’s producing better care by reducing the waiting time for imaging procedures, by decreasing exposure

to radiation from repeated examinations, and by improving remote access to specialists—with the ancillary benefit of lowering the number of transfers from referring hospitals to tertiary institutions.

When the program is fully implemented, Nenadovic says, “The benefits have been estimated as being in the range of $850 million to $1 billion annually, across Canada.” Infoway’s project partners (Canada’s provinces and territories) have been co-investing in the project. Additional funding from the Canadian government is contingent on future health-care priorities.

Julie Ritzer Ross is a contributing writer for Radiology Business Journal.

In 2005, Integrating the Healthcare Enterprise (IHE) published the Cross-enterprise Document Sharing for Imaging (XDS-I) integration profile,

extending the capabilities of XDS by incorporating DICOM instances and providing a blueprint for image exchange among disparate institutions. Nonetheless, the will remained weak through the latter half of the decade when it came to sharing images among institutions, and few projects were mounted that employed the profile.

Six years later, health-care reform, a growing campaign to limit radiation exposure, and a federal push for interoperability in health IT have heightened interest in XDS-I and other image-sharing strategies. On December 2, 2010, at the annual RSNA meeting in Chicago, Illinois, during a session called “Image Exchange and Distribution,” Eugene Igras, president of IRIS Systems (Calgary, Alberta) delivered a high-level review of XDS-I in the context of real-world applications, including large-scale Canada Health Infoway projects.

The typical scenario that Igras lays out is quite familiar: A primary-care physician issues a request for an exam to be performed at a community hospital or a specialty center, frequently by printing a requisition on a piece of paper that is handed to the patient; the technologist at the community hospital acquires the image and stores it in the local PACS; and the radiologist sitting in

a diagnostic imaging outpatient clinic (or another hospital) issues a report and stores it in that facility’s own RIS.

The images and reports sought by primary-care

physicians; the prior examinations required by radiologists; and the laboratory data, medication history, patient demographics, and patient history are all available in segmented places, so making them available with the push of a single button is a complex and expensive proposition that can involve multiple interfaces.

“If you have 10 organizations involved in the provision of care, then you have 10 times nine interfaces—a very expensive enterprise to run,” Igras says. “This is part of the challenge: a complex and expensive venture.”

Apart from cost, Igras enumerates a number of other challenges: limited support for access due to the lack of a universal discovery/retrieval mechanism; difficulties in integrating diagnostic imaging records due to differences in format, semantics, and structure; the difficulty of creating a longitudinal patient record; and the limited assurance of data accuracy, relevance, comparability, and integrity.

“Care organizations store lots of

information,” Igras notes. “You may have a single study that stores 256 slices. Which image is relevant to the case?”

Actors and TransactionsIgras notes that IHE, an organization

formed to improve the way that we share information, has published several integration profiles that tackle sharing patients’ diagnostic imaging records, including XDR (to exchange records electronically using system-to-system messaging) and XDM (to exchange various media, such as CDs or DVDs, that contain imaging information).

XDS was first introduced in 2003 for sharing documents across a network, and XDS-I, introduced in 2005, builds on the profile to share diagnostic images, diagnostic imaging reports, key image notes and overlays, postprocessing measure-ments, presentation states, and relevant images associated with a report. XDS-I is typically used with several other profiles: Consistent Time, Audit Trail and Node Authentication, Patient Identifier Cross-referencing, and Patient Demographics Query.

XDS-I employs four XDS actors (see figure). The first, Document Source, is typically the publisher of the document, and it creates document descriptions (metadata) and supports the submission of document sets. Usually, there would be multiple document sources, either RIS or

XDS-I: Blueprint for Image Exchange

Eugene Igras

Business Using XML.The advantages of an architecture

based on XDS-I include—in addition to the fact that documents can be stored in all kinds of formats—that the architecture is scalable and that it is based on health-care, Internet, and business IT standards. “If you have a solution today composed of multiple systems, you can always add new systems or remove some of the existing systems,” Igras says.

Another benefit of an XDS-I architecture is that it allows a single PACS to operate as the Imaging Document Source, effectively transforming that PACS into a superPACS. “This is practical if you have multiple (and many smaller) sites, and they have multiple PACS vendors,” Igras explains.

In this scenario, the PACS are implemented in such a way that they push information to a diagnostic imaging repository, and that becomes the Imaging Document Source. “It’s a PACS on steroids; it is capable of doing extra things—more than a customary PACS does,” Igras says. “It reduces complexity and cost because, in this case, the only interface I have to implement from my consumer system is to the registry. It improves access, it facilitates the discovery and retrieval of data, it does the integration quite cleanly, and it improves the quality of information.”

XDS-I is not, however, a panacea. A major interoperability issue is finding a way to integrate this document-centered system with other systems based on (or capable of ) transactions that deal with discrete data. “We don’t have a good standard that embraces how to support data synchronization between local/feeder systems and the XDS-I infrastructure in a standards-based way,” he notes. “There are a number of proprietary solutions, but nothing that would be one recipe that would bring it all together.”

Other issues include verifying the quality of data that have been transferred among multiple systems, lack of uniformity across terminology (an underestimated issue), and establishing policies for unaffiliated organizations that use the XDS-I infrastructure. Nonetheless, recognition of XDS-I is on the rise, with more than 30 health IT vendors fully or partially supporting the profile at present, Igras says.

—Cheryl Proval

registered in the Document Registry, which facilitates document discovery.

Document Consumer may, for instance, request all documents on a patient generated in the past six months, and the registry replies with a list of 12 items. The care provider can then choose the items that he or she wants and retrieve the manifests from the Document Repository, identifying the Imaging Document Sources where the images reside so that Document Consumer can retrieve the DICOM objects.

“The system provides you with the capabilities not only to store this information—specifically, the report and the manifest in the Document Repository—but also to link them,” Igras notes. “This is critical so that you know what is linked to what: They are not stand-alone pieces.”

Distributed Image and Document Sharing

Igras says that the architecture of XDS-I can support enterprise image sharing, as well as a document-centered health record in which the documents are stored in a persistent way. Because the source documents remain autonomous, you don’t have to push the images anywhere; you just access the data from the PACS. It uses the publish-and-subscribe method, and the registry, which Igras calls the heart of XDS-I, is based on the standard called Electronic

www.imagingbiz.com | February/March 2011 | Radiology Business JouRnal 31

other repositories that store documents of all kinds. The second actor, Document Repository, is responsible for the persistent storage of documents and imaging manifests, and for their registration in the third actor, Document Registry, which is basically a registry of pointers or metadata. This is where information about the documents themselves is stored. The fourth actor, Document Consumer, is the application that issues queries to find the information needed to retrieve the document.

In addition, the profile uses two imaging-specific actors. The first, Imaging Document Source, is a producer and publisher of imaging documents, responsible for providing documents, metadata, and imaging manifests to the Document Repository and for supporting the retrieval of DICOM objects referenced on a published imaging manifest. The second imaging-specific actor, Imaging Document Consumer, accepts the imaging manifests and retrieves documents from the imaging document source using DICOM and WADO.

Vital to trafficking, the manifest created by the Imaging Document Source is a document that identifies the author of an image, when it was captured, who the patient is, and many other data points about the image itself. The manifest is published in the Document Repository and stored as a document. Subsequently, the manifest is

Figure. The XDS-I profile uses a set of actors from the XDS profile, as well as two imaging-specific actors, to facilitate the transactions required for enterprise image and document sharing. Green denotes actions based on the HL7 standard, blue indicates DICOM, red indicates EB XML, and purple denotes HTTP Get (a WADO–HTTP based transaction designed to access DICOM objects from a Web browser using HTTP); image courtesy of Eugene Igras, IRIS Systems Inc (Calgary, Alberta).

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All Clouds Are Not Created Equal

In the collaborative models described here, education, service, and collegiality have ensured radiologists a seat at the cardiac-imaging table—sometimes, near its head

CardiaC imaging | Models of Collaboration

Cardiology and radiology: Are they two specialties working in tandem for optimal patient care or two opposing armies in

a turf battle? The answer, of course, is complicated, and can’t be approached without an acknowledgement of the ground already ceded to cardiology.

In today’s hospitals, cardiac ultrasound, cardiac catheterization, and (in many cases) nuclear cardiology are all the purview of the cardiologist. Newer, noninvasive techniques such as CT angiography (CTA) and MR angiography provide a fresh proving ground for each of the two specialties to demonstrate their unique worth—while they are under pressure to care for patients more efficiently and cost effectively than ever.

As cardiologist Guy Weigold, MD, director of cardiac CT at Washington Hospital Center, Washington, DC, points out, “You take an image of the heart, and put it in front of a cardiologist and a radiologist, and those two people are going to see very different things. The cardiologist is going to see the disease and innately understand the clinical implications, but would have a hard time appreciating the subtleties of the artifacts. The radiologist, on the other hand, might have a better understanding of the artifacts and other issues related to image quality, but doesn’t innately understand the clinical implications.”

Models for collaboration between cardiology and radiology vary widely. At Washington Hospital Center, for instance, the bulk of cardiac imaging is handled by cardiologists, although cardiac CT and MRI are still shared. Cardiologists do an initial interpretation for disease, and radiologists perform a second interpretation with the intention of identifying any incidental findings and issuing necessary follow-up recommendations.

By contrast, at the University of Maryland Medical Center (UMMC) in


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Baltimore, radiologists still perform most cardiac imaging, according to Charles White, MD, chief of thoracic radiology. “We’re all the way on the side of the spectrum where radiology really does the bulk of the CT and MRI,” he says. “We do it all. We’re happy to have the cardiologists’ participation, but the issue has been that they are involved in so many other things that there hasn’t been anyone with the time or bandwidth to be heavily involved from their side. We value their clinical expertise, but the protocol, patient work-up, and decision making of the imaging piece are all performed within radiology.”

natural EvolutionThis model evolved, White says, from

the fact that the radiology department at UMMC was an early developer of a strong cardiac MRI program. When cardiac CT became increasingly prevalent, it made sense for radiology to continue superintending its use.

“It was not much of a stretch for us to expand into cardiac CT,” White recalls. “A turf battle is more likely to occur when you have a vacuum—when there wasn’t a cardiac CT or MRI program before, it was new ground, and so it became a new negotiation. A lot depends on referral patterns and on whether the services and relationships that already exist are good.”

Ricardo Cury, MD, director of cardiac imaging at Baptist Hospital of Miami in Florida and of Baptist Cardiac and Vascular Institute, concurs. “Of our cardiac CT, 40% to 50% comes from the emergency department, and radiology already provides emergency-department work for CT imaging, so it makes sense for radiology to do cardiac CT for the emergency department as well,” he says.

He adds, “We also have a history, here at Baptist Hospital of Miami, of over 15 years of providing very good service for nuclear

cardiology due to the efforts of Jack Ziffer, MD. That helped, over time, to maintain cardiac CT and cardiac MRI. Obviously, building that confidence from other clinicians is a process that takes time.”

James Earls, MD, a radiologist with Fairfax Radiological Consultants in Virginia, notes that in the case of his group, its primary hospital client tasked it with developing a program that would be shared between cardiology and radiology. “When we went out and purchased the cardiac CT scanner for the hospital, it said we would share it equally,” he says. “Because we have an established outpatient cardiac CT program (we’ve been doing it

since 2002), the cardiologists had a lot of respect for the radiologists’ experience doing it even before we opened the joint program at the hospital.”

He adds, however, that Virginia happens to be a very restrictive state when it comes to issuing certificates of need; otherwise, most of the cardiology practices probably would have tried to get their own scanners in the past.

What of scenarios wherein the natural evolution of roles has favored cardiology, not radiology? “Cardiac CT and MRI are relatively new fields,” Weigold notes. “The bulk of the work being done on any given CT or MRI system in the hospital is, far and away, not cardiac in nature. Here, I think the radiologists feel they have tons to do already; they’ve never felt the need to try to wrestle it away from the cardiologists. At the end of the day,

a lot comes down to the economics of things—the practicalities.”

The Efficiency FactorIn many cases, in fact, it would

appear that the turf battles of a happier, wealthier time in health care have all but evaporated. In today’s hospitals, efficiency is the watchword when it comes to caring for cardiac patients. “Everyone’s busy, and there’s a lot of work to be done,” Weigold says. “It’s not efficient to have two physicians working on the same task together. That’s the major hurdle: How do you make it efficient?”

In fact, Washington Hospital Center’s collaborative cardiac program began with Weigold and a representative from the radiology department literally reading each case shoulder to shoulder—an arrangement that enabled each to learn from the other, but that proved to be cumbersome over time.

“Up until recently, the radiologists were occasionally doing the initial

reading of the study, but the radiologists have become so busy with their own CT work that they don’t anymore,” he says. “Right now, we have three cardiologists reading scans each day, and the radiologists look at the scans separately for incidental findings. The final report is a collaboration—they’re still with us, but in a virtual way.”

In a similar way, White observes, the cardiologists at UMMC have plenty on their collective plate without dipping a toe into cardiac CT and MRI. “I don’t feel that the cardiologists want to be doing more,” he notes. “They’re busy in many other aspects of cardiac imaging, including echocardiography, catheterization, and transesophageal echocardiography, so they have a nice amount to do. We’ve had a very amicable relationship with them over the years.”


We’re all the way on the side of the spectrum where radiology really does the bulk of the CT and MRI. We do it all.

—Charles White, md, chief of thoracic radiology, University of maryland medical Center, Baltimore, md

Of our cardiac CT, 40% to 50% comes from the emergency department, and radiology already provides emergency-department work for CT imaging.

—ricardo Cury, md, director of cardiac imaging, Baptist Hospital of miami, miami, FL


At Fairfax Radiological Consultants’ hospital, where cardiac imaging is shared as evenly as possible between the two specialties, a reading panel is split between cardiologists and radiologists who alternate half days. “We obtain the study and interpret it, and we dictate the results into our PACS, where they’re accessible for the cardiologists,” Earls says. “Both sides read their studies in a timely fashion—the morning shift, by 1 pm, and the afternoon shift, by 5 pm.”

He adds, however, that it would be much more difficult for a general radiologist to maintain this pace. “Several of our radiologists are cardiac specific, and that’s very helpful,” he says. “The fact that we’re subspecialized makes a big difference.”

At Baptist Hospital of Miami, the imperative for increased efficiency has been a boon to the radiology department. “Radiology brings a lot to the table because you have one physician reading the whole image, as opposed to a model wherein two physicians read one study,” he says. “That would be cumbersome—and even more cumbersome if you’re providing the service beyond regular hours.”

This, of course, raises the issue of the detection of incidental findings outside the heart. While Weigold and Cury both take it as an assumption that incidental findings by radiologists should be a consideration in parceling out cardiac imaging, Earls is operating in a hospital that no longer pays for the second interpretation. “My group said we wouldn’t do it anymore,” he says.

At the 2010 annual meeting of the RSNA in Chicago, Illinois, Earls presented “Cardiac Imaging: Should You Evaluate or Ignore the Extracardiac Structures?” on December 1, as part of a controversy session on this topic. The approach he advocates for those facing similar financial sanctions is one of informal, collegial collaboration.

“In theory, as radiologists, we’re responsible for everything on the film, and a small (but significant) number of people will have clinically important extracardiac findings,” he says, “but that doesn’t mean cardiologists can’t be trained to find them. Often, they’ll call us and say, ‘There’s something in the lung here,’ and we’ll take a look. We don’t get paid for it, but we’ll informally tell them, and we’ll recommend an additional study as necessary, depending on the finding.”

Business modelsMoney, as Earls’ experience indicates,

is a critical factor in how collaboration between cardiology and radiology develops. “There are places where the cardiologist reads the heart and the

Ask cardiac imagers from both sides of the care team—cardiology and radiology—what they see as the most critical advance in imaging

technology, and their answers all have one thing in common: dose reduction. “Prospective gating (or step and shoot) is one; iterative reconstruction is another,” according to Charles White, MD, chief of thoracic radiology at the University of Maryland Medical Center in Baltimore.

Guy Weigold, MD, director of cardiac CT at Washington Hospital Center, Washington, DC, from the cardiology side, concurs. “CT is a very nice example of how we can use a noninvasive method to get a ton of information on the status of someone’s heart function and disease, and tremendous strides have been made in getting that information with lower and lower radiation exposures,” he says.

He, too, cites prospective-triggering techniques and iterative reconstruction as game changers, saying, ”When you look at cardiac CT now, it’s actually one of the most

innocuous tests that uses ionizing radiation, and it gives us a wealth of information, compared with, say, a stress test.”

Ricardo Cury, MD, director of cardiac imaging at Baptist Hospital of Miami in Florida and of Baptist Cardiac and Vascular Institute, adds, “In 70% of our cases, we are using prospective triggering, which significantly minimizes the radiation dose to levels of 2 or 3 mSv—which is very low, compared with most diagnostic tests. That has been a major achievement.”

James Earls, MD, a radiologist with Fairfax Radiological Consultants in Virginia, notes that in the software arena, automated reconstruction of complex datasets has been a boon to imagers’ efficiency and confidence. “The automated software we now have for both MRI and CT has made our jobs much easier in terms of processing and reading these studies—and made us better and more accurate, too. I’ve gone from spending an hour on a cardiac CT case to a few minutes or less,” he says. Weigold agrees, saying, “Automating the process, to make it as consistent as

Technical Advances: radiation-sparing Techniques and automated aV Toolspossible from one reader to the next, is key.”

All four imagers note that each of the major CT vendors seems to be taking a different path to higher image quality at a lower dose, and Earls speaks for the group when he says, “We’re trying to figure out which is the best way, which is fun.”

Cury adds, “Each vendor definitely has its own pathway; they are all facilitating how we acquire these studies in a shorter period of time, with better diagnostic image quality and better spatial resolution, leading to further improvement in the accuracy of CT angiography.”

As the technology continues to improve, Weigold takes heart that imaging will facilitate earlier and earlier diagnosis of coronary-artery disease and other cardiac conditions. “Once cardiac disease has progressed, there’s not much you can do about it except bypass,” he says. “A lot of people are still walking around with undiagnosed coronary-artery disease. CT will be the way of the future to pick it up earlier.”

—C. Vasko

Several of our radiologists are cardiac specific, and that’s very helpful. The fact that we are subspecialized makes a big difference.

—James Earls, md, Fairfax radiological Consultants, Fairfax, Va



radiologist reads the rest, which to me is less than optimal,” White says. “I’d like radiology to have a piece of the heart. You can always have one of each on a study, but the problem is that Medicare requires one primary name on a study.”

At UMMC, where radiology has what White characterizes as a huge component of cardiac imaging under its purview, “Our business model is radiology predominant,” he says. “The business piece of it, the reimbursement, all goes to radiology. Cardiology does not share in that.”

Fairfax Radiological Consultants’ cardiac program at its hospital solves this problem by splitting interpretations as evenly as possible between cardiology and radiology, with each side acting as an informal consultant to the other as needed. Even this simple arrangement is the result of some negotiation on the part of both specialties, Earls notes.

“There was a loophole when we set up the nuclear-cardiology program,” he says. “They were alternating a cardiology reader with a radiology reader, but if a patient was referred from a cardiologist’s practice, he or she could still read those cases, allowing the majority of studies to be read by someone who wasn’t the assigned reader.” When it was time to establish the hospital’s cardiac CT program, Earls was alert to the possibility of this loophole recurring: “I put some things in place to make sure we’d really be doing it 50–50,” he says.

At Baptist Hospital of Miami, which specialty handles a patient’s interpretation is dependent on a number of factors, including the clinical indication and the source of the referral. “Here, cardiology is mainly doing echocardiography. Nuclear cardiology is shared (nuclear radiologists perform the interpretations and cardiologists perform the stress tests), and radiologists trained in cardiac imaging are doing cardiac MRI and CT,” Cury says. He attributes radiology’s

success in these two modalities to its provision of CT interpretation for the emergency department (and to high-quality service).

“We worked out a very good model on patients presenting with chest pain to the emergency department; if their risk score on the scale for thrombolysis in myocardial infarction, or TIMI, is 0, 1, or 2, we do coronary CTA (CCTA), and if it’s more than 2, we do myocardial-perfusion imaging with SPECT,” he says. “We have our own data showing that CTA really decreases the length of stay in the hospital for patients with chest pain, and it is very accurate. There’s a unique opportunity for radiology in getting involved with this type of imaging in the emergency department, and a lot of data supporting the use of CCTA in that setting.”

At Washington Hospital Center, where cardiology controls most cardiac imaging (with the exception of overreading by radiologists), Weigold notes, turf battles have been avoided largely as a result of a strong, respectful relationship between the two specialties. “It was naturally fostered because we were under the same roof, which is a little unique,” he says. “It may be the reason the paradigm is not replicated much in the community.”

Serving Each OtherBoth sides agree that providing the

optimal level of service to each other enhances collaboration—and, of course, improves patient care. “Level of service is fundamental,” Cury says. “With our emergency-department interpretations, every case is read in less than 60 minutes. This is not easy to achieve—by the time the scan is done, you have a lot of images to process and reconstruct, but it improves our interaction with cardiology and emergency-department physicians by providing that good service. We call and discuss the results with them, and we’re also available to discuss which tests would

be best for the specific clinical situation.”White adds that providing good

service is one way that radiologists can maintain their place at the cardiac table. “If you’re not giving anyone else a reason to home in on the business, it lessens the chance that will happen,” he says. “A good service model is key, and you have to be willing to talk. If there’s a desire for cardiologists to get involved in imaging, it’s not realistic or wise to shut the door. Cardiologists have the patient—that’s a big advantage, and it would be silly to alienate them. My approach is to provide good service and keep an open door.”

Earls agrees. “I try to attend a lot of the multidisciplinary meetings where surgeons and cardiologists get together—being there, being able to speak the lingo, ensures you still have a place in the imaging,” he says. “A lot of people just sit up and demand it, whereas we’ve been demonstrating that we do a good job. The cardiologists respect us—they’ll give us a study and ask our opinion. We’ve had some turf issues over the years, but we treat each other respectfully.”

Cury also notes that education is critical. “It’s important for radiology to have expertise in cardiac imaging and sufficient training to provide the service at a high level, as well as to work with the cardiologists and emergency-department physicians to develop protocols and try to select the best test for the best patient,” he says. “I’ve also seen many cardiologists who have a lot of experience with CCTA, and over time, they can identify major pathologies outside the heart. This shouldn’t be an argument for radiology to have a place in cardiac imaging: The most important argument is for a high level of training and service to each other.”

Weigold concludes that the success of collaborations between cardiology and radiology will largely be dependent on the attitudes of the individual clinicians involved. “It has a lot do to with personalities and their tolerance, willingness, and interest in getting this collaboration going,” he says. “Here, we quickly found out that we could learn a lot from each other.”

Cat Vasko is associate editor of Radiology Business Journal.

It has a lot to do with personalities and their tolerance, willingness, and interest in getting this collaboration going.

—guy Weigold, md, director of cardiac CT, Washington Hospital Center, Washington, dC

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Case Study

St. Joseph’s Healthcare System: Successful PACS Replacement Across a Multi-hospital Healthcare System

OverviewThis case study examines one healthcare system’s experience transitioning from a legacy PACS to a newPACS from a different technology vendor. Historically, PACS replacement has been so problematic, costlyand disruptive to radiology operations that healthcare systems have tried to avoid PACS replacement despite high levels of dissatisfaction with an existing PACS vendor. This case, however, shows how superiorpreparation and a results-oriented PACS vendor can minimize the downside and optimize the upside ofPACS replacement.

St. Joseph’s Regional Medical Center (SJRMC), a leading academic tertiary medical center and state designated trauma center, consists of three hospitals and two outpatient imaging centers in northern NewJersey. St. Joseph’s was an early PACS adopter, implementing its first PACS in 1996 and replacing it with oneof the big modality vendor’s PACS in 2003. When they set out to replace their PACS again in 2008, they already had two PACS vendors under their belt and 12 years’ PACS experience.

St. Joseph’s had some compelling reasons for PACS replacement. The radiology department in one hospitalalone was performing nearly 300,000 imaging procedures a year and the legacy system was unable to handleincreasing data storage and distribution requirements. The system crashed often resulting in downtime thatcost the healthcare system operationally, as well as delaying treatment and extending patient length of stay(LOS). Adding insult to injury, SJRMC was still printing and storing film for Ultrasound, Nuclear Medicine,Angiography, and Mammography. This constituted about 35% of total image volume.

Moreover, thriving in the very competitive New York metro area required SJRMC to stay on the leading edgeof technology, providing a state-of- the-art imaging service to the referring community. They needed to moveaway from outdated, thick–client architecture and implement a true web-based system that would enableradiologists to do primary reads remotely, and allow referring physicians to access images via the Internet.

SJRMC approached PACS replacement with trepidation, but knew how to leverage their experience totheir advantage.

The Challenge

SJRMC issued a PACS Request for Proposal (RFP) in January 2008 stating that the replacement PACS vendorwould be required to create one archive across the health system for consistent patient identification andimproved access to images and information. This involved migrating 7 years’ worth of images and associateddata. They wanted to eliminate “silos” of information stored in different locations, and fully intended this tobe their last “forklift upgrade.” High- availability and scalability were key requirements.

Other requirements defined in the RFP include:

• Improving imaging services’ productivity and workflow through filmless and paperless processes; • Reducing operational costs and imaging service inefficiencies;• Enabling SJRMC to incorporate future imaging service opportunities (new radiology imaging

technologies, cardiology, and other ‘ologies);• Supporting radiology service 24/7 with provision for remote reading and enabling Referring Physi-

cians to access images and reports through a common portal;• Reducing hospital length of stay (LOS) at Wayne Hospital – by 6 hours / 0.25 days;• Providing 99.99% PACS system availability (uptime) for components, systems (hardware) and software.

Jim CavanaghVP/CIO

St. Joseph’s Healthcare System

“This wasthe most

uneventful ‘go live’

I have ever experienced.”

Infinitt_CaseStudy_7.875x10.875_Layout 1 12/29/10 1:30 PM Page 1

SJRMC radiologists read by subspecialty area (e.g., Diagnostic, Body CT, Brain, etc.) and the exams are read across all facilities. The radiologistswanted the new PACS to provide a centralized image-reading model that would quickly provide all exams to key reading sites such as the imagingcenters. They also wanted customized reading worklists that would enable them to continue their specialty reading processes when readingfrom any location.

After all their due diligence, the challenge was to find a technology partner that would have an equal stake in the project, and accept penaltiesif performance fell below their standards.

The Solution

SJRMC chose INFINITT North America as their replacement PACS vendor in 2009,having been impressed with the radiologists’ user interface, Infinitt’s reputation forcustomer support and their sophisticated technology solution. They liked the factthat INFINITT was a nimble company, yet had solid financial backing and experiencewith hundreds of installations globally. They recognized INFINITT’s strong commit-ment to R & D, evidenced by their track record for upgrading and refining theirproducts, and developing their own interfaces, migration tools and gateways.

In 2009, INFINITT migrated 30 terabytes of data to an existing SAN archive and implemented the system across five locations: a freestandingdata center, St. Joseph’s Hospital, St. Joseph’s Wayne Hospital and two imaging centers. Four separate HL7 interfaces were fully-tested beforego-live. The rollout went smoothly, exceeding everyone’s expectations. According to Jim Cavanagh, CIO/VP at St. Joseph’ Regional MedicalCenter, INFINITT was the only one of six PACS vendors considered that proposed to handle data migration internally. INFINITT had experiencemigrating huge volumes of image data from more than 20 different vendors’ globally.

“Bundled in with the new PACS system, the INFINITT migration solution was much less expensive than the third-party solution proposed byother vendors. INFINITT was also the only vendor to propose a virtual environment for failover and high availability,” said Cavanagh.

Shortly after the contract was signed, Infinitt migration specialists analyzed SJRMC’s legacy PACS data, and developed a strategy that wouldenable the full database to be migrated before the new PACS went live. INFINITT used additional migration gateways to speed the migrationprocess: 30 terabytes of data were transferred within a 6-month period. On the day the system went live, Jim Cavanagh made the remark thatit had been the most uneventful go live he had ever experienced.

SUMMARY OF RESULTS

• Report turnaround, measured from exam completion to report signature, was reduced by 30% within the month after ‘go live’, and42% in total, while exam volumes have increased about 8% annually.

• Remote access and roaming protocols now support sub-specialty reads, making it possible to leverage the radiology group’s expertise.

• St. Joseph’s has now eliminated film for interpretation in all areas except mammography. The film processor has been relocated tothe Radiation Oncology department.

• A dramatic reduction in paper handling has saved more than one FTE (full time equivalent) at St. Joseph’s hospital alone, allowingthat labor to be shifted to technologist staffing. (Techs doing non-tech jobs also causes other inefficiencies such as poor utilizationof modalities.)

• Documentation needed by the radiologists is scanned into PACS and readily accessible with exam images. This also factors into patient safety, as it’s much easier to lose a paper-based note than an electronic one.

• With an ED Notes feature, communication between the ED docs and radiologists has improved greatly, and the radiologist is oftenable to read the study before the patient leaves the table. The ED doctor gets instantaneous feedback; if another view is needed,they can get it right then -- eliminating the need for an additional appointment.

• With all facilities operating on the same software version with the same application, there are no extra functions or steps requiredfor updating or synchronizing other databases.

Infinitt_CaseStudy_7.875x10.875_Layout 1 12/29/10 1:30 PM Page 2

Though technological, logistical, and political hurdles confront those seeking enterprise image management, the goal is worth pursuing and progress is being made

PACS | Enterprise Image Management

Radiologists have become PACS experts, sometimes by default. Because diagnostic images made the greatest demands on

early information systems in health care, the most sophisticated systems were first developed to handle these images and associated data. These systems became PACS, which grew out of the homegrown image-management systems of academic radiology departments to become commercial products; eventually, they became essential to the practice of radiology in hospitals and radiology practices.

Because PACS grew out of radiology departments, radiologists have never been simply consumers of a PACS product in the way that banks, for example, are purchasers of financial-transaction software. Radiologists were fully involved in specifying and troubleshooting commercial PACS, even after the systems had been widely adopted, and commercial PACS offerings could not have been developed without the input of the radiologists who used the first systems.

40 RadIology BusInEss JouRnal | February/March 2011 | www.imagingbiz.com

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PACS | Enterprise Image Management

This did not mean, though, that the needs of radiologists always drove the implementation of PACS. For some institutions, the cost savings associated with eliminating film (and its libraries and associated staff) became the primary driver; the increased procedural volumes that could be handled when the film-based radiology department went digital were also powerfully attractive.

The increase in the quality of care that is likely to result from PACS use is another strong motivator, since the typical PACS installation can reduce the time that elapses between image acquisition and patient-care decisions, can reduce the need to repeat examinations due to the loss of films, and can provide better access to prior studies for comparison. In addition, PACS can keep referring physicians happy by providing rapid access to images and reports.

Many of the reasons to adopt PACS, therefore, were as compelling to the institution as to the radiology department. This continues to be the case—and now, the same cost, quality, and competition concerns have extended the need for PACS beyond radiology to every specialty that uses and retains images in the course of diagnosis and treatment.

Because radiologists are the physicians with PACS experience, they are being consulted in the process of expanding PACS use to the enterprise level. Sometimes, they are also being expected to allow other specialties to ride piggyback on their existing PACS. Because making PACS work outside radiology involves much more than simply enlarging an archive’s capacity or adding workstations in other departments, this piggyback PACS may be an idea whose time has not yet come.

According to “Enterprise Imaging,” which was presented on November 29, 2010, at the annual RSNA meeting in Chicago, Illinois, it could be too soon to expect a PACS solution that is perfect—straight off the shelf—for the entire enterprise. Because the need for the advantages of PACS is obvious to institutions, to specialists who use images, and to many of the physicians who refer patients to them, the search for the fully integrated enterprise PACS continues.

As information systems increase in processing power and archival capacity, that goal comes closer to reality, but as the three presenters report, each specialty has workflow and image-handling needs that must be taken into consideration as the enterprise PACS is built. Radiologists, to preserve the integrity and function of their own PACS, should be prepared to explain to cardiologists, pathologists, and other image users that they can’t just plug their departments into the existing PACS somehow. Planning, hardware and software outlays, and workflow adjustments are all to be expected first, and a thorough understanding of how each specialty uses images is required.

PACS for CardiologyBenoit Desjardins, MD, PhD, is

assistant professor of radiology at the Hospital of the University of Pennsylvania in Philadelphia. He is a

noninvasive cardiovascular radiologist who works closely with the hospital’s cardiology service, he reports. “I have dual appointments in cardiology and radiology, and by knowing very well what IT is in radiology, I can appreciate that IT issues in cardiology are different,” he says. “The first major difference is cardiology data: It has another level of complexity, and there is a mix of both imaging and nonimaging data.”

He continues, “Cardiology information is inherently 3D in nature, in a way that’s quite different from radiology information. In radiology, we use 3D all the time in reconstruction, but it doesn’t typically give us much more information. In cardiology, though, you’re dealing with branching structures, and when you look at them in 3D, it really adds a lot

of information. Cardiology imaging also makes use of color, so PACS needs to be able to handle these images with color displays.”

Cardiology, however, has much in common with radiology where image management is concerned, and many cardiology exams use the same modalities involved in radiology studies. The two specialties have CT, MRI, ultrasound, and nuclear-medicine modalities (including PET, SPECT, and scintigraphy) in common; in smaller facilities, they might be sharing some or all of that equipment.

These similarities have had a twofold effect on the adoption of PACS in cardiology. The broad use of digital imaging has made cardiology the easiest first step in extending a radiology PACS to another department, especially in cases where the equipment is already delivering images to the existing PACS for radiology studies.

Unfortunately, their reliance on the same technologies has also meant that, in many hospitals, cardiologists and radiologists have been competing for the same cases ever since the imaging equipment was installed. This has influenced the ability of the two specialties to cooperate in planning and implementing a PACS that could serve them both.

In some hospitals, the result has been the creation of an isolated PACS for each specialty; in others, cardiology has made do with less-than-PACS information systems because no agreement to let cardiologists make any use of a radiology department’s PACS could be reached.

Despite the similarities between cardiology and radiology in equipment use, the piggyback PACS is not an

42 RadIology BusInEss JouRnal | February/March 2011 | www.imagingbiz.com

In radiology, we use 3D all the time in reconstruction, but it doesn’t typically give us much more information. In cardiol-ogy though, you’re dealing with branching structures, and when you look at them in 3D, it really adds a lot of information.

—Benoit Desjardins, MD, PhD, Hospital of the University of Pennsylvania, Philadelphia, PA


adequate solution, Desjardins says. The primary problems, he adds, are cardiology information’s lack of integration, lack of standardization, and lack of access/distribution.

For technologies not shared with radiology, Desjardins says, there are several problems that are an additional challenge for enterprise information management. Many systems are proprietary; dedicated, single-purpose workstations are frequently in use; there is little or no standardization of output (with free text being common in reporting); and the equipment is often unable to communicate with PACS or with other information systems. Desjardins describes image-management systems in cardiology as being roughly as advanced as radiology PACS were in the 1990s, so there is substantial room for improvement.

Even if cardiology is the specialty most like radiology in its image-management needs, its workflow is still quite different from that of radiology, and the most efficient PACS implementation for cardiology must accommodate these differences. “The workflow in cardiology is also very different from the workflow of radiologists. Typically, the cardiologist will have a mixed workflow involving some imaging,” Desjardins says, but also incorporating outpatient visits and inpatient rounds.

“In radiology, most studies are elective and are, therefore, scheduled in advance and interpreted later. In cardiology, most studies are stat cases. They are performed with almost no data entered in the information system beforehand, and the cardiologist interprets the images as they are being acquired. In radiology, images are shared with the rest of the hospital; in cardiology, they are typically not shared, although there are exceptions,” he adds.

“Another difference is that cardiology images can be separated by hours, or even days. Exams take much longer to acquire than a typical radiology exam,” Desjardins says. Some two-part tests might be conducted with 24 hours between segments, for instance, so that the cardiologist can observe changes in perfusion, or between stressed and resting states.

In some cases, radiology-department PACS have been customized to accommodate the workflow of cardiac radiologists (which resembles that of cardiologists), so these systems will be less likely to require major modifications before they can be used by cardiologists. Elsewhere, a fair amount of tinkering might be required before the highest levels of efficiency can be achieved in a joint cardiology–radiology PACS.

“One of the main differences in imaging is that cardiologists are trying to image the heart—a structure that moves. It moves in a cyclic fashion, though, so imaging only needs to record one cycle and then play it over and over again to get all the information that’s needed about the motion of the heart,” Desjardins says. “Other images in cardiology are vascular, so they do not deal with a structure that moves, but they are dynamic themselves—they could represent the progression of the injection of a contrast agent into a vessel, for example, to detect lesions or asymmetry in filling of the vessel.”

Desjardins says that capacity is another issue that requires attention. “There’s been a huge volume surge in cardiology imaging data. The imaging technologies used in cardiology now generate much more information, and there has also been an increase in imaging activity in cardiology. There are more patients, but there’s also more of an imaging focus in cardiology, and there’s more of a need for digital management because of this

explosion of information,” he says. “You need a lot of storage, and you need generous bandwidth to handle the data.”

Cardiology uses a different set of views (based on echocardiography conventions) than those that radiology uses, Desjardins explains, so a PACS must be able to manage those differences, in addition to the more quantitative nature of cardiology data and the presence of nonimaging signals (such as ECG output) that must be coordinated with the images.

Enterprise integration of cardiology can be done, Desjardins says, in steps. Initially, he recommends sharing storage with radiology for economies of scale. Further integration will proceed in stages, but the organization must first decide whether support for any merged systems will be provided by cardiology, radiology, IT, or some other department.

“More advanced ways to display cardiology images are coming to market right now,” Desjardins reports. Some hurdles will be technological, but the main obstacles will be logistical and political. “After the problems of integrating cardiology have been solved, then the issues involved in integrating the enterprise can be addressed,” he says.

PACS for PathologyPaul J. Chang, MD, is professor and

vice chair of radiology informatics and medical director of pathology informatics at the University of Chicago School of Medicine. He notes that the benefits of infrastructure integration are considerable for both pathology and radiology departments. “Their deliverable, like ours, is a report based on the interpretation of images, even if their images are slides. As we have embraced structured reporting, they also have a similar initiative (called synoptic reporting),” he says.

There are many similarities in the image-management needs of the two specialties, but there are additional requirements, specific to pathology, that are unlikely to be met by existing radiology PACS without modification. “Anatomic pathologists are really trying to model what radiology has done, in the past few years, in their workflow. Some of that makes sense, but some of it does not, because we are very different—but

PACS | enterprise image Management


similar enough to make some of the same mistakes,” Chang says.

The nature of the anatomic-pathology workflow is a particular challenge, since it is quite different from the typical workflow pattern seen in radiology departments. Radiology workflow has been shaped by RIS availability, but anatomic pathology has not been affected by the use of similar systems because the laboratory information systems used by some clinical pathologists have not often been used to handle anatomic pathology.

As a result, Chang says, many (if not most) anatomic pathologists have no advance notice that a case is on the way to them. Instead, it is added to the worklist when a new specimen bucket is delivered to the rack that often serves as a pathologist’s inbox. “If the first time we knew that a CT scan was to be interpreted was when a patient just hopped onto the CT scanner—without any scheduling—how efficient would our department be? That’s how pathology runs in the vast majority of places,” Chang says.

In addition, pathology poses greater challenges in image management than cardiology does because so much of the work is analog in nature. Instead of beginning a case with the acquisition of digital images, as radiologists and cardiologists who use PACS nearly always do today, the anatomic pathologist begins with a piece of the patient.

While the pathologist’s report can be structured so that it becomes digital more easily, and while pathology images can be digitized—or, in some cases, captured using cameras and microscopes capable of generating digital output—there is no digital replacement for the thoroughly analog anatomic specimen. It must be manipulated in several ways before a slide can even be ready for the microscope.

In many anatomic-pathology laboratories, Chang says, the only digital

element of the workflow is that the images are digitized at the end of the process (if at all). “The fundamental thing that we exploit, in radiology informatics, is the fact that at the time of acquisition, everything is digital. Anatomic pathology is still not digital until the end,” he explains. The typical case-organizing mechanism in anatomic pathology is also an analog item: specimens, slides, notes, and reports are held together using the thick rubber bands more often found in produce departments, holding together bundles of broccoli.

It’s very difficult to justify complete digital pathology archives, from a business perspective, Chang says, because an anatomic-pathology department (when its images are digitized) can generate 10 terabytes of data in a day—more than a typical radiology PACS handles in a month. A single slide can require 15 gigabytes of storage for just one of multiple focal planes.

Chang says, “Many of the researchers and vendors in pathology informatics actually have it wrong, though. They think that they are too much like us, when in reality, their use of digital information is very different.” Pathologists don’t require comprehensive prior studies for comparison; they usually need only a single slide, and it will have been designated as the one important image for

future retrieval by being marked with a blue dot during the initial interpretation, Chang says. “This is a fundamental difference that vastly simplifies the storage requirements,” he adds.

PACS for Other SpecialtiesSteven C. Horii, MD, is professor of

radiology at the Hospital of the University of Pennsylvania in Philadelphia. As he explains, the desire for enterprise PACS goes beyond the scope of adding cardiology and pathology to radiology’s image-management systems. Other specialties that use and store images, such as surgery, want access to advanced image-management capabilities.

When they know what radiology can do with PACS, they can become increasingly insistent that they should be able to leverage the radiology system for their own purposes. For this reason, Horii says, radiologists should be prepared to answer the questions that other specialists have about PACS—and about what those specialists are likely to require before their departments can become functional parts of an enterprise PACS. “Things we don’t think of as images can wind up on our plate, if we’re not careful,” he says.

“Virtually every specialty generates images. Medicine is largely a visual profession, but not all images are kept—and those that are kept are stored in a huge variety of formats. Surgeons who capture images in the operating room now want to be able to review them later in their offices,” Horii adds. “Obstetricians use video, gastroenterologists print gastroscopy photos to add to charts, and various departments print on thermal paper, inkjet and laser paper, polymer, and film. Dermatologists use film or digital cameras to take full-body photos to track the skin changes that can indicate melanoma.”

He continues, “There are some specialties, such as ophthalmology, that use DICOM formats and digital images. Many other standards also are used, and then there are all kinds of proprietary formats that make our lives more difficult—and there are ways of storing data with no format at all.”

As with cardiology and pathology, other specialties will probably find

Anatomic pathologists are really trying to model what radiology has done, in the past few years, in their workflow.

—Paul J. Chang, MD, University of Chicago School of Medicine, Chicago, IL

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PACS | enterprise image Management


that their primary obstacle to smooth integration with existing information systems is that their workflow differs substantially from the pattern seen in radiology, for which PACS is designed. For example, dermatologists might benefit from access to prior images for comparison during diagnosis or to assess the patient’s response to treatment. Pathologists, however, use their images in the present, so there is no need for rapid retrieval of prior studies; images are stored primarily for use in education and in defense against possible legal challenges.

Using the same storage rules that radiology employs to determine whether a case of a particular age needs immediate retrieval, slightly less rapid accessibility, or long-term (slow-retrieval) archival storage would be wasteful in specialties that have no need for rapid access. In addition, it could slow retrieval—depending on the system in use—for radiologists who are sharing PACS with other specialties, compromising speed of access for the specialty that needs it most.

In a medical center or multispecialty practice, Horii says, the digital images generated can come from

neurologists, ophthalmologists, otorhinolaryngologists, dentists and orthodontists, maxillofacial surgeons, pulmonologists, gynecologists, orthopedists, and infectious-disease specialists, in addition to more obvious sources. Horii calls on radiology and IT departments to conduct a careful evaluation of the radiology PACS to determine whether it is capable of handling any of these images from outside radiology—and if so, how much such activity it can manage without overloading the system and reducing its usefulness for radiology.

What Horii defines as unexpected images that can become candidates for enterprise image management include ECGs, EEGs, and the output of fetal monitors and intraoperative patient monitors, since tracings and graphs are actually images. He asks, “Should these be stored as images or as the actual numeric data that they represent (such as voltage versus time) and then reproduced

Virtually every specialty generates images. Medicine is largely a visual profession, but not all images are kept—and those that are kept are stored in a huge variety of formats.

—Steven C. Horii, MD, Hospital of the University of Pennsylvania, Philadelphia, PA

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from those data as needed? How do I get back to the original numeric data if all I’ve done is capture it as an image?”

Images alone, in such cases, have the same shortcomings as scanned handwritten documents: They can’t be indexed and they can’t be used quantitatively, so the opportunity to do anything with them, beyond looking at them again, is lost. For medicolegal reasons, however, it can be important to store the original images, since the numeric data are easily manipulated. It could, therefore, be necessary to store both the tracings and graphs (images) as originally captured and the numeric data first used to generate them.

Horii considers enterprise PACS a challenge, but not an insurmountable one. He notes that one promising approach is the use of a federated PACS, in which a network of domain-specific PACS is created. Each domain has its own database, which is accessible throughout the enterprise; radiology becomes a component of the federated PACS, but is not its host.

Another possibility is the use of an enterprise multispecialty PACS with a single database, but Horii says that this “is not realizable at present, with some exceptions.” In settings where radiology’s PACS will act as the host, a combination of federated PACS and custom integration—with some workflow modifications—will probably be required, he says.

Piece by PieceDespite the conclusion of the three

presenters that an adequate enterprise PACS should not be built simply by cobbling together extensions of the radiology PACS, they agree that the pursuit of the enterprise-imaging goal should not be discouraged. Information systems undergo continuing revision in response to innovations in both hardware and software; professional bodies are working to refine the standards that permit systems to exchange data without losing any of its value. Giving up on enterprise PACS would be advocating a return to the stand-alone information systems that have handicapped so many hospital departments because they didn’t allow information to be exchanged with other systems.

Where these separate systems are already in place, they will become far more valuable if they are reconfigured to work with an enterprise image-management system. Where there is no legacy departmental system, the opportunity to create PACS components that will extend the benefits that radiology already enjoys to cardiology, pathology, and other specialties should not be overlooked.

While the presenters emphasize that building an enterprise PACS is not likely to be a plug-and-play operation, that does not make the pursuit of integrated image management for the whole institution

less important—any more than needing custom-made shoes would be an excuse to stay barefooted. There are gains to be had at each stage of PACS implementation, long before the complete enterprise solution takes shape at a given organization. For the sake of cost control, workflow management, staff recruitment and retention, referrers’ satisfaction, and better patient care, work toward enterprise PACS will continue at the vendor, professional-society, facility, and specialty levels.

Kris Kyes is technical editor of Radiology Business Journal.

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Minnesota and Washington take different paths in the journey to acceptance for clinical decision support

Decision support | Journey to Acceptance

Is it goodbye to radiology benefit management (RBM) companies and hello to automated decision-support systems? Not really, as the two

aren’t mutually exclusive. Nonetheless, computerized decision-support tools are gaining ground in the outpatient setting.

With CMS about to begin a Medicare decision-support demonstration project for high-end outpatient imaging, and with Minnesota embarking on a consortium-mandatory, statewide decision-support installation, automated protocols that guide referrers to the most appropriate high-end imaging tests for their patients are about to be put to the long-term test.

Cally Vinz, RN, vice president for clinical products and strategic initiatives at the Institute for Clinical Systems Improvement (ICSI), Bloomington, Minnesota, is a true believer in clinical decision support. She calls it a win–win–win for referring physicians, health insurers, patients, and even radiology providers, who won’t have to spend time straightening out inappropriate requests for CT, MRI, and other high-tech imaging exams.

The enthusiasm that Vinz expresses for clinical decision support is based on experience with a pilot project in Minnesota that has outlived itself by two years. Those results have been so

positive, she says, that health-insurance providers in Minnesota are now paying to implement clinical decision support statewide and to make it mandatory for ICSI members. Minnesota is also turning to a commercial decision-support vendor to upgrade its system.

If the rest of the nation wants to ride Minnesota’s coattails, Vinz says, there’s no reason that clinical decision support can’t be implemented nationally to hold down costs and guide referring physicians to appropriate imaging tests. “We hope this is how it gets done across the United States,” she says. “I could envision one set of appropriateness criteria across the country.”

That would be a big step, but even states that have studied Minnesota’s program are proceeding slowly. The Washington legislature, in 2009, created an Advanced Imaging Management Workgroup to study and implement evidence-based decision making for high-end radiology, with the goal of holding down cost. The workgroup did exhaustive surveys and issued guidelines to which health plans and providers have agreed. Now, according to Jeff Thompson, MD, medical director of the state’s Health Care Authority (Lacey, Washington), both RBM prior authorization and decision-support automated tools are being used.

Some health care providers, Thompson says, have been given a gold-card pass to use existing decision-support systems developed in-house. For other health plans, the use of a single RBM is allowed. For state-run health programs—Medicaid, worker’s compensation, and the Public Employees Benefits Board—a commercial physician review organization has been hired either to implement clinical decision support or to invoke prior authorization, depending on the nature of the requested imaging tests and the described clinical indications, Thompson says.

For all the ink being expended on clinical decision support at the moment, many problems are still to be solved. Chief among them are what Thompson calls hard stops—the outright denials of requested imaging exams, for which RBMs are notorious.

Also a caution with clinical decision support, Thompson adds, is that the embedded scoring on appropriate use for imaging exams is based primarily on ACR® utilization guidelines or those developed by other medical specialty societies. These guidelines—on which decision-support software programs rely—often lack evidence-based data and are more like recommendations, Thompson says.

50 RAdiology Business JouRnAl | February/March 2011 | www.imagingbiz.com

By George Wiley

Clinical Decision Support:The Journey Begins

“We looked at Minnesota, but we don’t know if that program had a return on investment (ROI) that reduced overutilization; we haven’t seen any published studies,” Thompson says. “I think it’s a rule of thumb that we believe RBMs would have the higher ROI, but the issue is that they cause a lot of disruption of care or access, so we want to balance

that in looking at utilization strategies.”It is this very disruption of access,

however, along with the burden and expense of using RBMs’ prior authorization, that has turned Minnesota away from RBMs and in the direction of clinical decision support.

icsi’s savingsMinnesota’s ICSI is a collaborative

funded by member health insurers and health-care providers within the state. The five largest ICSI members operate health plans and/or run hospitals and clinics that cover and care for about half the state’s population of 5 million, according to Vinz.

Vinz says that one of ICSI’s five largest health-care providers found, during the initial year of ICSI’s decision-support pilot project, that physician staff spent an average of 10 minutes per advanced imaging order responding to prior-authorization restrictions put in place by RBMs. In contrast, the time needed to use computerized decision support and get authorization, Vinz says, was 10 seconds. That’s how long it takes for the ordering physician using clinical decision support to click through the steps to arrive at the appropriate imaging test, whether that turns out to be simple radiography or an MRI or CT study, Vinz says.

Barry Bershow, MD, is vice president for quality and interim executive regional

medical director for Fairview Health Services, Minneapolis, Minnesota, a major hospital/clinic operator that is one of the ICSI big five. Fairview Health Services ran the data that Vinz cites, and Bershow confirms the findings.

“We found that staff was averaging over 300 hours per month talking to RBMs,” Bershow says. “When we threw

the switch to clinical decision support, it was 10 seconds per hit. We feel we have, so far, saved staff time of 300 hours per month—times 36 months.”

Bershow doesn’t have a dollar figure for those savings, he says, but multiplied across ICSI, they are considerable. He says, “The health plans are happy enough with the results that they’re paying the total costs for the decision-support vendor, so that for all the providers covered by the health plans, the health plans pay the per-click costs.”

Vinz estimates that the total staff time saved amounts to the equivalent of five FTEs. The cost of running clinical decision support amounts to one-eighth of the expense of using an RBM, she says.

More savingsStaff time turns out to be only a

small part of the total savings that ICSI attributes to using its decision-support system. At the time the pilot began in 2007, according to a recent ICSI white paper,1 high-end imaging costs in Minnesota had been growing at the rate of 8% per year for three years. After the decision-support system was put in place, this growth flattened dramatically. For the past three years, high-tech diagnostic imaging growth has been close to zero. The savings attributable to the use of clinical decision support during that time are estimated at $84 million, according to

the white paper.Clinical decision support might

result in better exam selection than prior authorization does, too. In one Minnesota experiment, where decision-support ordering was compared with prior authorization, prior authorization resulted in 79% of orders meeting appropriateness criteria. For clinical decision support, that success rate was 89%, the ICSI white paper reports.

Bershow says that clinical decision support has been so successful that none of the state’s health insurers or state health programs now require prior authorization. Minnesota is on its way to becoming a decision-support state. Even for Medicare, there have been savings because of clinical decision support, Bershow adds. Despite the numbers of Medicare patients in Minnesota growing by 25% since the decision-support pilot began, there has been, overall, a slight decrease in the number of Medicare high-tech diagnostic imaging tests performed. Bershow says, “We think this clinical decision support is a highly effective system.”

Brian Rank, MD, is an oncologist who also serves as medical director for HealthPartners Medical Group. The group’s parent company, HealthPartners, Bloomington, Minnesota, is both an insurer and a health-care provider. Its network includes three hospitals and 70 clinics, and it insures about 1.25 million members. The medical group, Rank says, has about 700 physicians and serves more than 425,000 outpatients.

Rank says that HealthPartners was the first entity to pioneer clinical decision support in Minnesota, using a homegrown application that was later offered to other Minnesota health plans for the ICSI pilot study. He adds that the new decision-support vendor that ICSI is using will create access to far more data than could be compiled with the original homegrown system.

Rank credits Minnesota employers for the push to deploy clinical decision support. Health-care costs were skyrocketing and caregivers were being dragged down by the cumbersome and entangled prior-authorization processes involving multiple companies and telephone contacts, he says.

www.imagingbiz.com | February/March 2011 | RAdiology Business JouRnAl 51

I think it’s a rule of thumb that we believe RBMs would have the higher return on investment, but the issue is that they cause a lot of disruption of care or access, so we want to balance that in looking at utilization strategies.

—Jeff thompson, MD, medical director, Health care Authority, Lacey, WA


Now, as clinical decision support is being rolled out statewide, it’s those same employers who will see the financial benefits. Rank says, “Our ability to hold down costs allows them to continue to offer health care to their employees.”

Medicare patients, tooMedicare and Medicaid patients in

Minnesota will now be served by clinical decision support as well. According to Vinz, the Minnesota health plans, along with health-care providers, have agreed to use the decision-support system for Medicare and Medicaid patients, even though those patients aren’t enrolled in the health plans.

“We don’t want them to sort the patients,” Vinz says. “We don’t want different patients getting different care, so we have contracted with providers for all patients to have the system used for them.” There is no contract or formal approval from CMS, however. Vinz says, “CMS is not requiring us to do something different right this minute.”

This is significant because CMS is in the process of rolling out its Medical Imaging Services Demonstration to test clinical decision support on Medicare patients nationally. That test might determine whether CMS uses clinical decision support or turns to RBMs to control utilization (CMS now uses neither decision support nor RBMs).

Minnesota’s Medicare-patient pool of a nearly 2 million will be far larger than the patient pool in the CMS demonstration

project; ICSI is hoping, Vinz says, that CMS will look at its results, as well as the demonstration project, in judging how well clinical decision support compares with RBMs’ prior authorization. “Our goal is that CMS will accept clinical decision support as an alternative to RBMs and won’t require anything different from us for a Medicare claim,” Vinz says.

Leveraging one eMrMany who discuss Minnesota health

care use the word collaborative. Not only is ICSI itself a collaborative, but the decision-support rollout will use a single decision-support vendor chosen by the participants in ICSI. That vendor will have an easier time interfacing its decision-support software with health-care providers’ electronic medical records (EMRs) because only one EMR product is in use in most of Minnesota. The use of a single EMR product reflects another way in which Minnesota providers have collaborated to achieve uniformity and simplicity.

Vinz says that even though there’s only one EMR product, a separate decision-support interface will have to be designed for each provider network. The EMR vendor will do each installation, Vinz adds. She estimates that even for large caregivers, however, the interface won’t cost much more than $10,000—a negligible amount, given the potential for savings.

For rural or small-practice physicians who don’t have an EMR system, ICSI and its decision-support vendor have

created an Internet application that will allow these small providers to use clinical decision support, too. Their cost for in-office connection will be about $1,000 each, Vinz estimates. This represents the cost of a laptop computer and a wireless router to connect to clinical decision support using the ICSI website.

The beauty of having either EMR or Internet access to clinical decision support is that ICSI can make the use of clinical decision support mandatory for its members—and for any other Minnesota provider choosing to join the program, which is open to clinics and physicians statewide.

Mandatory use will be simple to enforce, Vinz says. If a referring physician ordering an imaging test doesn’t enter a decision-support code, then insurers won’t pay for the exam. In order to get a decision-support code, the referring physician will have to complete the decision-support process to arrive at the most appropriate imaging test.

The exception is that, in some cases, the radiology provider will be the one to apply clinical decision support to an order, and the decision-support number will be entered after the initial order. Some radiology groups are offering to run clinical decision support as a service to referrers, in fact.

Jim Trevis is ICSI’s director of marketing and communications. He makes the point that whether the decision-support system is used on the front end by referrers or on the back end by radiologists, the data hub will be the same. The locus will be the decision-support tool. “The appropriateness criteria are in the tool, and the user will either feed something in or pull something out of it,” Trevis says.

Vinz points out that health insurers will also have access to their insured patients’ records and will be able to see whether clinical decision support has been used when their physicians ordered imaging tests. If not, the tests won’t be paid for, she says. All the interfacing and the transmission of data, Vinz adds, will be carefully protected to meet federal patient-privacy regulations.

rolling out slowlyBecause the decision-support


Our ability to hold down costs allows them [Minnesota employers] to continue to offer health care to their employees.

—Brian rank, MD, medical director, Healthpartners Medical Group, Bloomington, Mn

The appropriateness criteria are in the tool, and the user will either feed something in or pull something out of it.

—Jim trevis, director of marketing and communications, institute for clinical systems improvement, Bloomington, Mn

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application in the ICSI pilot project was different from the commercial decision-support system that ICSI has since chosen, the actual rollout of the permanent, statewide decision-support system is just starting in Minnesota. Different providers will implement the new decision-support system as interfaces are completed and after testing is done.

Rank says that HealthPartners is upgrading its EMR and will add the new decision-support application in the second quarter of 2011. “I don’t think there will be any integration issues,” he says.

He adds that one of the benefits of the decision-support system will be that referring physicians will get immediate feedback on the appropriateness of the studies that they order—something that did not happen with RBMs. “Personally, I think the RBMs are indiscriminate,” Rank says. “They make it hard for the people at the point of care to find the right study, but a physician needs that support.”

As a referring oncologist, Rank reports that the decision-support system is easy to use. ”I just type in a few words, like ‘evaluate liver metastases,’ and then I choose the exam. The worst thing that used to happen when I ordered a study was that at the end of the radiology report, there would be a note that if I’d ordered an MRI instead I’d have gotten the information I needed. We’re trying, with clinical decision support, to put that information up front for physicians,” he says.

Vinz says that training referring physicians to use clinical decision support will be nearly effortless. “The training is a one-time shot. For Web users, it’s an introduction, and then it becomes intuitive, like Amazon or PricePoint,”

she says. For clinics, decision support is accessed through the EMR, so the training will amount to learning clicks. One major health network is integrating all 75 of its clinics at the same time, Vinz says.

radiologists Give supportDespite the benefits of clinical decision

support for insurers, clinics, and referrers, radiology groups might lose some imaging volume because of the greater focus on appropriate utilization and the consequent reduction in unnecessary exams, Vinz notes.

The prospect of lost volume does not concern Steve Fischer, CIO for Center for Diagnostic Imaging (CDI), a multistate radiology practice that is headquartered in Minneapolis and that operates about a dozen outpatient imaging centers in Minnesota (as part of its much larger national network).

Fischer says that CDI welcomes the technology—so much so that it is providing a link between referrers and clinical decision support until integration with EMRs can be completed. “In Minnesota, we had more than 18,000 physicians who referred to CDI last year. Almost all of those referrals were for high-tech imaging,” Fischer says. “The vision is to have clinical decision support at the patient’s point of care, but since most EMRs don’t, as yet, support high-tech imaging clinical decision support, we’re bridging the gap by incorporating clinical decision support in our order-intake process.”

CDI has set up a physician portal that allows referrers to issue exam orders that CDI will then run through clinical decision support. That’s what CDI is doing for the Williams IntegraCare Clinic

in Sartell, Minnesota (one of many rural clinics that the radiology group serves).

Mark R. Halstrom, MD, is a primary-care physician and is currently the only full-time physician on staff at Williams IntegraCare Clinic, which is largely a chiropractic clinic. Halstrom says that CDI has taken over all the preauthorization requirements for his clinic. He fills in queries on the clinic’s EMR and then sends the order sheet to CDI by fax. The radiology practice then schedules the patient for the exam.

“As far as I know, I’m not getting denials from the insurer,” Halstrom says. “I assume CDI is doing its job to get its bills paid. If there’s a problem, I expect CDI to notify me of that.” Fischer says that the radiology group will be obtaining the required decision-support confirmation numbers through the group’s interface with the ICSI website.

“From our perspective, since we’re dependent on the referring physicians, we make it easy and convenient for them to order,” Fischer says. “Clinical decision support has allowed us to make sure they’re ordering the right exam and that there’s not overutilization.”

Fischer says that the decision-support ordering process has another big advantage: It encourages providers to accumulate patient data that radiologists can use to understand the images that they are interpreting better. In this way, patient care is upgraded, he notes.

When CDI radiologists have finished their interpretations, those reports, under the new decision-support format, will be sent back to ICSI as blinded data. They are then broken down by an analytical software system and sorted for positive and negative findings and other outcomes, Fischer says.

“At some point, there will be some sort of yardstick to measure the quality of radiologists’ interpretations,” Fischer says. “None of that was in the ICSI pilot. This is where no person has gone before; it’s going to take a number of years to mature.”

It is through the analysis of referrers’ ordering patterns and radiologists’ findings that advocates of clinical decision support hope to stymie critics who accuse clinical decision support of

The vision is to have clinical decision support at the patient’s point of care, but since most EMRs don’t, as yet, support high-tech imaging clinical decision support, we’re bridging the gap by incorporating clinical decision support in our order-intake process.

—steve Fischer, cio, center for Diagnostic imaging, Minneapolis, Mn



not being sufficiently evidence based. “The problem is that the ACR guidelines have a lot of holes,” Bershow says. “About 30% of orders don’t have good decision support built into them.” This is exactly the criticism that planners in the state of Washington have expressed.

Bershow says, however, that the new decision-support product that ICSI is using appears to have added sophistication and to have improved the decision-assistance capability of the tool. “We’ve had a number of times where the physicians have said they had been ordering the wrong test for years,” he says, “but now they’re guided to the right thing.”

Vinz says that the opportunity to compile useful outcomes data is more likely to be present with clinical decision support than with RBM use. “The RBMs need to position themselves to be more transparent,” she believes. “The provider isn’t learning why they deny the exam. In addition, the RBM data are based just on utilization. With decision support, we have the opportunity not just to get utilization data, but to correlate those data with radiological exams and identify the impact on patient outcomes. High-tech imaging’s evidence is not far along, so this will help get feedback into the appropriateness criteria.”

Bershow says that patients often arrive at the physician’s office demanding a CT or MRI exam. The decision-support tool, displayed on a screen in the physician’s office, has made it “a lot easier for physicians to stand up to the patient,” he says.

As Vinz notes, with clinical decision support, the patient won’t be blindsided when a test is denied a day or more later, as can happen with RBMs. The authorization, through clinical decision support, is part of the ordering process.

Washington’s Different ViewSince the state of Washington passed

legislation in 2009 to require public and private health entities to take steps to control the cost of high-tech diagnostic imaging, the workgroup that the legislation created to study cost control has been listening to proponents of both clinical decision support and RBMs. As Thompson says, “The different players have been at the table throughout these discussions.”

It’s not surprising, from a political standpoint, that Washington has approved the use of both an RBM and a decision-support system, in addition to creating gold-card status to let some providers continue to use in-house utilization-control mechanisms already in place. As Thompson notes, though, the larger goal has been to achieve consistency in approving high-tech imaging exams for certain uses, whether through a decision-support system or an RBM. The idea is that consistency is achieved when clinical evidence establishes clearly appropriate or inappropriate uses for high-tech diagnostic imaging.

Even before Washington passed legislation, Thompson says, Medicaid had restricted PET largely to lung- and gastrointestinal-cancer exams. The state is trying to establish strict utilization guidelines for other advanced modalities, he adds, but the task is not easy.

“Everybody’s got guidelines,” Thompson says. “Everybody’s got clinical decision support; everybody’s got an RBM. Some RBMs use clinical decision support and some decision-support systems are starting to look a little bit like an RBM. Everybody says that his or her system can do it better, but there’s limited information on saving money, based on what any baseline of utilization is.”

So far, Thompson says, in addition to PET, the state workgroup has focused on nonspecific abdominal pain as a common inappropriate indication for CT exams. It is studying other states and other data to isolate other tests. “We’re trying to go to the source data to find out who’s done the homework,” Thompson says.

the Gold cardVirginia Mason Medical Center

(Seattle, Washington) is well known for a method of continuous process improvement that it uses throughout its operations. The Virginia Mason Production System (VMPS) is modeled on Japanese production techniques known to maximize efficiency. The VMPS is a fitting parent for an imaging-utilization technique like clinical decision support.

It’s no surprise, then, that according to radiologist Craig Blackmore, MD, MPH, Virginia Mason Medical Center has been using an in-house decision-support system since 2005. Virginia Mason Medical Center’s hospital is licensed for 336 beds; Virginia Mason Medical Center also operates a network of outpatient clinics. It is one of the Washington health systems to be given a gold card to continue its own imaging-utilization program.

Blackmore, an expert in evidence-based medicine who has a background in public health, is scientific director of the Center for Healthcare Solutions at Virginia Mason Medical Center. “The big difference between Virginia Mason Medical Center and Minnesota,” he says, “is that Virginia Mason Medical Center is targeted at specific imaging studies and indications. Where there is a lot of utilization and good evidence of overutilization, we try to fix those problem areas, instead of using more of a shotgun approach.”

Where there is evidence to support inappropriate ordering, referring physicians are barred from ordering those imaging tests, Blackmore says. He uses the example of an MRI exam for lower-back pain on a patient’s first visit. “We look at the whole continuum of care for the patient, not just radiology,” he says. “We look at lower-back pain, but we also identify other benefits, like physical therapy.”

With decision support, we have the opportunity not just to get utilization data, but to correlate those data with ra-diological exams and identify the impact on patient outcomes.

—cally Vinz, rn, vice president for clinical products and strategic initiatives,

institute for clinical systems improvement, Bloomington, Mn

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A patient complaining of lower-back pain and wanting an MRI exam at the first encounter might, instead, be routed to physical therapy, Blackmore says. The patient might be disappointed that the physician couldn’t order an MRI exam, but in the end, be glad to get physical therapy. “You have to provide other services of value,” Blackmore notes.

He says that Virginia Mason Medical Center has established strict, evidence-based guidelines that are built into its decision-support system to limit the use of several other exams, including MRI for headache and CT for sinusitis. There is always the chance for the ordering physician to consult with a radiologist or another specialist, Blackmore stresses. “We work with clinicians and the people who pay the bills to identify those exams that are highly utilized. We drill down for good evidence for what should be used,” Blackmore says.

Decision Support PlusBy sticking to strict, evidence-based

standards, Virginia Mason Medical Center has been able to deny exams on good grounds and limit overutilization for specific exams more effectively than Minnesota’s generalized decision-support tool does, Blackmore contends. “Our rate of imaging is down 20% to 25% in those specific areas,” he says.

Blackmore can’t put a dollar figure on those savings, but the cost of care at Virginia Mason Medical Center has been going down and not up, he reports. “Minnesota has reported slowed growth in imaging,” he says, “but we’ve gone further and shown a decrease of 20% to 25% in those areas.”

Blackmore doesn’t dispute that clinical decision support is a good tool, and he praises ICSI for its decision-support rollout. He demands more evidence to support appropriateness criteria, though. “Nobody likes preauthorization; it’s effective, but it’s inefficient,” Blackmore says. “Clinical decision support is so much more efficient, and so much easier on providers and patients, that it’s definitely the way of the future.”

He continues, “The standard has always been that we can always do what we want if it’s safe and somebody will pay for it, but in a world of limited resources, there is only money to pay for what works. We definitely need more evidence to show what does and doesn’t work.”

The likelihood is that ICSI, Virginia Mason Medical Center, Washington, and perhaps the rest of the United States are on the same long path—all headed toward a decision-support system that selects exams based strictly on evidence supporting the best patient care. The vision that Vinz holds of the whole country using something like ICSI’s decision-support tool could be on the mark, after all—just not yet.

George Wiley is a contributing writer for Radiology Business Journal.

Reference1. Institute for Clinical Systems Improvement. Decision support for ordering appropriate high-tech diagnostic imaging scans at the point-of-order. http://www.icsi.org/htdi_decision_support_white_paper/htdi_decision_support_white_paper_.html. Accessed February 1, 2011.

DeciSion SuPPoRt | Journey to Acceptance


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Nobody likes preauthorization; it’s effective, but it’s inefficient. Clinical decision support is so much more efficient, and so much easier on providers and patients, that it’s definitely the way of the future.

—craig Blackmore, mD, mPH, Virginia mason medical center, Seattle, WA

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This is admirable—and, at the same time, more than a little disconcerting for those in positions of executive leadership. It’s admirable because many have learned to be top-notch business people in the process, and it’s disconcerting because many of them now find that their institutional knowledge is not so easily transferred to the next generation of leaders within the practice. How is succession going to work?

I believe that this fact is one of the reasons that Radiology Business Journal has been so successful. In essence, we have tailored the content of the publication to provide a place where imaging executives (both those who have arrived and those just now emerging) can find a full range of topics that are fundamental to the business of radiology.

In short, we are providing the profession with the radiology MBA, and when one looks over the archive of thought-provoking articles that touch on economics, management, leadership, and finance, one can clearly see why this publication has been dubbed the thinking person’s radiology publication.

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profession’s leaders very seriously. There is no question in my mind about how this commitment to generating timely, deep, and relevant information has set us apart from the majority of other publications (which typically are not written and edited by those who actually work in the business of radiology). We do, so it is important for us to publish articles that actually make a difference in the management of the practice’s business.

This also is true in the hospital setting. Several years ago, it became clear to us that an important dialogue needed to be initiated between those in the radiology practice and those in executive positions at the hospital. In order to build lasting and mutually beneficial relationships, each of these groups should obtain imaging information that is relevant to it—and that could (and would) make a difference in the overall management of the medical imaging enterprise, to the benefit of each of the stakeholders. Among these are patients, payors, referring physicians, and the employees of the imaging organization.

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Curtis Kauffman-Pickelle is publisher of ImagingBiz.com and Radiology Business Journal, and is a 25-year veteran of the medical-imaging industry.


The Radiology MBAAs the old guard passes the mantle of leadership to the next generation, leaders in radiology must equip themselves with the business tools necessary to navigate the change By Curtis Kauffman-Pickelle

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