The Perfect Blend

When it comes to RIS and PACS, understanding and embracing the difference between the terms interfacing and integrating defines the chasm between inefficient and optimized workflows in healthcare environments both big and small. For a Long Island-based imaging center, closing that chasm took time, teamwork and forward-thinking vendors. Having grown to eight locations spread across Nassau and Suffolk counties, Zwanger-Pesiri radiology has been providing radiological services to the region for more than 55 years. With 25 board-certified staff radiologists, the full-service imaging center provides the entire spectrum of MRI and CT scan modalities as well as Nuclear Medicine, ultra sound and DEXA Bone Densitometry.

Interfaced Verses Integrated
Like most imaging centers in the early ’90s, Zwanger-Pesiri operated in a healthcare environment that was just awakening to RIS and PACS as separate systems—let alone systems that must work together. According to Zwanger-Pesiri Radiology Director/CEO Steven Mendelsohn, M.D., the center’s initial RIS and front-end computerization process began in 1993 followed by their initial PACS a year later. Each office had its own individual server and database and was not integrated. As Mendelsohn recalled, each PACS provided the ability to read images performed in that particular office, with all of the images stored on CD/DVD at the time. Each office had a jukebox of 100 CDs, giving them the ability to keep approximately a month’s worth of studies “online or near line.”

Today’s widely accepted Health Level 7 (HL7) standard introduced by the Healthcare Information and Management Systems Society allows for communication between information systems and many other components within the healthcare enterprise. Digital modalities use the Digital Imaging and Communications in Medicine (DICOM) standard to facilitate the transfer of images over networks. For HL7 and DICOM to come together, the two standards need a translator. This interface function can be embedded on either the RIS side or the PACS system side. Traditionally, this function has been housed in a bridge/broker that makes the necessary conversions from HL7 messages to DICOM data (which can be understood by the PACS).

Brokerless interfaces are considered integrated and offer the benefits of both worlds. In this scenario, the RIS and PACS are integrated without an interface engine needed to broker the translation between HL7 and DICOM. The benefit of integrating the RIS and PACS is the automation of DICOM modality work lists (DMWLs). While this is possible in an interfaced environment via the brokers, the main difference is the next step. In an integrated system, the radiologists using the RIS can find out the information about the study in the PACS. Once the system identifies the matching study, it can then find the images and get them to the radiologist.

When an order is entered into the RIS, the patient information is automatically available at the modality. The goal of this end-to-end systemic approach is to not only streamline the information/image storage and review process so everything is one click away, but also to streamline and integrate the workflow for front office staff, technologists, clinicians, radiologists, transcriptionists, billing and referring physicians.

Former Challenges
This lack of integration presented a number of challenges for the imaging center in the 1990s. The primary challenge was that patients would come to one office for the initial study and then to a second office for further study, requiring different ID numbers for the different databases. “This meant that if we had to compare, we didn’t know that there was a prior comparison and when we did use a prior comparison, we had to manually load the CD at the first office, transmit it via the T1 line to the second office and then load it from there to the local radiologist’s computer,” says Mendelsohn. The result was a comparison process requiring 20 minutes and two human beings.

After getting the CD downloaded to where the radiologist was working, the entire paper and film folder had to be physically moved to their location. “We continued on in this way until 2004 as we struggled with more volume and CDs, making the whole infrastructure of comparing priors really torture,” says Mendelsohn.

According to Zwanger-Pesiri CIO Matt Dewey, at this time the system infrastructure backbone was based on a UNIX system with dumb terminals for their RIS while the PACS was not connected between the offices. “It worked pretty much like a mainframe or mini computer would work where everything was a serial device,” says Dewey. “It had the old green screen terminals and it ran using WordPerfect 4.1 for UNIX as the transcription element with everything done via tape. The radiologists had to be in their respective office all of the time and couldn’t crossread for another office at the time because their was no way to ship the data between the offices.”

Process of Discovery
Zwanger-Pesiri needed to have an integrated database where all of the offices had access to the same data. This meant a search not only for a truly blended RIS/PACS system, but also an EMR platform that could create a true end-to-end solution. As they looked for the RIS/PACS solution, a key component of the search was that any of the competing vendors needed to be able to take the imaging center’s existing databases and integrate them into one unified database.

The process of discovery had them looking at small and large vendors with numerous site visits to talk with peers and see how possible solutions worked in practice. The Zwanger-Pesiri principals brought IT people, technologists, radiologists, a billing person and the scheduling manager in order to assess solutions from all possible angles. “Bringing only radiologists to site visits would have been fraught with problems because they only look at the workstation and PACS end of the system,” says Mendelsohn.

According to Dewey, interfaced systems are somewhat cobbled together, creating slow and inefficient workflows that cost time and accuracy. At the time, there were solutions that would work, but further site visits revealed an integration approach from Merge Healthcare to be more of what they were looking for. An upgrade of this magnitude requires intensive upgrade testing regardless of a single integrated vendor solution or multiple vendors, says Dewey. “Numerous things can go wrong between two interface-driven applications without intensive integration testing, but a blended system presents fewer of those challenges.”

In 2004, Zwanger-Persiri purchased the Fusion RIS/PACS from Merge Healthcare and went through several implementation stages. The imaging center began the transition by installing normal Windows-based computers enterprisewide while simultaneously updating the network. The center put terminal emulators on the new computers so that they could pull out the terminal devices but still access the legacy UNIX system. Additionally, they switched from serial to network-based printers.

Data Migration and Training
The biggest challenge to the transition was migrating all of the old data to the new storage system. While migrating even the previous two years’ worth of images would be challenging, Zwanger-Pesiri elected to migrate their entire database going back to 1990. Due to the difference in storage platforms between the two systems, the process could not be automated, and took a labor-intensive 3-month process to complete. “We ended up doing it on a patient by patient basis to confirm that we were attaching the PACS images to the correct RIS patient,” says Mendelsohn.

The process required an additional four FTEs for the entire duration of the migration. A significant portion of the time was spent eliminating duplications, as different offices within the enterprise had different ID numbers for the same patients. According to Mendelsohn, migrating the data totally changed the center’s infrastructure, giving it a fully integrated system. “With an integrated RIS/PACS we have all of the prior reports, so any time that the radiologists click on any given study, they have the priors going back to 1994 as well as the report, thereby eliminating the need to access a big jacket, folder, papers, remote storage, far distant storage, to view every report,” says Mendelsohn.

After doing all of the preparation, the system went live in November 2004. Merge Healthcare sent four trainers to Zwanger-Pesiri for an initial week of staff training. At the time, Dewey was the manager of second level support at Merge. As the largest rollout to that date for Merge Healthcare, the implementation of the Fusion RIS/PACS brought its own challenges. “Even if it’s a turnkey system, it takes quite a bit of time to get everyone trained and to configure a system of this magnitude,” says Dewey. “The more time you put in the front end of a system like this, the better results you’re going to get later, so there was a lot of time put into laying out how they were going to do the procedures, the rooms and routing features.”

Workflow Process Gains
Scheduling has historically been a challenge for the center, as each study had to be scheduled by phone for a particular office. The result was that each office had no idea what was scheduled in the other offices. If an office’s schedule was filled, they would just tell the patient to call one of the other offices. Today, Zwanger-Pesiri has centralized all scheduling in one office and one place, but patients and referring physicians still call the same numbers, creating continuity in the streamlined process. “Besides the fact that it gives us more space within our offices, it makes it so all of our schedulers can balance the workload better,” says Dewey.

According to Mendelsohn, the new system allowed the intake process to be reduced from as many as eight forms to two. Now that they are in a reasonably paperless environment, patients fill out their intake sheets— which basically confirm history, referring doctor’s name and HIPAA compliance— onto two sheets of paper. Consequently, when documents are scanned into the system and the radiologist is not physically in that office, they can click on an icon and actually see the scanned-in referral. Additionally, the natural loss of some employees allowed staff consolidation and the opportunity for others to be moved to different positions within the practice, as it grew from four to eight sites.

When the technologist brings the patient into the modality room, modality worklists from the RIS populate the console so that he doesn’t have to re-enter the patient’s name, demographics and other vital information. “The technologist has the modality worklist at the console as he starts to scan the patient, which reduces a lot of misspellings and inaccurate registrations,” says Mendelsohn.

Workflow Versatility
From the data information flow, the modality studies are segued into different work queues. Then, when the radiologists wish to read cases, they will open up the queues and claim the cases that they want. This process automatically brings the cases over to the local workstation where they can be read. The technologist can send the stat cases directly to a radiologist’s work queue where they are marked stat and the radiologist can attend to them immediately.

Originally, the system was set up so the technologist could choose which bin (what Merge calls worklists) the case is going to go to, such as Mammo and CT workgroups. They quickly found that they could skip that step due to the system’s routing intelligence. In addition to the system’s versatile routing capabilities, are prefetching and auto routing capabilities. “If the radiologist can see the script that the referring sent to us, and see all of the paperwork that the patient has submitted, as well as notes from everyone else in the system regardless of where they are, it allows us to do things like reading all of our musculoskeletal— or any of our specialties for that matter— in any office,” says Mendelsohn. “Having so much more vital data available to our radiologists, employees and administration systemwide increases efficiencies and patient care.”

Prior to 2004, Zwanger-Pesiri had to have a radiologist in each office that specialized in reading each type of study. This often resulted in generalists reading work that should have been done by a true specialist. In today’s environment, the integrated RIS/PACS allows a specialist to read each corresponding study type regardless of their location and the originating location of the study. Consequently, they may only need one radiologist in each office instead of two or three.

Reading and Routing
Recently the center installed systems at the homes of Zwanger-Pesiri principles Dr. Mendelsohn and Dr. Khodadadian. The systems are equivalent to those in the office with the same monitors and computers that allow them to see the same images as radiologists in the offices. This also allows more time flexibility for the radiologist as the system can track everyone’s location at all times.

 After the study is completed, the technologist presses the “complete” key and associates the images from the modality to the RIS, while the images from the specific modalities are attached to that patient’s RIS file, which then goes to the local servers in each office. The studies from the various offices are forwarded from the local server to the centralized master archive throughout the day, or at the end of the day.

 According to Dewey, all of the offices are essentially the same from an IT perspective. “The offices all have computers to run the RIS and computers on the back end of the PACS as well as machines to control the printing.”

“Each of our offices has a store and forward server that acquires all of the images throughout the day and night and sends them to my main PACS archive,” says Dewey. “The physical size is about two racks for my main archive and I’m at 36 terabytes in capacity.”

Transcription
A key benefit of the integrated RIS/PACS is that radiologists have all of the associated documentation and images in a study available to them with just one or two clicks of a mouse. This allows them to review the study while simultaneously dictating the review notes into the system via microphone.

Once the radiologist has completed dictating his notes for the associated study, all of the notes are digitally sent to a dictation server where transcriptionists can transcribe the voice file notes as part of the study to be sent to the referring physician. Radiologists dictate their notes into the system, either as they review the study or at a later date. Then, transcriptionists transpose the digital voice file into digital text, thereby eliminating errors that can occur with voice recognition software.

Currently, the center has 13 transcriptionists who access the voice files from the transcription server. When the system was first centralized in 2004, there were three or four transcriptionists in each office. The result was that, depending on workloads, some offices were ahead on transcriptions while others fell behind. The center eventually fell behind as much as five days in reporting.

The answer was to also centralize transcription and move them all into one facility. Reports are now typed in 10-15 minutes after they are dictated. Today, all but three transcriptionists work from home dramatically improving workflow and efficiency. “This works because I’m only paying them for the time they’re logged in to the system,” says Mendelsohn.

Because of how the system is laid out, transcriptionists, radiologists and back office staff can get to the data and pull out specific information and make reports much easier than was done in the past as staff had to go to the vendor, request a specific report and the vendor would produce it. “While Merge will do that for their customers, they will allow you to do it for yourself via Crystal reports so you can touch the data directly and get data out,” says Dewey.

Once radiologists receive reports on the “to-be-signed” screens, the reports are proofread. If the radiologists wish to look at the images, they only need to press one button (PACS), so, while they are proofing the report, they can actually see the images for the case that they are signing. They then click, “sign the report.” All the radiologists’ signatures were previously scanned into the system and are appended to the coinciding report. Once the report is signed, it is faxed to the referring physician within a few moments.

 The imaging center creates paper reports for referring physicians, which are printed at the end of each day. As back office staff prefer to send some reports by mail, rather than fax, the system allows them to batch all of the reports for a given doctor, and have them automatically forwarded and put into one envelope for mailing. Once a study is completed, it goes to Billing and is auto-routed to the coders for checking.

The Future
Network upgrades are in the works to accommodate the larger studies that are now becoming commonplace. “Traditionally, MR, CT and the studies themselves were relatively small, but we are doing more and more CTAs, which can consist of up to 1.5 gigabytes, which is big for any system to try and move around,” says Dewey. “So we plan to address the issue of greater bandwidth, as well as adding some redundancy as the database grows.”

As the radiology landscape rapidly changes, Mendelsohn, Dewey and everyone at Zwanger-Pesiri see the future of RIS/PACS becoming clearer. Both men see a future where interfaced products and platforms become integrated allowing you to get all the tools in one spot rather than separate modality workstations. Integrated workflows of the present and future mean more than just efficient clinical environments. They are an integral step in the process towards clearer diagnosis and better healthcare for everyone.