Interpreting From Multiple Facilities: The Case for a PACS-driven Workflow

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Gerald RothFor the first five years of its existence, Tower Saint John’s Imaging, a full-service outpatient imaging center in Santa Monica, California, that is a joint venture between Saint John’s Health Center and Tower Imaging Medical Group, used its own RIS, PACS, and speech-recognition products separate from those of Saint John’s Health Center. The same radiologists interpreted studies from both sites, but the integration of patient care between the imaging center and the hospital was not optimal, according to Gerald Roth, MD, president and CEO of Tower Saint John’s Imaging. When the PACS at the hospital began to fail, and the facility began to consider a replacement PACS, Roth recognized an opportunity to improve the delivery of imaging services through a unified PACS. Although Tower Saint John’s Imaging is located just a block away from Saint John’s Health Center, Roth notes, “One block was as good as a couple of miles” in terms of distributing imaging work between the two facilities when they were on disparate systems. In addition, patients who were seen at one facility were often invisible to the other facility, and valid comparisons with prior studies did not happen on a reliable basis. When the hospital decided to replace its legacy PACS with the Synapse® system from FUJIFILM Medical Systems USA Inc, Stamford, Connecticut, the imaging center made the transition to Synapse as well. The PACS Choice Each facility, however, continued to operate using a separate RIS—a decision that has resulted in radiologists’ use of a PACS-driven workflow for almost two years now. The decision to operate on a PACS-driven (rather than RIS-driven) workflow initially created some difficulty because the Sisters of Charity of Leavenworth Health System (Lenexa, Kansas), of which Saint John’s Health Center is a member, had mandated a RIS-driven workflow at all of its facilities. “I had to take the issue up the chain of command and show that our situation was unique in that we had to integrate an imaging center that had its own RIS,” Roth recalls. “After understanding our rationale for a PACS-driven workflow, they were amenable to that.” Tower Saint John’s Imaging had experimented with RIS-driven workflow in the past, but had not found it to be the most effective way to read. Ira Smalberg, MD, who serves as medical director of radiology at Saint John’s Health Center, says, “It just wasn’t popular. Nobody really liked it. They found it to be less efficient.” The Synapse platform from Fujifilm includes a feature called CommonView that aggregates imaging studies based on user-defined demographic criteria. Roth explains that Tower and Saint John’s settled on surname, date of birth, and the first few letters of the patient’s first name as its means of unifying all of the exams for a given patient in the same folder (or PowerJacket, in Synapse terminology). “If the radiologist asks for a PACS-driven workflow, then Synapse is ideal because it can aggregate data from two different RIS platforms, even if the patient has a different medical-record number in each,” Roth says. “It requires a little configuration and a little getting used to, but it’s extremely helpful, and it increases efficiency.” Now, Smallberg and Roth agree, the benefits of the integration are readily apparent. Optimizing Interpretation for the Radiologist In an era of increasing subspecialization among radiologists, Smalberg says, the PACS-driven workflow is a boon. “Having a single worklist allows us to do more subspecialty reading; if we had two different PACS, we’d be logging in and out, and it would be less efficient,” he notes. Roth adds, “If you have five radiologists at one site and two at another”—which is exactly how Tower Saint John’s Imaging staffs Saint John’s Health Center and its outpatient imaging center—“it can be hard to load balance exactly.” The PACS helps the Tower Saint John’s Imaging team manage the different caseloads between the two types of facilities. Roth notes that hospitals tend to have a backlog of cases awaiting radiology staff in the morning, with the caseload lessening throughout the day, whereas outpatient imaging centers have few cases waiting in the morning, but experience steadily increasing volume. He says, “In the morning, the imaging-center personnel can help the hospital, and then, as the work at the imaging center builds up, the hospital personnel can help out as things get quieter at the hospital.” As a result, Tower Saint John’s Imaging needs fewer FTEs to provide the same level of service; in fact, with the addition of voice-recognition software at the hospital, average weekday report-turnaround times have improved from 21–23 hours to just 1.5 hours. “The new PACS and the PACS-driven workflow really improve patient care,” Smalberg says. Also vital to improved patient care is enterprise-wide distribution of the images and their associated reports, Roth says. Here again, the Synapse platform from Fujifilm delivers the necessary infrastructure, if implemented correctly. “When you implement Fujifilm Synapse or use other Web-based applications, make sure the hospital is willing to have them accessible via Secure Sockets Layer,” Roth warns. “It’s really important—it makes a huge difference in terms of accessibility to physicians, compared to having it hidden behind a firewall needing VPN access.” Roth is an advocate of a PACS-driven workflow even in situations where only one RIS is involved. He understands, however, that in some institutions, a RIS-driven workflow is favored: “I think these decisions might be made by IT people, and they’re very accustomed to having one overarching system that pulls data from the others—they like having one place to which they can funnel all physicians,” he says. The problem with that, he adds, is that radiologists are very different from many other physicians in that informatics tools are the basis of their work. “Other physicians use computerized tools, but they’re not sitting in front of a screen all the time,” he observes. “Radiologists are interacting with one computer program eight to 10 hours a day. The radiologist needs to be working within the PACS. It makes no sense to have the RIS do a call to the PACS when many PACS now have good filters for worklists.” Roth concludes, “A good, modern PACS should be able to aggregate data from different sources, should be able to take the data feed from the RIS, and should be able to display scanned documents and the technologists’ comments and notes from exams. I believe strongly that radiologists should work from that.” Cat Vasko is editor of and associate editor of Radiology Business Journal.