IT as Gatekeeper: Who’s on PACS?

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Allowing physicians, whether they are referrers or outside specialists, access to an outpatient radiology practice’s PACS is a subject that is being discussed with increasing frequency among CIOs.

Craig Roy is chief information officer and head of IT (information technology) for Radiological Associates of Sacramento (RAS), a private practice that serves 23 sites in Northern California. RAS radiologists read for two major Sacramento area hospitals as well as manning the group’s own outpatient clinics.

Roy says that how doctors are allowed access to electronic images—and under what parameters they are given access—is a hot topic among CIOs. For one thing the radiology practices must keep an eye on the legal requirements of the federal Health Insurance Portability and Accountability Act (HIPAA), which is designed to keep patient medical records private unless the patient gives consent for their dissemination.

HIPAA however is quite liberal in allowing dissemination of patient information, including images, between medical specialists once the patient has signed a consent form with the initiating doctor. Images can be sent by doctors to other doctors for consult without the patient’s direct consent once the original form has been signed.

While transfer of patient data for treatment purposes is clearly allowed, there are HIPAA best practices that are annoying to doctors, Roy says, especially a recommendation that system entry passwords be changed at least every 90 days. RAS has made this a requirement for continuing PACS access despite the displeasure of its referring doctors. “Security overrides the inconvenience,” Roy says. “We do the same thing for all our internal systems.”

Roy says IT at RAS has become the gatekeeper for access to electronic images. “We aren’t the only component, but we are a large part of the process.”

For technological and security reasons, RAS has created an external or peripheral PACS to hold the images being accessed by referrers. Only images show up on this PACS, not reports by the radiologist. Reports can also be accessed electronically, but typically they are mailed, faxed, or couriered, Roy says.

About a year ago, RAS completed an online physician profiling system that has streamlined access to the peripheral PACS. Access to the internal PACS from which RAS radiologists interpret is much more closely controlled, Roy says, although the images a referrer sees are the same on both PACSs.

Marketing’s Role
A perhaps counterintuitive aspect of PACS access by a referrer is the role played by the marketing department. This is true not only at RAS. A radiology practice’s marketing department can become itself a de facto gatekeeper to PACS images. At RAS, both IT and marketing act as a combined gatekeeper. The process as Roy outlines is this.

Marketing makes the office call on the prospective new doctor client, one who is not already part of the RAS network. This can be the case whether the doctor is primary care or a specialist. Once the physician agrees to join the RAS network of referrers, marketing sets up an appointment for a RAS IT specialist to make a visit to that doctor’s office to connect the doctor’s computers to the RAS peripheral PACS. This can be a lengthy process.

“We get a support ticket to our help desk from marketing. We schedule a time with marketing when we can visit the doctor’s office,” says Roy.

If the physician is part of a larger practice, there may be firewalls and other technical factors from the physician’s end that the RAS technician has to solve to make the connection.

Roy says he has one technician assigned to the connectivity task and that the technician makes about three visits per week to connect a new doctor.

When a physician is set up for connectivity to the peripheral PACS, a “physician profile” is initiated that will tell the radiology technician at RAS how that doctor wants to receive images. It could be over the PACS, it could be a CD, or a paper print, or a filmed image. The profile also tells the tech how that doctor wants to get the radiologist’s report. This physician profile shows up on the technician’s screen every time an exam is ordered by that physician.

Primary care physicians and specialists too are connected to the peripheral PACS. If a specialist not connected wants images, RAS will send a CD. If that’s too slow, then the specialist must sign a HIPAA waiver before the PACS can be accessed, Roy adds.

Roy says about 60% of all RAS imaging