Ron Hosenfeld and RivRad: Building an Effective Distributed Reading Solution

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The road to a distributed reading model is paved with WAN accelerators, DICOM gateways, and sleepless nights, to hear one practice CIO describe it. Nonetheless, three and a half years after he began building a distributed reading solution to support the subspecialty reading model of Columbus, Ohio-based Riverside Radiology, CIO Ron Hosenfeld sleeps better and Riverside Radiology has a robust and reliable information-technology infrastructure to support teleradiology over an expanding geographic area for its 60-plus radiologists.

As many radiology practices hope to compete based on the subspecialty reading model, the experience of Riverside Radiology’s Hosenfeld will no doubt prove instructive.

Riverside has experienced systematic growth in the past four years. When Hosenfeld, a mechanical/electrical engineer with Air Force satellite communications experience, joined Riverside Radiology in 2004, the practice had 8 to 12 employees and 34 radiologists. Today, there are more than 60 radiologists covering six hospitals and 16 outpatient centers scattered over an area 160 miles in diameter. Last year, the practice read 900,000 studies and employed 150 people. Hosenfeld has four IT staff reporting directly to him and two additional employees who do operations and analysis.

“Teleradiology has been a huge focus in relation to our ability to support the subspecialty reading model,” Hosenfeld says. “That’s been a clear driver in our technology as a whole. The greatest challenges we face now are both workflow-related and end-user–support related: the ability to give a remote user the feeling that there is someone there to support them, answer their needs, and keep the small problems as small problems.”

Countering Chinese Water Torture
Beginning with a Synapse PACS from FUJIFILM, Stamford, CT, Hosenfeld has built a global worklist by taking different feeds from multiple sites and running the studies through an HL7 interface engine both to track and to manipulate data as the are received to create a common worklist.

“We do an awful lot of work through our interface engine, taking all of the different feeds from the different sites and creating a common worklist within our PACS and our voice-recognition systems,” Hosenfeld explains. “Workflow is still a constant struggle and ongoing process all the time. We want to make the radiologist as efficient as possible, and while three clicks are not a lot, if you add up three clicks over 150 cases, it starts to detract from their workflow. All of the things that you hear users complain about, we try to focus on, because over time it does make a difference. It’s Chinese water torture related to clicks on the computer.”

Hosenfeld’s team created several DICOM gateways that allow the PACS to accept and modify examinations coming from outside centers so that they fit into the practice’s workflow. Integrating voice recognition with the PACS has also yielded happy dividends in a single-screen sign-on for any of the 10 sites from which radiologists read. “That had to be planned for so that it was responding to us, and we were not responding to it,” Hosenfeld notes.

Still, Hosenfeld acknowledges that the worklist is not truly universal. “Some of the [information] is controlled by facilities that give us a limited snapshot of it, so we can’t combine that completely with our data because of HIPAA security,” he notes. “We are able, however, to make it seem very transparent, or nearly transparent, to radiologists through some tools that we put in front of that.”

Hosenfeld’s team currently is working on writing the software for a dashboard, what he calls a home page for reading, where the radiologists can launch any of the work that they are responsible for, regardless of the source of the work or the location of the radiologist.

“Subspecialty reading has been one of the founding principles of our group in that we have fellowship-trained, board-certified radiologists who come to this group specifically to read their area of interest,” Hosenfeld says. "If you’re a neuro MR specialist, you are not going to have a full day of work from a single facility, but if we can consolidate all of the neuro MR from the central Ohio region, we can now keep several specialists busy all day long reading only the cases that are most interesting to them.”

Bandwidth Economies
One of the early hurdles that Hosenfeld had to clear as the practice followed a rapid growth trajectory was finding enough bandwidth