Taking Care of Maine
Maine is a sizable state geographically, but its extreme northeastern positioning takes it off the beaten path. It’s a place tailor-made for electronic transmission of radiological images, and Radiology Specialists of Maine (RSM) in Brunswick is turning to technology to expand coverage in ways that it hasn’t before. It may be something of a pioneering effort. The motive isn’t profit so much as improved patient care. “One does not need to be a megagroup to perform good work or do good deeds,” according to Robert B. Finegold, MD, FACR, a radiologist who grew up in Maine and returned there to work for RSM. “It just requires a neighborly attitude and a mutual desire to do what one can to serve patients well.” Finegold says that the group of seven radiologists is moving with deliberate goodwill as it broadens coverage, careful not to encroach on competing radiologists’ turf. It’s the way things are done in a state where radiologists are familiar with one another, Finegold says. He has served as Maine chapter president for the ACR and on numerous ACR state and national committees. Maine, which has a population of about 1.3 million, is served by 39 hospitals, Finegold says. The majority of Maine’s population lives in the coastal third, he adds. Like those in many places, Maine’s radiologists are growing older, Finegold says, but because Maine is off the beaten path, “Attracting quality people with both current and diverse work sets to meet local imaging needs is a challenge for much of the state.” Add to that the fact that Maine’s telecommunications/informatics infrastructure is loosely put together with, as Finegold says, “different Internet service providers, clients in various stages of PACS/radiology information system (RIS) acquisition, and limitations in the time of client IT specialists in coordinating reliable interconnectivity,” and the backdrop against which RSM is trying to extend patient care becomes clear. There are no grand integrations of radiology data transmission in Maine. Because of this, RSM has turned for technology to the one place where most of Maine’s radiology providers are at least on common ground: the service that they use for after-hours preliminary interpretations. RSM is using the technology of its after-hours vendor to pioneer integration between sites where integration otherwise doesn’t exist. For now, this is a pilot project for RSM. It is limiting use of the technology to interpreting MRI for two radiologists at a hospital in Norway, a town of about 3,000 people 45 miles northeast of Brunswick, away from the populous coast. Finegold says that RSM wants to see how well the technology works in Norway before it extends coverage to other entities. How the pilot project plays out will partly determine what happens next. Major clients To see the lack of systems integration in Maine, you only have to look at RSM’s client list. For 40 years, RSM and its predecessor entities have served two Brunswick hospitals, which are still the core of its business. Mid-Coast Hospital is midway between Brunswick and Bath, a smaller town 10 miles or so to the west. In addition to being a vice president of RSM, Finegold is chair of the radiology department at Mid-Coast. The hospital is licensed for 104 beds and has about 100 doctors on staff. RSM’s other hospital is Parkview Adventist Medical Center in Brunswick. Parkview is an acute care hospital with 55 beds, 28 of them assigned to acute care. RSM has a third major client, the InterMed Group. InterMed is Maine and Brunswick’s largest multispecialty physician group, according to Finegold. InterMed has its own radiology clinic, which RSM helped it organize, including selecting a PACS and obtaining some staff. For all three clients, RSM provides full services, administering the radiology departments as well as providing radiation-safety officers and other departmental staff. It does all the study interpretations and provides interventional radiology services to all three. InterMed is a daytime business, but for the two hospitals, the coverage by RSM is 24/7. Neither the two hospitals nor InterMed are connected electronically to share images. Each has its own stand-alone PACS/RIS and supporting equipment, which it owns independently. RSM has no PACS of its own; indeed, it has no office as a corporate headquarters except for a post-office box. RSM dispatches its seven full-time radiologists to the locations assigned, where they make up the radiology staff. For all three entities, RSM uses the in-house equipment and suffers through the inconvenience of zero integration, where greater efficiencies in radiological interpretation might otherwise come into play. Enter NightHawk To provide night coverage to the two hospitals, RSM purchases after-hours preliminary interpretations from NightHawk Radiology Services, Coeur d'Alene, Idaho. NightHawk’s US board-certified radiologists work daytime hours abroad while US radiologists sleep. Like other NightHawk clients, the radiologists at RSM do the final readings on all their NightHawk examinations when they come in the next day. Occasionally, Finegold or another RSM radiologist will be called in for a night reading, but this, Finegold says, is very rare. Because of NightHawk’s track record, Finegold says that most radiology groups and/or hospitals in Maine are also NightHawk customers. This has direct ramifications when it comes to the coverage extension that RSM is undertaking in Norway. It might also affect coverage expansions that RSM attempts elsewhere at some future date. In order for NightHawk radiologists to read for US hospitals and clinics, they must meet professional guidelines and rules, particularly on the state level, meaning they must be US.board-certified, with appropriate licenses and privileges at each hospital. Hospitals must clear the NightHawk radiologists to read examinations for their patients. What this means, when most radiology groups and hospitals in Maine are using NightHawk, is that the after-hours service (which also has a daytime component) becomes a network of vetted professionals who can, if need be, serve as a link between clients. Because the physicians in Norway are clients of NightHawk, they can transmit even daytime images to NightHawk and ask NightHawk, in turn, to pass them on to the radiologists at RSM, who are also NightHawk subscribers. This is exactly what is happening with the MRI images that the Norway radiologists send to RSM. Where there is no direct link to route images from Norway to Brunswick, NightHawk fills the gap. It becomes a technology workaround. “The already established network permits us to respond readily to any of our colleagues' interpretation-assistance needs (consultations, primary readings, coverage needs, and scheduled or emergency work) if we are asked,” Finegold says. “It would be possible to provide assistance using the same network to clients outside the state, or possibly provide readings if there is any future need or opportunity.” NightHawk Radiology thus leverages its after-hours service into an any-hour integration engine for image transmission between its client sites. TALON NightHawk Radiology saw this coming, so it introduced software and a service called TALON Clinical Workflow Solutions specifically to meet and encourage these integration demands. TALON software runs on a radiology workstation, where it helps tie a PACS and RIS together and create a single worklist, but TALON is more than software. As part of this daytime service, NightHawk Radiology technicians and experts perform quality control on incoming images, adapt them as requested, and send them on to the recipient’s workstation. Finegold calls the NightHawk technicians editors. When he comes in to read the MRI studies arriving via NightHawk from Norway, he says, the MRIs have already been organized in the way that he wants to see them and put into a prioritized worklist. Not only has NightHawk done this, but it has also sent along from Norway pertinent patient information, prior studies, and prior reports, all electronically attached to the current study that RSM receives. If Finegold has any questions, he says, he can “instant message these quality-control people right on the screen.” Finegold interprets the MRI study and dictates his report by phone into the Norway hospital’s dictation system. Even this step will become faster when the Norway hospital, as part of the state’s Maine Health Networks program, gets the HL7 interface needed to allow electronic report transfers, Finegold says. When that planned system becomes operable in Maine, a voice-recognition program that is part of TALON will be used to create a report from direct dictation that will then be reviewed by the NightHawk editors and sent on to Norway. “When we started doing the Norway hospital, we did it by courier. Days would go by before they got a final report,” Finegold says. Using NightHawk and TALON, the days have been cut down to hours. “At the moment, TALON is great,” he adds. “It more than pays for itself.” The Role of PPMC To house the TALON-related workstation, which belongs to RSM, the radiology group has rented an office from one of its hospital clients. Finegold says he’s interpreting for Norway for about two hours per day, reporting on six or seven MRI studies. Whether RSM will use TALON to expand its coverage elsewhere is a decision that still has to be made. It’s a decision the RSM radiologists will make in company with their practice-management consultant and biller, Physician’s Professional Management Corporation (PPMC), Lewiston, Me. PPMC has been involved in RSM’s NightHawk/TALON use from the beginning, according to Leo Beliveau, PPMC’s COO and vice president. He says that PPMC first pointed RSM toward NightHawk for after hours coverage and more recently gave its stamp of approval to TALON as proven technology. “One of the barriers to a group of RSM’s size is that they don’t want to hire their own IT technician, so to have off-the-shelf technology is highly desirable,” he adds. Because RSM has no imaging equipment of its own and makes its money strictly from professional interpretation fees, it’s even more important that efficiency for the group be enhanced, Beliveau says. He points to TALON as an example of how efficiency can be increased and gives the system good marks so far. “The initial reports are that everybody is very pleased,” he says. If RSM decides, in the future, to expand its coverage to other sites, PPMC may act as a conduit for that expansion, Beliveau suggests. “We have over 20 different radiology-practice clients at different locations,” he says, “and many have need, from time to time, of assistance for overflow, or whatever the case may be. We can see where one client’s needs meet another client’s service offerings. Because we are connected in the marketplace, we facilitate [meeting] needs.” Indeed, PPMC helped facilitate RSM’s relationship with both the Norway hospital and the InterMed Group, Beliveau says. He agrees with RSM’s philosophy of expanding congenially and not stepping into turf battles with other radiology providers. “There is enough business out there for good service providers with good turnaround time to get work without being aggressive in the marketplace,” he says. While TALON is working out now, both Beliveau and Finegold are hesitant to say how, or even whether, the system will be employed if RSM decides to expand coverage in the future. “In RSM’s case, this is a first step in an ever-changing marketplace where advances today may need to be revisited tomorrow,” Beliveau says. “Recognizing what those changes are will be the task, going forward.” For his part, Finegold calls further integration through TALON one possibility, but he notes that one of RSM’s hospital clients and the InterMed Group are now using the same PACS vendor. Integration through such shared technology may be another way to expand services or become more efficient, he suggests.