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Interoperability Imperative

March 23, 2011
by Mark Hagland
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How one multispecialty medical group got strategic around diagnostic image-sharing

Craig Roy, who has been with Radiology Associates of Sacramento (RAS) for more than 14 years, first as director of IS and then as CIO, has been focused intensely on improving and optimizing the informatics landscape for his 60-plus-physician medical group, Radiology Associates of Sacramento. The group, which continues to expand through acquisition and development, currently includes about 45 radiologists, about 15 radiation oncology physicians, and four nuclear medicine specialists, and provides services in a broad range of areas, from radiology to nuclear medicine, to radiation oncology, gynecologic surgery, vascular surgery, urology, and medical oncology.

As Radiology Associates of Sacramento, already the largest private radiology group in Northern California, has continued to grow and expand, the need for its physicians to make use of interoperability solutions has become more and more pronounced. Early this year, RAS announced that it had successfully implemented two of the five components of the iConnect suite of interoperability solutions from the Chicago-based Merge Healthcare (the suite’s zero-footprint viewer, and its vendor-neutral archive), in order to successfully share diagnostic images and other clinical content across disparate clinical systems. Roy spoke recently with HCI Editor-in-Chief Mark Hagland about his experiences in driving interoperability forward in a multispecialty physician group environment. Below are excerpts from that interview.

Healthcare Informatics: Is the growing diversity of your medical organization part of what moved you towards an interoperability strategy?

Craig Roy: That’s right. We had acquired these businesses and simply took over whatever information systems they had and converted them over to our core system; so we added a module for medical oncology, for example. Our urology group uses NextGen [the Horsham, Pa.-based NextGen Healthcare] as its EMR. Meanwhile, our radiation oncology solution is from [the Stockholm-based] Elekta.

Craig Roy

HCI: What has the timeframe been for your IT development?

Roy: About two-and-a-half years ago, we started to talk about the strategy of bringing newer businesses into our practice in order to make our group stronger, since we saw the radiology specialty becoming somewhat commoditized. So we looked at clinically relevant practices that we could integrate into our practice. And the non-radiologists have come in within the past two-and-a-half years. We first brought in the vascular surgeons; then the medical oncology and urology specialists thereafter, within about a year. We’ve since incorporated one oncology group and two urology groups.

HCI: So you needed to create a vendor-neutral archive to support image management across the archive?

Roy: We actually had had Emageon, now part of Merge, as a vendor-neutral archive, for over five years. And we chose Merge as our PACS [picture archiving and communications system], partly because of their adherence to DICOM standards; Merge was our first PACS system. And one of the driving factors behind choosing a PACS system was that Merge’s archive was set up according to DICOM standards, and we could use that in the future if we wanted to change out PACS vendors. Since that time, you know, everyone has a little bit of proprietary aspect built in, but it’s still possible to use any viewer with their archive.

HCI: When did you go live with Merge’s vendor-neutral archive?

Roy: We went live right around the spring of 2004.

HCI: And you went live with iConnect at the beginning of the year, right?

Roy: Yes. For us, being a privately held group, a private radiology group, we have contracts with hospital systems and so forth, but we’re not a part of the hospital medical group system. And that’s important to remember, because when we as radiology groups want to do reads and make images available to the referring doctors who are part of the hospital medical group, we run into difficulties putting a viewer for medical images on their systems, since those are pretty much locked down.

So that’s been a challenge for us all along; and we’ve only ever asked for a level playing field, but we’re kind of an outsider trying to promote our business. So the beauty of the iConnect for us was to find out that there was actually no footprint—no download of an ActiveX or Java client, for the review of these images.

I’m sure you can understand how critical that is for us. We used to have a contract form that would basically hold my IT department hostage, if a physician had a problem, and they would call us to come back and fix it. And even when a vendor upgrades their software, they usually require a new version of these applets, and often, the new versions of the applets conflict with older versions of the applets.

HCI: So how has it all worked out?

Roy: It’s working fine; we have a number of doctors using it. Right now, we’re in the beginning stages of this; there are about 50 outside referring physicians using the system; we do have some of our own physicians using it, though it has a more limited tool set than the full Merge. And the other thing is, I didn’t have to build any results interface or interface of a dictated report from a radiologist, to the iConnect server, because the iConnect server pulls directly from my PACS server.

In other words, because we had built this directly in our PACS infrastructure, we didn’t have to build it again. And if a referring physician wants to look at prior data or images, they can do so. It’s not like this is a separate system sitting out there with limited storage and after a certain period of time, cases fall off. Because this accesses our archive, it’s pretty unlimited.

HCI: What is the current quantity of storage in your system?

Roy: Altogether, we’re approaching about 100 terabytes, with about 70 of those terabytes being imaging-related. And the next big area of growth will be from cone-beam CTs in radiation oncology; the image acquisition, in comparison to diagnostic imaging, is a lot larger.

HCI: What strategic lessons have been learned so far?

Roy: Let me put it in terms of challenges. One of the challenges that we face as a group is ensuring that vendors pay as close attention to the folks who are in maintenance mode, as possible. We’re paying huge maintenance fees every month, and that’s a steady revenue stream for most vendors; and they kind of lose sight of you when you’re trying to move to an upgrade, or whatever, because they’re kind of focused on the next large group to land. And that’s not any vendor in particular, it’s just true of IT in general.

The other challenge is meeting specific IT needs that might not be of a standard cut. For example, we’re branching out into teleradiology. And we already have contracts with some groups that have freestanding imaging centers and a couple of hospitals, and so forth; and that business model is tweaked a little bit from our normal business model.

Meanwhile, it can be a bit challenging when we need to tweak the IT model; it is hard for our vendors to keep up with our pace. The other thing is, if you’re doing business outside the four walls of your group, you can run into the challenge of disparate systems, medical record numbers, and so on; all that kind of plays havoc with us. And so the more integration you can get, the better off you are.

HCI: Do you see other CIOs of other groups like yours following the same types of paths forward?

Roy: I think we’re all faced with similar problems, with regard to reimbursement and such. But every group like ours has a little bit of a different relationship with hospitals. Here, we don’t have our PACS systems in the local hospitals. I know of medical groups that actually provide the PACS systems for the hospitals. I’d love to have that scenario, not just to build a kingdom, but it would become 100 times easier to build business not only with the hospital, but with the referring physicians.

With one of the hospitals here, where there are prior cases done at the hospital or one of our outpatient imaging centers, we have a collaborative archive to share cases for prior relevancy, and we also allow referring physicians to access that archive, with an agnostic viewer. But with the other hospitals in the area, we have all different types of arrangements.

HCI: Are you optimistic about the future?

Roy: Yes, I’m very optimistic going forward.


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