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PACS In the Cloud—Plus Teleradiology

December 6, 2011
by Mark Hagland
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How one Nevada community hospital satisfied its physicians and avoided capital drain syndrome

The 380-bed St. Mary’s Regional Medical Center in Reno, Nev., a member of the 40-plus-hospital, San Francisco-based Catholic Healthcare West system, is typical in its situation in the imaging informatics area. As at other community hospitals of its size and type, St. Mary’s leaders have been facing the challenge of updating the hospital’s picture archiving and communications system (PACS) with limited funding and intensifying physician end-user demands. Among a growing number of hospitals, St. Mary’s leaders have chosen to replace their outdated first-generation PACS system with a cloud-based solution; in their case, they went live in July 2010 with the combination solution from the Minneapolis-based Virtual Radiologic (vRad) that provides both cloud-based PACS and teleradiology (external reads) services.

Recently, Dan Ferguson, M.D., St. Mary’s chief medical officer, who also fulfills the organization’s CMIO responsibilities, spoke with HCI’s Editor-in-Chief Mark Hagland regarding his organization’s path in the PACS area. Below are excerpts from that interview.

What is the background behind your organization’s choice of a cloud-based PACS solution?

I took this position in February 2009. One of the first issues I was faced with was a failing, end-of-life, PACS system. It was a big issue for our surgeons, especially neurosurgeons and others, who could no longer obtain remote access. It was a ten-year-old system no longer supported by the vendor. The issue was that we were faced with a capital expense that we really could not bear at the time. We simply did not have the capital to replace the PACS system.

So my boss, the CEO, came here from the Sacramento service area. And he had known vRad as a teleradiology provider, and had had a very positive relationship with vRad, in that capacity. So we reached out to them because of that past relationship, and explored the possibilities. And they said, gosh, we think we can help you. So by the summer of 2009, we had an agreement in principle that they would provide teleradiology services, and that we would adopt their technology solution for a PACS solution and for a radiology workstation solution. So our radiologists actually work on the same platform that the radiologists nationwide who use vRad use. Our radiologists actually work on identical hardware and software, as well as the voice recognition piece.

We have six radiologists in our group, and they all have a specialized workstation at home, and there are four workstations here on campus. So 24/7, they have access. And the benefit is, if need be, though it rarely happens—from 7 AM to 11 PM, my radiologists read. From 11 PM to 7 AM, the vRad radiologists read. So if my guys are really backed up, we can actually send studies to vRad. They do all of our reading from 11 at night to 7 AM.

Now, that rarely happens. Now, you heard about the air race disaster this summer [the Sep. 16 airplane crash at the National Championship Air Races in Reno, which killed 11 people and injured many more]? We got 28 patients from that disaster here. And those 28 patients underwent a total of 96 different imaging studies—head CT, pelvic CT, etc.—done in five hours. And Dr. Kim was our radiologist on that evening, and he read about two-thirds of those studies; but Dr. O’Connell was at home and was asked to help out, and he read about one-third of them. So the technology gives us tremendous flexibility. And if Dr. O’Connell for some reason had not been available, Dr. Kim could have gotten backup from vRad at that time.

Dan Ferguson, M.D.

And my neurosurgeons, my orthopedic surgeons, all my referring physicians, have access. And prior to going live in July 2010, we had begun in the fall of 2009 to design the program; this was an innovation for all of us. So we started working with the vRad people and our staff, and it took us until the summer of 2010 to architect it all. You can imagine that the workflow of a teleradiologist working out of his or her home is very different from the workflow of a hospital-based radiologist. And we conceptually understood that in the abstract, and thought we understood all aspects of it; but after go-live, we had additional issues we hadn’t thought of. And vRad was very helpful in helping us to make changes to the system.

The other major change was the shift to voice recognition. We had employed six full-time transcriptionists who had transcribed in the traditional way. And it took my radiologists some effort to get there; but now, 100 percent of our reports are generated by voice recognition, and the report is signed in real time, so the turnaround times can now be measured in minutes. And that’s a huge technology change for my radiologists. And we’ve eliminated those transcriptionist positions.

And the physician edits his or her own report and then signs it real-time, correct?

Yes, that’s correct; and this is a huge step forward, and I’m very proud of our radiologists, whose group’s name is Radiology Consultants, Limited (RCL). They worked very hard with the vRad people on all this.

What are your lessons learned from all this?

The big lesson learned is to make sure that the solution truly supports the workflow of the clinicians. We really did stumble in the initial go-live; there were a number of things we hadn’t thought of. But though we had fully engaged the radiology department staff, we hadn’t, in my view, engaged the radiologists fully enough in the design and implementation phases. The other learning was that we did experience some downtimes and experienced some loss of productivity. And we’ve lost internet connectivity for brief periods of time, by every way you could lose it, and through every failure point of WANs possible. So we put a server here in this building, to maintain Internet connectivity.

Based on your experience, what would your advice be to CIOs and CMIOs?

I just think they should be willing to consider novel approaches to providing a platform for their physicians to work on. In our case, having a teleradiology solution like vRad that also provides the viewing capabilities, and doesn’t require any additional capital costs; and in addition, it really lowers our operational costs. In fact, our vRad costs are actually lower than the yearly maintenance fees we used to pay to our old vendor. We don’t pay that to vRad; we pay them a per-study fixed maintenance fee. And we also don’t have to go through repeated upgrades here. I just think this approach is something that people should consider. Some people might have control issues—the idea that you don’t completely control the environment that you’re working in, that you’re dependent on another entity for our radiology solutions; maybe that’s a scary idea for some people. But it has worked well for us.

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