Saint Luke’s Health System is a Kansas City-based integrated health system that encompasses 10 hospitals, 918 staffed beds, 9,000 employees, 450 employed physicians, and 2,440 affiliated physicians, delivering patient to care to patients in a 67-county service area surrounding the Kansas City, Missouri/Kansas metropolitan area; it is a health system with $2.8 billion in annual revenues.
In a presentation that was presented on July 16 in a webinar sponsored by the Institute for Health Technology Transformation (iHT2-a sister organization to Healthcare Informatics under the Vendome Group, LLC corporate umbrella, Deborah Gash, vice president and CIO of the St. Luke’s Health System, shared with webinar attendees the story of her organization’s implementation of a cloud-based information exchange system for diagnostic images.
Like many hospital-based organizations, Saint Luke’s had been struggling with a complex, disjointed system of diagnostic image management, with diagnostic images not readily available, or difficult to share between and among clinicians and care sites; access to studies not timely; and with complicated, awkward practical challenges around the fact of diagnostic images constantly being moved around from one location to another, being lost, not capable of being read, and so on.
“As CIO, I try to get out and meet with our various stakeholder groups and talk with them about their technology and really hear first-hand from them about what’s working well and not,” Gash told her audience. “And it has always come up that the access to information and in particular images, has been problematic. Our previous state was reliant on people, had lots of points of failure, and was a particularly challenging area for us. Although we had an enterprise PACS [picture archiving and communications system], we were really struggling with making those images from outside the organization available to our providers. Images might come via CDs from patients, or via ambulance service. So the only time we could view those studies was when a patient physically arrived and we physically had the studies with us. So being able to understand what was happening with the patients before that was very challenging for physicians.”
Meanwhile, Gash noted, “Patients would also bring CDs with them to physician appointments, and we’d have to process those images, when they were from imaging centers or other hospitals. Or we would have surgical specialists performing procedures in our organization, who might perform studies in their clinics, and would want those available during those surgical procedures, so they would be bringing media in for use during surgeries.”
As a result, Gash said, “Getting those CDs where they needed to be, and getting them loaded, and so on, required a lot of manual processes; and many of the CDs weren’t viewable if they didn’t have the right viewer; or even they had a viewer embedded, the viewer wouldn’t load; or CDs would get lost along the way. It created a lot of dissatisfaction, and I would hear about it from physicians all the time. And my security team would want to prevent the loading of CDs onto devices to block viruses and malware.” In sum, she said, “Overall, this whole process of handling images was very inefficient and a constant source of frustration.”
In fact, Gash said, the average cost of $7.00 to produce a single CD carrying diagnostic images, and the costs and hassles of having so many CDs going lost or not being able to be read, were mounting for the organization, which has been generating a half-million diagnostic imaging studies every year. “So this was very costly for us,” she said.
As a result, beginning in 2011, Gash told her webinar audience, “We ended up with a pretty aggressive requirements list” for some sort of new IT-based system that could solve all of the above problems. “I began by inquiring and looking and seeing what I could find in the market. And at that particular time, there really weren’t a lot of options available. I spent a whole day in the exhibit hall at the HIMSS Conference [sponsored by the Chicago-based Healthcare Information & Management Systems Society], and found some there.” Meanwhile, she said, I went to our PACS vendors first and explained the challenge. We focused on the methods that referring physicians used to access studies. This didn’t affect the radiologists as much because their expectation was that they would see the studies through their PACS, so we focused on the referring physicians. We looked at distributed architecture. And cloud-based architecture was very favorable to me as CIO, because the technical requirements were low and the speed at which I could deploy was much faster.”
Gash made it clear that moving forward with a cloud-based solution did mean engaging in a lot of provider and staff education. “I did have to spend a lot of time talking with people about cloud-based technology and security,” she said. “People weren’t very knowledgeable about it at the time. And we still have lots of conversations about whether it’s secure or not and whether we’ll get into privacy issues. So this is key: you have to spend a lot of time educating on security, etc. I even had to spend a lot of time meeting with risk management and others. It required a lot of socialization to get people comfortable.”
After engaging in a careful selection process, Gash and her colleagues ended up implementing a system from the Atlanta-based Accelarad (which was acquired by the Burlington, Mass.-based Nuance Communications in April 2014). “Once we agreed to proceed, we executed our contract and began our implementation,” she reported. “And it really was a quick process: about a90-day process to get our studies and seed the cloud. It took about 90 days to complete that, and once we had the system being fed by our information, we began looking at who we could get to participate and join and leverage the technology to access the information.”
Fortuitously, Gash reported, “I participate in a local CIO group here in the Kansas City market, and I get together with my peers on a quarterly basis, and we visit and chat and compare notes, and I shared with them the challenges we were having, and they were all having the same problems. And it was interesting that many of them went through similar processes and ended up with the same technologies. So now I have my peer hospitals leveraging the same technology, so it kind of by default created a regional information exchange for images. And it has really been an interesting experience in our market to share images in that way. So sharing with fellow CIOs helped our community to create this information exchange for images.”
Post-implementation, “It’s a streamlined process now,” Gash told her audience. There’s a mobile application, so many physicians will bring up studies on their iPads, and that’s been a nice win for our neurologists. If they have a patient coming in from another organization and study has been done, they can view those images from that study while talking on the phone with the referring physician. The same thing for surgeons, they no longer have to carry media around with them. We haven’t eliminated CDs entirely. But we’ve standardized the process.”
What kinds of lessons have been learned from this initiative? “The first thing you’ve got to do is to get your images to go to the cloud, so make sure that’s working,” Gash said. “And then there’s integration with your electronic health record system and your PACS system. There’s education that has to be done. For us, that physician education has to be done one-on-one. We would select key physicians, show them how to use it, set it up on their mobile devices if they wanted to use the mobile app, and through word of mouth, they would share with their colleagues, so we had a very quick rollout and that worked pretty well. Our PACS team did most of the training. In addition, she said, “We’ve monitored referrals, targeted towards high-volume referring organizations. We worked directly with our transfer program to promote that use also.”
One of the many positive results of this cloud-based image information exchange, Gash said, is that its use has not resulted in increased risk or data security incidents. What’s more, there is a big patient engagement aspects of all of this. “This also has implications for meaningful use Stages 2 and 3,” she said. “Many organizations need to increase patient engagement. And we’re currently focused on increasing patient engagement to meet meaningful use requirements and image access can help that. We want to meet our meaningful use objectives by the end of the year, so we’re very aggressive in trying to increase patient access to our portal. We think making images available is a way to do that. The Advisory Board cited a number of best practices to increasing use of patient portals, and they cited increased patient access to lab results and diagnostic images” as major benefits that patients are seeking from provider organizations.
Indeed, “We’re going to make the cloud image exchange accessible to patients,” Gash noted. “We’re working right now to put a URL into the patient portal and educate patients that they’ll be able to access their studies and even their radiology reports.” That go-live will happen “after the first quarter of next year,” as right now, the Saint Luke’s organization is strongly focused on the go-live of its ambulatory EHR next month.
What should other CIOs know about this kind of initiative? “There’s a lot of misinformation about cloud technology,” Gash concluded. “People are leery of adopting it, and it takes time to get people comfortable with using it. You have to socialize it at every level and educate people about it,” in order to be successful.