In December 2001, Porter Memorial Health System started the process of upgrading its diagnostic imaging department. The 334-bed system, composed of Porter Memorial Hospital, Valparaiso, Ind, and Portage Community Hospital, Portage, Ind, was already performing 160,000 imaging studies each year (with the assistance of Radiologic Associates of Northwest Indiana, Inc, which has 11 full-time and three part-time radiologists). In addition, the department served approximately 318 doctors with staff privileges, 300 of whom were referring patients regularly from Porter and Lake counties in Indiana and from Lake County, Ill.

The health system's technology was in need of an update, so plans were made to open a $6.25 million outpatient imaging center featuring an open MRI system, a 16-slice CT scanner, ultrasound, and a high-resolution digital mammography machine. At the same time, Porter Memorial Health System CEO Ronald Winger believed that the new center needed to be state of the art, from image storage and transmission standpoints. In December 2001, Winger approached Sanjay Shah, vice president and CIO, about installing a picture archiving and communications system (PACS) at the same time as the new imaging center.

Sanjay Shah, Vice President and CIO of Porter Memorial Health System.

His request was daunting, since Winger wanted the system up and running by the summer of 2002, but Shah was able to comply. Porter Memorial Hospital's PACS became fully operational on August 26, 2002, in time for the opening of the outpatient imaging center. The process of deploying the PACS, however, required Shah to overcome several hurdles. One of those was the fact that Porter Memorial Hospital did not have a radiology information system (RIS) in place, and another was Winger's mandate to market the PACS aggressively to referring physicians and radiologists in order to ensure that the technology would deliver optimal benefit to the hospital. Shah's tasks were made easier because his technology provider was flexible in working with Porter's specific requirements.

While one of the primary benefits of PACS is an immediate reduction in film-processing costs and storage needs, the benefits of the technology reach far wider. "The elimination of film represents a narrow focus within the reasons that any facility would want to implement PACS," Shah says, "but the facility could never cost justify the decision solely for that reason." The factors favoring the decision to add a PACS along with an outpatient imaging center were multiple: Porter Memorial Hospital wanted to increase its operational efficiencies, enhance its ability to recruit the most prominent radiologists to work at its facilities, and be recognized as a leader in diagnostic imaging.

"Most radiologists are not interested in joining a hospital system or radiology group that is not progressive, so we had to have the right tools and the latest equipment," Shah says. "PACS gives radiologists the ability to send images back to referring physicians in real time, and that improves service to the physician community. By offering physicians improved service, we become a place where they would rather send their patients. After our installation of PACS, we wanted it to be easy to make the decision to send patients to us." Whereas a competing facility might not even have sent results back to a referring physician by the time that the patient returned for a follow-up visit, the images and report were available as soon as they were completed once the PACS was in place. "We quickly recognized that PACS is not just for radiologists, but is meant for the whole physician population, including referring physicians," Shah says. "That adds a tremendous amount of value to Porter Memorial Hospital for everyone."

TECHNOLOGICAL HURDLES

Shah's first step was to talk to vendors about whether they could actually implement a PACS without a RIS already in place  to track and organize radiology studies. "The fastest RIS I have seen put in place took 6 to 9 months," Shah says. "We did not have the luxury of time to implement both." Of the companies that Shah considered, only AMICAS, Boston, was able to offer the health system the PACS solution that it required. "AMICAS genuinely understood what we were trying to accomplish, and it was a partnership from the beginning," Shah says. During his research, Shah also found that his PACS provider decision involved choosing between systems that were based on industry standards and those based on proprietary technology. One reason for choosing standards-based PACS, he explains, was that he wanted to be free to select and buy hardware. "In fact, we did negotiate on our own, and we bought our hardware and our storage hardware directly, and we did the network ourselves," he says. "We could buy those things directly because of the architecture of the AMICAS system, and that made it a more efficient, cost effective way to do business."

BECOMING FILMLESS

The interface provided by AMICAS bypasses the fact that Porter did not have a RIS in place. By connecting directly to the hospital information system for demographics, scheduling, worklist, and accession number. "We do not have a RIS and now we are realizing we may not need a RIS," Shah says. "We are reevaluating the whole need for an RIS."

Porter Memorial Hospital designed a box of marketing materials to promote the services of its new imaging center and the benefits of PACS to referrers.

In order to move seamlessly from having a film-based department to a running a digital one, the health system is replacing existing analog equipment with digital systems at a controlled pace. "We will be evaluating the condition, capability, and performance of existing components that might be upgraded to the Digital Imaging and Communications in Medicine standard or be replaced," Shah says. "Then we will begin planning and budgeting. One digital radiography (DR)/fluoroscopy system is already in place, with another in the process of being installed, and we expect to install additional DR/computed radiography systems during 2003."

Shah observes that, while the facility will continue to produce films when requested, it is clearly more interested in introducing digital image distribution and making a state-of-the-art statement in services. "Ultimately, we want this community to want more of what we are offering, and we want the outpatient imaging center to serve as a fully digital and filmless flagship, leading the way to converting the rest of the enterprise," he says. "Our progress toward becoming 100% filmless is based on a deliberate process of ongoing evaluations and a phased approach. By running that system both ways for a while, Porter can meet the demands of both the film-dependent customers and those more progressive customers who are eager for digital output."

Michelle Kraut, MD, radiologist at Porter Memorial Hospital.

Shah expects the facility to become filmless within a reasonable amount of time, but states that this process must account for the needs of the referral base. He says, "Some of those physicians will eagerly support digital image distribution and some may resist it. Therefore, production of some films to support these needs will exist for the indefinite future. By summer 2003, however, we would like to achieve 70% to 85% filmless image distribution." He continues, "Of course, ongoing evaluation and implementation are the keys to reaching the goals set for our PACS." During the design of the system, Shah also was adamant that access to images not be restricted by a referring physician's computer capabilities. "We wanted to be able to go to our referrers and tell them that as long as they had access to the Internet or a computer, we could give them access to these images," he says.

Therefore, credentialed physicians located anywhere within the health system can access diagnostic imaging results on any of the hospital's 500 computers, and Shah has provided high-resolution monitors in the intensive care unit and in the operating room. In addition, secure remote access will soon be available through the Internet. "The way we plan to operate is this: If you have a legal right to view these images, then you will have access to those images online with any kind of connection to the Internet," he says. "If physicians have a simple dial-up connection, it might take longer to obtain images, but the personal AMICAS application is equally effective with dial-up or broadband access. We do recommend having a broadband connection, however, because access will then be instantaneous."

Porter Memorial Health System owns several other medical office buildings in the vicinity of the outpatient imaging center, and the PACS is connected to those locations using Gigabit ethernet. "Physicians who have space in these buildings get high-speed access to the images, just as if they were physically in our facility," Shah says. In case referring physicians have no Internet access, each patient is provided with a CD at no charge that includes all the images from the diagnostic study. The patient can then take the CD to the primary care physician, who will be able to review the images, in any order, in order to make better clinical decisions. The CD is labeled with a toll-free number for patient scheduling, so that the physician can call for any additional studies that are needed. "The process is very efficient, and it helps market the hospital and its new level of service," Shah says.

MARKETING PACS

Marketing the new system has consistently been at the forefront of the facility's PACS strategy, and has included everything from distributing candies marked with memorable slogans to holding open houses at which radiologists spoke about what the new technology could offer referring physicians. The hospital system had the most success, however, with Shah's decision to create a demonstration room for the PACS technology before deploying it (see sidebar). "Press releases about the proof-of-concept room were sent to local publications, and this resulted in the publication of articles in the three area newspapers," Shah says. "We put up in-house posters at all our branch facilities, we put flyers in physicians' mail slots, we sent emails to our associates, and we posted information on our web site."

In addition, he adds, "We mailed invitations to physicians to visit the center, we ran newspaper advertisements for the public open house, and we sent 1,500 invitations to community dignitaries for a VIP open house. We also ran an outpatient imaging center booth at the State Healthy Fair/Expo, which had an attendance of 1,200." In another bid to create appropriate marketing interest, Shah invited the media to a series of open houses in the demonstration room to show reporters what the PACS technology could do. "Our presentations to the board, the media, and the public have all been powerful, and the initial reaction has been very positive from the community and the referring physicians," Shah says.

"Radiology is a critical part of our overall strategy, and I think that we have shown the community that, with our new PACS, we will be able to ensure that convenient, efficient, and accurate radiology services are part of the exemplary overall services that we offer our patients," he continues. "Ultimately, this system will allow us to treat a greater number of patients in a shorter amount of time, which will result in shorter waiting times and better service for our patients and our referring physicians."

Elizabeth Finch is a contributing writer for Decisions in Imaging Economics.