David Katz, MD, (left) president and managing partner, and Daniel Castaldo, director of information systems, Next Generation Radiology, Great Neck, NY, work continuously to keep the practice's PACS current.

Picture archiving and communications systems (PACS) help radiology enterprises grow by giving them a competitive edge, seen mainly in the form of faster, better service. As proof, consider the dramatic expansion experienced by Next Generation Radiology, Great Neck, NY, a Long Island group practice that installed a PACS in 1998. "Our market is one of the most densely populated New York City suburbs and a very, very competitive radiology environment," David Katz, MD, president and managing partner, explains. "Normally, it's very difficult to achieve much growth in a market like this. While I can't give PACS all the credit for the growth that's come our way, there's no question the technology has been an integral factor. PACS has made us more productive, swift, and cost efficient."

When Next Generation Radiology began installing PACS in 1998, the group consisted of only two radiologists and a handful of support personnel divided between an imaging center in the city of Great Neck and a satellite office about 20 miles away. Today, the group has eight radiologists and 60 employees in four full-service locations for imaging (with a fifth dedicated to billing), offering modalities that include MRI, CT, ultrasound, radiography, fluoroscopy, bone densitometry, nuclear medicine, mammography, and positron-emission tomography. Imaging volume, in 2002, consisted of 38,000 examinations, and the projected total for 2003 is 56,000, based on trends seen during the first half of the year, according to Katz.

"The most pivotal task that PACS permits is the very easy, quick routing of images to the right radiologist," he says. "By that, I mean the type of image a radiologist is asked to look at is the one for which he or she has the specialized training and experience. For example, we have one member of our group who is a fellowship-trained neuroradiology subspecialist with a certificate of added qualification. PACS makes it a simple matter for us to give him all the neuroradiology work, not only from the center where he happens to be located, but from all three of the other centers where those particular images are being generated."

DIVIDED WORKLOAD

That makes for better readings as well as more productivity, Katz says. Radiologists reading their assigned cases need not do so alone, however. Thanks to PACS, a radiologist at a workstation can send an instant message to a colleague or colleagues at the other centers to request a quick consultation. "If I want to collaborate with one of my partners across town concerning something I'm seeing on an image, I no longer have to get on the phone, talk to the receptionist at that particular office, ask for the radiologist, and then wait to be connected so that I can pose my question. Instead, all I have to do is send an instant-messaging request right from my workstation. The system sends it, and the image at issue, directly to my partner's workstation and flashes that there is a message that needs to be looked at and responded to right away. This represents a huge time savings, and it translates into superior service for our clients," Katz says.

PACS also permits a more equitable distribution of cases among the group's radiologists. "Let's say I'm at office number 1 and getting swamped, but, for whatever reason, office number 3 is not nearly as busy at that moment," Katz says. "What happens now, with PACS, is that the less-busy radiologists at office number 3 radiologists can help me by picking up my cases from the reading queue that appears on their own workstations. That way, I'm not falling behind and ending up with reports available to referring physicians hours late."

Actually, Next Generation Radiology's personnel begin to worry about tardiness when there is a possibility that reports might be late not by hours, but merely by minutes. Voice-recognition and digital-dictation capabilities have been integrated with the group's PACS, so reports and images can be (and typically are) in the hands of referring physicians before the patients concerned leave Next Generation Radiology at the end of the imaging examination. "The average radiology group on Long Island has a 24-hour to 36-hour turnaround on reports," Katz says. "If we can get a top-quality product out in minutes, by comparison, you can see why we are, more and more, being preferred by referring physicians and their patients."

PACS helps to enhance speed in other ways, including improving throughput in the modality suites. "PACS is the foundation of a digital environment; as a result, we're doing a lot less filming these days," Katz explains. "The only time images are output to film anymore is when patients and referring physicians request hard copy, which is infrequent, or when the study involves mammography or is produced using one of the few remaining analog radiography machines. Less filming means faster throughput, since filming takes time. For patients, that's terrific because it means we get them in and out of here more quickly than ever, and that's what matters to them most."

Less filming has also been good news for the group's balance sheets. "Our film costs today, for all four imaging centers, are roughly equivalent to what was being spent on film 10 years ago, when all we had was one imaging center," Katz says.

AHEAD OF The CURVE

Next Generation Radiology's PACS consists of a full-blown image-distribution system with a half terabyte of archiving capacity. eMed is the product vendor. Tied to this system are seven dual-monitor workstations, of which each office has at least one for use by the radiologists; there also are four technologist workstations. At each facility, network infrastructure is ordered around a pair of T1 frame-relay lines. Every line is outfitted with its own router and connected to a product that causes the pairs to function as one, according to Daniel Castaldo, the group's director of information systems.

"This arrangement provides redundant capacity so that, if we lose a circuit, we can continue operating. The system will be slowed down, but rarely to an extent that the radiologists would notice. It's also very, very secure," he says. In addition, each imaging center (plus the billing office) is equipped with its own compression server. "This allows me to compress locally prior to transmitting images across the T1 lines," Castaldo says. "The result is a big savings in bandwidth requirements and a much faster transmission time."

Images earmarked for short-term archiving are copied to a hard-drive disk array, then written to magneto-optical disks, where they remain until reaching the age of 18 months. Afterward, those images are removed to off-site permanent storage, which currently consists of jukebox archives. In its initial deployment in 1998, the PACS at Next Generation Radiology amounted to one dual-monitor workstation in each of the 2 imaging centers operating at the time. No jukebox was included, so storing images meant having to load them onto optical disks that were then shelved until needed for comparison with current examinations, Castaldo recalls.

The archive server that Next Generation Radiology initially acquired was a state-of-the-art model in 1998. It would have been antiquated technology just 2 years later, had it not been for the efforts of Castaldo's department to keep it not only up to date, but actually ahead of the technology curve. This was accomplished using various upgrades, patches, and integration methods.

Work flow, too, was different in the early days of the PACS deployment. For example, technologists originally pushed images to specific, individual workstations. Today, all work is delivered directly to a central archive. "Radiologists seated at their workstations retrieve images for reading by querying that central archive, which is integrated with our radiology information system (RIS)," Castaldo says. "When a case is completed by the technologist, it shows up on the RIS as needing to be read. It also shows up in our PACS archive as a set of images that have not yet been denoted as read. The radiologist picks a patient name from the system-generated work list, and the images come up on the screen. The radiologist uses the dictation system to enter findings into the RIS. The system immediately transforms the radiologist's spoken words into text, which means that the report is typed and ready for editing as soon as the radiologist has finished speaking. When he or she is satisfied with the report, the radiologist hits a key to approve it and off it goes."

The integration of PACS with RIS and voice recognition was vitally beneficial to the group's growth ambitions. Castaldo says, "When a patient arrives in the office, the receptionist notes this in the billing system, which is interfaced with both PACS and RIS. Alerted to the patient's presence in the office, the RIS then automatically initiates a request to the PACS long-term archive to start pulling up all of that patient's prior images and have them loaded into the near-term archive. This way, if the radiologist wants to compare any prior image of that patient to the newest image or images taken moments earlier, he or she is not going to have to wait for the older images to be found and displayed. Instead, because they are preloaded into the near-term archive, retrieval time is cut to almost nothing. The radiologist's productivity is thus maintained at the highest possible level."

Recently, Next Generation Radiology installed a PACS software add-on to make images and reports available to referring physicians via Internet. Roughly 15% of Next Generation Radiology's referring physicians, at present, use this option to gain access to images. A year earlier, that number stood at less than 5%. "In recent months, there has been a sharp increase in interest in web-based access," Katz says. "I think it has to do with the fact that the referring physicians, like everyone else with a computer at home or in the office these days, have become very accustomed to (and comfortable with) using the Internet."

GROWTH AS JUSTIFICATION

Many radiology groups that invest in PACS are able to justify the cost by balancing it against savings resulting from reduced film use, at least if their PACS investment starts on the modest side and their film-related expenditures immediately decrease sharply. At Next Generation Radiology, however, justifying PACS with savings from decreased film use has not been possible. "In our situation, the reduction in film costs is more than outweighed by the cost of the PACS equipment, its service contracts, and the salaries-and-benefits paid to the technical personnel we've had to hire to manage it," Katz says.  "We justify PACS by looking at the volume of new business attracted to the practice by virtue of the higher-quality radiology we're able to deliver in a more cost-effective manner, and with greater rapidity."

For Katz, the growth brought to Next Generation Radiology has indeed been sufficient to justify PACS acquisition. In fact, the tide of fresh cases attracted to Next Generation Radiology actually caught the group by surprise, Katz notes, although he has no complaints raise in that regard. "To be honest, we've been shorthanded around here, and that's something that should have limited our ability to grow," Katz says. "It has not done so because PACS has made it possible for us to send some of our images to universities and highly specialized centers where radiologists can lend us a hand by doing the readings there. Because it's all done via PACS, it's like having those university-based radiologists right here in the office with us. That's been tremendously helpful."

In the months and years ahead, Katz says that he would like to harness the practice-building potential afforded by the group's PACS technology further. "We're hoping to establish another couple of multimodality centers in our market area. PACS will certainly help us achieve this and other growth-oriented goals," he says. "Meanwhile, I'd like to focus on developing innovative ways of continuing to improve the way we report, including things like web-based access and wireless technology. For example, with wireless connections, my referring physicians will be able to access images and reports from anywhere, with whatever means they have available (such as using a handheld personal digital assistants while relaxing on the back patio at home on a Sunday afternoon) when emergency calls come in concerning their patients."

Katz adds, "After everything we've experienced so far, I am more convinced than ever that the PACS business model is the model of the future for group practices. PACS has allowed us to add value dramatically to our practice and has given us a mechanism for attracting a lot of business. From the feedback I've been getting, it's clear that a respectable percentage of the referring-physician business we're attracting now has been coming from clinicians who would not otherwise have been interested in using us, were it not for this value-added capability of reporting faster, better, and more reliably. Without PACS, we would not have been able to grow as a practice and become the size of group we are today. It simply would have been an impossibility."

Rich Smith is a contributing writer for Decisions in Imaging Economics.