When Neil Johnson, MD, transferred from Australia to the Cincinnati Children's Hospital Medical Center (CCHMC) in 1991 to work in the medical-imaging department, he experienced culture shock. The US hospital he had moved to was further behind—technologically speaking—than the "down under" hospital from which he came.

CCHMC's medical-imaging department was still very much film-based, and some patients—those with the more complex cases—had files with 50 lbs worth of film. Also, the department was without a RIS, so radiologists were dictating notes into hand-held tape recorders. Those tapes were then handed to a transcriptionist, who transcribed them on an electric typewriter. The radiologist would review the transcription, write any corrections, and send it back to be retyped.

"I was surprised, because we had a much more sophisticated system in Australia," recalls Johnson, who is now CCHMC's medical director of information services.

Obviously, the nature of the setting affected workflow and productivity. "In 1992, the average time between the study and the radiologist signing off on the report was 174 hours," Johnson reveals. Now, nearly 15 years later, things are much different. "The average now, across the board, is only 6.7 hours," he says. And that's because Johnson set about changing the system. Through a slow and methodical process, he helped bring the department up to speed with information technology (IT) that has greatly reduced film and paper.

According to observers, this so-called "filmless, paperless, wireless" environment is the healthcare environment of the future—whether in a departmental or enterprise-wide scope. Some healthcare professionals even indicate that the future is here already, and facilities should fall in line if they want to keep up.

Indeed, many facilities seeking the desirable state-of-the-art status have converted—or are in the process of converting—to such tools as electronic medical records (EMR), digital imaging, and wireless networks to improve patient care and staff productivity. And it's not enough just to have these tools; they need to be integrated.

Projects involving conversion and integration are complex undertakings, but the payoff is enormous. As such, organizations considering adaptation would do well to review success stories and case studies, and to heed the advice of those who already have ventured forth into this rugged but very inhabitable frontier.

Cultural Change in Cincinnati

Johnson's experience at CCHMC can serve as a schematic model for a strategic plan, and his observations based on that experience provide valuable insight. He recalls that when he arrived in Cincinnati in 1991, "it was obvious what had to happen."

Changes soon started taking place, as the department embarked on a 15-year journey that involved the automation and integration of all of its patient-care processes. In 1992, the hospital's first RIS was installed—a technological advancement for the organization, but also the start of a cultural change. "We did a lot of process change within the department," Johnson remembers. "The RIS was important, but the key was adopting an attitude focused on cutting down cycle times as much as possible. When we achieved that, the next stage was PACS, to further shorten cycle times and increase service."

Five years after installing the RIS, the imaging department seriously looked at PACS. A Pathspeed from GE Healthcare (Waukesha, Wis) was finally installed in 2000. After that, it took the department only 3 years to change from film-based imaging to digital. Cumbersome film-based processes were replaced by electronic acquisition and display of images as well as storage and transmission in multiple places throughout the network. The completed implementation not only brought a significant decrease in film utilization, but it enabled workflow improvements as well.

Still, PACS was only one part of the hospital's deployment of clinical information systems. Everything else would be put in place piece by piece, and Johnson credits this gradual approach as vital to any successful integration.

After managing the film issue, Johnson and colleagues wanted to attack the paper problem, as the hospital's paper-based processes were inefficient. The team created the Integrating Clinical Information System (ICIS), which helps with record-keeping, billing, order entry, medication tracking, and more. Based on the Invision software bundle developed by Siemens Medical Solutions (Malvern, Pa), ICIS encompasses the hospital's entire clinical-information system.

"ICIS is the name that Dr Brian Jacobs and I put together to describe the whole cluster of computed applications and databases that consist of our always-changing clinical-information systems," Johnson explains. "It is a continual work in progress. We set about putting that in place in 2002, and it has taken three years. It's hard work, because it is a huge culture change."

ICIS includes computerized clinical order entry integrated with both the clinical-documentation system and the medication-administration record. "We are now paperless for nursing documentation and inpatient patient orders, except for very complex chemotherapy cases," Johnson says. "We're still paper-based in outpatient clinics, but we're currently working on that."

Together with performance-improvement programs, ICIS has produced substantial improvements in patient safety and satisfaction, staff efficiency, and regulatory compliance. Among the most notable improvements, the hospital witnessed a 35% reduction in medication errors and a 52% improvement between the time medicines are ordered and when they are given to patients. With vital images and information quickly available, physicians and nurses can make important clinical decisions much more quickly and accurately.

Today, ICIS is used throughout CCHMC and will be expanded to include chronic-care portals. In addition, Johnson is upgrading the PACS to include voice-recognition dictation as part of a goal to produce radiology reports in approximately 1 hour.

The hospital's success underscores the efficacy of the project's design and its gradual approach, but the effort also earned notable, official validation. In 2003, CCHMC became the first pediatric hospital in the United States to earn the prestigious Nicholas E. Davis Award of Excellence from the Healthcare Information and Management Systems Society (HIMSS of Chicago).

Route to Successful Implementation

Johnson says that several things must be in place for a successful implementation project. But the most important element—and any healthcare and IT professional will concur—is an excellent traditional HIS, which needs to be in place first.

Ed Fisher, who recently oversaw a massive IT upgrade as CIO at William H. Backus Hospital (Norwich, Conn), strongly agrees. "You first need a solid infrastructure. That is the key to moving forward, as you can quickly roll out new applications, because you're not problem-solving your network and PCs during the rollout," he explains. "You know how your environment works, so you pick the application that best meets your needs and adapt it to your network."

Another important component that must not be left out of the equation, Johnson believes, is what could be called the "human factor." In some ways, this element can be even more important than the technology itself, he implies. It involves experienced and dedicated clinicians and multidisciplinary leadership from clinicians for clinical projects. It is not a province strictly for the technology team.

"It is very important that these systems not be given to technical-information system people to implement," Johnson notes. "The biggest mistake hospitals can make is expecting the data center or technical people to implement them. [Administrators] think that the computer is the most important thing, when it is actually only about 15 percent of the project. Two-thirds of a project is clinical discipline, the training, and the leadership."

As such, he strongly recommends that anyone embarking on the implementation of large, enterprise-wide clinical systems read the works of John Kotter, a Harvard Business School professor who has written books on leadership in corporations. The corporate leadership model, he feels, is very applicable when it comes to successful IT projects. Specifically, he cites the eight rules outlined in Kotter's Leading Change (1996) that easily can apply to IT implementation:

• establish a sense of urgency;
• form a powerful guiding coalition;
• create a vision;
• communicate that vision;
• empower others to act on the vision;
• plan for and create short-term wins;
• consolidate improvements and keep the momentum for change moving; and
• institutionalize the new approaches.

"If you skip any of these rules, then [the project] will fail," Johnson stresses. "But the most important thing is having clinical leaders running the clinical projects."

One strategy that Johnson discovered to be very effective was to create small tests of change. "For instance, when we were implementing CPOE [computerized physician order entry], we did it gradually but with a lot of urgency, unlike some larger West Coast institutions that failed spectacularly when they tried to do it in a couple of weeks throughout the institution," Johnson relates. "We started by just ordering chest X-rays in intensive care. It took us a few months to get the software right. Once we got it right, we took chest X-rays to other units. That's what you have to do: perform small tests of change to learn how your systems work."

CCHMC used this same approach with the integration of nursing documentation and EMR—everything was done unit by unit. "Each unit that went live saw the complete efficiencies created when putting all three of those things in," reports Johnson of the CPOE, nursing-documentation, and EMR systems.

The observance of the "human factor" and the adoption of the rules can help alleviate the biggest problem encountered during large-scale projects: resistance to change in an organization's culture.

"The speed with which you change an institution's culture is the key limiting factor," Johnson explains. "It can't be done overnight. You must be respectful of the difficult work required and the impossibility of changing an institution too quickly. Failures come from expecting sudden and massive change based on technology."

One specific area where an institution can expect some resistance is the change from film-based to filmless. "Some of our doctors resisted," Johnson says. "They wanted to hold a picture in their hand, or they didn't want to take the time to log on to a computer."

Ways to cope with such resistance include extensive and specialized training for physicians. One-on-one sessions and around-the-clock availability might be necessary when systems go live.

Backus Hospital's Fisher says he senses resistance whenever voice recognition comes up. "Some physicians don't want to hear about it, because they've heard so many things bad about it," he says. To accommodate the physicians' unease, Fisher assembled a physicians' advisory group to deal with voice recognition and other issues.

Aligning Objectives at Backus

Backus Hospital, a 213-bed, acute-care community hospital that serves approximately 150,000 area residents, has been experiencing significant expansion to include off-site imaging centers as well as ambulatory clinics and specialty facilities. About 3 years ago, the facility initiated a strategic initiative involving implementation of new IT. As part of its plan, Backus hired its first-ever CIO—Fisher, who was brought on to help develop a plan that would align the hospital's IT infrastructure with its business objectives as well as address improvements in patient safety and privacy.

"[The facility] wanted the CIO to build a strategic IT plan to match up to the hospital's strategic plan," Fisher recalls. "The hospital wanted to advance from the 1980s technology. When I came on board, the applications were about 80 percent complete. There were disparate databases, an adequate network, and 250 desktops. The plan called for us to go to an integrated systems strategy with a very robust and redundant network."

Originally, the system was focused on financial applications. The hospital's administrators wanted to shift the focus to healthcare delivery. Fisher's integration plan needed to focus on reduced operational complexity, paperwork, costs, and medical errors as well as consolidation of patient records into a readily accessible database—all while meeting HIPAA regulations.

"We knew we'd be adding a lot of hardware and expanding the network, and we did that in the first year," Fisher says. "So we were out there looking for new applications, cleaning up the hospital's infrastructure. Since then, we've gone from 250 desktops to more than 1,000."

Fisher looked at application infrastructures built upon one consolidated database containing a single set of patient records. He selected the Health Care Information System (HCIS) developed by Meditech (Westwood, Mass). The company's client/server HCIS distributes data across the enterprise on a standard platform of Intel processors. In 2002, Fisher and his staff collaborated with Meditech's consultants to install the application software; then, the team performed data conversions from the legacy environment.

HCIS went online in April 2003, and the gains were evident immediately. Operational efficiency increased throughout the entire organization. Less paperwork and fewer reports were transported through regular mail.

Patient records could be accessed instantly so that changes could be made in real time. And information was accessible from just one location instead of several. Further, Fisher anticipated cost-savings involving budgeting, cost analysis, cost containment, billing cycles, and improved cash flows.

In 2004, Backus Hospital was able to integrate its iSite PACS from Stentor Inc (Brisbane, Calif) with Meditech's EMR. This combination enabled users to view diagnostic-quality images throughout the hospital directly through the existing EMR system. Essentially, the system provided a "one-stop" access point where referring physicians could access images within the EMR. "We negotiated a whole suite of interfaces between the two companies. There were some frustrations at first, coordinating two vendors in a hospital," Fisher notes. "But we now have an interface that works exactly as we want it to work, and everyone seems to be happy."

Next, Fisher tackled the challenge of bringing images and data into the operating room (OR), which wouldn't be easy. "We wanted to have true PC power in the OR, because you really needed that to drive PACS. But we needed something that would satisfy the standards of our epidemiology team," he says.

The epidemiologists were concerned about the spread of disease from standard PC cooling fans, among other issues. Fisher also was concerned with security, space considerations, and bandwidth. After exploring options, Fisher settled on the PC blade developed by ClearCube Technology (Austin, Tex). It met all the needs by placing the interior mechanics of a PC on a central rack in the IT department. At the same time, the monitor and input devices are deployed at the point of care.

"Today, physicians don't hang as much film in the OR as before. They just bring it up on the monitors," he says. "That's convenient when they've started a procedure and can simply pull images up on a monitor."

For the future, Fisher is looking at voice-recognition technology for radiology, which would be integrated with PACS. "But that's department specific, of course. For the enterprise, we are getting ready to turn on CPOE. And then in the latter part of this year, once the hospital's new pharmacy is completed, we will start up a project for bedside medication verification," he reveals.

The CPOE, he says, would eliminate the handwritten paper orders that are processed every day. "We've analyzed CPOE pretty well," he says, "and I think we are down to the last piece to reach a paperless patient chart."

WellStar: A Change in Plans

Sometimes, implementation—no matter how well thought out—will require major modification at some point in the process. A perfect example is the facilities integration that took place within WellStar Health System (Marietta, Ga).

One of the largest not-for-profit hospital systems in Georgia, WellStar includes five hospitals that joined together to serve Cobb County, one of the state's fastest-growing areas. The organization was formed in 1997, and, at one point, it had only one imaging center. Still, it was determined that, to better serve physicians and patients in the growing community, five more imaging centers needed to be built within the system. Further, these would be outpatient centers operating in a digital environment, which would increase staff productivity, decrease report turnaround time, and better manage the ever-increasing number of imaging procedures.

When the new buildings were designed, the plans didn't even include provisions for file rooms, film processors, or any of those film-related considerations. When construction on the first new outpatient center began in 2001, WellStar brought in Agfa Corp (Ridgefield Park, NJ) to install the technology. "We're a very diverse organization, so we had a lot of different equipment—both legacy and DICOM—and we thought that Agfa could take all of our equipment into a digital environment," says Robert Mandler, WellStar's executive director of medical imaging/radiology.

When installation began, Agfa installed its basic PACS solution, the Impax Basix, to accomplish the transfer of digital information. Soon afterward, the second new imaging center opened. Both facilities were equipped with Agfa products, including the Agfa Diagnostic Center (ADC) CR package. Also, Agfa linked WellStar's existing RIS to the Basix system and installed its Web server, the Impax Web 1000, which made it possible to transport all images and reports to referring physicians.

The two centers quickly realized substantial benefits related to customer service, staff productivity, cost savings, and better service to referring physicians and patients. WellStar intended to equip the rest of its new imaging centers in this fashion. However, about halfway through the project, the company realized that this wouldn't be enough, due to the size of the radiology workforce. What was truly needed? An enterprise-wide PACS.

So, the original plans were scrapped. Instead, WellStar opted to link all of its new imaging centers and hospitals with Agfa's enterprise-wide Basix solution that featured a large hub-and-spoke configuration. In the modified plan, the hub would be a central Oracle server and database archive that would link each facility. "And we still were able to turn the Basix servers into gateways when we brought everything into the central core of the enterprise-wide Impax solution," Mandler says.

The hub-and-spoke configuration provided a central archive and far better image-distribution capabilities. All digital images and data could be moved wherever necessary—an important aspect, as WellStar is a diverse operation with a great deal of subspecialization in radiology. Images needed to be moved to locations where the appropriate radiologist could provide the highest level of interpretation available.

Currently, all of WellStar's imaging centers are up and running. Mandler anticipates that by spring 2005, complete digital-to-analog conversion will be accomplished within the hospitals. Along with the film, Mandler has seen a reduction in paper. Eventually, he'd like to see it all go away.

"Agfa has integration solutions, such as voice recognition, that we are working toward," Mandler says. He concedes that voice recognition is not easy to implement, but he anticipates a time when WellStar's PACS operation will be totally integrated to be paperless and filmless, with the capability of generating reports with voice recognition.

Looking back on the experience, specifically the substantial change in plans, Mandler says, "With a project this big and complex, there will always be significant decision points along the way."

Simulated Scenarios

Sometimes, out of necessity, implementation of integrated systems requires an innovative approach—one that seemingly invents a new rule. Take, for instance, Memorial Hospital Miramar (Miramar, Fla), a new facility in the five-hospital Memorial Healthcare System. The hospital, which opened this past March, is a digital, wireless facility that even features robotic technology. It was built to alleviate the patient load at the system's Memorial Hospital West (Pembroke Pines, Fla), which registered 172,852 outpatient visits, 5,403 deliveries, and 81,532 visits to the emergency department in 2004. "It had several expansions of its emergency department, but it just couldn't keep up any longer," says Forest Blanton, Memorial Healthcare's director of clinical informatics.

Miramar's entire infrastructure, which enables expansion and support of modern communications technology, is manufactured and managed by Cisco. In addition, the hospital uses an overall patient care system developed by IDX Systems Corp (Burlington, Vt). "The main product is Carecast, which includes centralized scheduling, a pharmacy system, clinical documentation, clinical orders, emergency-department management, and patient tracking," Blanton explains. "We're also using its Imagecast, which is a radiology-management system that incorporates PACS, so all of the X-rays are essentially filmless."

Capabilities include PACS; bar-coded medications that match up with bar-coded patient wristbands; a computerized patient-tracking system for the emergency department; and an online bed-charting system that displays vital signs, symptoms, and other essential medical information. Every room is equipped with a computer for instant access to records, research, and consultation.

But Miramar's system had to eschew an incremental rollout of technology. "Because it's a new hospital, everything had to be up and running at once," Blanton says.

He concedes that an incremental rollout takes longer but provides the ability to adjust as the facility moves forward. Thus, it's less risky. But Miramar, which needed to open as quickly as possible to shoulder the overwhelming patient load at its sister hospital, did not have that luxury. So, to help alleviate any risks, the team simulated day-to-day functions to make sure the computer technology and paperless records systems were ready for the facility's opening. The simulations were conducted over the course of several weeks and involved complex scenarios of a detailed level of activity.

These simulations, Blanton explains, were a manner of integration testing, where systems were tested through a series of scripts involving patient care and movement activities. During the earliest simulations, he reports, potential issues were identified and corrected. "Follow-up simulations came after that, and in the last couple of weeks, we used much more ad-hoc sort of situations, with no preparation for the staff," Blanton reveals. "We did this not only to test the systems but also to develop processes and ensure that the staff was sufficiently oriented and prepared for any event."

He adds that the simulations were both fascinating and valuable. "They revealed where procedures and systems needed to be enhanced, modified, or slightly reconfigured," he says. "But also I think it has given the institution a great deal of confidence in the way that things work."

However, Blanton points out—as others have indicated—that the infrastructure first needs to be solid. "Our IT team was very foresighted and careful about that," he says. "They've ensured that the network is robust and has been designed to be fault-tolerant and fail-safe. It will do the work it needs to do with a great deal of reliability."

The Future Is Now

The trend toward the completely electronic environment has been slow but inexorable. Increasingly, the medical landscape is being filled with more and more healthcare facilities that don't have physical areas, such as file and storage rooms or the medical records department.

As many see it, that is the future of healthcare. Some even feel that the future is already here. As Backus Hospital's Fisher puts it, "The clock has been running already."

ONE STEP AT A TIME One facility implements a filmless workflow by incorporating a film digitizer, providing greater access to images and increased efficiency by Thomas Burnsides Salinas Valley Medical Hospital moved toward being an electronic facility by incorporating film digitizers. Sometimes, converting to a filmless operation, one small step at a time, is just the beginning for a facility en route to becoming an electronic practice. A perfect example of this strategy is the 250-bed Salinas Valley Medical Hospital (SVMH of Salinas, Calif). As the foundation for a PACS network is perfected at the hospital, a laser film digitizer converts "outside" analog films and SVMH's plain films to digital DICOM files, after which they are appended to any digital exams (such as CT and MR) performed at SVMH. The "filmless" digitized analog diagnostic X-rays are sent to an image server and are made available for viewing on PCs by radiologists and other physicians anywhere in the enterprise. For example, in SVMH's new neonatal ICU, all plain films performed in the unit are digitized using the 2905 Laser Film Digitizer from Array Corp USA (Hampton, NH) and sent to the server, allowing physicians to access the images instantly from a PC on the hospital floor—or anywhere else, at any time. SVMH digitizes a variety of images for high-speed transmission, whether the film is a CT, MR, heart, lung, or leg. If the image can be put on a sheet of film, it's being digitized with the Array unit. The digitized image is just as good as the original hard copy, which is key, as SVMH's reputation as an imaging department is judged by the quality of the images that medical professionals receive. Also important to this filmless X-ray application is the different sizes of films that are digitized simultaneously. According to Chuck Farnsworth, SVMH diagnostic imaging operations supervisor, "We'd be a slave to the digitizing process if we had to adjust film dimensions individually. Now, if one patient has multiple exams involving different sizes of films—whether 14 by 17 inches or 8 by 10 inches, for example—every film [up to 100] for one case can be loaded and printed together, with no monitoring required." All of the imaging equipment in SVMH's diagnostic imaging department today is native DICOM. A new image network provides 1 gigabyte transfer rate to the desktop, with connectivity established to the hospital's outpatient imaging center—with whom the facility shares patients—as well as to local physicians' offices. Farnsworth says that SVMH "is not filmless yet, but hopes to be by the end of 2005. There will always be analog images coming from outside facilities that will need to be digitized for comparison to existing electronic images." Thomas Burnsides is the director of diagnostic imaging for Salinas Valley Medical Hospital (Salinas, Calif).

Dan Harvey is a contributing writer for Medical Imaging.