Jennifer Decker Arevalo

McHenry County Orthopaedics in Crystal Lake, IL, adopted PACS in 2002, a year after moving into a new 35,000-square-foot facility. The new site offers state-of-the-art technology, including digital and computed radiography. 

"Implementing PACS has not changed the way we practice medicine," said Dr. William D. Cox, Jr., a board-certified orthopedic surgeon at MCO. "In our view, PACS has enhanced the way my five partners and I operate our practice. Ultimately, PACS has enabled us to improve operational efficiencies, workflow, and our bottom line."

The orthopedic practice has fully embraced the latest advances in technology to enhance patient treatment and could thus lead the way for other orthopedists who might be hesitant to add PACS to their practices. 

"Adopting new modalities such as PACS was all about changing the dynamics of running an efficient practice from a bottom-line business perspective," said Manette DeCremer, office administrator for the 11-year-old practice. 

Physicians and practices that may be adverse to change could find this a daunting proposition. DeCremer faced the issue head on when MCO added PACS. 

"We selected a vendor that understood our objectives and offered more than one solution to meet our long-range needs," she said. 

The practice chose SourceOne Healthcare Technologies, a consultative distributor that has access to PACS, CR, and DR equipment from a number of vendors. 

"Finding a consultative distributor that provided multiple options to meet our needs took the 'fear' out of adopting PACS," DeCremer said. "I do not believe a practice can find the 'customized' solution by going directly to a vendor that offers only one or two options. A good consultant will bring options and solutions that a single vendor cannot offer."

There are many PACS vendors and setups available on the market. Good vendors should map out a practice's existing workflow patterns before purchase to identify any problem areas and how they can be improved or redesigned. PACS should accommodate the orthopedic surgeon's workflow, not the other way around. Vendors with a background in orthopedics are in a better position to understand this.

MCO has reaped many workflow benefits from PACS.

"PACS has improved our surgeons' workflow, and they have benefited from the 'extras,' like being able to read radiographs on a monitor, thus making it possible to obtain more accurate diagnoses and determine improved treatment plans," DeCremer said.

PACS allows MCO's orthopedic surgeons to select related studies and simultaneously view previous images on a monitor for comparison, instead of waiting for radiographs or searching through the patient's x-ray folder for other images. They can review an examination at any workstation, at any time and location, even offsite. 

The surgeons can access tools that allow them to electronically magnify, zoom, pan, or rotate images, as well as measure angles. Radiographs that are too light or dark no longer have to be reshot or taken over to a hot lamp for better viewing. The physician simply adjusts the contrast on the monitor.

With the addition of PACS, radiographers at MCO have eliminated time-consuming tasks inherent in an analog environment:

 running test films through the processor 

 pulling, typing, and filing flash cards 

PACS allows radiographers to move from one case to another after each study because the images are instantly available. The process is much more efficient and productive than running films through the processor and waiting to assure that they are acceptable before releasing the patient.

"At MCO, the productivity of our radiographers has improved by 50% since we installed PACS," DeCremer said. "We now have a 1:3 ratio of radiographers to physicians, rather than a 1:1 ratio before PACS. The numbers build a strong case for PACS."

Throughout the workflow chain, all of these changes streamline the process and improve patient flow, safety, and care. Patient satisfaction is increased: Less time is required for taking digital images, retakes are eliminated, dose exposure is decreased, errors are reduced, patients no longer have to pick up and transport their own films, and physicians have more time to consult with patients.

"Physicians should never change the way they interact with and treat their patients," DeCremer said. "Decisions on whether or not to add new digital modalities, like PACS, should always be based on whether the technology will deliver your primary goal - to provide the best care possible. If you accomplish this, then all of the bottom-line business goals and objectives will fall into place, including optimizing your workflow. We are never satisfied with the status quo. We will continue to add modalities when it makes sense for our practice and, most important, for our patients."

Articles

McHenry County Orthopaedics in Crystal Lake, IL, adopted PACS in 2002, a year after moving into a new 35,000-square-foot facility. The new site offers state-of-the-art technology, including digital and computed radiography.

Workflow benefits of PACS outweigh fear of change

Although most orthopedists have heard of PACS or seen the software on display at a medical conference, few have had the time to learn about it in detail. A growing number of orthopedists are contemplating integrating PACS into their practice, however, and understanding filmless radiology prior to purchase and implementation is critical. 

Filmless radiology, also referred to as filmless or digital imaging, allows data to be displayed on a monitor and the digital x-ray image to be manipulated, duplicated, transmitted, and saved within seconds. To decrease reliance on film radiographs, orthopedists may consider switching to a filmless radiology system that uses digital or computed radiography (DR and CR, respectively), said Dr. Herbert Alexander, president of Alexander Orthopaedics in Ketchum, ID, in the American Academy of Orthopedic Surgeons (AAOS) 2004 

With DR, specialized hardware exposes an x-ray image onto an electronic apparatus and then directly converts the x-ray beam into a digital image without the use of a cassette or exposed plate of any kind, Alexander said. 

CR, on the other hand, uses conventional x-ray equipment and special cassettes. These contain an imaging plate coated with storage phosphors that are activated with a low-energy laser to capture x-rays. Once the exposure is complete, the CR reader converts the x-ray into a digital image. Presently, most orthopedists are opting for a CR filmless radiology system due to lower cost and interoperability with existing x-ray equipment, according to Alexander. 

To manipulate and view the digital images created with DR or CR, as well as digital CT, MRI, or ultrasound images, PACS software is required. A PACS can be purchased as separate or complete components including:

 a server to store images for immediate retrieval 

 a permanent mass storage unit to archive images on disc or tape (like a jukebox) 

 computer workstations with high-resolution monitors 

 a printer to provide hard copies for patients, if necessary 

 a communications network to unite all components 

Special tools and features within PACS software allow orthopedists to magnify, zoom in on, rotate, and flip images, as well as adjust contrast and brightness and measure angles and distances. Instead of writing on film, information can be saved, deleted, or redrawn onto the images. As an additional benefit, digital templating can be used for alignment, sizing, and planning in the OR.

Orthopedists should find a PACS designed by and for orthopedic surgeons, Alexander said. Orthopedists require software written specifically for them, not other specialists, and need features and functions that are customizable to their daily tasks. 

As vendors have discovered the income potential from the sale of PACS to orthopedists, they are aggressively pursuing the market, some with products that may not be orthopedic-specific. Through due diligence, orthopedists and administrators can separate the wheat from the chaff. Physicians should shop around, talk to other orthopedists, interview vendors, and view demos and exhibits at conferences such as 

Healthcare Information Management Systems Society 2006

Society for Computer Applications in Radiology 2006

American Medical Informatics Association AMIA 2005

 in October. They should plan site visits to see a system in use and keep current with the latest information through society and technology Web sites.

Although not essential, many orthopedists find it easier to use one vendor for all of their PACS components. Longevity in the industry and financial viability are important qualities to look for in a vendor, along with training and 24/7 technical support and maintenance. Physician training is a key factor to success, and it needs to happen before, during, and after implementation. Everyone who uses the PACS needs to be trained, but if this is not feasible, implementers can choose a physician or staff member who can train the trainers and be a liaison with the vendor.

Before purchasing a PACS, orthopedists should check that it requires user IDs to ensure that only authorized viewers access the images in compliance with Health Insurance Portability and Accountability Act regulations and has firewall security to deter viruses. The software and equipment should be Digital Imaging and Communications in Medicine compliant. The DICOM standard is a set of rules to allow the seamless exchange of medical images from one machine to another, especially if they are from different vendors. This standard is similar to Health Level 7 (HL7) standards for interoperability between health information technology systems.

The conversion to digital imaging does not happen overnight. A few orthopedists choose to digitize all or part of existing film libraries, which can be labor- and cost-intensive, while others opt to digitize as they go. 

Cost can be an issue with digital imaging conversion, but for many orthopedists, it is not their number one priority, according to some vendors. There will be substantial upfront costs, along with yearly software license fees, but these are generally offset by the discontinued use of conventional x-rays, according to Alexander. 

Physicians may also explore the impact PACS may have on efficiency, workflow, and productivity. 

Determining where efficiency can be improved involves examining the amount of time saved and how quickly the system works. Another consideration when evaluating a PACS, therefore, is bandwidth or the transfer rate. Bandwidth is a measure of how much data can be transmitted in a certain amount of time (usually 1 second) and is usually referred to as kilobits per second (Kbps) or megabits per second (Mbps). Imaging files can be extremely large, as more and more include 3D rendering. To send these types of files quickly from one location to another requires a 5- or 10-Mb bandwidth.

PACS can offer tremendous advantages for orthopedists. Film, jackets, and labels become things of the past, along with expenses associated with hard-copy film developing, handling, processing, storage, retrieval, and disposal. Fewer retakes are required due to poor image quality, since PACS software allows for image enhancing. Duplication costs are eliminated as images are no longer lost or retaken, thus lowering patient radiation exposure. As long as they have the patient ID number on hand, multiple viewers can see copies of the original digital images immediately on different monitors in separate locations, even offsite through dedicated networks or the Internet. 

"Filmless radiology and PACS are here to stay," Alexander said. "By learning the basics of PACS and filmless radiology, fear of the unknown and resistance to learning something new can be abated and orthopedists can begin to see the obvious value in switching."

Although most orthopedists have heard of PACS or seen the software on display at a medical conference, few have had the time to learn about it in detail. A growing number of orthopedists are contemplating integrating PACS into their practice, however, and understanding filmless radiology prior to purchase and implementation is critical.

Digital imaging management steps into orthopedic realm

A successful PACS implementation outside of the radiology department requires planning, organization, and flexibility, according to research presented at the PACS 2005 conference in San Antonio.

Dr. David L. Weiss, clinical head of imaging informatics at Geisinger Medical Center in Danville, PA, highlighted the need for flexibility when implementing PACS in emergency departments, operating rooms, and intensive care units.

To make the conversion process as seamless as possible, Weiss recommends performing a needs assessment through committee to determine what hardware specifications are required and also what physicians prefer. 

Physician preference and/or volume and efficiency demands may dictate the number of monitors needed in the ED, for example. PACS software and monitor resolution should be the same as that used in diagnostic radiology.

In the OR, monitor placement and type may be important. Standard or large flat-panel display monitors can be mounted on the wall, whereas an articulating arm monitor could be on the ceiling. Both can be used with a PACS workstation, preferably wireless, on a cart. If cost, not diagnostic quality, is an issue, the workstation on a cart or wall-mounted monitors are cheaper options, according to Weiss. 

During surgery, certain specialists may need the capability to review key and reconstructed images or navigate and control images on the monitor, using specialty-specific software and a mouse and keyboard in sterile wrap. 

In the ICU, the type of PACS being used - such as an enterprise PACS or a separate Web-based server and software - should be the same as that used in diagnostic radiology. This may determine the necessary hardware. Work list functionality with filtering capabilities by location, physician, and resource are important software features that should be included so that physicians can see what they need to read.

In each of these areas, the appropriate space, lighting, and acoustics are key. Involvement and input from IT and clinical and support staff are also important in the conversion process, along with technical support from the radiology department. 

Although many considerations are involved in implementing a PACS, the benefits usually outweigh the initial high costs and trepidation of computer-phobic physicians. Benefits include instant access to images by multiple viewers in multiple locations; cost-savings in film purchasing, processing, and storage; elimination of lost images and retakes; improved physician productivity; decreased support personnel time for retrieval; and improved patient care and overall physician efficiency.

Emergency, operating, and intensive care units demand flexible PACS implementation

Electronic health records are beneficial for small or solo physician practices, according to researchers from the University of California, San Francisco reporting in the September/October 2005 issue of 

Since more than two-thirds of U.S. physicians work in small practices, the authors sought to determine the costs and benefits of EHRs to this group. Although EHRs have the potential to greatly improve patient care, physicians, especially in smaller practices, have been slow to adopt the technology. Researchers from the Medical Group Management Association recently surveyed its members and found only a 12.5% EHR adoption rate in medical groups with five or less full-time physicians.

The UCSF report provides necessary data to help policymakers formulate both financial and nonfinancial incentives for physicians to increase their rate of EHR adoption and quality improvement benefits, while keeping down costs.

After evaluating 14 practices in 12 states, the authors determined that initial EHR costs were approximately $44,000 per full-time equivalent provider per year and ongoing costs were $8500 per FTE per year (about 19.5% of initial cost). The average cost per FTE provider was $22,038 for software, training, and installation, $13,000 for hardware, and $7473 for revenue losses from reduced visits during training and implementation. 

Although this initial monetary outlay may seem substantial for a small group or solo practitioner, the report stated that financial benefits averaged approximately $33,000 per FTE provider per year. Increased coding levels and efficiency-related savings accounted for the financial gains. 

It took only 2.5 years for the majority of practices to pay back their initial and ongoing EHR investment and to see net benefits greater than $23,000 per FTE provider per year. Providers also found additional benefits after implementation, including more personal time and the ability to work from home and access records when on call. 

Even though data organization, accessibility, and legibility improved, however, overall quality improvement increased only slightly, since few of the practices set specific performance targets and protocols for delivering better chronic and preventive care. Some of the practices encountered financial risks due to billing problems, reduced revenue in the beginning, and system crashes.

The motivating factor for most of the participants who purchased an EHR system was to improve quality of care. Yet the biggest gains were in coding benefits and billing improvements. Because the providers consistently used EHR templates to document and conduct visits more thoroughly, they billed at a higher coding level and received higher reimbursements. 

The authors noted that EHRs do provide cost benefits for smaller practices and should greatly improve quality of care. Since the study found only a slight quality improvement, however, the authors recommend that policymakers focus on revenue gains that are quality related rather than coding related in their pay-for-performance initiatives that encourage physicians to purchase EHRs.

Electronic health records are beneficial for small or solo physician practices, according to researchers from the University of California, San Francisco reporting in the September/October 2005 issue of Health Affairs.

Jennifer Decker Arevalo

Articles

Workflow benefits of PACS outweigh fear of change

Digital imaging management steps into orthopedic realm

Emergency, operating, and intensive care units demand flexible PACS implementation

Even small or solo practices can benefit from EHRs