A PACS pact

By Aine Cryts, Imaging Economics

When four competitive health care providers decide to share a PACS, trust is as much a concern as technology.

Essentially, we need to remove unnecessary costs from the health care system. This isn’t new. Health information exchanges and EHRs get data on patients to more providers and provide a picture of the patient’s condition.

Adar Palis, Executive Vice President and COO, Harrison Medical Center

A long-distance runner with painful, persistent knee pain ends up in the emergency department at Harrison Medical Center in Bremerton, Wash. Three days previous, she’d had a scan of her knee done at The Doctors Clinic in East Bremerton, which is less than a quarter of a mile away. Her emergency department physician accesses her images and tells her she likely has patellofemoral pain, also referred to as “runner’s knee” among recreational athletes.

From the patient’s perspective, this is a simple—though perhaps not ideal—scenario. But imagine if Harrison Medical Center and The Doctors Clinic weren’t involved in Northwest ImageShare, a community PACS shared by four health care providers in Kitsap Peninsula, a small community of 250,000 in Washington state. That long-distance runner just might need to be rescanned.

Northwest ImageShare—which also includes Advanced Medical Imaging of Silverdale and Olympic Imaging of Bremerton—is possible because, in the fall of 2011, Ty Walker, executive director of information technology and chief information officer, and Adar Palis, executive vice president and chief operating officer, at Harrison Medical Center, had been listening to their physicians’ complaints about accessing patients’ images—whether in the emergency department at 2 am or during routine visits. Walker and Palis also were getting feedback that patients were unhappy about the need to be rescanned.

Image access matters

Before Northwest ImageShare, explaining the need for rescans to patients was difficult. “Just telling the patient that you can’t [access their studies] is a challenge,” said Brennan Dobbins, director of clinical and ancillary services at The Doctors Clinic. “They’re concerned [about] what’s going on with them, and then we can’t be supportive [in getting access to their studies].”

You can add to that the fact that “a lot of patients are held responsible for repeat studies, based on [the images] not being available,” said Dobbins. She notes that insurance only pays for the scans once and patients want to know why they can’t access those images after the fact. “You have to empathize with them,” she said. “I’d be upset and want to know how did this happen.”

The ability to share images across providers is important for many reasons, says Palis. For patients, these reasons are convenience, the cost factor, and the need to avoid excessive radiation. There is also the need to remove waste from health care, which requires the need to collaborate across health care organizations in order to reduce exams and costs.

Radiologists, for example, want to make it as easy as possible for any referring physician to send patients to their practice and, in turn, to receive images and reports in a way that’s not cumbersome. Referring physicians want to be able to order a test and pull up the report as part of their diagnostic presentation to a patient. Essentially, the goal should be to make it as easy as possible for referring physicians to access images and reports, according to Palis.

“The ultimate goal,” said Palis, “is to improve care quality and cost, particularly when there’s a team of specialists helping the patient. It’s important that they’re not spending their time sending images from one specialist to another. Essentially, we need to remove unnecessary costs from the health care system. This isn’t new. Health information exchanges and EHRs get data on patients to more providers and provide a picture of the patient’s condition.”

Competition and cooperation

The solution Palis and Walker came up with was to get the imaging centers in their surrounding area on the same PACS system as Harrison Medical Center—although each health care entity would have its own image database.

Here is how Palis plays out the scenario he’d like to see at his hospital: A physician could search for “Adar Palis,” for example, and pull up any images from any facility within Northwest ImageShare. “That way,” says Palis, “you could reduce the burden on the physician, reduce unnecessary exams, and improve the time the patient spends in the emergency department. There’s a secondary financial benefit, too,” he noted. “The more people you have on one system, you drive down your costs, while increasing the quality of care provided to patients.”

That sounds like a great idea—in theory. But, considering the competitive environment in which the four providers work, it would prove to be no easy feat.

Building trust and managing change

As is the case in communities around the country, Harrison Medical Center, The Doctors Clinic, Advanced Medical Imaging, and Olympic Imaging are all competitors, which meant that trust had to be built between these four providers.

Of primary concern to all of the providers were two issues: that each entity would be able to protect access to its referral basis (and not share referring physicians’ names along with patients’ images) and that there would be no data mining. This meant that while each organization would be on the same PACS system—managed centrally by Harrison Medical Center—each entity would have its own image database.

Before working together as Northwest ImageShare, the four providers were going in different directions and that caused a constant struggle, said Palis. “People are terrified about affecting competition as opposed to [focusing on] collaboration. That’s why it’s taken us a year and half to get to this point. It’s hard to get people to sit at the table to see the vision.

“It’s not about the hospital controlling the practices,” said Palis. “It’s what’s best for physicians, patients, and the companies involved. It’s a constant struggle to determine how we keep that competitive nature while sharing and reducing overhead.”

Some of the challenges might have appeared to be technology-related on the surface, but they actually involved the need to build trust and manage change. For example, The Doctors Clinic had been accustomed to running their own PACS system, which meant that they were also accustomed to responding to their physicians’ concerns.

“Every one of our 70 plus physicians is looking for something—perhaps that’s a [software] fix. We were concerned that [with Northwest ImageShare], we’d have to contact Harrison for help,” said Dobbins. The solution was for The Doctors Clinic’s PACS administrator to meet with the technologists and PACS administrators at Harrison Medical Center. That’s how the teams started to build trust and to believe they could work together.

Dobbins notes that what was most difficult was managing change. That is to say, getting the staff members and physicians through the change.

“Every single person is going through the grieving process [because of the change], even if they understand it’s a good thing,” she said. “They’re angry and decide they don’t want to do it. There’s a lot of stress involved. My team constantly encouraged our end users as they were going through this.”

Having trainers on-site from Sectra and the overall support from administration was very helpful, notes Dobbins. But perhaps even more important was the time that Dobbins and her team spent with those experiencing the change, which meant they were “sharing it with them, rather than doing it to them.”

Contractual agreements and costs

From a contractual perspective, Harrison Medical Center has made a 10-year commitment to use Sectra PACS. The center has agreements with The Doctors Clinic, Advanced Medical Imaging, and Olympic Imaging, which include access to Sectra PACS and support for their physicians. Included in Harrison Memorial Hospital’s agreement with the other providers is the cost of hardware leasing, which is included in the per-exam cost of $1.58.

The imaging groups involved in this arrangement are contractually obligated to provide connections to Harrison Medical Center’s data center, says Walker, who notes that Harrison maintains the data center and provides the storage on which all of the images reside. Further, Harrison Medical Center is responsible for providing secure backup of all images.

According to Walker, Harrison Medical Center has been transparent about the costs per exam and passes through the price they pay to Sectra. Walker notes that this per-exam cost provides a compelling argument to any practice in the area paying as much as $5.00 per exam—not to mention the tangible impact of the ability to access patients’ images.

Asked why Harrison Medical Center and Northwest ImageShare ultimately chose Sectra PACS platform, Walker notes that there were many reasons with one of those being Sectra’s cross-platform worklist feature. With this feature, an entity can search the same patient exams across affiliates’ databases without seeing specific referring information, said Walker.

In terms of the progress of the project thus far: Harrison Medical Center has been up and running on Sectra PACS for 14 years, The Doctors Clinic has been live since October 2012, Advanced Medical Imaging is due to go live in May, and Olympic Imaging is due to go live in early June.

Lessons learned and future goals

A year and a half into this project, the providers involved have learned a great deal. Palis advises that providers interested in pursuing a project similar to Northwest ImageShare involve their physicians up front and also engage with the imaging staff during the decision-making process. He also would encourage “really talking about trust. These are competing companies [interested in] sharing a technology platform. You have to put the issues on the table and [discuss] how you can address those issues.”

Further, Palis said, don’t rush into anything. “You get one chance to do it right. A small community hospital [for example] can’t afford to do it wrong. They don’t have the funds to do it wrong. Map it all out. Work with your vendor to see how they’ll make the connections.”

“[Northwest ImageShare] wasn’t something we could whip together in a week. There was no real push—you need a realistic timeline to get this done,” said Palis.

Author: Aine Cryts. Featured in Imaging Economics, May 2013.

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