| Customer Stories
Zwanger-Pesiri Radiology Workflow Success Story - (PDF Version)
Situation
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| Zwanger-Pesiri Radiology Facility |
In 2004, all the elements were in place for Long Island-based Zwanger-Pesiri Radiology to stage a major growth spurt. The imaging center had been providing its vast coverage area with state-of-the-art, multi-modality radiologic services for over 50 years and the yearly procedure totals were mounting fast. The problem was that Zwanger-Pesiri’s early 1990s-era RIS and PACS solutions were geared to serve single sites in a non-integrated model. Each of the four offices in 2004 had its own individual server and database, and each DR PACS enabled image review only for the office in which it was located, with all images stored on CD/DVD. Each office had a jukebox of 100 CDs, providing online or nearline access to about one month’s worth of studies.
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Robert Day
Chief Technical Officer |
Using relevant priors in such a model was still manageable in 2004, but increasing procedure volumes, especially patients having follow-up scans at a different Zwanger-Pesiri location than their original procedure, were beginning to drag on the workflow, according to Robert Day, Chief Technical Officer. “We employed three to four FTEs whose job all day long was to manage relevant priors,” he recalls. “They would handwrite patients’ names from the schedule and determine if there were any priors to begin with. Then, if we needed to compare, we had to load the CD manually at the first location, send it by T1 line to the second imaging location and then deliver it from there to the local radiologist’s workstation. By 2004, it was becoming pretty torturous to compare priors, which took 20 minutes and required two people to complete.”
Other issues related to Zwanger-Pesiri’s distributed, non-integrated operation – such as transcriptionist staffing, turnaround time of transcribed reports to referring physicians and the absence of diagnostic modality worklists for the imaging systems – also were becoming obstacles to the imaging business’s growth.
Requirements
In February 2004, Zwanger-Pesiri mounted an intensive RIS/PACS search and evaluation process, involving representatives from billing, scheduling, administration and IT, and culminating in several visits to imaging sites that operated the solutions of eight different imaging informatics vendors. Zwanger-Pesiri officials had determined that the best way to unite their multiple-site distributed operation was to implement a centralized PACS in an integrated RIS/PACS solution.
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Maria Ball
Chief Operating Officer
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“We were ahead of our time in stipulating that the integrated RIS/PACS be provided by a single vendor, because it was typical then to have a RIS vendor and a PACS vendor work together to try to broker a RIS/PACS solution,” says Maria Ball, Zwanger-Pesiri’s Chief Operating Officer. “But we didn’t want vendors pointing fingers at each others’ solutions if something went wrong. We wanted total accountability from one vendor.”
To maintain continuity of patient records, the imaging center also insisted that the new vendor migrate not just the PACS images, dating back to 1998, to the new PACS, but also all RIS records going back to 1990 to the replacement RIS, a total of about 900,000 RIS patient records alone. “None of the vendors that made it to this point rejected this requirement, but most were apprehensive about it,” Ball says. “They were afraid that if it weren’t successful it would create a negative first impression, so some of the companies discouraged it.”
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Matt Dewey
Chief Information Officer |
“We were adamant about migrating our legacy RIS records because they’re critical for streamlining the process of looking at relevant prior studies,” adds Zwanger-Pesiri Chief Information Officer Matt Dewey. “Similarly, we knew we didn’t want to maintain the existing RIS, because it would take up space and force the radiologists to go to two different places to look at current and prior studies. Everything should be in one system.”
A good price and robust billing application in the RIS/PACS solution also were key requirements for Zwanger-Pesiri, as was the option to purchase the workstation hardware from any vendor.
Solution
At the time of the IT evaluation, Merge Healthcare appeared to be the only vendor that was offering a completely integrated RIS/PACS solution.
“Some vendors claimed to offer an integrated RIS/PACS, but in reality these were brokered RIS and PACS components from two different manufacturers,” Day notes.
“In 2004, the integrated Fusion RIS/PACS configuration was new even for Merge,” says Dewey, who was – until shortly after Fusion RIS/PACS became operational at Zwanger-Pesiri – a Merge Healthcare service representative. “In fact, Fusion RIS/PACS became a released product just two months before Zwanger-Pesiri went live with it, which made it one of the very first to be implemented in a clinical site.”
Zwanger-Pesiri officials were eager to implement their new RIS/PACS solution and wasted no time in making it operational, Day recalls. “It wasn’t phased in anyway. We didn’t roll it out in one office, test it and carry it over to another office,” he says. “The hardware was brought in and we literally flipped a switch and went 100% live.”
When Zwanger-Pesiri recruited Matt Dewey from Merge Healthcare to become the imaging center’s head of IT, his first order of business was to obtain licenses for diagnostic modality worklists (DMWLs) for all imaging systems that could use one to link the RIS-based patient EMRs with the diagnostic modalities.
“We were astonished by the number of typographical errors and erroneously entered MRNs – I would estimate 10 percent or higher,” Day observes. “In the past, we would try to cross-reference an MRN and we realized that one whole modality was using the accession number to type the patient in. It was a mess. Today, if a modality doesn’t have a DMWL, I almost don’t want to use it.”
Migration of the legacy RIS patient records to the new Fusion RIS/PACS was an arduous and labor-intensive process, involving the hiring of part-time employees who spent three months migrating the studies. But for an imaging center with a five-decade presence in the community, continuity was critical, according to Ball.
“We wouldn’t accept a situation in which previous records were unavailable, or available in two separate places,” she states. “It’s so important, because most of our patients are recurrent and so comparisons to previous studies is vital in many instances.”
Results
With a centralized RIS linking all of Zwanger-Pesiri’s locations, scheduling is no longer done in isolation for each site. In the past, each office had no idea of the number or type of examination scheduled in its counterparts – often requiring the patient to call another office if one location’s schedule was filled. With Fusion RIS/PACS, all examination requests from patients and referring physicians are funneled to a single scheduling application, facilitating a more streamlined process.
Workflow has been further accelerated by enabling network access to scanned documents during the intake process, allowing radiologists to review patient history, HIPAA compliance and referring physician information forms from any imaging site by simply clicking on an icon in the RIS. Additionally, when the technologist brings the patient into the scan room, DMWLs from the RIS fill in console fields, eliminating the need for technologists to re-enter patient information. “With one-click access to the patient record just before the examination, data entry errors have been dramatically reduced,” Day observes.
The Fusion RIS/PACS distributed radiology model made the radiologists’ physical locations mostly irrelevant from an image reading standpoint, improving load balancing among the centers and increasing productivity and efficiency. “Recall that in our previous set up, just locating and loading relevant priors was a major job, particularly if the patient had scans at two different offices,” Day says. “Now, all relevant prior studies are available at the radiologist’s fingertips – just a couple of mouse clicks away.”
While Zwanger-Pesiri’s recent growth mandated the hiring of an additional nine radiologists (25 to 34) over the last four years, the centralized, distributed Fusion RIS/PACS model has enabled the organization to do more with less by greatly improving the productivity of each radiologist regardless of their office location. It even allowed the imaging center to retain a subspecialist radiologist who otherwise would have been unable to work in an office setting.
“This radiologist decided that her home priorities would preclude her commuting to the practice each day,” Ball relates. “So, we recently set her up with a networked workstation at home. In this way, we avoided losing a competent physician and a good producer in a subspecialty that Zwanger-Pesiri values. This same patient advantage applies to our other subspecialty radiologists based in our locations. Relevant cases simply are sent to wherever our subspecialist radiologists are regardless of where the exam was performed”
Interestingly, the transcription workflow presented as one of the most critical issues during the IT evaluation period. “Our turnaround time for transcription was really starting to cripple the practice,” Day says. “If I had to pick a single thing that we have improved 10-fold, it would be our transcription turnaround time. With integrated digital dictation, the time from when the radiologist dictates the report to when the transcriptionist faxes it to the referring physician has been compressed radically.”
Technologically, the transcription medium at Zwanger-Pesiri evolved from magnetic tape audiocassettes to digital voice file notes dictated by the radiologist that are sent to a dictation server for the transcriptionist to transcribe. “The 10 transcriptionists were based three to four per office because they had to be close to the radiologist,” Day explains. “They would have to type and print it, and have it proofread by the radiologist, all of which yielded stacks of paper.”
Moreover, the physical space required to accommodate the transcriptionists was becoming limited as Zwanger-Pesiri’s needs grew. Fusion RIS/PACS’s integrated digital dictation transformed the office-based transcription workforce into a virtual transcriptionist pool that not only did not strain the imaging center’s physical plant, but it also fostered greater productivity via increased flexibility.
“Our transcription staff leveled out to our present complement of 13 transcriptionists even as our study volume grew,” Ball says. “When we acquired Fusion RIS/PACS, we were able to centralize transcriptionists under one roof. Today, all but three transcriptionists work from home – and for the home-based staff, work can be conducted at any time in the 24-hour cycle, dramatically improving workflow and efficiency.”
The professionalism and regard for high quality, compassionate patient care over the decades put Zwanger-Pesiri staff on a course for unprecedented expansion in the early years of the 21 st century. But a new imaging informatics paradigm was needed to provide the infrastructure for that growth, Ball maintains.
“An integrated RIS/PACS, once properly engaged, made growth easier to manage,” she says. “Zwanger-Pesiri has realized an approximate 33 percent growth in studies performed since Fusion RIS/PACS installation and we are predicting that we will perform a record 320,000 procedures in 2007. Even though we operate eight sites, we now can practice as one large unit, making all resources easier to allocate and allowing our whole operation to function smoothly.”
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Today, Zwanger-Pesiri’s eight locations in Nassau and Suffolk counties in Long Island provide the latest diagnostic technology the medical field has to offer, including the revolutionary 64/128-slice CT scanner, 3.0 Tesla ultra high field MRI, 1.5 Tesla open MRI, PET/CT system, SPECT nuclear medicine, ultrasound, digital x-ray, digital mammography, stereotactic biopsy, interventional radiology, and DEXA bone densitometry. All 35 Zwanger-Pesiri radiologists are board certified.
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