The Fusion of PACS and RIS

Larry Ranahan is chief executive officer of Meridian Regional Imaging, a Chicago-based provider of professional services for diagnostic radiology, management, staffing and billing focused on free-standing imaging centers and practice-based imaging facilities. Contact him at lranahan@meridian-mri.com.

Today’s providers of outpatient diagnostic imaging services face increasing challenges in managing information systems technology and costs, especially when considering rapid growth patterns, increasing cost containment pressure from insurance companies and never-ending complexities of Medicare and CMS. Meridian Regional Imaging, Mundelein, Ill., has been a regional provider of professional radiology interpretations, and related radiology billing and management services since 1999. From its inception, the organization has been a technology-driven practice, with a vision of a streamlined workflow that maximizes radiologist productivity and provides premier subspecialty interpretations with high-end customer service.

Meridian provides services to freestanding imaging centers (17 sites) and physician-owned imaging facilities (eight sites), performing nearly 70,000 exams annually. In 2003, four radiologists interpreted about 38,000 MRI exams. During Meridian’s first three years of operation, volume and operating costs moved in parallel. However, after a period of rapid growth, Meridian realized that new market realities no longer justified the cost of maintaining and expanding a fragmented set of systems.

The Problem
The organization’s RIS, PACS and digital dictation infrastructure was no longer efficient in supporting the primary workflow and did not optimally support the bottom line. Significant investments had been made in RIS and PACS, including a RIS implementation in 2000 at a Meridian-directed imaging center that failed to meet the organization’s broader business requirements. That failure resulted in the organizational philosophy that information centric solutions provide better opportunities to efficiently manage complex environments. Patient data, such as medical record numbers, demographics, exams, reports and billing information must be controlled and directed from a single source—the RIS.

In 2001, Meridian began constructing a foundation of patient information in our existing RIS from RIS Logic, a company that would later be acquired by Merge eFilm (now Merge Healthcare). Despite successfully implementing an interface between our RIS and existing PACS, a critical issue emerged—the quality of data exchanged between the disparate systems.

Incongruity of key data formats, including the medical record and accession numbering, led to significant reworking of exams. The radiologists were delayed interpreting new studies, as well as accessing relevant comparison images. It took the brute force of additional staff to manage the potential compromises in service and clinical quality. Consequently, in late 2003, Meridian sought a solution that fulfilled the vision of an integrated, seamless workflow for a group of four staff radiologists growing to eight.

Meridian sought to expand its existing image and information systems infrastructure with a model that would sustain a 30 percent annual growth rate, while covering expenses for RIS, PACS and other capital investments, as well as the necessary staff to manage and operate the expanded system. At the time, operating and overhead expenses represented 34 percent of total expenses and 30 percent of revenues. Labor costs were being driven by inefficient processing of images in a highly decentralized environment, and inefficient data and workflow coordination between the three key systems—especially the RIS-PACS workflow. The classic problems of duplicate and inconsistent data entry, along with data quality control challenges of linking the various systems, seemed intractable. Further, Meridian faced significant immediate capital and human investments just to manage the planned growth as determined by initial vendor responses, both existing and prospective.

Requirements and Solution
Meridian’s projections needed to sustain a high growth rate, as well as ensure an orchestrated shift toward multimodality, full-service diagnostic imaging facilities. After an initial RFP failed to produce the desired solution, we performed a comprehensive review of revenue, cost and productivity, establishing a baseline matrix of measures to quantify financials goals and measure the success or failure of our efforts.

The focus shifted to identifying a single primary vendor solution for RIS and PACS built on industry standards using off-the-shelf hardware. The vendor had to demonstrate a commitment and capability to deliver an integrated, single work list driven solution. The costs to acquire, convert and expand the software and hardware were key criteria, as well as reducing or eliminating the increased cost to post-process exams. Also on the wish list were streamlining data entry, remote data management and distributed workflow. The overall goal was to cap variable operating costs, so Meridian could capture true economy of scale.

In 2003, Meridian upgraded its RIS to a new Merge Fusion RIS. In 2005, during the PACS selection process, Merge acquired eMed Technologies’ Matrix PACS as part of a merger that created Merge eMed. The ability to integrate our existing Fusion RIS with the Matrix PACS made Merge eMed very attractive to us. The PACS fit Meridian’s existing centralized data center model, and supported a WAN distributed image acquisition and reading environment. In June 2005, Meridian awarded the project to Merge eMed, based on the vendor’s product capabilities and long-term vision. Most importantly, the solution met Meridian’s existing and projected capital funding budgets.

Outcomes
By integrating the Matrix PACS with our existing Fusion RIS, Meridian was able to reallocate some of the project’s funding. We could now focus more heavily on integrating the new PACS into the existing systems. We replaced all pre-existing diagnostic reading workstations, increased the number of reading stations from seven to 12, and deployed a Web server to provide online images and reports to the referring community. Meridian also increased its online storage capacity from less than .5 terabytes to 2.5 terabytes, with the ability to expand to 5 terabytes.

Prior to installation, Meridian radiologists had immediate access to just four months worth of stored online image data. If the images they needed were not among the spinning data, IT had to exchange spinning drives with those in archived storage. Post-installation, all data are on spinning drives, providing Meridian’s radiologists with unlimited, immediate access to image studies. This we achieved with a capital investment significantly lower than the amount we originally projected to expand Meridian’s existing PACS.

The solution provided for a single point of data entry and the sharing of critical patient data without additional intervention. There was an immediate return on investment by reducing the labor required for each exam by 80 percent. Prior to implementation, it took 7 to 10 minutes to process an exam, depending on imaging modality and exam type. Post-implementation, the processing time was virtually eliminated in 50 percent of the exams, and overall labor was reduced to less then three minutes per exam. Ultimately, sustainable high growth was maintained with labor cost reduced per exam by 60 percent and staff levels from 3.5 FTEs to 2.25 FTEs.

The original investments in the Fusion RIS and, more importantly, the continuity of longitudinal data provided the foundation for achieving the project’s primary goals and objectives. This allowed Meridian to define a data migration strategy that established the RIS data as the “gold standard” and perform a rapid migration of more then 100,000 exams from the existing PACS archive into the new image manager archive. In the process, a complete normalization and reconciliation of all RIS and PACS data was performed to establish a stable, integrated data environment. This foundation contributed significantly to capturing workflow improvements and cost reductions, thus driving the ROI anticipated from the project.

By mid-2006, the ratio of direct operating expense to revenue had dropped to 22 percent. The overall expense ratio improved to 30 percent from 34 percent in six months. The changes were beginning to be reflected in the overall financial performance of the organization. In June 2006, the addition of two new major clients added 23,000 new exams to existing volumes with a relatively modest capital investment and no additional staffing. This is expected to drive the ratios down by an additional 7 to 10 percent.

The Future
One of the key features of this project turned out to be the decision process itself. The project began in November 2003 and the new system went live in October 2005. In the nearly two-year cycle, implementation was only 13 percent of the total effort. The final decision actually turned out to be the beginning of a cycle of continuous process improvements. By focusing on finding technologies that fit the organization, and achieving the financial goals, Meridian has an information solution that works. With a strategically planned image and information system infrastructure in place, Meridian has been able to provide new services and capabilities to its clients, while improving clinical and service performance by reducing turn-around time and providing the referring community with immediate Web-based access to results.

The organization also has expanded its presence across the Midwest. Today, Meridian provides near real-time radiology, with subspecialty focused diagnostic imaging services, to the communities we service. The next step of the system’s evolution is currently underway—implementation of an integrated voice recognition and digital dictation solution. This enables us to expand upon our integration and workflow simplification goals.