Improving Care in a Rural Region with Consolidated Imaging (Maine)

Project Final Report (PDF, 141.07 KB) Disclaimer

Improving Care in a Rural Region with Consolidated Imaging - 2009

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    RFA: HS04-011: Transforming Health Care Quality Through Information Technology (THQIT) – Implementation Grants
  • Grant Number: 
    UC1 HS 015328
  • Project Period: 
    09/04 – 12/07
  • AHRQ Funding Amount: 
  • PDF Version: 
    (PDF, 58.18 KB)

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions in care settings, and the use of electronic exchange of health information to improve quality of care.

Business Goal: Implementation and Use

Summary: While quality and patient safety initiatives increasingly focus on the use of health information technology, the development of health information exchange (HIE) systems has not progressed as well as expected. The challenges associated with establishing these systems likely play a significant role in slow adoption rates. Few HIE initiatives have included radiology in their systems, even though some argue that radiology is an ideal first step in HIE.

With patients’ increasing mobility across health care organizations, radiologists have difficulty acquiring relevant prior exams (RPs), which compromises the ability to provide accurate diagnoses. Some health care organizations, especially those in rural areas, have not adopted picture archiving and communication systems (PACSs) because they are expensive to buy and operate. Many of the health care organizations that have adopted PACS have not been able to operate them effectively.

This project offered three hospital radiology departments the option of sharing one PACS. A large urban tertiary hospital in Maine implemented a shared PACS with two rural hospitals to provide the rural hospitals with access to PACS, improve the quality and cost of providing radiology services at all three hospitals, and improve each hospital’s ability to share radiology information with the other hospitals.

The evaluation focused on: 1) implementation challenges and their solutions, 2) realized benefits, and 3) the impact of a shared PACS on access to and use of RPs. Information from pre- and post-implementation interviews with radiologists, emergency department (ED) staff, and management, site visits, and analysis of post-implementation data from the shared PACS was used to examine implementation and impact (e.g., access to and use of relevant prior exams).

Specific Aims

  • Implement a regional, consolidated approach to PACS using a partnership model within a rural health network. (Achieved)
  • Evaluate the process of implementation, including the technological, clinical, economic, environmental, and cultural factors that impeded or accelerated the process. (Achieved)
  • Quantify the impact of the PACS regional implementation on health care access, cost, and quality. (Achieved)

Impact and Findings: The hospitals in the project anticipated that the shared PACS would bring more benefits than a standalone PACS, including greater access to RPs, cost savings, and assistance with radiology coverage. Overall, the staff at all three hospitals felt that the shared PACS met these expectations. Additionally, the ability to read exams remotely saved time for radiologists who would have had to drive to other locations, often in inclement weather. Interviews indicated that radiologists perceive a change in their access and use of RPs before and after implementation. The radiologists all stated that they had improved access to RPs, especially in situations where they were not aware that an RP existed. Before the shared system, radiologists only knew there was an RP if it was within their own institution or if a patient said s/he had a prior exam at another facility. Both radiologists and ED physicians also commented on how access to and use of RPs improved the quality and efficiency of care.

Several technical challenges were encountered during the shared PACS implementation. For the system to be effective, it must be able to share clinical and administrative data from disparate systems. Developing an enterprise master patient identifier (EMPI) for the shared PACS was a significant challenge. Due to limitations in the EMPI product and its implementation, all potential "first-time" matches had to be reviewed by a person. Because radiologists often dictate radiology exams within a few minutes of exam acquisition, these delays are significant. Both rural hospitals had significant problems with wide area network (WAN) connections and transmission costs. To obtain their WAN connections and adequate bandwidth from their local telecommunication providers, the hospitals had to wait at least a year. This problem may lessen in the future as the telecommunications infrastructure improves in rural areas.

Unexpected differences in knowledge, workflow that could not be changed, and limited human resources also challenged the team. The knowledge differences made it more difficult for rural staff to communicate what they wanted in the system and for the implementation staff to fully comprehend the needs of the users. Furthermore, the PACS implementation at the urban hospital had been tailored to their desired workflow. The needs of the other organizations were not always met because of limitations of the software to support disparate workflows, or because a change in workflow would impact all sites using the shared system.

This project demonstrated that a shared PACS is not only feasible but can provide more benefits than standalone systems. While implementing a shared system can be challenging, most users at the participating hospitals felt that the process went smoothly overall. Benefits of the system include improved access to and use of RPs from other hospitals, availability of more information to make better diagnoses, and improved communication between physicians to assist in clinical decisionmaking. Access to RPs across organizations also improved the quality and efficiency in providing care for patients transferred from the rural hospitals to the urban hospital. Lastly, the shared system increased the availability of back up radiology coverage to the participating rural hospitals and improved radiologists’ efficiency in delivering this coverage.

Selected Outputs

Loux S, Coleman R, Ralston M, et al. Evaluating the implementation and impact of a shared Picture Archiving and Communication System (PACS). Annual conference of the National Rural Health Association; 2008 May 7-10; New Orleans, LA.

Loux S, Coleman R, Ralston M, et al. (2008). Consolidated imaging: Implementing a regional health information exchange system for radiology in Southern Maine. In Advances in Patient Safety: New Directions and Alternative Approaches. Vol. 4. Technology and Medication Safety. (pp. 43-54). Rockville, MD: Agency for Healthcare Research & Quality. Available at:

Coleman R, Ralston M. Sharing of a single PACS by several disparate hospitals and business entities. Radiology Society of North America Conference; 2007 November; Chicago, IL.

Coleman R. Maine Consolidated Imaging: A regional approach to PACS. Rural Health Information Technology Conference; 2007 September 12-14; Kansas City, MO.

Loux S, Coleman R, Ralston M, et al. Evaluating the implementation of PACS in two rural hospitals. Rural Health Information Technology Conference; 2007 September 12-14; Kansas City, MO.

Coleman R. Utilization of an Enterprise Patient Index to enable a regional consolidated imaging record. The Society for Imaging Informatics in Medicine Conference; 2006 April; Austin, TX.

Grantee’s Most Recent Self-Reported Quarterly Status (as of December 2007): Grantee did not provide self assessment.

Milestones: Did not report.

Budget: Did not report.

Improving Care in a Rural Region with Consolidated Imaging - Final Report

Coleman R. Improving Care in a Rural Region with Consolidated Imaging - Final Report. (Prepared by Maine Medical Center under Grant No. UC1 HS015328). Rockville, MD: Agency for Healthcare Research and Quality, 2008. (PDF, 141.07 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
Principal Investigator: 
Document Type: 
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This project does not have any related resource.
This project does not have any related survey.
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This project does not have any related survey.

A Clearer Picture: Sharing PACS Helps Improve Care in Maine

Robert ColemanImagine the following scenario: Someone who lives in a small town in rural Maine gets in an auto accident, and is transported to the closest hospital.

Upon arrival, physicians discover that the patient needs a surgery that will require transporting the patient to another hospital. A CT scan is taken. As the patient rides in the ambulance, doctors at a larger hospital area are already reviewing that patient's scan and deciding on the right course of treatment. Instead of waiting for another scan, surgeons can begin working on the patient immediately.

Fortunately for the patient, the hospitals involved in this situation used a shared system, called a Picture Archiving and Communications System, or PACS, that allows them to store and transmit a patient's imaging records in real-time. Instead of using traditional film-based radiology, the system is digital.

In many cases, small, rural hospitals don't have the resources to support a full-time radiologist or have the equipment to send and receive medical images electronically. But that began to change for many hospitals in Maine thanks to a $1.4 million grant to Maine Medical Center from the Agency for Healthcare Research and Quality (AHRQ) to expand its PACS network to other hospitals in the state.

Maine Medical Center in Portland, which is owned by MaineHealth, implemented a PACS at its hospital in 2002. The hospital soon saw the system's benefits and wanted to share it with other hospitals in its system that were in rural areas of the state. Using the grant from AHRQ, Maine Medical was able to expand its PACS system to Miles Memorial Hospital, a member of MaineHealth, and Franklin Memorial Hospital, which is not in the MaineHealth system. To date, the PACS has been extended to seven hospitals, and numerous outpatient imaging centers, making it possible for these organizations to share images with radiologists and physicians at other locations, thereby helping to save time, money and improve patient care.

"It gives them [physicians and radiologists] access to relevant, prior exams that might have been done at other organizations. They are available within just a few minutes of when the images are taken," said Bob Coleman, director of radiology informatics at Maine MedicalCenter.

Using the system, medical staff can begin to diagnose patients without waiting for records to arrive or performing additional, unnecessary tests. Smaller hospitals that can't afford a full PACS system on their own -- or hire the support staff it takes to maintain such systems -- now have access to these images without having to maintain the system or pay for the associated on-going system support costs. In turn, patients get the benefits of having a team of radiologists at many hospitals review their records.

Disparate Systems Present Technology Challenges

Along the way, Maine Medical experienced some challenges implementing the system. There was a natural reluctance from some radiologists at smaller hospitals to work with radiologists at larger hospitals, for fear they might lose autonomy. But Stephanie Loux of the Maine Rural Health Research Center says that changed when the radiologists realized that having the PACS system helped them do their jobs, rather than taking them away.

"We've shown that it's not about stealing business. It's about providing better patient care," she said.

There were also technology challenges surrounding how to link the right radiology reports and images to the right patients since every organization used a different patient identifier for the same patient. However, the radiology informatics team at Maine Medical Center was able to utilize an enterprise master patient index system to link the patient identifiers from each organization. Likewise, manipulating radiology orders from each site through a central radiology information system allowed each organization to match exam types from the hospitals. When radiologists open an exam, relevant information from disparate organizations -- regardless of differences in patient or exam identification -- automatically display for comparison review.

The benefits of the shared system are significant. Prior to PACS, large "jackets" of film needed to be moved from organization to organization -- at a significant cost -- just to provide the radiologists with access to relevant prior exams. No longer do film-based images need to be moved from site to site, which caused delays in interpretation and negatively impacted patient care. Even with the advent of digital systems, data sharing between organizations involved passing around CDs or DVDs containing imaging data, which are easily lost. In other cases, physicians had to become experts at reviewing images electronically through different PACS at each organization. In the shared PACS scenario, access to images is streamlined. Ideally, all images are available in a single system, creating a virtual regional imaging record for patients, regardless of where they are treated.

The eventual goal of the project is to ensure that wherever a patient goes in Maine, their radiology images and reports will follow them. "Ubiquitous image access is our goal. We recognize, though, that not every hospital in the world will want to share our PACS," Coleman said, "So we are now looking at methods to streamline the transfer of data between disparate systems -- not just share the same system. The shared PACS project demonstrated the benefits of seamless access to images, and has raised the bar considerably."

Project leaders envision that sharing of images will be one of the catalysts that lead to the electronic sharing of other medical information across the state.

"Health information exchange improves patient care," Coleman said. "We have improved patient care in Maine, and we hope to do more."

This project does not have any related emerging lesson.

Project Details - Ended


This project created and evaluated a health information exchange system among three hospitals by developing a shared Picture Archiving and Communications System (PACS). This project evaluated implementation of a shared PACS in two rural hospitals ( Franklin Memorial Hospital and Miles Memorial Hospital) and an urban tertiary care hospital (Maine Medical Center). The evaluation focused on: 1) implementation challenges and their solutions; 2) realized benefits; and 3) the impact of shared PACS on access to and use of relevant priors (RPs.) Pre and post implementation interviews with radiologist, ED staff, management, and others, site visits, and analysis of post implementation data from the PACS were used to examine implementation and impact (e.g., access to and use of relevant prior exams). Implementation was viewed as successful and beneficial by nearly all three hospital staffs. Although the process presented technical, communication, and human resource challenges, hospital staff realized many benefits from the shared system. Radiologists had improved access to RPs, could provide more efficient evening and weekend radiology coverage, and had greater opportunity to consult with sub-specialty radiologists. The shared system also provided greater security for radiology coverage.