Improving Care in a Rural Region with Consolidated Imaging

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."