August, 1996 Integration: The key to image management By Ed Laufenberg, Sales and Marketing Manager, SMS Healthcare Imaging Solutions Perhaps no other industry has watched the development of imaging more closely than healthcare. Imaging has the potential to make information easily accessible, so that, once digitized, that information can be categorized and stored, making it accessible whenever and wherever it's needed. Why is that so important for healthcare? Imaging systems can help healthcare organizations manage the massive amounts of information that can be as essential to patient care as advances in surgical techniques. It's also important to support the universal goal of healthcare organizations: the computer-based patient record (CPR), a repository that encompasses all types of patient information--current and historical clinical data, demographic and financial information. Given the ever-escalating need to share information--clinical, demographic and financial--among providers, healthcare organizations and payers, the computer-based patient record is crucial for a healthcare enterprise to operate optimally from both a care and financial perspective. However, for the CPR to be complete, it must be capable of handling all types of information, including multimedia data types, such as voice, video, and images (document and medical), thus the focus on imaging. Many imaging companies are eagerly marketing their products to healthcare organizations. For healthcare, which has traditionally turned to healthcare information system (HIS) companies for information solutions, this can present some confusion. Should a healthcare organization choose to go with a vendor that exclusively provides imaging? Or is the better choice a healthcare information systems company that offers an imaging solution? While there is a proliferation of generic imaging solutions available, there is a great deal of debate as to whether they are easily transportable from industry to industry. This appears to be particularly true for healthcare. To be effective, the imaging product must be integrated with existing information systems (such as patient accounting) in order to streamline claims processing, and with clinical systems (such as radiology) in order to provide physicians not just with medical images but also with the reports associated with the image. Imaging products that are independent of other information systems usually require costly and complex interfaces to existing healthcare information applications and are not designed to synchronize with a hospital's software and processes. Given the highly specialized needs of the healthcare industry, this can mean that an organization is simply adding another process and may never realize the full benefits of an imaging solution. For example, if no integration exists between an accounts receivable workstation and the document imaging system, the user will not have ready access to necessary information which resides in the imaging system, and will have to continually exit in and out of different systems to retrieve required information. An imaging system should be developed on the premises that imaging is a core component of the computer-based patient record, must be integrated with existing health information applications, and must be extensible to other multimedia data types. Richard Bagby, CIO of The Reading Hospital and Medical Center, Reading, PA, concurs: "SMS' decision to image-enable its applications means that we can easily use imaging as a tool as we build the computer-based patient record." The significance of integration Imaging must be integrated with existing financial applications, such as patient accounting, in order to streamline claims processing and with clinical systems, such as radiology, in order to provide physicians not just with the reports associated with the patient, but with the images as well. Mitzi Winters, Vice President of Patient Business Services, Baptist Health System, Birmingham, Alabama, cites integration as a valuable aspect of an information system. "Without the integration with our HIS applications, we could not realize the tremendous cost savings and gains in productivity that we have. The imaging system is intertwined with our applications. For example, when a user is working on claims in the patient accounting system, that individual is also automatically accessing imaging. Every bit of information required to process a bill is included in the patient's imaging folder, so we are completely performing that operation electronically. "Patient service is also greatly enhanced," Winters continues, "because we can scan in information such as an insurance card. And we only do it once. A 'flag' alerts clinical areas that the information has already been scanned in at registration and is in the folder. Payers and patients alike are quite pleased with how quickly we can access necessary information. Quite literally, the time it takes to find patient information has dropped from 24 hours to two minutes." SMS' Image Management System (IMS) provides features such as automatic creation of an imaging folder when a patient is admitted or registered; automatic indexing and routing of newly acquired images; automatic updating of the imaging indexes when patient information is changed elsewhere in the system; and access to images from the application workstation. Workflow tools While most imaging systems employ workflow, these separate tools can be redundant to the workflow already existing in healthcare information applications. Better to use the logic and workflow already contained in existing applications, so neither data or function is duplicated. By extending existing applications to incorporate imaging capabilities, users can gain maximum effectiveness from existing applications. For example, in patient accounting, receivables management software produces on-line worklists that are automatically linked to the imaged documents (such as bills). The integration of imaging allows appropriate documents to be automatically retrieved and displayed in the flow of the application. In the clinical arena, the medical images are managed by the workflow of the radiology management system (RMS). For example, when a patient is admitted to the intensive care unit (ICU), that patient's X-rays are automatically routed by the RMS to the ICU workstation and are immediately available for clinical review. Bethesda Health Corporation, Boynton Beach, FL, is currently using both document and medical imaging. Bill Stewart, Vice President of Information Systems, explains that his organization was investigating methods to streamline radiology processes in the ICU. "In the ICU, patient X-rays are taken with portable machines. The film is then processed in the radiology department. If a physician wanted to view the film, he or she had to leave the ICU to go to radiology or request that the radiology department make a copy and hand-carry it the ICU. Neither process was productive or efficient." Implementation strategies How an imaging system is implemented can be as important as the functionality itself. Implementing the system must take into account an organization's unique environment, requirements, strategic objectives, and risk factors. SMS recommends an incremental implementation in order to allow an organization to gain experience with imaging technology in low risk, easy-to-cost-justify situations. This protects existing system investments, enables organizations to deploy imaging at a pace that is aligned with their strategic objectives, and allows organizations to build success with imaging. For most healthcare organizations, the business office is ideal for the initial implementation of an image management system. First, a high percentage of the documents used in this department can be electronically transferred, thus minimizing the labor associated with scanning. Second, the department is self-contained, which increases the probability of success. Third, the productivity gains and cost savings can easily justify the implementation costs. For example, SMS customers using imaging in this environment have reported a payback period from 1 1/2 to 2 1/2 years. Paul Marier, Chief Information Officer of St. Elizabeth's Medical Center, Boston, MA, part of the Caritas Christi Health Care System, was able to quickly cost-justify the system. "The success we've achieved in admitting and patient accounting will pave the way for our next phases of imaging implementation." The image management system is also supporting St. Elizabeth's and Caritas Christi Health Care System's long-term strategic goals to centralize all business office functions across the enterprise. After gaining experience in patient accounting, most healthcare organizations choose medical records for subsequent imaging implementation. King's Daughters' Medical Center, Ashland, KY, has implemented imaging for medical records documents in the emergency department and for outpatient visits. According to David Oliver, Information Systems Director, "As soon as a patient file is received, we immediately scan in any information that has not been electronically captured. Now that the files for emergency and outpatient visits are paperless, our staff no longer wastes time tracking down files to retrieve information to copy and route it to the appropriate parties." The process reengineering component Experience in implementing imaging has demonstrated that process reengineering can actually accelerate imaging implementation. Process reengineering ensures that imaging not only functions with existing applications, but is also synchronized with practices and procedures. Such a project usually begins with preparation and analysis in advance of the imaging system delivery and installation. The user environment and the flow of information are analyzed, and the work processes that imaging will affect are documented. The next step of process reengineering is a collaborative effort (including management, users, and the implementation team) to refine or create new processes and procedures, eliminate obsolete ones, and education to effectively implement process changes. This enables an organization to take full ownership of the system and to capitalize on the potential of imaging. Washington Hospital Health Care System (Fremont, CA) Director of MIS Bob Woods, says this approach greatly contributed to the organization's achievements with imaging. "From a process perspective, we've completely changed the way we operate--we have not just added another system. Processes are now completely automatic--all the necessary information is instantly available. Imaging hasn't simply changed how tasks are completed, but has reduced the number of tasks our staff now needs to complete. It's truly unique in my experience." Bill Stewart of Bethesda says that the reengineering process was a crucial step in the imaging implementation. "Many imaging companies attempt to retrofit imaging with existing information systems. But without integrating the systems and processes, you simply can't derive the full benefits a paperless operation can offer. In the business office, by making process reengineering part of the imaging implementation, we've achieved an 20% cost savings and greatly reduced AR days. We've completely eliminated some steps and have become much more productive. Our staff, who was closely involved in the reengineering, reports that jobs are less clerical in nature, which is improving morale and job satisfaction." Prior to the implementation of imaging in the Patient Accounting area, Marier explains, St. Elizabeth's was completely paper-dependent. "The first step was a reengineering of the patient information flow. We examined every process--from the time a patient is admitted until a bill is paid. Using imaging has streamlined business office operations to the point that we have been able to reduce the number of procedures from 600 to 150. The efficiencies gained by utilizing this tool are exciting, and there's complete consensus among our staff at every level on the value that imaging has brought to our organization." The future is in multimedia SMS is continuing to commit resources to the ongoing enhancement and development of imaging solutions in support of the computer-based patient record. One such development effort is a collaboration with General Electric Company (funded by the Department of Commerce) to develop multimedia information technologies for more efficient handling of medical information. The project's goal is to further the development of the technology used to capture, integrate, and transmit multi-media medical information--including voice, video and medical images-- across geographically diverse healthcare networks. The first phase will address the challenges of secure transmission of high resolution radiology images and related clinical information across local and wide area networks. Ed Laufenberg is the sales and marketing manager for SMS' Healthcare Imaging Solutions and can be reached at 610-219-1220.
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