It may have Americans losing sleep - but today’s emphasis on productivity, efficiency and pooling of resources is nothing new in the Canadian nationalized healthcare system which has always faced the challenges of limited budgets. And capitalizing on cutting edge technology to meet these challenges is nothing new to Raziel Gershater, chief of diagnostic imaging for North York General Hospital, a 500-bed hospital in Toronto.

In the forefront of computerized radiology, ten years ago he installed a modest PACS system - then controversial and in its infancy - to allow his department to share a costly MR scanner located at a larger nearby hospital.  Again embracing high-tech healthcare, in 19xx, his department served as one of the first beta sites for Internet-based computerized radiology to make the most of his staff and budget. 

And now, as North York General merges with nearby North York Branson Hospital and doubles its case load, once again it is relying on the acquition of a cutting edge PACS solution. The hospital is using an enterprise-wide, Internet-based PACS to streamline workflow, increase productivity and boost diagnostic accuracy to meet new demands.  As a PACS purchaser with his finger on the pulse of the industry, Gershater brought singular knowledge, experience and sophistication to bear on his decision. In other words, he was one tough customer.

INTERNET CUTS COSTS

“I consider computerized image management to be so important that it constitutes a new radiology subspecialty--and Internet technology is the way of the future” says the highly experienced doctor, who was the driving force behind North York’s choice of PACS developer Algotec, based in Duluth, GA and Raanana, Israel.  Algotec had provided North York with its beta Internet system and was the first company to receive FDA clearance for a JAVA-based web engine.  Today, it still has one of the largest number of web-based PACS installations worldwide.

North York--and the industry--have come a long way since the hospital first started with PACS ten years ago.  Back then, North York’s preliminary installation consisted of a simple T-1 line that carried images to a single workstation, enabling on-premises soft-copy reading of MR from the nearby hospital.  In time, other components--including dedicated workstations, and a storage archive provided integration of CT, MR and digital fluorography.  These were from a variety of manufacturers and pre-dated DICOM.  Naturally, compatibility was a major issue.

To find the best fit among manufacturers, North York’s medical imaging department became a beta-site for many of the first PACS components from manufacturers large and small.  The Internet web engine was only one of several Algotec components Gershater used on a trial basis.

In 1993, North York was a beta site for one of Algotec’s full-featured ProVision primary workstation. By 1995 the department was up to ten units, nine of which the hospital purchased on its own for softcopy CT, MR and ultrasound reading.  “The stations were fast, sophisticated and reliable.  My radiologists wouldn’t use anything else,” he said.  “Naturally, one year later, I was extremely interested when Algotec offered to make us one of the first experimental sites anywhere for new Internet-based computerized radiology.”

FAMILIAR FRUSTRATIONS

Despite all this, until recently, Gershater faced many of the same frustrations as most medical facilities with growing commitments to PACS--small budgets, keeping pace with changing technologies, the need to tweak and build on to existing components rather than buying new, to build in scalability and upgradeability, and to work around the limitations of the current state-of-the-art. The result was an all-too-familiar patchwork of components that failed to achieve the desired level of reliability and that required heavy maintenance.

THE CHALLENGE

Last year, as the merger with Branson approached, Gershater finally received funding to capitalize on his PACS expertise and passion with a full-scale state-of-the-art system.  Gershater had extremely specific objectives in mind for his new system and the knowledge and experience to meet them.  He felt Algotec was the right fit.  Having worked firsthand with numerous vendors as a beta site, he knew the challenges his situation would pose many of them.

A particular issue was that North York’s new radiology department would comprise several locations that had to function together seamlessly. The move to a new level of filmless would require a distributed PACS architecture that functioned flawlessly as a unified system.  And it had to be available at an affordable price.

First and foremost, Gershater felt a system based on web technology was important to make the most of his budget.  The sophisticated Algotec web-browser he had already tried allows an ordinary PC to function as a full-featured diagnostic image and data review workstation.  This requires no additional hardware or software, making image distribution throughout multiple locations far less costly.

To create the system, Algotec used JAVA applets to take advantage of the hospital’s existing  Internet and intranet connections to deliver data as well as all necessary software to all connected computers.  Furthermore, JAVA simplified off-site teleradiology and Gershater knew that Internet technology would keep the department poised to upgrade to emerging PACS technologies.

SEAMLESS INTERFACE

Past experience also convinced Gershater that North York needed components optimized to work together.  "We absolutely wanted to work with a single vendor, ” he said.  Through his longtime involvement in the industry, Gershater knew that most vendors outsource some PACS software components.  “We knew Algotec created every product sold in-house and had the capabilities to tailor a system to our needs from square one.  Moreover, we knew the breadth of their product line would meet all our needs, from virtual endoscopic software to data storage, workflow management tools and even video conferencing.  In fact, Algotec develops components sold as part of the systems of numerous major PACS players. With Algotec, we were going right to the source."

Naturally, reliability is a paramount issue to anyone considering PACS.  Gershater asks a lot: “Ninety-eight percent reliability may be acceptable for MR or CT, but not for the system that drives your department.  It means you may not function two percent of the time.”  Algotec’s system is the most fault-tolerant in the business.  It uses a decentralized model, processing information on several CPUs.  If one fails, the others take over.  Short of a hospital-wide network failure, the system is always up and running."

Also on Gershater’s must-have list were speed, of course; sophisticated workflow management tools, which make the most of the department’s time by transmitting tasklists, images and other information throughout the department; automatic fetching and routing of prior patient studies; tools for communicating with referring physicians; and flawless interface with the general hospital information system.

SOPHISTICATED SOLUTIONS

Algotec went to work putting together a system from its Imaginet family of products. The system includes the MediStore, a high-speed easily upgraded clinical data repository, and MediLink, which provides a HL7 interface with the Cerner healthcare information system.  The MediFlow suite of advanced workflow tools manages and automatically routes information where needed.  It automatically generates daily worklists for the entire department and pre-fetches and routes appropriate images and HIS/RIS files.  It also e-mail images and reports to referring physicians. These tools eliminate significant interdepartmental time and paperwork.

With the new installation, additional ProVision primary reading and reporting workstations provide everything North York’s radiologists need in one unit.  Sophisticated image viewing and analysis tools, automated work management features and a highly customizable interface are combined with Internet access, optional advanced volume-rendering and voice recognition report dictation.

Rounding out the system is Algotec’s latest MediSurf web access engine, which features optional video conferencing and an advanced data-push feature to automatically send studies where needed, eliminating time-consuming hospital-wide searches for pertinent information.

SPEED AND PERFORMANCE

Comments Gershater: “The system performs beyond our expectations.  The MediStore tiered archive is so fast that we almost don’t need pre-fetching features.  We can actually work efficiently in a query and retrieve mode.  And I’ve honestly never seen a web browser come close to MediFlow’s workflow tools.” 

He finds that several of ProVision’s unique features greatly increase departmental efficiency.  For example, the primary workstation allows multiple studies to be opened at one time, enabling several radiologists to work efficiently on a single station, if needed.  Along with important multi-tasking capabilities, the station offers an interface so intuitive that radiologists unfamiliar with PACS and computers in general can be up and running in a half hour.  “I’ve had numerous radiologists come though our department over the years and no one has had any significant learning curve with this system. Also, the volume-rendering software is breathtaking,” he says.

INTELLIGENT FEATURES

MediSurf web browser also has many time-saving features, including single-key shortcuts and split screens.  Pop-up menus are just part of the intuitive interface. “We found many other systems look cluttered and confusing on-line. The Algotec system uses screen real estate extremely intelligently," he said.

According to Gershater, the system also meets North York's needs because the interface is highly customizable, and each user can save and retrieve individual protocols.

SERVICE AND REASONABLE PRICE

Gershater was also pleasantly surprised with the company’s responsiveness and accent on customer service.  “Honestly, we had some reservations that a smaller company with possibly leaner operations might not offer the responsiveness PACS demands.  But Algotec has a highly trained network of support personnel throughout the US and Canada.  And while we have yet to experience a serious system problem, they were on site to fine-tune the system almost immediately when requested.  In short, as a small service-oriented firm, Algotec meets our needs.”

One aspect of the system that did not come as a surprise was the price for all this performance.  Given all his experience, Gershater knew he had been given a highly advanced, full featured system at an extremely reasonable cost.  And that’s one very direct way to make the most of a departmental budget.