The strategic deployment of information technology has enabled Riverside Radiology Associates to market its subspecialty reads to a rapidly growing clientele

Marcia Flaherty, CEO, and Ron Hosenfeld, CIO, Riverside Radiology Associates, Columbus, Ohio.

Some radiology practices invest in information technology simply to support digital modalities. Others, like Riverside Radiology Associates in Columbus, Ohio, invest in it to support an entire business model on which rests the growth strategy of the practice.

Not that Riverside would be unable to grow without investments aimed in that direction. But the acquisition of a robust complement of informatics piecesand the hiring of professionals with the high-level skills to implement and maintain themhas made it vastly easier for Riverside to develop into a finely tuned, subspecialized organization capable of attracting an abundance of satisfied customers from near and far.

"We've worked very diligently over the last couple of years to position ourselves with a number of excellent IT solutions, and today we're reaping the benefits," enthuses Ron Hosenfeld, chief information officer, a former IT specialist for a major corporation whose rolled-up-shirts-sleeves approach to overseeing the Riverside informatics systems and infrastructure has helped the group offer (in addition to subspecialty reading) PACS archive hosting to a lengthening roster of referring physicians and hospitals.

READ ANYTHING, ANYWHERE

Riverside Radiology maintains offices in six locations throughout the greater Columbus area. They are home to 38 radiologists, nuclear medicine physicians, and interventionalists, plus a clinical and administrative staff of 100. The group performs in excess of 500,000 procedures a year. Services include diagnostic x-ray, CT, MRI, ultrasound, nuclear medicine, cardiovascular imaging, vascular interventional radiology, interventional neuroradiology, mammography and women's imaging, and pain management.

The informatics side of the practice takes in fully integrated PACS and RIS—the latter including subsystems for billing, electronic medical records, voice-recognition transcription, and wireless text messaging. There are workstations at every radiologist's desktop (a deployment scheme that has allowed Riverside to go fully paperless). The informatics components are networked in such a way that each radiologist also has the ability to read diagnostic-quality images and dictate reports at home or on the road. Moreover, text messaging provides a facile means of putting customers in quick contact with the radiologists, regardless of their geographic location at any given moment.

"We seek to provide optimum customer service, and our informatics capabilities allow us to do that by enabling our radiologists to read anything anywhere anytime," Hosenfeld says.

As for the communications infrastructure that supports all of this, it consists of multiple, privately routed T-1 lines and Ethernet-over-fiber cable. "We've considered stepping up to T-3 lines," Hosenfeld says, "but we've decided to do that only as necessary—and only as it becomes economically feasible. Prices are headed downward, so it's something we're keeping an eye on and an open mind about."

Hosenfeld contends that a strength of Riverside's informatics and communications strategy is that it involves many different solutions, rather than a single, all-encompassing formulation. "We've been careful to not pigeonhole ourselves," he says. "Consequently, we have the ability to more facilely embrace important technologic advances and readily integrate them with what we already have in place."

THE HOST WITH THE MOST

PACS is, of course, the cornerstone of those informatics solutions.

"Without PACS, you have no access to images—however, as a stand-alone technology, it's not nearly the tool it can be without the other informatics components," Hosenfeld says. "PACS really starts to perform only when you add on and integrate the rest of them. That's what makes it possible for our practice to offer the subspecialized reading model that has been so key to providing the high-quality, high-level interpretations that our customers expect from us."

More important, where growth ambitions are concerned, Riverside's PACS permits relatively simple, low-cost archive hosting. "Our customers who want the advantages of filmless imaging but who can't afford to buy their own PACS are able to enjoy all the benefits of PACS ownership without the expense, just by tying into our system," Hosenfeld explains. "For example, there is a small hospital north of Columbus that utilizes our PACS. They generate their own images and do their own interpretations, but they store and retrieve and distribute those images using our PACS. It's a very smart alternative for their storage of digital imaging."

Hosted PACS customers can also access Riverside's RIS. However, the preferred approach entails taking the customer's own RIS (or even a practice-management package that offers RIS-like functions) and interfacing it with Riverside's PACS. Hosenfeld reports. "We can ensure better system performance by linking their RIS to our PACS," he explains.

Riverside does not engage in formal marketing of its PACS hosting service to attract customers. They learn about the offering through word of mouth. "Usually we're approached by a practice or an institution that hears about what we're doing and then decides to see if we can help them," Hosenfeld says. "They come to us after exhausting most of the options for a PACS solution that's within their means."

The first Riverside hosted-PACS customer materialized almost that very way. Says Hosenfeld, "We had been reading MRI images from an orthopedic practice that was in the process of merging with another large practice. They knew their combined image archiving and communications needs were going to be a lot bigger as a result of this merger, so they asked our advice about ways they might be able to address them. One of the suggestions we offered was a hosted PACS arrangement. We said, We've got enough PACS power and archiving capacity that we could easily tie you in, provide you with a secure partition, and it would be just like you had a PACS of your own, except at a fraction of the cost.' They didn't need a lot of persuading to see the value of that proposal."

Making PACS available to outside entities was a service Riverside had contemplated well ahead of that initial opportunity. Marcia Flaherty, practice administrator and CEO, says the group settled on this course after concluding that Riverside's future growth prospects could best be nurtured with a business model built on workflow-enhancing and efficiency-promoting technologies. "The idea," she says, "was to spark growth by spreading our informatics capacities and expertise across a large customer base, which would also have the effect of making it easier to justify our acquisitions of the kind of sophisticated technology we had in mind—and of our recruitment of someone with Ron Hosenfeld's level of IT expertise. We knew that having an asset like Ron would be very attractive to potential customers, since their own ability to recruit people with Ron's level of expertise would be fairly limited. But we couldn't convince anyone with Ron's abilities to come aboard without making the commitment to acquire the sophisticated informatics products."

AVOIDING SLUGGISHNESS

As one might expect, there are a number of technologic challenges associated with PACS hosting.

"The primary difficulty is maintaining wide-area network speed and availability—the more remote the site, the more difficult that becomes," Hosenfeld says. "To address it, we've developed a couple of in-house, cost-effective solutions. The first involves use of caching servers—one installed at each remote site. The image generated at the remote site is sent to our primary archive in a normal compression format. Then, we make a copy of that image, put it into a very highly compressed format, and send it to the customer's cache server. In that way, the customer enjoys near-instantaneous access to the image. Without this strategy, our only other recourse would be a supremely costly investment in WAN speed—which would not necessarily guarantee us the level of performance a hosted user would find truly satisfactory.

"The second solution we developed involves use of local-area network accelerators and supporting technology. These provide a bit-level comparison of the information flowing across the network and eliminate duplicate and overhead traffic [generated by Windows™ communications protocols]. This dramatically speeds things up."

Returning to Riverside's growth hopes, it helps that the group has chosen to take a decentralized approach to the distribution of its own image and text data, Hosenfeld discloses.

"We don't have one centralized computer room that contains all the information," he says. "Instead, we've opted to go with a series of smaller systems deployed at a number of facilities around central Ohio. We did this because we wanted to be able to give each Riverside physician, technologist, and administrative worker the most performance out of the system they were using most frequently. Also, it gave us enhanced protection against data loss in the event of disaster."

This distribution strategy is currently being revised to accept a degree of consolidation. Current technology's power and performance attributes are such that Riverside can replace multiple older servers with a smaller number of newer ones. But consolidation is not feasible in all instances. "As an example, our billing system has about 25 employees who access it directly and do a lot of high-traffic, high use on that system, whereas the other users of that same system are far fewer and their usage demands are much, much less," Hosenfeld details. "Therefore, the billing employees are colocated with that system, and we have to keep it that way. It would be detrimental in terms of their ability to have the kind of system performance they require were we to consolidate their operations into a centralized server system."

TEN-YEAR PERSPECTIVE

Successfully translating Riverside's vision for the future into practical IT solutions for today hinges on how well the IT team understands what each informatics system user wants and needs to accomplish, Hosenfeld contends.

"That's where so many IT solution-development efforts fall apart, in the translation between user and implementer," he says. "So, to avoid that, we start out by asking each user to describe their informatics-related need. But we don't stop there. We also ask the user to show us with some type of simulation what they hope to be able to accomplish. So that we can be sure that we've correctly internalized the user's wishes, we then describe back to them everything we've heard and seen—if we're able to do that, then we have confidence in being able to translate the need into a workable solution."

Most times, solutions are developed after the user approaches IT with a request for help. In the remainder, they are the result of the IT team noticing a problem trend and then recommending ways to improve things. However, "in all cases, we approach our solution-development efforts in such a way that we don't end up boxing ourselves into a corner with inflexible implementations that are fine for the need of the moment but not for that of the future," Hosenfeld says. "How? We like to take a 10-year perspective on decision-making: in other words, before we implement a proposed solution, we ask ourselves how we think we might feel about that decision a decade from now. If it seems like a decision that will stand the test of time, then we implement it. If there's doubt about that, then we don't. Granted, it's very hard to forecast what the future 10 years out will be like with regard to IT technology, but it's not that hard with regard to workflow and user preferences."

From her vantage point, Flaherty believes the informatics strategy adopted by Riverside will go a long way toward ensuring that the group prospers in the years ahead.

"We see our subspecialty model of practice as one that is becoming increasingly attractive to both physician practices and hospitals in our geographic area and outside our area—and having the capability to utilize the technology to build our enterprise is a critically important part of that attractiveness," she says. "For example, one of the interesting things we're working on right now is a system to electronically deliver referring physician images directly into the operating rooms of the hospitals where they work, which will free them of the present limitation of only being able to hand-carry in images on film or CD.

"Our informatics assets also increase our attractiveness to physicians we would like to recruit. In the last few years alone, we've been able to add several of the nation's foremost radiologists whose presence in our group has allowed us to further develop our subspecialty model. Take, for instance, our stroke program—we wanted to develop this as a world-class program and have been able to do just that with our recruitment of Dr Ron Budsig from Massachusetts General Hospital."

Had the practice chosen to defer or even eschew entirely these informatics investments, the growth picture of the moment would look significantly different. Says Hosenfeld, "We wouldn't have been able over the last 2 years to add the customers we have today—and that would be in no small part due to the fact that it would have been impossible to deliver the right examinations to the right physicians in a timely manner. We probably would have had to abandon the subspecialty reading model, and given up that business altogether.