Critical Care Plus-The Right Use of Technology Boosts Care, Saves Big Bucks
Critical Care Plus-The Right Use of Technology Boosts Care, Saves Big Bucks
A Clinical Imaging System can Change Your Culture, Care, and the Bottom Line
By Julie Crawshaw
By tapping into a new breed of technology, the cape fear valley health system (cfvhs) in fayetteville, NC, reports it is saving money for the system, time for physicians, and improving the care of critically ill patients.
The new technology is a clinical image management system (CIMS) that captures images from a variety of radiology systems and makes them available instantaneously to physicians throughout the system. The system is saving $2.5 million a year in costs, primarily by reducing lengths of stay (LOS) and providing physicians with the information they need much more quickly, says David Dillehunt, CSP, chief information officer for the health system.
Dillehunt oversees information issues for an integrated health care delivery network of four hospitals, 16 primary care physician practices, and six specialty physician practices. This year, he says, Cape Fear will handle between 400,000-500,000 outpatient visits and receive gross revenues of more than $5 million.
At the outset of his search for a CIMS he had two goals, he says. "We wanted a system that could provide superior access to clinical images and corresponding diagnostic information on an enterprise-wide level. We also wanted to sharply reduce film and film-related expenses within the radiology department."
Year after year, Dillehunt and fellow CIMS proponent George Binder, MD, reviewed new market offerings, but could not find any that met their needs. When they found ImageACCESS, a Windows NT-based CIMS from StorCOMM in Jacksonville, FL, they bought it.
"When we initially got the machine, of course, we were all used to films and regular radiology reports," says Anita Lee, RN, head of critical care nursing staff at Cape Fear. "Now, we can pull up images immediately. As nursing staff, we know what normal images look like, and we can immediately alert physicians to potential problems." Lee says that when doctors put in a Swan Ganz line to monitor cardiac output, for example, critical care staff can view the line on ImageACCESS.
"The system also has value as a teaching tool because doctors can use it to show us what a medial stinal shift actually looks like," she says.
CFVHS staff also use the CIMS system to educate nursing students who come to the hospital from the local college. "When we recently had a patient with a broken leg, we could see the fracture on the machine, not just read about it on the chart. I think it gives us a much better understanding, and that makes it easier for us to provide high-quality care."
CFVHS does not film its trauma cases now. The information is in its CIMS system, and can be retrieved by anyone who needs it. Binder says that when the system was a little bit slow in bringing up images, the culprit turned out to be a redundant system the hospital had built to protect itself. When the time-consuming loop it created was removed, speed increased. CFVHS recently acquired new, faster Pentium processors. Now the digital images are instantaneous.
Binder stresses that using CIMS images is much faster than using film. "I can be in another department and immediately read an image presented in the emergency room," he says. In one instance, Binder had two cases read before technicians could get another case filmed. Binder, an angiographer, says he can now read chest X-rays between reading angiograms without having to move from one area to another, which saves him a good deal of time.
The system also is useful at a 150-bed hospital about three miles away, which Cape Fear recently bought. "At night, we can cover them directly from here, instantaneously," Binder says. "Their radiological information is immediately available to us. For example, I can read a CAT scan or MRI and report back as soon as I see it. I don’t have to wait for film, or work with digitized film, which loses resolution. CIMS has no degradation in image quality."
Binder says the radiology department isn’t getting nearly as many physician visitors as it used to because other physicians can now pull up the images and read the accompanying dictation from their own workstations. He also points out that reduced reliance on file room personnel improves efficiency as well.
How CIMS Technology Works
• Captures images for use in the system.
• Stores and files electronic images.
• Retrieves and distributes, moving images to the end user.
• Display allows users to review images.
At CFVHS, the Image Access system acquires images from CT, magnetic resonance (MR), ultrasound, and plain film via film scanners. The CT and MR devices at the medical center are DICOM-compliant modalities. DICOM (digital imaging and communications in medicine) is a standard protocol that formats image information at the device level. The CIMS can use raw and processed DICOM data directly imported from those devices. It acquires images from the non-DICOM-compliant devices via its image capture software. Both DICOM and the image capture software acquisition interfaces result in an electronic collection of data that contains all the clinical images in the exam, plus associated patient information. Users also can add reports, annotations, or comments.
Electronic exams are stored on a centralized electronic database. The image server acts as a "traffic cop" for the entire system, processing requests and retrieving and distributing exams on demand. Images are processed and uncompressed in two phases.
The system initially stores image information on what are called a redundant array of inexpensive drives (RAID), a series of high-capacity hard drives that have fast access speeds. After seven days on RAID, exams are transferred to less expensive archive storage media.
"We chose a seven-day active period since demand for exams is considerably less after one week," Dillehunt says. Cape Fear currently uses two types of archive storage: WORM drives (write once, read many) and a magneto optical jukebox. The two-phase storage strategy is a compromise between slightly slower access speeds and less expensive storage media.
Dillehunt says he did some personal struggling with the issue of cost justification for the project because all the systems reviewed were initially designed to make things better for the radiologist. Radiologists’ productivity would improve dramatically because they could read more film much faster. "But that doesn’t do much for the hospital," Dillehunt observes. "The radiologists, after all, are in private practice. They don’t even work for us, and spending a lot of money to make things better for them only goes so far."
Just before Dillehunt looked at the system he eventually purchased, he attended a presentation that articulated the very issues with which he’d been struggling. From that he realized that the ability to distribute images across a health system quickly would put needed information into the hands of the decision-makers at the point of patient care level.
"That has a tremendous positive impact on the quality of care and cost savings within your health care system," he says.
The system’s CIMS retrieval and distribution mechanisms are built on an open client/server architecture. Display stations located throughout the medical center run the CIMS’s view station software. CFVHS currently has stations in radiology, emergency medicine, the operating room, and five intensive care units—surgical, medical, coronary, neonatal, and cardiac surgery. The view station software can be customized based on user name, so that no matter where a user logs onto the software, he or she will encounter the same interface.
Shortening Patient Stay Creates the Biggest Dollar Savings
Dillehunt points out that manufacturers typically try to sell a CIMS system based on the fact that it will reduce film costs. There are film cost savings, but Dillehunt sees the real benefit of a good CIMS system is that it can reduce patient length of stay. Every day the patient remains in the hospital longer than necessary translates to money coming off the bottom line.
"You have to expend money to take care of that patient, even if it’s just for taking up a bed, but you’re not going to get paid any more for it given today’s reimbursement methodologies," Dillehunt says.
Dillehunt’s research revealed two major time frames within each day to get information to physicians they need to decide the next step in their patients’ care. This could mean anything from moving a patient from a critical care room to a regular floor to performing another laboratory test. Physicians spend their time in between morning rounds seeing patients in their offices. If they don’t receive the information they need while they are at the hospital it means the patient stays for at least another half a day.
When Dillehunt did a financial audit, he found that patients who went through hospital areas that used the CIMS technology had hospital stays that averaged three-quarters of a day less than those of non-CIMS patients. That translated into a savings of $647,000 over a three-month audit period, which adds up to $2.5 million per year of actual dollars saved. "In health care, that’s a big, big deal," Dillehunt says.
Dillehunt’s audit covered the length of stay (LOS) for 1306 patients who had been admitted to the surgical, medical, or coronary intensive care units. Approximately 632 patients had been admitted during a preimplementation span from December 1997 to February 1998, and 674 had been admitted during the postimplementation span from December 1998 to February 1999.
His methodology measured all direct costs that comprise patient care, such as unit staffing, actual procedure costs, and supplies. Indirect (overhead) costs such as electricity and administration were not taken into account. The LOS reduction was accomplished at a time when the case mix index actually rose by 6.8%, meaning that the patients were actually sicker.
A previous study, conducted by CFVHS ultrasound supervisor Carmen Perri, also demonstrated CIMS-based savings to the health system. This study showed that the savings and increase in productivity brought about by the CIMS were projected to increased revenue in the ultrasound department alone by nearly $1.2 million per year. Combining the results of these two studies shows an annualized benefit of from $1.2 million to $3.7 million in increased revenue and $2.5 million in actual reduced costs.
First Get it Accepted, Then Use it Appropriately
To be used correctly, a CIMS system must first find acceptance. Dillehunt observes there are still a number of clinicians and physicians, both hospital- and non-hospital-based, who are reluctant to use some of the modern technologies. "By the time the younger physicians graduate from medical school, they are well immersed in computers," he says. "But a well-respected older physician does not want to risk looking stupid in front of others and may resist the technology."
Dillehunt emphasizes that the technology is phenomenal if it’s used appropriately; faster data transmission and shorter stays are what justify spending money on a CIMS system. "The real bang for the buck’ with this technology is in changing your culture to make more efficient use of the data and treat the patients faster with better quality information," he says.
Though all CIMS technology captures, stores, and files images, the StorCOMM system Cape Fear uses also distributes the data to anyone who has a need for it. Dillehunt says that because it takes a long time to move a radiology image through a network, most CIMS systems distribute the image directly to the workstation on the floor where the patient is staying.
However, he observes that most physicians will go to where their first patient is and call up an image, but don’t want to log into a computer on every floor where they have a patient. "They want to be able to call up all the information they need quickly, at one terminal," he says. "If the technology is not well designed, there’s too much lag time in calling up the images. If you can make it work fast and consistently, the doctors will love it." StorCOMM’s ability to call up images from any location was a major point in its favor.
The next goal for using CIMS at Cape Fear is viewing the progression for wound care. "For instance," Binder says, "we can now document the effects of, say, hyperbaric therapy, bring the patient back in four weeks for another picture, and compare it with the old one for a true objective pictorial description’ rather than a subjective written statement."
Finally, as an example of the care improvement the system can provide, Dillehunt tells of a patient who had just undergone a radiological diagnostic test. The supervising nurse became concerned because the patient was behaving strangely. She called up the image and saw it looked peculiar and immediately called the neurosurgeon, who got the patient into the operating room post-haste.
"Had we been using the old manual process for moving an image, it would have been more than 30 minutes before the physician got the information that the patient was in critical condition," Dillehunt says. "Having the CIMS system kept the guy from becoming a vegetable. I don’t know how to put a dollar value on that."
Sources
1. David Dillehunt, CPS, Cape Fear Valley Health System, P.O. Box 2000, Fayetteville, NC 28302-2000.
2. Anita Lee, RN, Cape Fear Valley Health System, 1715 Empress Lane, Fayetteville, NC 28304.
3. George Binder, MD, 1329 Robeson Street, Fayetteville,NC 28305.
4. Image Access system manufacturer: StorCOMM, 7 Corporate Plaza, 8649 Baypine Road, Jacksonville, FL 32256; (888) 731-0731.
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