One of the main reasons the Kettering Medical Center (Kettering, Ohio) network installed PACS was to boost referral volumes by providing better service. This strategy has worked. We experienced explosive growth that would have completely overwhelmed our previous film-based system and more than justified our PACS installation.

It was just a few years ago that we were experiencing stagnant imaging volumes. In September 1997, Kettering engaged an outside consultant to perform medical imaging benchmarking studies for both Charles F. Kettering Hospital, a 522-bed facility, and sister facility, Sycamore Hospital, which is licensed for 180 beds.

That report was presented in January of 1998. Its findings concluded that:

1) Imaging volumes were flat in 1996 and 1997; and

2) Referring physicians were generally dissatisfied with the service they received. There were delays in scheduling patients for MRI and CT exams, long turnaround times for reports and difficulties or delays in obtaining or viewing patient studies on film.

Working in conjunction with hospital administrators, we used this report to spur a series of changes to improve service to referring physicians, including the adoption of PACS and CR systems and the addition of new MRI and CT equipment to handle the demand for these modalities.

In early 1998, a pilot project was conducted in which images from a CR unit at an outpatient facility were transmitted to Kettering for radiologists to read on a diagnostic workstation. Radiologists immediately recognized the advantages of digital display, including the ability to apply different filters for optimized imaging of bones and soft tissue, control display settings and use of digital measurement tools.

This pilot project demonstrated the speed at which images could be transmitted and read, and the decision was made for Kettering and Sycamore hospitals to share a PACS and for these facilities to use their improved service to recruit additional imaging referrals.

Prior to installing PACS, the IT
staff upgraded the hospital networks to support the transmission speeds and bandwidth required by PACS. A centralized radiology information system was enhanced to facilitate proper tracking and centralized access to patient imaging studies conducted at both facilities. Standard hospital PCs were upgraded to support image display.

A Kodak PACS was installed and became operational at both facilities by the end of 1998. The original PACS included four diagnostic worksttions, 30 clinical review workstations, a digital linear tape library and four CR systems. Clinical review workstations were installed in ER, ICU and at nursing stations, while diagnostic workstations were installed in the main reading rooms at Kettering and Sycamore. Since the installation, imaging exams (except mammography) at these facilities have been produced, stored and read from digital files.

Sycamore Hospital is seven miles from Kettering and the two are linked with a microwave point-to-point communications system. All imaging studies captured at both facilities are transmitted to Kettering for archiving and made available for soft copy reading at both facilities.

Initial and subsequent training was conducted by the vendor. A select group of representatives from each area of the imaging department was charged to train the medical center staff.

Imaging systems and a PACS archive
Since PACS was installed in 1998, additional imaging systems have been added to satisfy the growing need for these services. The hospitals added GE Medical Systems NVi and GE Open Profile MRI systems, a Siemens Medical Solutions Somatom Plus 4 Volume Zoom CT scanner and ATL 3000 and Philips ATL 5000 ultrasound units. The PACS network now supports studies from three MRI systems, four CT scanners, nine ultrasound systems, five fluoroscopy units and 11 portable units.

The rapid growth in imaging studies consumed the original storage device and in April, a Kodak DirectView archive that includes two terabytes of RAID (Redundant Array of Independent Disks) and a 25 terabyte L700 tape jukebox were installed to handle new imaging studies. Both archives are networked and the system has been reconfigured to support pre-fetching of studies stored on either archive for radiologists to review with current studies. The RAID archive can be expanded up to seven terabytes to handle future growth.

Healthy financial payback
In late 2001, Kettering contacted the same consultant to assess the benefits and financial impact of PACS. This report documented exam volume growth, equipment utilization, technologist productivity, clerk productivity, supply costs and radiologist productivity. Results for the 12-month period that ended in May 2001 were compared to the previous report that referenced figures for the calendar year of 1996.

This comparative report showcased the unqualified success of the PACS at Kettering and Sycamore hospitals. Since the adoption of PACS, we have achieved improved equipment utilization and striking gains in radiologist and technologist productivity. In addition, PACS has reduced film-related expenses and the need for additional clerical staff.

The financial rewards of our efficient digital image management system are dramatic. The initial investment in PACS was quickly regained, and the system began to generate positive cash flow just 18 to 24 months after it went into full operation.

PACS has streamlined the flow of images; reports and images can be viewed by ICU and ER physicians just minutes after an exam is conducted instead of days later. Referring physicians can view reports and images from clinical workstations just a few hours after the exam is conducted, and many referring physicians can access images from their offices or from home using a new Web-based distribution system.

As these promised service gains materialized, orders for imaging services increased. Fortunately, revenue growth was similarly impressive, due to an efficient and productive PACS.

PACS supports dynamic growth
Annual imaging exam volumes at Kettering Medical Center expanded an average of 46.5 percent for all modalities based on annual totals from 1996 and from June 2000 to May 2001. The highest demands were for MRI and CT exams, which increased by 90 percent and 143 percent, respectively. In addition, ultrasound and fluoroscopic exams both increased by 70 percent, while fixed radiographic exams grew by a more modest 27 percent.

In summary, Kettering conducted approximately 75,500 exams in 1996 and was conducting more than 110,000 exams a year by mid-year 2001 — which accounts for the 46.5 percent increase. At Sycamore, growth in total exam volume was 24.7 percent by mid-year 2001, to 40,000 studies annually, but that figure does not reflect the installation of an MRI unit in mid-2001 that greatly expanded that facility’s volumes.

Equally important, from our perspective, is the total number of images produced by both facilities. The number of images produced increased by 87 percent, as the total combined image volume mushroomed from almost 1.4 million images a year to more than 2.6 million images a year.

Technologist productivity surges 20%
Consultants report that most facilities that adopt PACS experience an improvement in technologist productivity of between 5 to 25 percent, and we are certainly at the top of that scale. Combined staff productivity at both facilities increased by more than 70 percent in CT alone.

At the middle of 2001, we were showing decreases in productivity in MRI and radiography because the demand for these modalities had not yet caught up with the additional equipment that we had installed. Even with those decreases, overall productivity was up almost 20 percent across all four modalities. In 2002, requests for MRI and radiography studies have consumed the capacity of additional units and radiologists, so current productivity gains are even higher than the report indicates.

At the productivity rate achieved by mid-2001, the hospitals would need to add 11.2 FTEs to keep pace with volume growth. Averting the need to add staff saved an estimated $1.5 million by mid-2001. We attribute at least one third of this savings, or $500,000, to the adoption of PACS.

Equipment productivity, as defined by the number of exams per unit per year, has increased in all modalities. At Kettering Medical Center, productivity for CT exams/unit was up 59 percent, while productivity for fluoroscopic and fixed radiography exams increased by 40 percent.

Increases in equipment utilization lead to dramatic capital equipment savings. Dealing with increased volume at our previous productivity levels would have required nine new imaging units at a cost of approximately $4.8 million.

We recognize that some of the increased productivity may be due to the use of newer, high speed imaging equipment. However, the elimination of film-handling duties has also reduced exam times. We consider that at least one-third of the capital saved, or more than $1.6 million, can conservatively be attributed to the adoption of PACS.

Other savings result from the consolidation of space required to perform fixed radiographic exams, due to the use of CR technology. With a 20 percent increase in volume for general radiography exams, the two hospitals are handling the workload in four radiographic rooms, instead of the seven rooms previously required. We have therefore regained use of 1,000 square feet and the associated savings.

Lean clerical staff, higher volumes
Our facilities will need to maintain access to film archives until the beginning of 2004, since that will be five years since the conversion to PACS was completed. Currently we have a few more clerks than we did in 1996, but our figures for annual images per FTE indicate strong gains in productivity that are attributable to PACS.

Once we can rely upon our digital archives, we will begin to reassign staff and we expect a reduction of approximately $300,000 a year in wages and benefits. We are already benefiting from improved productivity, which has eliminated the need to add staff that an all-film environment would require.

With a workload of 110,500 exams and 2.16 million images, we would have needed to add 4.5 clerks (based on the 1996 average of 8,500 exams/FTE plus a slight increase for additional images per study). Salaries and benefits for 4.5 employees is approximately $135,000 a year or $270,000 for the past two years.

Substantial supply savings
Even based on 1996 film and chemistry costs, the facilities would have spent more than $2.5 million for film and chemistry for the 2.5 years from the start of 1999 to mid-year 2001. Instead the facility spent about $750,000, for a total savings of $1.75 million. About 85 percent of those film expenses were incurred by providing referring physicians with hard copy film. Currently, a Web-based distribution system for PACS eliminates 85 to 90 percent of all film charges, so the savings going forward will be even more striking.

Productivity gains by radiologists enhance service
The substantive enhancements in radiologists’ productivity have been some of the unexpected gains from PACS. The radiology group has boosted productivity by 60 percent in terms of annual number of images read per radiologist. Each radiologist now reads an average of 30,000 exams per year, and radiologists report their work day remains the same or is slightly shorter.

Radiology services are provided by a private group, so the hospital system does not directly participate in this financial savings, but it does benefit indirectly. The radiology group was understaffed prior to PACS and would have needed to add three additional radiologists to handle the increase in imaging volumes if PACS had not been implemented. Since there is a nationwide shortage of radiologists, it would have been very difficult for the group to achieve full staffing. Therefore, it’s probable that service levels would have deteriorated, which could have significantly reduced exam revenues for the hospital system.

PACS evaluation criteria
While the success of PACS can only be measured by retrospective examination, its roots are based in the evaluation and selection of the right platform and the preparation conducted prior to installation.

Fortunately, our initial evaluation of PACS was extremely detailed and ensured that the PACS platform we selected would deliver maximum performance. Some of the technical issues we considered when selecting PACS were:

• Support for fibre channel and storage area network (SAN) architecture
• Scalability
• Object-oriented database management system
• Fully featured diagnostic workstations (Kodak’s workstation was originally designed by a neuroradiologist and has some unique features)
• Support for a teleradiology system that was interfaceable with PACS, and
• Platform designed to interface with imaging modalities from a variety of vendors

In addition, we favored an NT-based platform that facilitates installation of supporting applications, including RIS.

As with any PACS installation, vendor service is a critical issue. Conducting a pilot implementation equips a facility to test the service capabilities of the vendor, which is just as important as equipment performance. During our pilot we evaluated the responsiveness and technical expertise of the service team, and have found Kodak’s support then and now to be excellent.

Future: PACS expansion
We plan to expand our PACS in the future by adding new digital capture devices, bringing new hospitals in the network online and by expanding image distribution through our Web-based system.

The facilities also recently purchased two CR systems from Kodak. A Kodak DirectView CR 900 will support four exam rooms in the central radiology department at Kettering. Kodak DirectView remote operations panels will allow technologists to key patient and study data in each exam room. A Kodak DirectView CR 800 system will be installed in an outpatient imaging center and one of the existing CR systems will be used by a mobile imaging unit that serves nursing homes in the Kettering network and the surrounding areas.

The Kettering Medical Center Network now includes two additional facilities, Grandview Hospital and Southview Hospital. In the future, we plan to upgrade the RIS and networking infrastructure of these facilities, and extend our PACS to serve them as well.

Our image distribution system extends PACS to approximately 300 referring physicians and we expect to expand digital distribution to other physicians who are large consumers of our imaging services.

PACS key to service and growth
In looking back, PACS played an influential role in improving service to referring physicians and driving an impressive growth in our imaging services. Imaging volumes were flat in 1996 and 1997 and physicians were dissatisfied with our service.

Just a few years later the situation has been reversed, with annual image study growth of 50 percent at Kettering and 25 percent at Sycamore since the first report. Volumes to date indicate these gains will be even stronger by the end of 2002.

In our experience, a well-designed, well-implemented PACS can serve as a catalyst for growth in imaging services and revenues. It’s not quite a “field of dreams” in which “if you build it, they will come,” but it does provide outstanding service that allows hospitals to drive higher referral volumes and greater revenues.

The PACS team at Kettering Medical Center Network in Kettering, Ohio, is made up of: Bilal Ezzeddine, Ph.D., the Medical Imaging R&D director; Ted Miller, M.D., the Network Imaging medical director; Peter Roe, the Network Imaging director; Gregory Courtney, the PACS administrator; and Todd Smiley, the Medical Imaging manager.