Medical imaging exchange within Orlando Health’s expansive system of six community hospitals, two specialty hospitals, a cancer center and nearly 3,000 physicians with privileges was turnkey; despite its best efforts, instantaneous image sharing with its 50 referring facilities continued to elude the organization.
“We do between 6,000 and 7,000 transfers into this hospital a year,” explains Carlos Carrasco, chief operating officer, 808-bed Orlando Regional Medical Center, the system’s flagship hospital. “For those that are emergent and those that are urgent, we want to make sure we understand as much as possible about the patient before they arrive. That’s what really wasn’t available to us.”
CDs, if the institution even received one with the transferred patient, were often incompatible with its PACS. A homegrown image-sharing network proved impossible to sustain because it broke a cardinal rule for technology adoption: The solution added steps to the workflow.
As an emergency physician, Timothy Bullard, MD, medical chief, business development and innovation, was acutely aware of the problem. In particular, surgical specialty physicians needed to see medical images to prepare patients who required transfer, and avert those that were unnecessary.
Pipeline to referring network
In 2012, Bullard took the idea of using Nuance’s PowerShare Network, a secure medical-imaging exchange network solution, to leadership at Orlando Health, for the purpose of facilitating image exchange among affiliate hospitals. According to Carrasco, it didn’t take a lot of business case to convince the system to sign onto PowerShare Image Sharing, the first offering from the Nuance cloud network.
Once the solution was introduced, it was quickly adopted throughout Orlando Health’s referring network. Referring physicians at network hospitals have the ability to upload and share images within minutes to confer with Orlando Health specialists about emergent patients. Today, by the time 75% of patients are transferred into the system, Orlando Health already has their images in its PACS.
“It allowed us to be a better partner to our referring physicians, it allowed us to not transfer patients if not necessary, it allowed us to be more prepared when the patient gets here and it allowed us to improve the quality of the support we could provide to other institutions,” Carrasco says. “It was more about delivering good patient care in a cost-effective manner than a revenue-based business case.”
The need to demonstrate accountability for both population health and resource use is resulting in a shift in strategic priorities for healthcare systems, Carrasco says. “You see it in ACOs, you see it in at-risk insurance contracts,” he notes. “Those changes in business model are changing how we create business cases.” In January 2013, Orlando Health became the first hospital system in Florida to become a Medicare Shared Savings Program ACO.
“A lot of institutions are pursuing clinical integration plans in which they can provide stronger integration with other providers,” Carrasco says. “We are really trying to integrate more closely with our partners to provide good care for patients. When that is a part of your strategy, this is a good tool to have in your toolbox to enable better communications.”
Safe, secure, compliant
In order for the system to successfully implement the solution, Orlando Health first had to convince the leadership of its 50 referring facilities, one by one, that engaging with the PowerShare Network would not compromise patient data. “Anytime you are going to integrate into someone else’s IT system, you have to demonstrate that you are going to be safe,” Carrasco notes.
Before that, however, he had to demonstrate to each institution that the ability to exchange images would bring quality and efficiency gains of mutual benefit to both partners. “There has to be a reason for them to want to engage at a level that is more than what they’ve done before,” he says.
After Carrasco received buy-in, he typically was connected with an IT representative at the referring facility, a relationship he handed off to Nuance. “They were able to demonstrate without any variability that they were able to offer a secure and compliant method to share the information,” Carrasco recalls. “The architecture and design of the system allowed us to make that a fairly smooth transition.”
PowerShare Image Sharing proliferated rapidly throughout Orlando Health’s referring network because of its ability to talk with a wide variety of PACS. Nuance was particularly facile at quickly integrating with those PACS it had yet to encounter, Carrasco says.
The key to its swift adoption by users was embedding the process into the technologist and physician workflow. After the integration has been completed, sending an image is as simple as clicking on the file and then right-clicking to send to Orlando Health.
“That is a pretty smooth workflow,” he says. “It doesn’t add a lot of cost, it doesn’t reduce the productivity of the referring facility’s imaging staff like it would to go burn a CD, find a computer, load the CD, walk someone through the process and then call back—there’s a lot of steps to that.”
Rapid transfer speed was another key to acceptance, particularly among the core users of the system—the trauma surgeons, neurosurgeons and critical care physicians often involved in patient transfers.
“The ability to get the image up quickly so that it’s available at the time of conference when the physicians are talking to each other is important,” Carrasco says, “particularly for the surgical specialties that are so reliant on imaging to make a clinical decision.”
More pull than push
Physician adoption of the system was more of a pull than a push, Carrasco says, and it didn’t hurt that the CMO and system champion was an emergency physician. “Dr. Bullard is very determined,” he attests. “We have some strong physician leadership that helps us accomplish things that otherwise would be very difficult.”
Carrasco spent more time responding to people requesting access and use directions than convincing them to use the system. “It built its own momentum as people used it and discovered it was useful and reliable,” he says.
The core use for the system was inter-facility transfers, which Carrasco tracks carefully. “Around 75% of the patients transferred into us have images pre-loaded when we look for them,” he says. “It’s all about building it into the workflow: How do you accept transfers, what questions do you ask, how do you make it efficient for the referring facility to upload? When you can build those steps in, it becomes just part of the transfer process.”
Meanwhile, at Orlando Medical Center, the facility for which Carrasco has responsibility, more than 85% of patients arrive with their medical images uploaded prior to transfer.
“The trick with that is the workflow,” he reiterates. “You have to make it easy. If you make it hard, then it is very difficult to sustain. It’s a very efficient system that allows us to improve communication and collaboration, provide efficient care and really prepare for the needs of the patients so that we can provide the best patient experience possible.”