Implementing a Tele-radiology System at Kindred Hospital Las Vegas

Implementing a Tele-radiology System at Kindred Hospital Las Vegas Context On May 26, 2001 Kindred Hospital Las Vegas received notice from Desert Radiologists that the company would no longer be able to provide Kindred with radiological reading services. Desert Radiologists cited the national radiologist shortage and increasing demand for its services as primary reasons for terminating the contract. The notice ended a four-year agreement between the two health care providers and left Kindred Hospital without any Radiologists to read its patients x-rays. Management at Kindred Hospital was dismayed and disappointed by the notice. Desert Radiologists is the largest provider of radiological services in the Las Vegas area. The company provides diagnostic and therapeutic services to various hospitals, medical clinics, and HMO s. The majority of Desert Radiologists business is generated through its main clinic, which is located next door to University Medical Center, one of the largest medical facilities in the city. The main clinic schedules radiology appointments for numerous medical facilities in the area. Outpatients are seen for various procedures, which may include x-rays, ultrasounds, CT scans, bone scans or MRI s. Stable hospital inpatients, usually transferred by ambulance, can also be seen at the clinic. Most hospitals in Las Vegas, like Kindred, provide on site x-ray and ultrasound services to patients. MRI s and CT scans however, require very expensive equipment and can only be justified when there is heavy patient volume. Desert Radiologists also offers radiological reading services to Las Vegas medical facilities. In the state of Nevada, radiology exams must be read by a credentialed radiologist. Many outpatient clinics and smaller hospitals do not have round the clock radiologist coverage. These facilities must send their x-ray and other radiological exam results to an offsite radiologist to be read. This was the nature of the agreement between Desert Radiologists and Kindred Hospital. Many medical facilities using Desert Radiologists (DR) reading services utilize a tele-radiology system to transmit digital x- ray images electronically. Management at Kindred felt that it may need to invest in such a system in order to either persuade Desert Radiologists to reconsider or to find a new Radiologist group. 1

Background Health care practitioners have been utilizing x-rays since the early1900 s. The field of radiology has grown into one of the most important areas of medicine. Many applications have been developed to increase the scope of radiology. Recent advances in computer technology have created a completely new realm of possibilities for radiographic imaging. The ability of health care providers to diagnose and treat illnesses is constantly improving thanks to today s ongoing technological advances. The field of diagnostic imaging includes X-rays, Magnetic Resonance Imaging, ultrasound, Computed Axial Tomography, or CAT scans, and fluoroscopy. In the medical field, still X-rays are used most often to examine bones, fluid accumulation in lungs, intestinal blockage, and the presence of foreign objects. New uses for x-rays are constantly being discovered. When used in conjunction with a radio-traceable element, x-rays can even be used to assess soft tissue structures as well. For example, barium is used to assess swallowing and digestive function. X-ray machines can be either stationary or portable. The units create a twodimensional images onto photographic plates or sheets of film. Most medical facilities still utilize standard x-ray film and processing procedures. Processing the film is an expensive and time-consuming procedure. The x-ray processing machine needs to be located in or adjacent to a dark room. A reservoir of processing chemicals must be connected to the processor. Monthly maintenance is often required to ensure proper function. Technology now exists that can eliminate the need for x-ray film. The image on the photographic plate can be digitized, creating an electronic image. This digital x-ray can then be stored on a disk, retrievable at any time. Many radiographic clinics and radiology departments within hospitals are moving toward a digital imaging environment. PACS, or Picture Archiving and Communication System, refers to an information system that distributes and archives digital images and associated reports throughout a medical system. The most advanced PACS are fully integrated within a company s medical information system network. Many PACS start out as a tele-radiology system for on call radiologists. Tele-radiology refers specifically to the electronic transmission of radiographic patient images from one location to another. A basic tele-radiology system is comprised of three main components: an image sending station, a transmission network, and an image receiving station. At the image sending station, the x-ray film or image must be digitized. The film can be placed in a scanner, which with the help of computer software converts the analog image into digital information. There are a number of companies that produce scanners or digitizers. The digitizer is the most expensive component of basic tele-radiology sending stations, costing between $25,000 and $30,000. The most important issue when deciding on a digitizer or scanner is the image resolution capability. The industry standard for image resolution is 2K x 2K. Many models on the market however, scan at much higher 2

resolution. The only problem with producing very high-resolution x-ray images is that it becomes more challenging to transmit larger files over the network in a reasonable amount of time. 2K x 2K equates to 150 Dots Per Inch, which most radiologists feel gives a reliable reproduction of the original x-ray. Current computer system requirements for tele-radiology are fairly easy to satisfy. A PC with 128 Mb of RAM, 333 MHz processor, and a network interface card will meet the needs of most tele-rad systems. The receiving computer will also require similar specifications. If the Radiology Technician is satisfied with the digital image, he or she may send the image to the modem to be transmitted as electrical impulses along the transmission network. The speed with which digital x-ray images can be transmitted is vital to the level of system performance. Fast network transmission ultimately means that reports of procedures will reach medical professionals more quickly. This can be critical to saving patients lives in emergency situations. Speedy image transfer also equates to less waiting time for Radiologists and Radiology Technicians, which may increase productivity and lower a facility s labor costs. Several options exist for the transmission network. When dealing with network communications, bandwidth is a very important consideration. The more information that can pass through in a measured timeframe, the faster the x-ray images can be read by the radiologist. Some of the more common methods of network transmission include: analog or normal land-line, ISDN, T1-T3, DSL, satellite, and coaxial cable. While relatively inexpensive, normal land-line is usually not the best answer. The high quality resolution required for reliable x-ray images requires more than the 30-50 Kilobits per second that regular modems are able to achieve. The time it would take to transmit a 2K x 2K image at that speed would not be practical. Compressing the radiographic images can be a solution to the bandwidth problem. Depending on the software being used, image compression is an often-employed option. However, compression can lead to unreliable images as well as higher costs. Integrated Services Digital Network utilizes existing copper phone wires and has capabilities of roughly 128 Kilobits per second. Availability of ISDN is good in urban areas but less so in rural regions. Setup costs can be moderately expensive ranging from $400 - $750. Monthly fees are competitive with other options at $125 - $175. DSL, or Digital Subscriber Loop, also utilizes existing copper land-lines. Like ISDN, DSL allows data to be transmitted over a dedicated digital circuit enabling simultaneous voice transmission. DSL however, does not require the user to dial-up to connect to the network. The service is constantly connected through a dedicated DSL modem. DSL offers upload speeds of up to 640 Kilobits/second and download speeds of 3 Megabits/second. Installation and activation charges run around $250 while monthly fees are approximately $180. DSL or ISDN can be purchased through local phone service providers such as Sprint or AT&T. Transmission speeds for both DSL and ISDN can be limited depending on the amount of other traffic on the phone lines. Problems may also arise if the user location is an excessive distance from the phone company switch. 3

T1, T2, and T3 lines are very popular with those companies that have been able to justify the cost. This type of network connection consists of a leased line and utilizes a secure point-to-point connection. Speeds are well into the Megabits/second range. The costs are derived from the level of usage and the distance between points of contact. These lines can be very expensive since each sending and receiving location needs a dedicated line installed. From the standpoints of speed and security, few other options compare with T1-T3 lines. Cable and satellite services are two options that offer similar benefits at similar prices. Transmission speeds are close to those of DSL. Monthly fees for a commercial business are in the neighborhood of $150 - $200. Installation and setup costs run about $300 for either cable or satellite. If the facilities do not have cable service already installed for television use, there may be additional fees involved. While a few other very high speed modes of transmission exist, the costs associated with their installation and usage prohibit considering them for a basic tele-radiology system. Digitizing and transmitting digital x-ray images requires the necessary software. Several companies offer acceptable tele-radiology packages. Software licenses for basic tele-rad packages typically run in the neighborhood of $5,000 - $10,000. Tele-rad programs include a method of digitizing x-rays, storing digital x-rays, and sending digital x-ray images. System performance is optimized when both transmitting station and receiving station are using the same software. Some vendors however, offer software that will function with various other systems. This is sometimes necessary because some radiology physician groups read x-rays for multiple facilities. Compatibility issues often arise in these situations. Storage of digital x-ray images is an important consideration when setting up a tele-radiology system. Due to the awkward size of x-ray film, most facilities are forced to have separate filing and storage areas as well as staff for management of radiological information. The accessibility needs for medical information usually require additional personnel for management and retrieval of x-rays in a medical records office. Quite often facilities will require patients to pick-up their own medical records to bring them to appointments. Accessing radiological information almost always involves adding considerable time to the already lengthy process of seeking medical treatment. The function of an x-ray archive is to identify, store and protect the data. Reliable identification of x-ray film can be challenging in manual systems. Print type can be misread if too small or faint. Patient information can also become blurred or scratched off if taped on. Storage of x-ray film can be very costly due to the significant space that is often necessary. Filing racks must be large enough to accommodate the largest film size. Companies often resort to utilizing offsite facilities for film storage. However, many states require facilities to maintain records on site for a specified period of time. Because of the unique physical characteristics of x-ray film, patient medical records and x-rays are usually stored separately. Security or protection of x-rays is difficult in even 4

the most organized setting. Films are often lost, damaged, or misplaced when checked out by various medical personnel. Digital archives must be able to perform the same functions as manual systems. Storing digital images can be faster, more secure, and less costly. Storage databases must have live, short-term and long-term availability. Physicians often need to make comparison studies between old and recent x-rays. Retrieving old films from offsite storage facilities may take days, which often results in the films never even being looked at by the patient s physician. With digital archives, images can be kept on a desktop for weeks and be reviewed several years later. The technology of digital radiography is having a major impact on the health care industry. 5

Planning Kindred Hospital was one of the few facilities that still hand carried x-ray films to the Desert Radiologists clinic. Top administration at Kindred felt that this factor might have played a role in the termination of the agreement. Desert Radiologists gave Kindred Hospital a 30-day notice, after which it would no longer read x-rays from Kindred. Kindred Hospital was faced with the urgent and difficult task of finding another radiologist physician group to read its x-rays. Kindred management knew that in order to attract a new radiologist group, the hospital would need to modernize and improve the quality of its radiological services. The management team decided to examine the benefits of implementing a Picture Archiving and Communication System for radiology. While the Kindred Hospital management team knew that it had to move quickly to find a radiologist group, the team did not want a hasty decision to result in a situation similar to the current problem. The team therefore, planned to identify the potential benefit drivers of the new system. Before the benefits of a PACS or tele-radiology system could be identified, the organizational processes that involved radiology services needed to be examined. Kindred Hospital Las Vegas, formerly known as Vencor Hospital, is a 52-bed Long Term Acute Care facility. The Kindred health care system operates nearly 60 hospitals nationwide, all of which are also LTAC facilities. Kindred s hospitals specialize in respiratory and geriatric care. Most of the hospital s patients are very debilitated and often stay well beyond 40 days. The most frequently admitted patients are those recovering from heart attack, stroke, lung disease, or kidney failure. Patients suffering from respiratory problems require frequent chest x-rays. 80% of all x-rays taken by the Radiology Department are chest studies. The debilitated condition of many of Kindred s patients, require that most x-rays be performed at the bedside with a portable machine. All x-rays require the order of a physician. After a patient s physician writes the order in the patient s chart, a member of the nursing staff will notify the Radiology Department of the order. At Kindred Hospital, all x-rays are performed by certified radiology technologists. After the technologist (rad tech) receives the order, he or she will take the portable x-ray machine to the patient s room and perform the x-ray. Under the agreement with Desert Radiologists (DR), the rad tech would develop the x-ray at Kindred Hospital and hand deliver it to the DR clinic to be read by a radiologist. After examining the x-ray, the radiologist would dictate a report that would be accessible by phone within three to four hours. A typed report would be sent to Kindred the following day and placed in the patient s chart. Rad techs performed an average of 12 x-rays per day at Kindred. The majority of the x-rays were done in the morning. The day shift rad tech would pick up orders written the previous day, perform the x-rays, and process the film. The tech would leave for DR typically between 10:30 6

and 11:30 am. The rad tech would make another delivery to DR at the end of the day before going home. In the case of stat or emergency x-ray orders, the tech would take the film to DR immediately. During the night, there was always a rad tech on call for emergency orders. After examining the process of performing and delivering x-rays involving Desert Radiologists, Kindred management identified several benefit drivers for the implementation of a PACS or tele-radiology system. Several potential cost saving benefits were identified. By transmitting x-rays electronically, rad techs would no longer have to drive to DR to deliver films. Kindred Hospital was paying 30 cents per mile for rad techs to drive their personal vehicles back and forth from the DR clinic. Total annual mileage reimbursement amounted to roughly $6,000 for the hospital. Kindred would also recognize a savings in hourly wages since it was paying techs while they drove to deliver the films. The hospital employed a single day shift rad tech for eight hours a day, Monday through Sunday, and an on call tech for coverage when the day tech was off. A round trip from Kindred to DR would take the techs between 45 minutes to an hour. On an average day, the day shift tech would take three trips to DR. The on call tech would be called in for an emergency x-ray usually once a night. Depending on how long it took to transmit x-rays electronically, Kindred could save up to 25 hours a week in driving time. At an average pay rate of $20 an hour, this could amount to a savings of up to $26,000 a year. Another potential cost saving benefit driver was the elimination of physical x-ray film studies. Advanced tele-radiology and digital x-ray imaging systems have the ability to create a paperless, film free environment. Many x-ray machines can now generate digital x-ray images and store them on an internal disk drive. These x-ray images can then be loaded into a digital archive and sent to other medical facilities and physicians via the tele-radiology system. Kindred Hospital would no longer have to purchase and process x-ray film, an expensive procedure costing approximately $30,000 - $35,000 a year. A completely digital radiology department would also save by not having to store x-ray film. Most states require medical facilities to maintain patient records for a minimum of seven years. The Radiology Department typically keeps x-ray records for six months after a patient is discharged. Kindred then pays several thousand dollars a year for a separate company to store its patients x-rays in an offsite warehouse. More important than the cost saving benefit drivers of the new system, were the business strategy and business objective benefit drivers. The most important consideration for Kindred was the care and safety of its patients. A phrase from Kindred s mission statement reads: We take care of people who can t take care of themselves. Through the exploration of benefit drivers of the new system, several key radiology processes were identified that could improve the overall quality of patient care. In interviews with staff physicians and nurses, it was discovered that Desert Radiologists voice recordings accessible by telephone were rarely even utilized. Physicians and nurses stated that they usually could not understand the reports because they were not loud enough, the person had a strong accent, or it was just too noisy around the nurse 7

station. They also stated that it was too time consuming to make the phone call. The staff usually ended up just waiting until the following day to check the report. Another problem identified by the physicians and nurses was the fact that x-rays were not available to the patients physicians when the films were out of the building. If a doctor wanted to see a patient s x-ray, she would have to include a request along with the order. The rad tech would delay taking the film to DR so that the doctor could view the x-ray. Holding x-rays for doctors meant that the final reports would be delayed. The situation was compounded for instances in which doctors did not see their patients every day. Missing films and reports was the third complaint physicians and nurses had about radiology services. There were times when reports or x-rays themselves could not be found and it was difficult to determine whether the x-ray was ever even performed on the patient. The new tele-radiology information system would have to improve upon these quality of care issues. Keeping the x-ray images in the facility and available to the physicians would be solved easily with tele-radiology. The digital x-ray image would always be stored on a computer in the Radiology Department, even after the image was sent to a radiologist. Preventing lost films and reports should also be resolved relatively easily with the new system. The system would have to provide a tracking feature to monitor whether the report had been generated by the radiologist. The last operational benefits driver could prove to be a little more challenging. The facility needed a better way of providing a preliminary x-ray report to the physicians and nurses. Kindred management would have to determine the importance of the preliminary report. The limited utilization of the voice reports was definitely a problem for emergency x-rays. It did not make much sense to perform a stat x-ray if the doctor was not going to know the results until the next day. The new system would need to provide a more convenient way of accessing preliminary reports. Identifying the key stakeholders involved in the implementation of the new information system helped Kindred management to realize the strategic benefit drivers. The primary stakeholders involved include the patients and their families, the physicians, and all employees. The employees most affected by the system would be the radiology staff and the nursing staff. Both the nursing and the radiology career fields are suffering from a shortage of qualified workers. For the most part, professional health care workers expect medical facilities to provide them with the means to be able to deliver high quality patient care. Clinical medical employees do not appreciate taking the blame for substandard care when poorly designed systems and processes are at fault. If Kindred Hospital can implement an effective tele-radiology system, it will improve the environment for the provision of patient care. Kindred could benefit from increased employee retention and improved morale. While the physicians that treat patients at Kindred Hospital are not actually employed by the facility, they are still very important stakeholders in the system. Since they are the source of patient referrals to the hospital, the doctors are extremely critical to the overall success of the organization. Physicians also expect facilities to provide for the 8

means to take care of patients. When a piece of equipment malfunctions or a key process breaks down, management is expected to come up with a solution quickly. If the overall environment for care is thought to jeopardize the well being of the patients, physicians will send them to other better-equipped, better-managed facilities. On the other hand, if medical facilities can consistently meet or exceed expectations, physicians will bring in more patients. A higher patient census means higher revenues for Kindred. Lastly, another critical strategic benefit driver of the system would be to develop a good relationship with a radiologist group. Without an agreement with radiologists, Kindred Hospital would have to contract out its radiology services. The cost of such a last resort option was estimated to be two to three times the annual operating budget of radiology services the previous year. Contract services can also be very difficult to manage in a hospital setting. Considering the strategic benefit drivers of the teleradiology system was ultimately what led Kindred management to go forward with implementation of the new IS. Investing in information technology was relatively new territory for Kindred Hospital Las Vegas. The facility had little experience with clinical information systems. While the hospital did have extensive payroll and billing systems in place, the only clinical information system being utilized was a pharmaceutical monitoring program recently set up by an outside vendor. Although the corporation had an Information Systems division, there were no IS personnel currently employed at the Las Vegas hospital. 9

Implementation The Chief Operating Officer was directly responsible for the implementation of the project. The first decision the COO made regarding the project was to dismiss the idea of creating a paperless, film free radiology department. After seeing the $150,000 plus price estimate of implementing a full-fledged PACS, he decided corporate would not be willing to make such an investment at this stage. He determined that Kindred Hospital Las Vegas could meet its objectives with a basic tele-radiology system. If the project was successful, he decided that this could be designated as phase I of an eventual PACS. Having no prior experience with tele-radiology systems, he felt that it was necessary to contact the corporate IS and Clinical Operations Departments for suggestions. The COO learned that there were no initiatives at the corporate level regarding radiology issues. Kindred Hospitals were free to implement policies and procedures that met the needs of the local facility. Contacting corporate IS and Clinical Operations did turn out to be more productive than the COO had expected however. The Director of IS was able to provide the name of a software vendor in California, Radiographic Digital Imaging, which had recently furnished a Kindred Hospital in California with a teleradiology package. Surprisingly, Operations was able to provide a $30,000 x-ray digitizer that was currently not being used. Apparently, there had been a failed corporate tele-radiology project two years ago and a number of digitizers or scanners were just taking up space. Unfortunately, the individual in charge of the project at that time was not able to help out since he was no longer with the company. The Director of IS also informed the COO that the Corporate T1 line that was being used for billing and payroll data could not be utilized for tele-radiology on a local level. He was told that tapping into the T1 line would breach the security firewall for all corporate information systems. The Director recommended a DSL connection since the hospital did not have cable television. The contact with corporate IS and Operations led to some major technical decisions regarding the project. Since Kindred Hospital Las Vegas lacked the core competencies to set up a tele-radiology system on its own, the management team was going to need all the help it could find. Kindred now had leads on the hardware, software, and transmission system for the project. The COO called Radiographic Digital Imaging (RDI) to set up an appointment for the company to come out to assess the situation. RDI offered to bring out a demo system the following week. The company also recommended going forward with the DSL connection. A week after receiving the termination notice from Desert Radiologists, the Radiology Manager at Kindred Hospital - Las Vegas resigned. The task of planning and implementing a new tele-radiology system without a department manager would be very difficult. With his hands full trying to secure a new radiologist group, the COO decided to appoint one of the other department managers to coordinate the tele-radiology project. After being brought up to speed with the project, the new project manager realized that 10

the technical concerns of the new system were not the only issues facing the organization. The tele-radiology system was an IT and Change Project that would create risks for Kindred Hospital. These risks would have to be assessed and managed effectively if the system was going to be successful. Since DR would read Kindred s x-rays for only two more weeks, time was going to be a major limiting factor in identifying the involved risks. While the project manager was assessing the full impact that the new system would have on the organization, he had to arrange for the set up of the DSL service. Sprint was the local provider of DSL in the area. Because of the excessive distance from Sprint s mainframe computers, the company could only offer its minimal level of service. Kindred would be able to download information at a speed of 512k and upload at 128k. Since the system would only be used to send digital images, the only speed to be concerned with was the upload speed. The charge from Sprint for the service was $150 per month with a $130 installation fee. The day after the DSL was connected by Sprint, RDI arrived to set up the hardware. The rep from the company brought a personal computer, a large flat screen monitor, and an x-ray film scanner. Since the software was already on the computer, the entire installation only took about an hour. When the rep was finished, he tested the system by scanning an x-ray. The appearance of a digital image on the monitor proved the system was operating correctly. The first problem of the system was identified when the rep learned the available upload speed with DSL. He stated that it would take five to ten minutes to transmit an image to another location at 128k using RDI s software. It could take even longer if the receiving facility was using different software. The COO and project manager decided that they would have to assess the impact that the time of transmission would have on the performance of the system when they were ready to test it. RDI charged Kindred $3,000 for the computer system, $5,000 for the software license, and $1,000 for the installation. The company would leave the demo scanner and take Kindred's scanner to install the software drivers on it. On the same day that RDI came to install its equipment, a radiologist group was identified that was interested in providing x-ray reading services to Kindred Hospital. The Lake Mead Radiologists group was well known in Las Vegas and was considered to provide quality radiological reading services. The radiologists main location was a large hospital in Las Vegas and they provided 24-hour coverage seven days a week. The group utilized tele-radiology on a regular basis to read x-rays. They did not use RDI s software, however their system was based on the same common DICOM platform. This meant that it should be compatible with Kindred s new system. Lake Mead Radiologists (LMR) was willing to be very flexible with Kindred Hospital. The group was ready to begin at any time and agreed to read either regular hand carried x-rays or transmitted digital images. With most of the technical decisions out of the way, the project manager shifted his focus to the organizational impacts of the project. He realized that the lack of staff involvement in the planning of the system could be a threat to the overall success of the project. The rush to provide a solution to the problem had forced the hospital s top 11

management to focus on the technical aspects of the project. The manager felt that the new system implementation was a content-driven IT and Change Project. The content of change was being enforced by the situation and the outcome was not easy to define. It was very clear that the process of obtaining x-ray reports needed to change. The principal driver of the intervention was improving the quality of patient care with respect to radiology services. Given the situation with Desert Radiologists, the implication of taking no action was potentially catastrophic. The staff had not yet been informed of the proposed project. Because of the way information traveled throughout the organization, most employees were aware that DR was terminating the agreement. Several different rumors had been circulating regarding both the reasons for the termination and how management was going to solve the problem. The project manager felt that communication of the project to the employees needed to begin as soon as possible. In less than two weeks, the system was to be operational. Knowing that the social culture of the hospital involved a moderate resistance to change, the project manager felt it necessary to establish a belief system for the staff. The key actors involved in the IT and Change Project were the nurses and the radiology techs. Training the techs was not considered to be a major concern. Since there were only three techs, with only one tech working at a time, the education and training for them was not expected to be difficult. The nursing staff however, comprised 60% of all the employees at Kindred Hospital. The nurses were often the individuals that had to communicate the results of the x-rays to the doctors or the patients and their families. The nurses also needed to know when x-rays were taken, when reports were expected, and what the reports meant. Since management was not highly experienced with the new technology, it would be difficult to give a detailed cause and effect description of the project. The belief system would instill values in the employees and help to convince them that the new IS would be congruent with the organization s mission and vision. An initial educational memo was created and distributed which informed the employees of the new teleradiology system. The memo stressed that the system was a Process Improvement initiative that would improve the quality of patient care. The project manager took advantage of the beliefs that had been developed through education of the hospital s mission and vision statements. It also informed the staff of the new radiologist group and of the benefits of the new IS. The memo was posted in the break room, and at the nurse station. The information was also covered in the next weekly nurses meeting. LMR sent their IT technician to facilitate the digital connection between Kindred Hospital and Lake Mead Hospital. The individual also agreed that 128k was a very slow upload speed. The project manager learned that there were three radiologists with LMR. There was a radiologist at Lake Mead Hospital seven days a week from 7:00 am to 5:00 pm. An on-call doctor covered all other hours. The three radiologists rotated every week as the on-call doctor. While on-call, the x-ray images would be sent to the doctors personal residence where they had a PC with the appropriate tele-radiology software. 12

After entering the four IP addresses that would be needed for image transfer, the tech sent a digital x-ray image to Lake Mead Hospital. After approximately five minutes, the system verified that the image was sent successfully. He then called a radiology tech at Lake Mead who confirmed that the image was received. While the transfer speed was slow, the test of the system appeared to be successful on the first attempt. The project manager met with the manager of LMR one week before Kindred Hospital would go live with the tele-radiology system. The two managers were able to identify the IS process flow that the radiology techs and nurses would need to be trained in. The radiology techs would take the x-rays and process the film just as they had always done. The tech would then digitize the x-ray by running it through the film scanner. The patient s name and the date of service would be entered into the system with the image. If the quality of the image was satisfactory, it would be sent to the radiologist. If it were after regular hours, the tech would have to check the on-call schedule to determine which site to send the image. Once the system showed that the image had been sent, the tech would call the radiologist to inform him that there was an x-ray on the system that needed to be read. After reading the digital x-ray, the radiologist would fax a preliminary handwritten report to the nurse station. The nurse supervisor would place the report in the patient s chart. If the x-ray was a stat order, the nurse would inform the patient s nurse and doctor of the results. The following day a typed report would be faxed to the nurse station from LMR s transcriptionist and placed in the patient s chart. At the end of each day, the rad tech would compile billing information for patients receiving x-rays and fax it to LMR. All film filing and storage procedures would remain unchanged. The new process, if executed correctly, would have minimal effects on the daily workload requirements of the rad techs and the nurses. Since recent previous change projects had not been very successful however, a high level of inertia was assumed to exist within the clinical element of the organization. The culture of the organization was one of isolationism. Department boundaries were not seamless when it came to multidisciplinary processes. Unfortunately, the employees from other departments did not always work effectively together. If one department s personnel perceived that they were forced to do the work of another department, there were frequent complaints even when it was all for the greater good of the patients and the organization. The project manager therefore decided to map out the entire process in the policy and highlight the scope of the new tele-radiology system. Possible expected breakdowns in the system and the process were mentioned in a separate memo so the staff would know how to deal with them when and if they occurred. Over a period of three days, the techs and nurses were trained to utilize the tele-radiology system. The rad techs were happiest about no longer having to drive to deliver x-rays. The nurses were happiest about having the x-rays in the facility at all times so that the doctors would not give them a hard time over not being able to see them. Kindred Hospital was now ready to utilize the new system. The first day that Kindred officially went online with tele-radiology went relatively smoothly. Problems began to develop however over the next few weeks. 13

Evaluation One of the first problems with the new IS was identified on the fourth day of use. The project manager was notified in the morning that an emergency x-ray was ordered during the night but no report had been received. The log in the Radiology Department showed that the x-ray had been taken. The image was also on the tele-radiology system which showed that the image had been transmitted. After calling the radiologist, the manager realized that the doctor did not know how to use the system properly. He was not clicking on the correct icon on his computer at home. Once he selected the right icon, he could view the x-ray. Fortunately, the x-ray did not turn out to be critical to the patient's care. Two nights later, the manager received a call at home from the night nurse supervisor asking for an x-ray report that was missing. After speaking with the on-call rad tech, he determined that the image was sent to the wrong radiologist. The tech had forgotten to change the location to match the call schedule. The following day the project manager implemented a new policy. Techs would verify that x-ray reports were received by the nursing staff before leaving the building. If reports were not received, the techs were to call the radiologists back. Various other problems occurred over the next few weeks that were not originally anticipated. One of the radiologist's fax machines broke down which forced the doctor to have to give the nurse supervisor the reports verbally. Several complaints were made by the nursing staff stating that they did not have time to take verbal reports. There were also several instances in which the radiologists did not have their systems turned on which prevented images from being received. Techs would have to make an extra phone call to tell the doctors to turn on the system. Using the tele-radiology system was actually taking longer than delivering the films by hand. One rad tech became so frustrated with the system that he resigned. The project manager met with LMR's manager again to discuss some of the issues with the system. The LMR manager reported that the radiologists also had some problems with the system. One of the radiologists did not feel that the quality of the digital x-ray image was acceptable. He did not have a problem with the RDI software specifically. He just decided that he did not trust any tele-radiology system. The LMR manager stated that the radiologist wanted to see the actual film to verify that he was making the correct diagnosis. The LMR manager understood that this would be a problem for Kindred since tele-radiology was supposed to eliminate the need for the radiologists to see the films. She offered to have LMR's courier pick up the film every day so that the radiologists could dictate their final report from the actual x-ray. Since the added burden of allowing LMR's courier to pick up the films would add only minimal work for the rad techs, the project manager (PM) agreed to it. The PM passed on some of the problems that the techs and nurses had been having to LMR's manager and she agreed to address them with the doctors. That same night the PM received another late call. This time the call was from the COO. He had received a call from the Director of Nursing who stated that the new system was not working out. She 14

had learned from the nurse supervisor that no preliminary x-ray reports were received that day. The COO asked the project manager to personally check every preliminary report to see that it matched with the x-ray log every day for the next few weeks. As the PM was examining the patient records the following morning, he began to wonder whether the system was worth the trouble the organization was going through. Managing the tele-radiology project had become a full time job. He thought that perhaps the hospital should have used the contracted x-ray services in the short-term while a team was assembled to better-analyze the situation. A major problem with the tele-radiology IS project from the beginning was that the risks were not assessed as well as they should have been. Management should have allocated more time and resources into the planning stages of the project. For Kindred Hospital, the tele-radiology system was a Key Operational IS investment and should have been considered as such at the start. Instead, top administration viewed the project more as a Strategic System. Radiology services had very little opportunity to give the organization a competitive advantage. Kindred had neither the budget nor the core competencies to consider tele-radiology a strategic project. The main objective should have been to avoid a business disadvantage. For Kindred, radiology is considered an ancillary service. The service is almost invisible to both internal as well as external customers. There would rarely be an instance in which the Radiology Department would have a chance to be praised for providing high quality patient care. Physicians and patients simply expect prompt, professional service without even thinking about it. The organization therefore, should have focused on simply integrating and reorganizing some of the existing processes that were involved. Although Kindred's top management considered tele-radiology to be strategic, it still only treated the project like it was a Support System. The CEO had very little involvement and the COO did virtually all the planning. The Director of Nursing was not consulted until most of the decisions had already been made. No staff nurses, physicians, or radiology techs were ever consulted. The management team did not consider the factors that affect the delivery of the required benefits from the system. Quality is the most critical element to the success of a Key Operational system. The categories of risk that had the most influence on the quality of the tele-radiology project are People Issues, Control of the Project, and Complexity. The People Issues risk was not addressed well at all. A planning team was never even really assembled. The planning team should have included a rad tech, a nurse, a doctor, the COO, the Director of Nursing, and the Radiology Manager. An individual from corporate IS could have also been involved through conference calls if necessary. The People Issue could also have been managed better by meeting with the Lake Mead Radiologists to determine their competency with tele-radiology. A project team could also have had better handle on the Control risk factor. The Time aspect of the project created a very challenging change management process. The team could have covered risk factors better to ensure that quality would not be sacrificed for expediency. Finally the Complexity risk factor would have been better handled by a software company that could provide a full service solution which should include several different forms of training. If the COO could have negotiated for more time from DR or allowed for a 15

short-term contract service, a project team could have listened to three or four vendors present the advantages of their different PACS or tele-radiology systems. The culture of the organization played a major role in the difficulties it had in implementing tele-radiology. There appeared to be an excessive amount of pride at the management level which may have proved to be a negative factor. There was not a strong attempt to fully understand the reasons behind Desert Radiologist's termination of the agreement. DR may have thought that Kindred never planned to explore teleradiology and therefore terminated the agreement for that reason. An investigation into DR s decision may have provided insight into existing problems with Kindred s radiology services. Top management also seemed very hesitant to ask for outside assistance, even from corporate headquarters, in planning for the project. It may have been helpful to understand why a previous tele-radiology project at another Kindred Hospital failed recently. The lack of both understanding and flexibility from the nursing and radiology personnel was also very detrimental. This could have been resolved through a better team approach including a more intense focus on communication. Finally, Kindred likely suffered from the consequences of IT-hype. Management had an overly-simplistic view of the intervention which led to inadequate resources being dedicated to the project. They were too eager to implement an IT solution without truly understanding the implications affecting the overall organization. 16

References 1. http://users.erols.com 2. www.auntminnie.com 17