Insider Magazine

Volume 8, 2020

Going Mainstream With AI: Exploring the Possibilities for Augmented Imaging Workflows

Capital Radiology on Improving the Referrer Experience

DBT, Promise and Potential of 3D Mammography

Physician Burnout, a Call to Action

Columbus Radiology, Taking the Clario SmartWorklist™ to the Next Level

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Stand Out Soaring imaging volumes, radiologist shortages, artificial intelligence disruption, growing dependency on information technology. No matter how healthcare service providers are equipped to respond to these challenges, Intelerad helps meet them head on.

Intelerad solutions scale to the highest ambitions.

From day-to-day care delivery to long-term strategy, our people have the expertise to foster our clients’ success.

Volume 8, 2020

2019: A Year of Milestones, Transformation and Opportunities In 2019, Intelerad celebrated a key milestone: two decades of providing state-of-the-art solutions to healthcare providers across the world. Intelerad now offers an array of solutions and modules which are used by over 300 clients globally, and developed and supported by a team of close to 450 dedicated employees.

Our story has always been tightly intertwined with that of the field of radiology itself. Our solutions have evolved alongside healthcare organizations, allowing them to respond to challenges and take advantage of opportunities as they arise. Innovation and customercentricity are key priorities for us, and we are there for our clients when needs evolve and when the field transforms.

Take for example our recent product launch of Odyssey™, an AI-augmented workflow solution. It is designed to encourage the adoption of artificial intelligence. AI is a disrupting force to be reckoned with, and we want our clients to be well prepared. Odyssey removes barriers for exploring the impact AI-based tools can have on productivity and outcomes. We also announced our internationally expanded nuage® cloud offering, including PACS in the Cloud and Long-Term Storage. The cloud is the way of the future and we offer clients the solutions they need to move away from costly infrastructure and IT management. We have been, and will always be, right beside our clients, every step of the way.

This is the story you’ll read in the following pages, from different angles. We discuss, for example, the pressure of soaring demands on radiologists, we share clients’ stories on how Intelerad solutions helped them overcome challenges, we talk about ways to improve workflow management. In the end, the following pages are about transformation and opportunities, and how we as a company can help our clients navigate it all.

And this is what makes us stand out from the lot: a consistent focus on innovation and scalability with a fully embedded customer-centric approach. This message is central to the new Intelerad positioning and branding we are unveiling this year at RSNA. We have been striking our own path for two decades and this path makes us, and our clients, stand out.

We are enablers of the remarkable, facilitators of the outstanding.

Hélène Gey Vice-President, Marketing and Strategic Partnerships Intelerad Medical Systems

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Content 6

A Record Year for Intelerad Medical Systems: Q&A With President and CEO Paul Lepage

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Capital Radiology on Improving the Referrer Experience

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DBT, Promise and Potential of 3D Mammography

Physician Burnout, a Call to Action

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The Power of a Smart Worklist

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Columbus Radiology, Taking the Clario SmartWorklist™ to the Next Level

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Intelerad's Chief Technology Officer, Chris Wood, on the Age of Artificial Intelligence

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A Record Year for Intelerad Medical Systems Q&A With President and CEO Paul Lepage Q: Paul, you’ve been Intelerad’s President and CEO for about a year now, what can you tell us about your experience at Intelerad so far?

A: I joined Intelerad because I knew it was an organization with a strong customer focus, sound business model and excellent growth potential. This past year as CEO was a tremendous honour and an amazing new challenge for me.

And it was quite a flagship year for Intelerad, which only reinforced my motivation.

Paul Lepage, President and CEO, Intelerad Medical Systems

Q: 2019 was indeed a record year for Intelerad, in many aspects. Can you share more about what your team has achieved?

A: Since my arrival last fall, we’ve hit a few key milestones.

We celebrated Intelerad’s 20 year anniversary. We inaugurated our brand new head office in Montreal, which allowed us to regroup 70% of our workforce under one roof.

We made a key acquisition with Seattle-based company Clario Medical. We announced a $75 million investment in R&D. All in all, it’s been a stellar year for Intelerad.

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Q: Your new head office is home to 300 employees right now, but the plan is to welcome even more players to the global Intelerad team?

A: Definitely. We significantly increased our workforce this year, reaching over 430 employees internationally. But we expect our workforce to double in size within the next 5 years, with at least 300 positions to be filled in Montreal and the rest elsewhere in the world, as we continue to push for international growth.

Q: How has the Clario acquisition influenced your business model?

A: This was our first US-based acquisition, and it was an overall great experience. The Clario SmartWorklist™ was a natural fit with our current product offering, and it allowed us to augment our robust and highly scalable enterprise imaging solutions. We look forward to continue evolving Clario’s universal worklist as a vendor-neutral platform and to further integrate it in our product suite. We are open to more acquisitions as we move forward, with partners who follow the same vision and with products that prove complementary to ours.

Q: Product development is a key focus right now, especially in the context of the $75M investment in R&D you recently announced. Can you tell us more about what this investment entails?

A: We have ambitious growth objectives, and innovation will be a key driver of that growth. As we announced back in May, we are investing $ 75 M in R&D over the next 5 years, specifically in cloud, AI-enabled and zero-footprint imaging solutions. This investment is already bearing fruit.

We recently announced the global expansion of our nuage® Cloud Managed Services and solutions like the nuage® Patient Portal are gaining traction in early adopter status.

We also made great strides in our artificial intelligence offering, with the recent launch of Odyssey™ and Odyssey Navigator™, our AI-augmented workflow solution powered by a partnership with Zebra Medical Vision, while the team in our Intelerad Innovation Lab is busy developing solutions that focus on improving the desired business and health outcomes of our customers via AI-enabled solutions.

As for our focus on developing zero-footprint solutions, considerable progress has been made in integrating our Clario SmartWorklist and InteleViewer Worklist™, and new features and capabilities for our InteleConnect® EV are being deployed.

It is vital for a technology company such as ours to have an ongoing focus on creating innovative, market-leading solutions for a global customer base. Our clients expect us to be at the forefront of innovation; not only are we equipped to do that, we also strive to be ahead of our clients’ demands. With this investment commitment, we are positioning Intelerad as a leading customer-centric medical imaging software company, with innovation capabilities that truly meet existing and future customer needs.

Q: What’s in store for Intelerad in 2020?

A: Growth, but how? By fostering our clients’ success and actively supporting them in their planned growth and their focus on quality of care. In doing so, we ensure that our clients continue to be great ambassadors for our products and hence contribute to keeping Intelerad’s best in class net promoter score. To support us in our growth objectives, we are taking a three-pronged approach focusing on 1) developing technology to help maximize radiologists productivity, 2) enabling clinical accessibility to images and data and 3) delivering infrastructure dependability by offering best in class managed services and deployment models.

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The Alternative to Legacy Imaging Workflow Intelerad’s Imaging Connectivity Suite™ delivers immediate access to radiology images and results across the entire healthcare system and clinician community including external referrers. As a scalable and agile solution to enhance clinical care, the Imaging Connectivity Suite gives you access to the latest diagnostic tools using web-based, highly customizable workflows for seamless onsite and remote reporting for any single or multi-site hospital environment. ›› Enables radiologists to read for multiple sites across the enterprise, provide subspecialty coverage to all facilities, accommodate after-hours shifts, and read from home ›› Create imaging workflows that enable better subspecialist utilization, improve collaboration amongst colleagues and help deliver higher quality care in less time

›› Unifies disparate systems into a single reporting worklist for radiologists across departments and regions ›› Provides patients web-enabled access to their radiology images and results from any desktop or smart device ›› Allows a seamless clinical view to clinicians with immediate access to radiology images and results across the healthcare enterprise

Volume 8, 2020

Capital Radiology on Improving the Referrer Experience Starting a high value, yet manageable, project of improving referrer support through Intelerad’s InteleConnect® EV portal facilitated an eventual full PACS migration.

“Intelerad has a continuously evolving technology roadmap and a laser focus on improving radiology workflow to support an enhanced customer experience, which gives us supreme confidence in their ability, as our technology partner, to support our future business goals.”

Brendan Revell, Head of IT Capital Radiology

Capital Radiology is a leading diagnostic imaging provider with facilities that extend throughout metropolitan Melbourne, Regional Victoria, Tasmania & Western Australia. Listed on the Australian stock market, the business has more than 800 employees. Supporting more than 40 radiologists and 60 sites across both Eastern and Western Australia, the Capital Radiology technical environment is complex enough to test the WAN capabilities of the best PACS infrastructure available.

A few years ago, Capital Radiology recognised they were facing a number of clinical and operational challenges including: • Pressure from referring physicians for a suitable image and report-viewing portal, combined with an overriding goal for the practice to improve referrer connectivity • The need for specialty-specific or seamless off-site reporting processes in order to further improve clinical outcomes. The existing technology infrastructure’s ability to support this was limited • Integration issues incorporating newly acquired sites • Difficulties inherent in reading and reporting across an organisation which was increasingly geographically dispersed • Bandwidth restrictions for some sites requiring manual intervention on a case by case basis. This resulted in some frustration and lost productivity • Overflow reporting limitations due to the manual management of non-streamed study images • Difficulties in delivering consistent and reliable turnaround times for diagnostic reports

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A Staged Roll-Out of Intelerad Solutions The initial project focused on addressing referrer-facing connectivity needs as the highest priority to improve the customer experience.

Capital Radiology were keen to source a provider who could implement a state-of-the-art solution in a modular approach whilst ensuring minimal day-to-day impacts on underlying infrastructure or business processes. This approach was a key consideration in selecting Intelerad’s Imaging Connectivity Suite™ consisting of InteleConnect® EV and InteleViewer™.

“Adopting InteleConnect® EV, InteleViewer™ and eventually IntelePACS®, has better enabled the business to handle a constantly evolving environment.”

Brendan Revell, Head of IT, Capital Radiology

The connectivity solutions were quickly installed over the legacy PACS with low operational-risk and minimum disruption, enabling Capital Radiology to quickly deliver substantially improved patient care and referrer support.

The Imaging Connectivity Suite is a stand-alone set of solutions facilitating access to diagnostic reports and images in almost real-time irrespective of where a referrer is located. The suite is an on-going overlay solution for a legacy PACS. There is no technological requirement to replace the whole PACS or RIS when implementing the Clinical Connectivity Suite, yet the benefits for the clinical community are substantial.

The solution can, however, also provide a platform for further PACS-related infrastructure upgrades.

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Diagnostic connectivity for Capital Radiology involved deploying InteleViewer™ as the primary diagnostic tool across the entire organisation and ultimately their underlying PACS. InteleViewer™ was a substantial component of the project as accompanying IT infrastructure upgrades were also needed.

Trials were set up concurrently across a few geographically varied but smaller sites. The ability of the solutions to support the organisation’s diagnostic needs across the Wide Area Network were observed, meaning all remaining sites could be rolled out quickly and smoothly. The support and experience of Intelerad’s responsive project management team was invaluable, both before and during the roll out.

The implementation of InteleViewer™ as the single, standard diagnostic viewing tool powerfully demonstrated its worth to the organisation as it helped resolve key business issues and established a new environment to seamlessly support the organisation’s growth plans.

Capital Radiology is continuously considering how technology enhancements can improve the radiology workflow, effectively improve business efficiencies, and connected customer care. “What has been achieved to date means we are well placed to reimagine how our technological solutions can positively impact our customers’ health care outcomes, with Intelerad as a key enabler.”

Brendan Revell, Head of IT, Capital Radiology

Operational, Organisational and Clinical Benefits • Increased efficiency and clinically-enhancing outcomes, enabled by a standardised reporting environment across all geographically-dispersed sites Capital Radiology found the reception from referrers to be so positive, it helped build critical momentum for undertaking the next project of replacing the diagnostic reporting solution and PACS. Knowing this project could be treated independently of referrer connectivity meant easier internal change management and improved IT-resource allocation as some of the required infrastructure had already been deployed.

InteleViewer™ supports onsite and remote state-of-theart reporting. InteleViewer™ can act as an overlay for a legacy PACS for a scalable and seamless reporting environment. Alternatively, it can be combined with IntelePACS® , for a comprehensive diagnostic and infrastructure outcome.

• Drastically reduced PACS support needs, compared to regular and highly technical IT involvement with prior legacy system • Improvements in report turnaround time with near real-time availability of study images achieved - particularly beneficial for remote reporting • Easier organisation of radiology resources for operational needs, such as by location, overflow or out-of-hours requirements • Seamless connectivity with referrers • Creation of a reliable and scalable foundation for future growth, facilitating the easier on-boarding of new branches and locations

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The Multi-Specialty Diagnostic Platform of Choice InteleViewer™ is an intuitive, feature-rich DICOM viewer renowned for its ease of use. Designed to provide an exceptional user experience, InteleViewer provides highly customizable toolsets and a flexible interface that allows radiologists (including subspecialists) to customize their reading and reporting workflow.

Built with AI in mind, InteleViewer incorporates native and third-party artificial intelligence functionality to provide streamlined and automated workflows across your enterprise. ›› Leverage fully optimized reading and reporting workflows, ideal for off-site reading

›› Drive higher diagnostic workflow productivity with a fully integrated Clinical AI Platform

›› Benefit from extreme performance, even in complex, variable bandwidth, and high-volume environments

›› Superior 2D and 3D mammography workflows within a fully-featured PACS

Volume 8, 2020

DBT, Promise and Potential of 3D Mammography The advent of 3D mammography has delivered game-changing promise and potential to the world of healthcare. The benefits continue to stack up – for patients and imaging operations alike. Studies confirm the advantages, patient-awareness continues to grow rapidly, and insurance coverage is becoming widespread.

By any of its many labels – digital breast tomosynthesis, DBT, tomosynthesis, or simply tomo – this modality offers patients as well as service providers a win-win that cannot be ignored.

Sobering Statistics Breast cancer by the numbers is a sobering study. For women in the United States, breast cancer death rates remain second only to lung cancer, and one in eight women – about 12 percent – will develop invasive breast cancer over the course of her lifetime.1 Globally, breast cancer is the leading cause of cancer death in women. More than two million new cases were recorded worldwide in 2018, according to the world’s largest breast cancer organization (Susan G. Komen), and every 50 seconds, somewhere in the world, breast cancer claims another victim.2 By rates of new cases, female breast cancer is number one on a Top 10 Cancers list created by the U.S. Centers for Disease Control.3

1 U.S. Breast Cancer Statistics. Breastcancer.org. Feb 2019 https://www.breastcancer.org/symptoms/ understand_bc/statistics 2 Breast Cancer Fact Sheet. Susan G. Komen. July 2019 https://ww5.komen.org/uploadedFiles/_Komen/ Content/About_Breast_Cancer/Facts_and_Statistics/Breast_Cancer_in_Women/BCFactSheetOct2017.pdf 3 United States Cancer Statistics. Centers for Disease Control and Prevention. https://gis.cdc.gov/Cancer/USCS/ DataViz.html

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In 2019, breast cancers will constitute approximately 30% of newly diagnosed cancers in American women.

A Proactive Defense Regular screening for and early detection of breast cancer is indisputably the best defense against this pervasive disease. Of course, patients want the best and most effective screening and diagnostic technology available to them.

Prevailing opinion increasingly favors DBT. Research studies continue to affirm the advantages of DBT over conventional 2D mammography in better detection – especially for the most lethal cancers – and reduced call backs.

In 2019, breast cancers will constitute approximately 30% of newly diagnosed cancers in American women.4

Research Supports DBT Advantage Published online in 2016 by JAMA Oncology, a study of three years of breast cancer screening data provided the first longitudinal evidence of DBT effectiveness, showing that the benefits of 3D mammograms can be sustained and improved over time.5

4 U.S. Breast Cancer Statistics. Breastcancer.org. Feb 2019 https://www.breastcancer.org/symptoms/ understand_bc/statistics 5 Effectiveness of Digital Breast Tomosynthesis Compared With Digital Mammography. McDonald ES, Oustimov A, et al. JAMA Oncol. Published online Feb 18, 2016; 2(6):737-743. https://jamanetwork.com/journals/jamaoncology/fullarticle/2491465

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Emily Conant, M.D., Division Chief, Breast Imaging at the University of Pennsylvania Health System, was a senior author of that study and the lead author of a 2019 study, also published in JAMA Oncology, that built on these findings.6

"These findings reaffirm that 3-D mammography is a better mammogram for breast cancer screening." – Emily Conant, M.D., University of Pennsylvania7

Detection Rates

Adoption Trends Up Thus, more facilities are embracing DBT technology. Statistics collected by the FDA, which certifies imaging facilities across the U.S. through the Mammography Quality Standards Act, show a nearly 60% increase in certified mammography facilities offering DBT between March 2017 and March 2019.9

Certified Mammography Facilities Offering DBT

40% 3,178 40%

Recall Rates

The 2019 study found that DBT screening increased breast cancer detection rates by approximately 40% overall, as compared to traditional 2D digital mammography. DBT was also found to detect breast cancers at earlier, more treatable stages, while resulting in 40% lower recall rates.8 The encouraging results of these and other studies is fueling an increased interest in and practice of DBT. Insurance coverage is becoming widespread, especially in the U.S., aided by state-level mandates in many cases. Medicare began covering DBT in 2015.

Barriers Removed by All-in-One Promise In the early days, the upfront investment required to offer DBT interpretations was prohibitive for many imaging operations.

The cost of acquiring and maintaining specialized workstations, plus the productivity hit of introducing a tangential workflow and new skillset to the users of those costly workstations, was a significant barrier to entry.

March 2017

4,074

March 2018

5,047

March 2019

Source: FDA.gov > Radiation-Emitting Products > Mammography Quality Standards Acts and Program > MQSA National Statistics

Maximize Growth Potential Developed in collaboration with DBT pioneers, Intelerad’s all-in-one integrated breast imaging solution extends its industry-leading PACS, offering a multi-modality worklist, user-configurable layout protocols, high-performance image streaming, and optimized workflow designed especially for digital mammography – all of which combine to maximize radiologist efficiency and effectiveness.

For an imaging operation, startup costs to introduce or expand DBT interpretation services have never been lower and organizations are capitalizing on the growth opportunities offered by this proven technology.

As patients, and especially women, become more discriminating consumers of healthcare services, they seek the best that technology can deliver. A high-performance, all-in-one solution unlocks the potential of 3D mammography for imaging operations as well as their patients, creating better outcomes for all.

Today, this barrier has been eliminated because the availability of all-in-one integrated breast imaging workflow solutions removes the need to invest in specialized hardware and software. What used to require a separate workflow and a separate, high-end workstation – perhaps in another room or even at another facility – can now be accomplished from the same fully-featured diagnostic viewer on all the same machines used for other interpretations and modalities.

6 Association of Digital Breast Tomosynthesis vs Digital Mammography with Cancer Detection and Recall Rates by Age and Breast Density. Conant EF, Barlow WE, Herschorn SD, et al. JAMA Oncol.

Published online February 28, 2019; 5(5):635–642. https://jamanetwork.com/journals/jamaoncology/article-abstract/2726028 7 Benefits of 3-D Mammograms Last Over Time. Breastcancer.org. Feb 2016 https://www.breastcancer.org/research-news/benefits-of-3d-mammograms-last-over-time 8 3D Mammography More Likely to Find Small Invasive Breast Cancers, Especially in Women Younger Than 50. Breastcancer.org. March 2019 https://www.breastcancer.org/research-news/3d-mammos-more-likely-to-find-small-invasive-bc 9 MQSA National Statistics. U.S. Food and Drug Administration. https://www.fda.gov/radiation-emitting-products/mqsa-insights/mqsa-national-statistics

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Cloud Managed Services You Can Depend On Intelerad’s Managed Services offer industry leading solutions for growing medical imaging organizations challenged by limited budgets, constrained IT resources or aging systems. This fully-managed solution allows businesses to avoid the challenges and expense of recurring investments in technology and staffing, while always benefiting from the latest, state-of-the-art technology, security controls and system redundancy.

The result: a greater return on investment, rapid expansion capability, enhanced performance, and securely protected data. ›› Facilitates predictable IT budgeting with an all-inclusive fee-per-study model ›› Protects your data with advanced security and ensures regulatory compliance ›› An operationally agile system that scales with your business needs

›› Advanced protection with state-of-the-art security controls ›› Geographically diverse production data centers backed up with uptime SLAs ›› 24x7x365 proactive monitoring and performance optimization to ensure peak performance

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Physician Burnout, a Call to Action Commonly defined as “a state of emotional, mental, and often physical exhaustion brought on by prolonged or repeated stress”, burnout has become a very real and pervasive problem within the radiology profession. In combination with an ongoing global radiologist shortage, a reinforcing vicious circle is created.

Imaging organizations are snapping to attention to address conditions which contribute to radiologist burnout, for good reason. Burnout has a negative impact on radiologists’ health, well-being, and job performance – in turn affecting patient health and outcomes, as well as the organizational bottom line. Understanding and reversing the upward trend of radiologist burnout benefits all.

Tipping Point The World Health Organization (WHO) has officially recognized burnout as an occupational syndrome. A detailed definition is included in the newest revision of the organization’s International Classification of Diseases (ICD-11), stating that burnout results from chronic workplace stress and is characterized by: • feelings of energy depletion or exhaustion; • increased mental distance from one’s job, or feelings of negativism or cynicism related to one's job; and • reduced professional efficacy.1 With this new legitimacy, in addition to growing acknowledgement of burnout within the medical profession and increasing awareness of the threat it poses, perhaps we can avoid the tipping point of which many experts in the healthcare industry have warned.

1 Burn-out an "occupational phenomenon": International Classification of Diseases. World Health Organization. 28 May 2018 https://www.who.int/mental_health/evidence/burn-out/en/

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“We are approaching a tipping point in which the rewards of being a radiologist and the conduct of other valuable work (e.g., research and educating trainees) are being overwhelmed by the pressures of an increasingly demanding clinical workday.�

Productivity, Meet Burnout.

Academic Radiology, Volume 25, Issue 12, December 2018

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Rates of physician burnout by specialty, Medscape National Physician Burnout & Depression Reports (2019, 2018).

2018

Which Physicians Are Most Burned Out?

Critical Care 48%

Neurology 48%

Family Medicine 47%

Ob/Gyn 46%

Internal Medicine 46%

Emergency Medicine 45%

Radiology 45%

Physical Medicine & Rehabilitation 44%

Urology 44%

Allergy & Immunology 44%

Surgery, General 43%

Cardiology 43%

Otolaryngology 42%

Pulmonary Medicine 41%

Pediatrics 41%

Infectious Diseases 40%

Nephrology 40%

Oncology 39%

Gastroenterology 38%

Anesthesiology 38%

Rheumatology 38%

Psychiatry 36% Public Health & Preventive Medicine 36%

Diabetes & Endocrinology 35%

Orthopedics 34%

Ophthalmology 33%

Pathology 32%

Dermatology 32%

Plastic Surgery 23%

Upward Trends Annual Medscape surveys of more than 15,000 U.S.-practicing physicians indicate that radiologist burnout rates are higher than rates for physicians overall. Nearly half (45%) of all radiologists surveyed for both the 2019 and 2018 Medscape studies reported feeling burned out.2,3 Radiologist burnout is not unique to the United States. A 2018 survey of Canadian radiologists and radiology trainees demonstrated similarly aboveaverage burnout symptoms.4 Imaging department leadership cannot ignore these indicators. After ranking as the 20th highest specialty for burnout in Medscape’s 2017 National Physician Burnout & Depression Report, radiology rose to 7th-highest in 2018 and was the 12th-highest in 2019. The negative impact of this upward trend will continue to expand if steps are not taken to counteract it.

2019

Which Physicians Are Most Burned Out?

Urology 54%

Neurology 53%

Physical Medicine & Rehabilitation 52%

Internal Medicine 49%

Emergency Medicine 48%

Family Medicine 48%

Diabetes & Endocrinology 47%

Infectious Diseases 46%

Surgery, General 46%

Gastroenterology 45%

Ob/Gyn 45%

Radiology 45%

Critical Care 44%

Cardiology 43%

Anesthesiology 42%

Rheumatology 41%

Pediatrics 41%

Oncology 39%

Pulmonary Medicine 39%

Psychiatry 39%

Orthopedics 38%

Dermatology 38%

Allergy & Immunology 37%

Plastic Surgery 36%

Otolaryngology 36%

Ophthalmology 34%

Pathology 33%

Nephrology 32% Public Health & Preventive Medicine 28%

Some findings are even more bleak. A 2019 study published in the Journal of Vascular and Interventional Radiology identified the prevalence of burnout for interventional radiologists at more than 70%.5 The study authors compare this to a distressing burnout rate of 54-61% for diagnostic radiologists and 28% for the general public.

Burnout Contributors The factors contributing to radiologist burnout are not state secrets.

Higher case volume – and increased workload in general – coupled with chronic staffing shortages are major contributors. As a complicating factor, study complexity is increasing even as pressures to work faster intensify.

The surge in bureaucratic and administrative tasks that consume a physician’s time has a huge impact, with radiologists feeling increased isolation and lack of autonomy as a

result. A priority on profits over patients is frequently lamented, causing many radiologists to question their staying power in the profession.

The Fallout The toll on radiologist well-being is perhaps the most obvious effect of burnout, with higher risks of depression, substance abuse and suicide.

Unfortunately, the fallout only extends from there.

Burnout affects physician job performance, too often resulting in higher error rates that impact healthcare quality and patient outcomes. In addition, other valuable aspects of physician work – such as education and research – are similarly compromised.

2 Medscape National Physician Burnout, Depression & Suicide Report 2019, slide 3. Kane. 16 Jan 2019 https://www.medscape.com/slideshow/2019-lifestyle-burnout-depression-6011056#3 3 Medscape National Physician Burnout & Depression Report 2018, slide 3. Peckham. 17 Jan 2018 https://www.medscape.com/slideshow/2018-lifestyle-burnout-depression-6009235#3 4 Prevalence of Burnout Among Canadian Radiologists and Radiology Trainees. Zha, Nanxi et al. Canadian Association of Radiologists Journal, Volume 69, Issue 4, 367 - 372 https://www.ncbi.nlm.nih.gov/pubmed/30270152 5 Over 70% of interventional radiologists polled experience career burnout. Interventional News. 11 July 2019. https://interventionalnews.com/burnout-interventional-radiologist/

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The Freedom to Read From Anywhere Designed with flexibility in mind, Clario SmartWorklist™ can adapt to the unique needs of any enterprise and offers a functionally-rich, vendor-neutral, zero-footprint worklist that aims to achieve worklist perfection for each individual radiologist in your imaging group. ›› Launch any viewer, voice recognition system or clinical application from a single worklist

›› Multiple-viewer support to integrate disparate medical image repositories

›› Anywhere, anytime access to subspecialty and shift-based worklists, sorted and organized according to the reading priorities of the group

›› PACS, RIS, Archive and VNA agnostic to allow multiple organizations to operate as one

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Economic Cost

Countering Burnout

Take Action

The sizable economic cost of physicians leaving the profession is spurring healthcare leadership to invest in measures for alleviating and preventing burnout. A 2018 Harvard report, A Crisis in Health Care: A Call to Action on Physician Burnout, cites a study finding a 30-40% likelihood that physicians will reduce their work hours in the subsequent two years for each one-point increase in burnout, on a seven-point scale.6

Imaging organizations can take immediate steps to alleviate burnout contributors. Adopting and encouraging practices known to relieve stress and frustration – such as exercise, breaks during the workday and taking time off – are an obvious first step.

Working to foster teamwork instead of competitiveness within the ranks is another highly recommended management approach.

A simple assessment of current technology solutions, including PACS, worklists and assignment engines, sub-specialty modules, advanced visualization and voice dictation systems – paying special attention to the performance and interoperability of these systems – may identify areas ripe for improvement.

When burnout causes physicians to leave their jobs, balance sheets suffer. The same Harvard report cites estimated lost revenue of $990,000 per departed FTE physician and a $500,000 to $1 million cost for recruiting and replacing a physician.

Some healthcare organizations have instituted new wellness positions, specifically tasked with promoting mental and physical health across their workforce. By addressing the issue of wellness – and specifically burnout – at the organizational level, it is hoped that effective interventions will reverse the increasing prevalence of physician burnout and bring about long-term cultural change.

The economic toll adds up quickly for healthcare organizations already fretting about the bottom line. According to a 2019 study published in the Annals of Internal Medicine, burnout-associated costs related to physician turnover and reduction of clinical hours were estimated – by a “conservative” model – at a staggering $4.6 billion annually, in the United States alone.7

Public Health Crisis Many view the increasingly pervasive issue of physician burnout as a public health crisis, as declared by the Harvard report. The authors warn that the consequences will become even more severe if action is not taken.

There is hope, however, when progressive healthcare organizations are proactive about minimizing the risk and effects of burnout. Awareness is growing and various measures have great promise to avert this potential crisis.

In addition, evolving Artificial Intelligence -powered solutions hold promise for reducing fatigue and interpretation time by making a first pass on studies, leveraging deep learning to identify and highlight areas of concern on which the radiologist can then focus their attention.

When radiologists are enabled to spend more of their time delivering the best possible patient care, and less time on bureaucratic and administrative tasks, better outcomes will result for all.

Technology Measures Better tools and resources for medical imaging can also help to eliminate radiologist time sinks, reduce frustration and enable more focus on reading and interpreting studies. But physicians need technology that will simplify their processes, not complicate them as the advent of Electronic Health Record (EHR) systems has done for so many.

Software solutions that can minimize time spent by radiologists on administrative processes while improving the imaging workflow are key. Prioritizing the ability to institute advanced, reusable, automated workflows for accessing, interpreting and reporting studies is pivotal for simplifying processes and maximizing radiologist efficiency.

6 A Crisis in Health Care: A Call to Action on Physician Burnout. Massachusetts Medical Society, Massachusetts Health and Hospital Association, Harvard T.H. Chan School of Public Health, and Harvard Global Health Institute, 2018 https://cdn1.sph.harvard.edu/wp-content/uploads/sites/21/2019/01/PhysicianBurnoutReport2018FINAL.pdf 7 Estimating the Attributable Cost of Physician Burnout in the United States. Han S, Shanafelt TD, Sinsky CA, Awad KM, Dyrbye LN, Fiscus LC, et al. Annals of Internal Medicine; 170(11): 784-790. 28 May 2019 https://annals.org/aim/article-abstract/2734784/estimating-attributable-cost-physician-burnout-united-states

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“We have been working with these technologies as a radiology group client as well as a reseller partner for multiple years. The combination of Intelerad’s workflow and diagnostic solutions with its intelligent worklist technology has allowed us and our clients to manage workflow more efficiently and intelligently. It’s been a key driver of our growth.”

Worth Saunders CEO of Greensboro Radiology and President of Canopy Partners

Volume 8, 2020

The Power of a Smart Worklist Establishing a unified, intelligent, cross-enterprise workflow is vital to the success and growth of today’s medical imaging operation – whether hospital-based, imaging center, or independent radiology practice.

Why Intelligent Workflow?

Removing the burden of deciding which study to read next increases the efficiency and productivity of an imaging organization’s most expensive and thinly-stretched resources – radiologists. Streamlining the process of locating relevant priors stored in other systems and using analytics to identify bottlenecks and implement solutions has the same benefit, while also increasing the quality of interpretation and reducing study backlog.

When radiologists only read exams for which they are credentialed, expensive overreads are eliminated. Establishing or enhancing multi-specialty 24×7 support grows the business. The possibilities are limitless once you open the door to the potential of intelligent, automated workflow.

Achieve Worklist Perfection Intelerad’s Clario SmartWorklist™ automates the process of organizing and prioritizing the radiology reading worklist across the entire organization for optimum efficiency, boosting practice productivity as well as radiologist satisfaction. Powerful, built-in analytics provide data and tools to identify issues and implement solutions.

The powerful assignment engine in Clario SmartWorklist constantly evaluates and prioritizes cases in the queue in real time, accounting for variables such as radiologist subspecialty, credentials, workload, location and availability while simultaneously factoring in service-level agreement (SLA) requirements and STAT escalation needs.

When cases require additional legwork from support staff, a parallel radiology support workflow allows cases to be moved back and forth between the reading worklist and a separate support worklist, with tracking and priority monitoring intact.

Organizations have complete control over the rules and criteria that govern case assignment. A smart, context-aware worklist means that the right study is always read by the right person at the right time, effecting a more balanced workload, higher quality, reduced turnaround time and higher radiologist satisfaction.

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Identify and Address Issues with Integrated Analytics More than a workflow manager, Clario SmartWorklist also provides an analytics platform with data and tools to measure practice productivity, value and quality. Performance dashboards track individual reading workload and progress. Integrated analytics are available to track and compare trends over time.

With a complete repository of workflow data, Clario SmartWorklist can be utilized to inform and identify productivity- and quality-related issues. With the built-in analytics features, business leaders or support teams can monitor and analyze a wide variety of metrics, such as: • Turnaround times for every segment in the exam lifecycle • Turnaround times averaged by shift, reading location, radiologist, modality, site, and priority • Time spent in dictation for each exam and aggregated by procedure code • When and where exams are read • By which radiologists exams are read (FT/PT/teleradiologist, subspecialty) • Exam metrics (e.g. body part, subspecialty, RVU, work unit, SLA compliance, subspecialist) • Operations requests for each exam, including time spent completing the request • Results communicated for each exam, including time spent completing the communication • Peer review error rate by time of day • Individual or team productivity, historically or real-time via Productivity Gauge

Establish a Universal, Unified, Cross-Enterprise Workflow With the ability to launch more than 50 different applications, Clario SmartWorklist can be used with a variety of legacy PACS, third-party diagnostic viewers and voice recognition systems.

Clario SmartWorklist can also be paired with Intelerad’s InteleOne® XE interoperability solution to seamlessly link users, from a single diagnostic viewer interface, to patient images and reports that are stored in any of the disparate systems found across an organization’s imaging ecosystem.

In combination, these two powerful Intelerad solutions aggregate reading tasks and relevant priors from any/all repositories across the enterprise into a single, actionable, intelligent worklist. The resulting unified, cross-enterprise workflow enhances productivity and resource utilization organization-wide. All authorized users, whether located at

an imaging center or hospital, stationed at a remote facility, or working from home, can experience the same seamless, universal access to patient orders, images, and reports, across diverse patient identifier domains.

“We have been working with these technologies as a radiology group client as well as a reseller partner for multiple years. The combination of Intelerad’s workflow and diagnostic solutions with its intelligent worklist technology has allowed us and our clients to manage workflow more efficiently and intelligently. It’s been a key driver of our growth.”

Worth Saunders CEO of Greensboro Radiology and President of Canopy Partners

Outsmart the Worklist Management Problem As if it weren’t smart enough, Intelerad’s intelligent workflow technology is AI-enabled and can be augmented with meaningful information through a vendor-neutral interface.

This is critical as the role of artificial intelligence in medical imaging continues to evolve and become more established.

By modernizing the reading environment with Intelerad’s intelligent workflow technology, medical imaging operations create new opportunities for optimizing business problems, consolidating disparate technology systems, and attracting and retaining radiologists. They can literally outsmart the worklist management problem.

A Smarter Way to Read In a radiology practice, resources are often scarce, always stretched thin, and too costly to waste. Yet valuable radiologist time is often consumed simply determining which study to read next. The pressure to keep turnaround time low and RVUs high, while maintaining high quality standards and fulfilling nonreading tasks, is unforgiving. The article Feeling the Burn on page 17 of this issue discusses the growing crisis of radiologist burnout in more detail.

The good news is that the increasing and unrelenting expectations put upon medical imaging organizations have inspired new technology solutions that can alleviate much of the strain. If maximizing productivity, increasing quality, and gaining important insight into business metrics for ongoing optimization are priorities for your business, investigate the power of a smart worklist.

Volume 8, 2020

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Disparate Systems.

One Worklist.

InteleOne® XE is a proven interoperability solution that unifies disparate medical imaging environments across multiple HIS, EMR, PACS and VNA systems.

Trusted by healthcare organizations of all sizes as well as the most complex healthcare networks and radiology practices, InteleOne XE connects patients, providers, and patient imaging data across the enterprise to enable community-wide, coordinated care.

Designed with security and scalability in mind, InteleOne XE offers flexible deployment strategies to help de-risk large-scale enterprise imaging projects by maximizing the use of legacy architecture while avoiding the need for data migrations. ›› Achieve a single, unified workflow ›› Gain access to patients’ complete imaging history

›› Rapidly onboard new facilities and scale intelligently ›› Maximize resource utilization and efficiency

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Columbus Radiology, Taking the Clario SmartWorklist™ to the Next Level Workload Balancing Achieved with Flexible Productivity Gauge Feature “We looked at so many technologies and without question, our selection of Clario SmartWorklist was a hands-down decision.”

Dr. Vikram Krishnasetty, MD Vice President at Columbia Radiology and Chair of Clinical IT Board at Radiology Partners

About Columbus Radiology Corporation Founded in 1946, Columbus Radiology Corporation (CRC) is a leading subspecialty radiology group with a long history of providing professional diagnostic and interventional radiology services throughout the state of Ohio. With a staff of 115 radiologists plus 20 additional non-clinical team members, CRC provides emergency/trauma and subspecialty interpretations 24 hours a day. CRC currently serves 22 hospitals and approximately 60 ambulatory sites, with an annual study volume of 2.1 million.

Rapid Growth Creates Need for Unifying Solution The CRC practice has had an established presence in the Columbus, Ohio area for more than 70 years. Over the last five to ten years, the practice has experienced some very rapid growth, expanding its client base to include sites in the Columbus surrounding area, as well as Cincinnati and Toledo areas. CRC continues to grow throughout the state.

To prepare for this growth and in order to remain competitive while ensuring continuity of the same high-quality service, CRC leadership began to search for some type of unifying technology solution that would streamline workflow and simplify the reading environment. With the number, geographic diversity, and technological complexity of client sites steadily increasing, CRC required a solution that worked with all systems.

Volume 8, 2020

“At that time, our clients were on at least eight different dictation systems, multiple different PACS, a variety of workstations,” said Dr. Vikram Krishnasetty, MD, Vice President at CRC and Chair of Clinical IT Board at Radiology Partners. “We could not add any more complexity to our reading environment, it was a serious barrier to growth.”

Clario SmartWorklist™: A Hands-Down Decision After evaluating many different technology approaches for overcoming this barrier, Intelerad’s Clario SmartWorklist™ was chosen for its extensive flexibility and implementation options.

An enterprise-wide worklist solution, Clario SmartWorklist intelligently manages reading workflow by automatically and dynamically organizing each radiologist’s reading tasks, accounting for variables such as radiologist subspecialty, credentials, workload, location and availability. The system can also launch more than 50 different applications, accommodating the complex, multi-vendor reality of today’s healthcare industry.

The ability to launch a client’s legacy PACS – as well as a wide range of dictation systems – from within the worklist was extremely important to CRC. It was not feasible to migrate all client sites to one central PACS, and Clario SmartWorklist ensured that this was unnecessary.

“Being able to implement an integrated solution with all that flexibility was a huge draw,” said Dr. Krishnasetty. “We looked at so many technologies and without question, our selection of Clario SmartWorklist was a hands-down decision.”

Auto-Next Feature Enables 50% More Efficiency Another key selling point was the ability to customize the Clario SmartWorklist implementation, avoiding the need for clients to make adaptations to their processes.

“It was almost invisible to the hospitals, they didn't have to change a thing,” Dr. Krishnasetty said. “We could make it all happen on our end. We could do it all in Clario SmartWorklist.”

By leveraging Clario SmartWorklist to unify and streamline workflow, CRC has been able to improve patient care and decrease turnaround times, while recognizing significant efficiency gains. Radiologists appreciate the ability to customize the interface for maximum productivity. The “autonext” reading mode, in which the system chooses and presents the next case to read, is popular. One CRC radiologist estimates that this feature alone makes him 50% more efficient.

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The Best Worklist is the One You Don’t Need to Look At Clario SmartWorklist™ offers a functionally-rich, vendor-neutral, zero-footprint worklist that aims to achieve worklist perfection for each individual radiologist in your imaging group.

Designed with flexibility in mind, Clario SmartWorklist ensures the right radiologist is presented with the right case at the right time, regardless of the complexity or disparate nature of your environment.

With the ability to launch over 50 other applications through highly tailored and dynamic worklists, Clario SmartWorklist can adapt to the unique needs of any enterprise. ›› Multiple-viewer support to integrate disparate medical image repositories ›› Auto-next reading mode radiologists can trust to present the most appropriate examination, without having to return to the worklist ›› AI-enabled Clario SmartWorklist can be augmented with actionable data through a vendor-neutral interface

›› Automatic examination distribution based on real-time variables such as availability, subspecialty, workload, location and more ›› Dynamic worklist activations to automatically show and hide overflow worklists based on criteria-driven thresholds

Volume 8, 2020

Partnership Broadens Adoption of Intelerad Solutions

Real-Time Feedback Eliminates Guesswork

As the adoption of Clario SmartWorklist paved the way for continued rapid business growth, CRC entered a partnership with a national practice, Radiology Partners. This enabled the practices to strategically pool resources for providing increased clinical value through AI and other technology investment, best practice development, expanded R&D, and other economies of scale.

A practice is able to define its own thresholds for the gauge, specifying the number, benchmark and color representation for each threshold. CRC has three: the gauge is green when individual output is at least 90% of the goal, yellow between 80% and 90%, and red below 80%. Fluctuation throughout a shift is expected and normal, but the objective is to achieve green status before completing a shift.

This partnership is mutually beneficial and has resulted in the adoption of Clario SmartWorklist and other Intelerad solutions, including IntelePACS® and InteleViewer™, more broadly throughout both organizations.

Collaboration on New Features Extends Utility of Product As CRC radiologists developed expertise with Clario SmartWorklist, they found a very receptive vendor open to exploring, implementing and collaborating on new features that would extend the utility of the product. This close relationship resulted in the development of a major new product capability for providing real-time feedback on team and individual productivity.

After several months of close collaboration between CRC and the Clario SmartWorklist product development team, a new Productivity Gauge feature was released to all customers, providing a real-time, visual indicator of individual productivity, as determined by customizable criteria set by the practice.

Productivity Gauge Enables Workload Balancing Every practice has the ability to define the unit of work used by the Productivity Gauge. It can be as simple as RVUs or the number of cases, or it can be a more custom calculation that is relevant to the specific operation and goals of the practice.

The system is continually monitoring the volume of work coming in, at adjustable intervals (for example, every 15 minutes). Dividing this volume by the number of radiologists currently on shift calculates the individual productivity rate needed to keep the whole team on target.

The Productivity Gauge is an excellent tool for workload balancing across the entire organization, helping team members meet workload and turnaround time targets while fostering a team approach, rather than a competitive or cherry-picking approach. With real-time feedback on output in comparison to the current productivity expectation – which team members know is calculated using a fair and equal distribution of work units – each individual can see if they are keeping up, ahead of the game, or falling behind.

“This is not designed to push radiologists to read ‘faster’,” said Dr. Krishnasetty. “The goal is to balance the workload so that each of us is doing our part to accomplish that day’s work.”

“Before the Productivity Gauge, you really had no idea if you were doing your work for the day or not. You just kind of had to guess,” Dr. Krishnasetty said. “Having that real-time feedback in front of you is rewarding, and it helps everyone stay motivated and on target.”

Customizable Gauge Enables Optimal Workflow, Maximizes Capacity After implementing the Productivity Gauge, CRC saw significant efficiency gains and reduced staffing needs. Today, the feature is critical for maintaining a highly productive workflow that maximizes reading capacity across the practice. If the greenyellow-red feedback is removed from the reading environment, productivity falls dramatically.

“Now, without the gauge, the whole practice workflow falls apart, because no one knows where they are,” said Dr. Krishnasetty. “We have had to call in multiple radiologists to deal with the backup.”

A Powerful Analytics Tool The data collected also assists management in monitoring trends, analyzing staffing needs, and making adjustments as necessary.

At CRC, the next horizon is to leverage the data predictively.

As a result of its adoption of Clario SmartWorklist, CRC has not only overcome the challenges of an overly complex reading environment, it has fostered a more productive and harmonious internal work environment through its collaboration on the Productivity Gauge feature. The close relationship with Intelerad continues to grow as CRC and Radiology Partners deploy additional Intelerad solutions within their businesses.

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Intelerad's Chief Technology Officer, Chris Wood, on the Age of Artificial Intelligence The product strategy we set now results in features or products that will arrive in months or even years in the future. We, therefore, build for the future, and the more accurately we predict what the radiologist of the future will want, the more successful our products and services will be.

To inform our strategy, we listen to our customers and potential customers, but we also consider other factors such as industry trends (e.g., practice consolidation), clinical practice changes (e.g., lung cancer screening), technology trends (e.g., cloud computing), and trends in consumer software (e.g., voice control).

Artificial intelligence is a technology that is sweeping through other industries, has been proven to be clinically impactful in radiology, and has the potential to help reverse a growing, worldwide, radiologist shortage. For these reasons, we are predicting that AI will be more than a feature or a product, but a disruptive force in radiology.

Chris Wood joined the company in 2018 when Clario Medical, the company he co-founded, was acquired by Intelerad.

He holds a graduate degree in medical physics from the University of South Florida, and has worked for 20 years in the medical imaging software industry.

He developed, or led the development of, some of the earliest products in the areas of 3D, PACS, image-guided surgery and CAD, while holding senior management positions at Picker International and Siemens, among others.

We are not unique in recognizing the potential impact AI can have in radiology.

There are over 120 startups developing AI applications for Medical Imaging, and over $1B (US) invested so far. These startups are facing many challenges, but getting their technology properly inserted into the workflow (without slowing down the radiologist) is perhaps the biggest challenge they face.

Radiologists’ early experience with AI systems have caused them to realize what other industries have already learned; humans and AI should join forces. AI’s larger impact comes when it complements and augments human capabilities, not when it attempts to replace them. By adopting this philosophy, we can solve the AI workflow challenges, allowing radiologists to improve the service they provide, while simultaneously boosting efficiency.

Volume 8, 2020

If we get this right, machines will do what they do best, and radiologists will do what they do best. This would be a disruption we can all embrace.

Intelerad has two decades of radiology workflow expertise. We are leveraging this experience to create AI management and AI workflow software that help AI and radiologists work together. We are building tools that allow radiology practices to define when AI is used, and under what conditions. We are integrating AI systems so that they work seamlessly with our worklist and image viewer. We are also developing workflow specific functionality using our own AI algorithms.

Our customers want to be efficient, and have access to the best technology so they can provide the best care to their patients. To be successful, radiologists need to control what AI they will use, when to use it, and how it will be integrated. To make this happen, Intelerad has published open APIs for AI integration, and we are building the best tools we can imagine to allow radiologists and AI to join forces. If we get this right, machines will do what they do best, and radiologists will do what they do best. This would be a disruption we can all embrace. 

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Daringly Accessible Easy access to clinical data across the patient care continuum is critically important to providing superior patient care, but replacing healthcare technology systems is expensive, time-consuming, and disruptive.

Intelerad solutions are designed to facilitate access to and exchange of clinical information across the hospital enterprise, leveraging existing imaging and IT systems so that healthcare providers can optimize and extend the life of their existing technology investments.

Foster collaboration and deliver better health outcomes by: ›› Providing secure access to all relevant imaging data at the time of interpretation, regardless of where it originates ›› Improving physician satisfaction through specialized, streamlined workflows that increase efficiency and productivity

›› Enabling viewing and storage of all imaging data throughout the enterprise ›› Delivering radiology results to care teams for seamless clinical continuity ›› Granting patients secure access to their clinical results through a flexible and intuitive interface