Any image, anywhere:

How Yorkshire trusts are delivering better, more efficient care by using the XERO Exchange Network to provide integrated clinical imaging

Janine Bontoft
Technology Programme Manager Yorkshire Imaging Collaborative (YIC)

Cindy Fedell
Chief Digital Information Officer Bradford Teaching Hospitals NHS Foundation Trust & Airedale NHS Foundation Trust

Stuart Viner
Consultant Head and Neck Radiologist Bradford Teaching Hospitals NHS Foundation Trust

The Yorkshire Imaging Collaborative (YIC) is a combined technology and business transformation project aimed at unifying radiology imaging and report sharing between eight NHS trusts across Yorkshire, as well as the recently established NHS Nightingale Hospital Yorkshire and the Humber.

The project was launched in 2017, with the overarching ambition to ensure that every patient in Yorkshire can attend an appointment and have full availability of their medical images and associated reports at the point of care. With the contracts for many of the region’s Picture Archiving and Communications Systems (PACS) set to expire, the project was born out of the need to procure new systems that were better, faster, and equipped to cope with the increase in demand for radiology services.

Initially, as a means of saving money, the YIC decided to push forward with a joint procurement programme, but soon found that the partnership could also resolve many of the radiology issues they were facing, such as staff shortages. Since then, the YIC has continued to push the envelope for regional collaborative networks, as it strives to achieve full integration of radiology workflows across Yorkshire.

8 × NHS Trusts

24 × NHS Hospitals

2.3 x Million People

The challenge

With staff shortages increasing each year and demand on services increasing, the YIC needed to redesign the radiology workforce across its nine sites.

As the Royal College of Radiologists’ (RCR) 2019 annual radiology workforce report shows, the UK radiologist workforce is now short-staffed by a third (33%), with the shortfall expected to hit 43% by the end of 2020. As a result, 70% of clinical directors of radiology departments feel they do not have enough radiology consultants to deliver safe care. In order to bridge the gap between service delivery and demand, NHS trusts routinely rely on outsourcing, locums and overtime. “The problem with radiology is that there is an ever-increasing demand on the service, but the number of radiologists retiring is higher than the number of people coming into the profession”, explains Janine Bontoft, Technology Programme Manager at the Yorkshire Imaging Collaborative. “This means that a large proportion of imaging studies acquired in the Yorkshire region are being reported by outsourcing companies, which is more expensive than using an in-house resource.”

For the YIC, the problems caused by the disparity between service demand and capacity was made worse by the challenges with integration between PACS across the region. The lack of interoperability meant that trusts were forced to rely on an Image Exchange Portal (IEP) to transfer images, which is renowned among clinicians for being unstable and inefficient. “If a consultant thought a patient had imaging done at another trust and wanted to see it, they had to contact the admin team”, explains Cindy Fedell, Chief Digital Information Officer (CDIO) of Bradford Teaching Hospitals NHS Foundation Trust and Airedale Hospital Foundation Trust. “The admin team would contact the trust where the image might exist and ask them to look for it, and send it to us via the IEP. From start to finish it would take between 24 and 48 hours.”

There is an ever-increasing demand on the service, but the number of radiologists retiring is higher than the number of people coming into the profession”

Stuart Viner
Consultant Head and Neck Radiologist
Bradford Teaching Hospitals NHS Foundation Trust

Despite being far from ideal, for outpatient appointments, using the IEP was manageable — clinicians could work around the expected 48-hour timeframe and plan their patient care accordingly. But for emergencies, the IEP was unsuitable. “In emergencies, when you’ve got a patient needing acute medical management, you need to act quickly”, says Stuart Viner, Consultant Head and Neck Radiologist at Bradford Teaching Hospitals NHS Foundation Trust. “You simply can’t afford to wait 48 hours for an image to download.”

The National Radiology Association estimates that the number of ‘suboptimal’ scans (with poor quality imaging) is approximately 20%, with outdated methods of image sharing being a significant factor. “In some instances, we were burning images onto a CD and putting them in a taxi to another trust to save time,” explains Bontoft. “But eight or nine times out of ten, the clinicians would re-examine the patient instead because it is so much quicker. It was bad for our patients in terms of having to take the day off work to revisit the hospital, but also because of the unnecessary exposure to radiation.”

With the contracts for several PACS systems across the region set to expire, and with the YIC committed to a joint procurement programme, Fedell and other senior members of the Collaborative began thinking about how they could improve image sharing across the region. “When we started talking about re-procuring our PACS, we were saying to each other ‘imagine if we had just one PACS, wouldn’t that be great?’”, explains Fedell. “However, it wasn’t feasible because of our geography, so we began looking into ways we could work differently across the region to solve our problems. We wanted to achieve total interoperability between our PACS. We just needed to find the right solution.”

[1]The Royal College of Radiologists. Clinical Radiology UK workforce census 2019 report. London: the Royal College of Radiologists 2020.

The solution

From the outset, the YIC established a business case and a list of minimum requirements for the suppliers competing for the new PACS contracts. “We asked the suppliers to respond with what their system can do”, explains Bontoft.

“As a minimum, we wanted to view images across the patch; the only supplier to meet the criteria was Agfa HealthCare.”

In October 2017, the final contracts were signed for Agfa HealthCare to implement its Enterprise Imaging (EI) solution and XERO Universal Viewer at the following eight trusts:

  • Airedale NHS Foundation Trust
  • Bradford Teaching Hospitals NHS Foundation Trust
  • Calderdale and Huddersfield NHS Foundation Trust
  • Harrogate and District NHS Foundation Trust
  • Hull University Teaching Hospitals NHS Trust
  • Leeds Teaching Hospitals NHS Trust
  • Mid Yorkshire Hospitals NHS Trust
  • Northern Lincolnshire and Goole NHS Foundation Trust

EI provided the trusts with a unified imaging platform, complete with clinical tools, reporting functionality and a powerful workflow engine to maximise productivity. XERO, a web-based platform, offered clinicians the ability to share images with other XERO users across Yorkshire, as part of a new ‘XERO Exchange Network’ (XEN). “Enterprise Imaging is designed for our radiologists,” explains Bontoft. “It is extremely functionally-rich, and it will help us to meet the increased demand for our services. But the most important part of this project is XERO, because it moves us one step closer to achieving total workflow interoperability.”

Two-Phase Implementation

The implementation process was divided into two phases.

Phase one saw the introduction of EI, starting with the Harrogate and District NHS Foundation Trust on 28th April 2018. The YIC planned to have all of its trusts live with the EI by the end of 2020, but the project has slowed as a result of the Coronavirus pandemic. Nonetheless, the YIC pushed forwards with its plans for phase two, to rollout the XERO Exchange Network. “All of our other programmes put on hold”, says Bontoft. “So I immediately took the opportunity to go and see my Programme Director and make a case for advancing the deployment of the XERO Exchange Network. I knew that radiology would be quieter than other departments because patient and routine appointments had stopped, and a lot of the routine imaging had stopped too. It was the perfect time for me to get hold of all of the people I needed and get them testing the new system.”

Early in 2020, the YIC began to connect the individual instances of the XERO Image Viewer at each site to form the XERO Exchange Network across eight trusts, as well as the recently established NHS Nightingale Hospital Yorkshire and the Humber. The network was live within four weeks. “We recognised the need to support each other, in particular, with the launch of the Nightingale Hospital Yorkshire and the Humber”, says Fedell. “If we needed to treat a high volume of patients at the new site, we would need the support of other radiologists across the region to support with the increase in patient volume, and we were so close to going live with the project anyway, we just turned it on.”

Bontoft adds: “XERO gave us the flexibility to plan for worst-case scenarios. If one of our hospitals had to be shut down because of COVID, we knew that wherever we transferred patients to — whether that was the Nightingale or another trust — it wasn’t a problem because the imaging could be seen anywhere.”

The implementation ran smoothly, particularly given the scale and uniqueness of the project. “We are the first to use the XERO Exchange Network”, explains Bontoft. “And we are the first group of trusts in the country to facilitate image sharing across an entire region. We are paving the way, and when you’re the first to do something you expect to encounter some issues. “But any issues we had are now resolved, thanks to the support of Agfa. From the beginning of our relationship, they have been responsive; they have talked to clinicians, and they have gone out of their way to build a solution that’s right for us. It has been a very collaborative experience.

Empowering the workforce. Improving patient care

The impact of the XERO Exchange Network has been immediate, with the new image sharing capability helping staff and patients to navigate the complex conditions resulting from the COVID–19 pandemic. “During a pandemic, you don’t want patients coming into hospital unnecessarily”, explains Viner. “So one of the main benefits of the XERO Exchange Network has been quickly seeing if a patient has been imaged somewhere else and preventing repeat appointments.

“Rather than going through the process of transferring images from one place to another, I can look into other PACS systems across the region, without having to transfer anything. I have rejected and cancelled multiple imaging requests because I’m so much better informed.”

Avoiding unnecessary repeat examinations also provided financial benefits for the YIC trusts, but Viner and his colleague consider the improvements to patient care to be the most significant. “In emergencies, we now have the imaging immediately available, so there is no delay in patient care,” he explains.

“I have also had instances where a patient has been scanned, and we’ve noticed an abnormality. XERO has allowed me to look into other PACS across the region to get a more complete view of the patient’s imaging history. This means that we don’t need to concern the patient by unnecessarily re-investigating something that’s already in their records.”

Bontoft adds: “It’s reassuring to know that our consultants now have access to previous images. It gives them the confidence to know whether or not something they have spotted has been identified before, which prevents patients from being recalled to hospital and facing unnecessary exposure to radiation. But not only is it saving time for patients and clinicians, it is also leading to better clinical decision-making and better patient outcomes; clinicians have far more information than they had before, at the click of a button.

The XERO Exchange Network has also provided significant time-saving benefits on administrative tasks, with less time spent transferring images via the IEP. “XEN cuts out administrative work”, explains Fedell. “Across all of our trusts, we had half a dozen people just moving images around — but now we can begin to scale back that resource and invest elsewhere.”

Summary of benefits

  • More complete view of the patient’s medical history
  • More informed clinicians
  • Better clinical decision-making
  • Reduces waiting times for patients
  • Avoids repeat appointments
  • Improves patient outcomes and experiences
  • Saves time for administrative based tasks

“Not only is it saving time for patients and clinicians, it is also leading to better clinical decision-making and better patient outcomes.”

Because of XERO, we have more capacity and a better understanding as a whole, rather than as individual trusts.”

Fast-tracking recovery

With fewer radiology patients during the peak of the national lockdown (March-May), trusts across the region were able to minimise their radiology backlogs, and no longer had to rely on outsourcing companies for support. But, as the number of COVID–19 cases declined, attention turned to restarting normal clinical services, and with it, the demand for radiology services started to increase.

“Demand has already started to increase as more people start coming to hospitals again”, explains Fedell. “And with more people visiting hospitals, we expect the demand for radiology services to exceed pre-pandemic rates. But XERO means that we can respond differently to sudden increases in patient volume, and it will become even more important as we come into different phases of the NHS recovery plan. Because of XERO, we have more capacity and a better understanding as a whole, rather than as individual trusts.

The rollout of XERO has also allowed the YIC to restart some of its services more efficiently. “We’ve been using the Nightingale hospital for outpatient appointments, which has allowed us to restart our Oncology list”, explains Bontoft. “Three of our trusts are sending patients to be imaged at the Nightingale, those images are then reported on at the ‘home’ trust — without the XERO Exchange Network we wouldn’t be able to do that.”

A collaborative future

The YIC’s next project is facilitating cross-site reporting, something which will help trusts to share the burden of radiology workloads. Viner explains, “When we sat down many years ago to do our ‘blue-sky’ thinking, we wanted to facilitate the ability to view and report on imaging and reports anywhere. We all agreed that having a cross-regional reporting system would help streamline resources, especially in smaller places where you’ve got one specialist radiologist. This next step will enable a total redesign of our radiology workforce.”

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