The University of California at San Francisco (USCF) Department of Radiology currently has a clinically operational picture archiving and communication system (PACS) that is thirty-five percent filmless, with the goal of becoming seventy-five percent filmless within the year. The design and implementation of the clinical PACS has been a collaborative effort between an academic research laboratory and a commercial vendor partner. Images are digitally acquired from three computed radiography (CR) scanners, five computed tomography (CT) scanners, five magnetic resonance (MR) imagers, three digital fluoroscopic rooms, an ultrasound mini-PACS and a nuclear medicine mini-PACS. The DICOM (Digital Imaging and Communications in Medicine) standard communications protocol and image format is adhered to throughout the PACS. Images are archived in hierarchical staged fashion, on a RAID (redundant array of inexpensive disks) and on magneto-optical disk jukeboxes. The clinical PACS uses an object-oriented Oracle SQL (systems query language) database, and interfaces to the Radiology Information System using the HL7 (Health Languages 7) standard. Components are networked using a combination of switched and fast ethernet, and ATM (asynchronous transfer mode), all over fiber optics. The wide area network links six UCSF sites in San Francisco. A combination of high and medium resolution dual-monitor display stations have been placed throughout the Department of Radiology, the Emergency Department (ED) and Intensive Care Units (ICU). A continuing quality improvement (CQI) committee has been formed to facilitate the PACS installation and training, workflow modifications, quality assurance and clinical acceptance. This committee includes radiologists at all levels (resident, fellow, attending), radiology technologists, film library personnel, ED and ICU clinian end-users, and PACS team members. The CQI committee has proved vital in the creation of new management procedures, providing a means for user feedback and education, and contributing to the overall acceptance of, and user satisfaction with the system. Well developed CQI procedures have been essential to the successful clinical operation of the PACS as UCSF Radiology moves toward, a filmless department.
PACS; continuing quality improvement (CQI); quality assurance (QA); filmless
Texas Children’s Hospital, a definitive care pediatric hospital located in the Texas Medical Center, has been constructing a large-scale picture archival and communications system (PACS) including ultrasound (US), computed tomography (CT), magnetic resonance (MR), and computed radiography (CR). Developing staffing adequate to meet the demands of filmless radiology operations has been a continuous challenge. Overall guidance for the PACS effort is provided by a hospital-level PACS Committee, a department-level PACS Steering Committee, and an Operations Committee. Operational Subcommittees have been formed to address service-specific implementations, such as the Emergency Center Operations Subcommittee. These committees include membership by those affected by the change, as well as those effecting the change. Initially, personnel resources for PACS were provided through additional duties of existing imaging service personnel. As the PACS effort became more complex, full-time positions were created, including a PACS Coordinator, a PACS Analyst, and a Digital Imaging Assistant. Each position requires a job description, qualifications, and personnel development plans that are difficult to anticipate in an evolving PACS implementation. These positions have been augmented by temporary full-time assignments, position reclassifications, and cross-training of other imaging personnel. Imaging personnel are assisted by other hospital personnel from Biomedical Engineering and Information Services. Ultimately, the PACS staff grows to include all those who must operate the PACS equipment in the normal course of their duties. The effectiveness of the PACS staff is limited by their level of their expertise. This report discusses our methods to obtain training from outside our institution and to develop, conduct, and document standardized in-house training. We describe some of the products of this work, including policies and procedures, clinical competency criteria, PACS inservice topics, and an informal PACS newsletter. As the PACS system software and hardware changes, and as our implementation grows, these products must to be revised and training must be repeated.
Successfully introducing a new technology in a health-care setting is not a walk in the park. Many barriers need to be overcome, not only technical and financial but also human barriers. In this study, we focus on the human barriers to health-care information systems’ implementation. We monitored the acceptance of a Picture Archiving and Communication System (PACS) by radiologists and hospital physicians in a large Belgian university hospital. Hereto, questionnaires were taken pre-implementation (T1) and 1 year after the radiology department stopped printing film (T2). The framework we used to perform the study was the Unified Theory of Acceptance and Use of Technology. Main findings were that both groups were positive toward PACS prior to the introduction and that each group was even more positive at T2 with extensive PACS experience. In general, the ratings of the radiologists were higher than those of the physicians, as the radiologists experienced more of the benefits of PACS and had to use PACS throughout the day. Two factors were salient for predicting users’ intention to use PACS: the usefulness of PACS (performance expectancy) and the availability of support of any kind (facilitating conditions). The results show that our approach was successful. Both radiologists and physicians give evidence of an excellent level of user acceptance. We can conclude that the implementation of PACS into our hospital has succeeded.
PACS; acceptance testing; computers in medicine; radiology workflow; UTAUT; attitude; university hospital
Texas Children’s Hospital is a pediatric tertiary care facility in the Texas Medical Center with a large-scale, Digital Imaging and Communications in Medicine (DICOM)-compliant picture archival and communications system (PACS) installation. As our PACS has grown from an ultrasound niche PACS into a full-scale, multimodality operation, assuring continuity of clinical operations has become the number one task of the PACS staff. As new equipment is acquired and incorporated into the PACS, workflow processes, responsibilities, and job descriptions must be revised to accommodate filmless operations. Round-the-clock clinical operations must be supported with round-the-clock service, including three shifts, weekends, and holidays. To avoid unnecessary interruptions in clinical service, this requirement includes properly trained operators and users, as well as service personnel. Redundancy is a cornerstone in assuring continuity of clinical operations. This includes all PACS components such as acquisition, network interfaces, gateways, archive, and display. Where redundancy is not feasible, spare parts must be readily available. The need for redundancy also includes trained personnel. Procedures for contingency operations in the event of equipment failures must be devised, documented, and rehearsed. Contingency operations might be required in the event of scheduled as well as unscheduled service events, power outages, network outages, or interruption of the radiology information system (RIS) interface. Methods must be developed and implemented for reporting and documenting problems. We have a Trouble Call service that records a voice message and automatically pages the PACS Console Operator on duty. We also have developed a Maintenance Module on our RIS system where service calls are recorded by technologists and service actions are recorded and monitored by PACS support personnel. In a filmless environment, responsibility for the delivery of images to the radiologist and referring physician must be accepted by each imaging supervisor. Thus, each supervisor must initiate processes to verify correct patient and examination identification and the correct count and routing of images with each examination.
The most frequently asked question without a correct answer is: “Just how many people does it take to operate a picture archiving and communication system (PACS)?” At Texas Children’s Hospital, our consensus is that we do not yet know. As soon as we felt we had adequate staffing to provide timely response for routine services, we found that including the Intensive Care Units (ICUs) increased our demand for urgent response beyond our capacity. The addition of inpatient bedside imaging to PACS also increased the demand for round-the-clock and weekend PACS services. Our answer to the staffing question changes every year, in accordance with changes in the scope of services that our PACS is expected to provide. Our administration drew up a 5-year plan for PACS implementation, concentrating on purchase and installation of equipment, but neglected to estimate requirements for full-time equivalents (FTEs) for PACS. Our administration reasonably assumed that existing employees would be galvanized into PACS personnel. It is now clear that new FTEs need to be created strictly for the PACS service. Our 5-year plan also did not anticipate significant changes in the extent of our healthcare enterprise. Our PACS accommodates limited remote service: providing a PACS Analyst to travel to the site when a problem is not resolved remotely is another demand on staffing. Our PACS service was formed using staffing numbers based on assumptions about the minimum number of employees needed to perform routine duties, field trouble calls, conduct training, and work on special projects, such as adding new acquisition modalities or troubleshooting longstanding problems. This staffing was based on a single shift operation, with on-call coverage for second, third, and weekend shifts. The number of employees also considered absences for vacation, sick leave, and training. The service has administrative overhead that should be covered by a secretary. Someone is also needed to supervise the team. Once the number of personnel is determined, detailed definition of qualifications and responsibilities is required. Each job description must accurately reflect what is expected of the employee, but must be constructed in such a way to be graded appropriately by Human Resources, without excluding potentially desirable applicants. In addition to competitive pay. other factors play an important role in recruiting and retention. These include training that the hospital provides, opportunities for advancement, relief from menial duties, adequate working space and facilities, and opportunities for self-development. There is high turnover of personnel in computer services, and we are in a highly competitive market. The correct number of FTEs must consider that we will have to operate the PACS during periods when one or more positions are open or occupied by “greenhorns.” In our case, where the vendor provides on-site service engineers, we are able to operate with fewer FTEs. The more distant and tenuous our vendor support, the more we would need to depend on hospital FTEs. While remote vendor maintenance is helpful, it is not useful in reducing the number of FTEs. Instead of adding PACS responsibilities to supervisors of imaging services, we are creating new PACS FTEs outside the PACS service. The idea is to give imaging supervisors the assets they need to perform the additional tasks involving PACS, such as first-line response to trouble, user training, and quality-control oversight. It also frees up PACS service personnel to deal with training and problems with customers outside the Radiology Department.
Installing a picture archiving and communication system (PACS) is a massive undertaking for any radiology department. Facilities making a successful transition to digital systems are finding that a PACS manager helps guide the way and offers a heightened return on the investment. The PACS manager fills a pivotal role in a multiyear, phased PACS installation. PACS managers navigate a facility through the complex sea of issues surrounding a PACS installation by coordinating the efforts of the vendor, radiology staff, hospital administration, and the information technology group. They are involved in the process from the purchase decision through the design and implementation phases. They can help administrators justify a PACS, purchase and shape the request for proposal (RFP) process before a vendor is even chosen. Once a supplier has been selected, the PACS manager works closely with the vendor and facility staff to determine the best equipment configuration for his or her facility, and makes certain that all deadlines are met during the planning and installation phase. The PACS manager also ensures that the infrastructure and backbone of the facility are ready for installation of the equipment. PACS managers also help the radiology staff gain acceptance of the technology by serving as teachers, troubleshooters, and the primary point-of-contact for all PACS issues. This session will demonstrate the value of a PACS manager, as well as point out ways to determine the manager’s responsibilities. By the end of the session, participants will be able to describe the role of a PACS manager as it relates to departmental operation and in partnership with equipment vendors, justify a full-time position for a PACS manager, and identify the qualifications of candidates for the position of PACS manager.
With the advent of electronic imaging and the internet, the ability to create, search, access, and archive digital imaging teaching files has dramatically improved. Despite the fact that a picture archival and communication system (PACS) has the potential to greatly simplify the creation of, archival, and access to a department or multifacility teaching file, this potential has not yet been satisfactorily realized in our own and most other PACS installations. Several limitations of the teaching file tools within our PACS have become apparent over time. These have, at our facility, resulted in a substantially reduced role of the teaching file tools for conferences, daily teaching, and research purposes. With the PACS at our institution, academic folders can only be created by the systems engineer, which often serves as an impediment to the teaching process. Once these folders are created, multiple steps are required to identify the appropriate folders, and subsequently save images. Difficulties exist for those attempting to search for the teaching file images. Without pre-existing knowledge of the folder name and contents, it is difficult to query the system for specific images. This is due to the fact that there is currently no fully satisfactory mechanism for categorizing, indexing, and searching cases using the PACS. There is currently no easy mechanism to save teaching, research, or clinical files onto a CD or other removable media or to automatically strip demographic or other patient information from the images. PACS vendors should provide much more sophisticated tools to create and annotate teaching file images in an easy to use but standard format (possibly Radiological Society of North America’s Medical Image Resource Center [MIRC] format) that could be exchanged with other sites and other vendors’ PAC systems. The privilege to create teaching or conference files should be given to the individual radiologists, technologists, and other users, and an audit should be kept of who has created these files, as well as keep track of who has accessed the files. Vendors should maintain a local PACS library of image quality phantoms, normal variants, and interesting cases and should have the capability of accessing central image repositories such as the RSNA’s MIRC images. Commercial PAC systems should utilize a standard lexicon to facilitate the creation and categorization of images, as well as to facilitate sharing of images and related text with other sites. This should be combined with a very easy to use mechanism to write images and related text when appropriate onto removable media (while maintaining a high level of security and confidentiality) to make it easier to share images for teaching, research, or clinical purposes.
Picture archiving and communication systems (PACS) are being implemented within radiology departments, and many facilities are entering the next stage of PACS use by deploying PACS to departments outside of radiology and to other facilities located at a distance. Many PACS vendors and department administrators have based cost-justification analyses on the anticipated savings from expanding PACS to these areas. However, many of these cost-savings analyses can be highly suspect in their assumptions and findings. Technology assessment (TA) at the hospital/health system level is an organized, systematic approach to examining the efficacy of a technology in relation to the health system’s mission and clinical needs. It can be an organized and unifying approach to aid in the distribution of limited capital resources. As extraradiology PACS deployment is a costly endeavor, TA may be used to plan for PACS implementation throughout the enterprise. In many organizations, PACS is thought of as a radiology domain as its first uses were centered on this image-producing service. Now, as PACS technology spreads to other service areas, such as cardiology, dermatology, pathology, orthopedics, obstetrics, etc, the need to incorporate other view-points in a system-based PACS is necessary to avoid having independent PACS that may duplicate archives and may not communicate with each other. How to meet the diverse PACS needs of clinical services can be a challenging task; a TA program has been demonstrated to effectively handle the clinical needs, demands, and timeframes of PACS planning and support throughout hospitals and health systems. A hospitalbased TA program can assist health care organizations to present PACS as a system-wide need and program rather than a radiology-based program gobbling up the capital budget. Submitting PACS to the TA review process can identify essential elements in planning and help avoid many of the pitfalls of PACS implementation and operations. Thorough cost and/or return on investment analyses, phasing decisions, workflow re-engineering, and outcomes assessment programs are a few of the issues that a TA program can address to help in the transition to a complete electronic image environment. The TA process includes clinician selection, evaluation criteria and their selection for technologies under review, a policy for review/authorization/denial, and measurement of expected outcomes.
Prior to June 1997, military picture archiving and communications systems (PACS) were planned, procured, and installed with key decisions on the system, equipment, and even funding sources made through a research and development office called Medical Diagnostic Imaging Systems (MDIS). Beginning in June 1997, the Joint Imaging Technology Project Office (JITPO) initiated a collaborative and consultative process for planning and implementing PACS into military treatment facilities through a new Department of Defense (DoD) contract vehicle called digital imaging networks (DIN)-PACS. The JITPO reengineered this process incorporating multiple organizations and politics. The reengineered PACS process administered through the JITPO transformed the decision process and accountability from a single office to a consultative method that increased end-user knowledge, responsibility, and ownership in PACS. The JITPO continues to provide information and services that assist multiple groups and users in rendering PACS planning and implementation decisions. Local site project managers are involved from the outset and this end-user collaboration has made the sometimes difficult transition to PACS an easier and more acceptable process for all involved. Corporately, this process saved DoD sites millions by having PACS plans developed within the government and proposed to vendors second, and then having vendors respond specifically to those plans. The integrity and efficiency of the process have reduced the opportunity for implementing nonstandard systems while sharing resources and reducing wasted government dollars. This presentation will describe the chronology of changes, encountered obstacles, and lessons learned within the reengineering of the PACS process for DIN-PACS.
Policies and procedures (P&P) constitute the mechanism for planning, standardizing, and documenting the provision of clinical services. Upon approval by hospital management, the P&P is an official statement of hospital rules and regulations. Each P&P establishes organizational responsibility for providing services. P&P are a mechanism for communicating standard operating procedures to hospital and medical staff. P&P serve as a reference document for unusual events, as well as routine procedures. P&P are often reviewed by inspection teams from the Joint Commission on Accreditation of Hospital Organizations (JCAHO) to determine whether the hospital has documented systematic practices. A picture archival and communications system (PACS) provides a new vehicle for providing radiology services. P&P that were designed for conventional film-based imaging are often not appropriate for electronic imaging. Because PACS is new and not yet widespread, good examples of PACS P&P are not yet available. JCAHO has no official requirements for PACS: PACS is viewed only as a means for the hospital to accomplish its work. Successful P&P development is a team effort, drafted by personnel responsible for executing the procedure, assisted by staff proficient in PACS technology, and tested in the field. The P&P should be reviewed and approved by management personnel knowledgeable about hospital and imaging operations. P&P should be written in clear and concise language. Successful P&P development is an ongoing effort. P&P must be periodically reviewed and updated to reflect changes in PACS technology and changes in clinical operations. New P&P must be developed when a deficit is noted. PACS security is a good example of a topic worthy of P&P development, especially in the face of the Health Insurance Portability and Accountability Act (HIPAA) legislation of 1996. What are the provisions for access control? Does the system include a feature for automatic shut-off of the software? Are there “generic” passwords and log-ins shared by a community of users? How are passwords assigned and how frequently are they changed? What security measures are in place to assure passwords are given to the appropriate user? Who grants and denies access? Service calls are another topic for P&P. Who initiates a service call? What is the process for escalating a service call from the operator level to the vendor? What immediate actions are expected by the operator in order to restore PACS services? How are service events documented? Who is responsible for determining when “downtime” procedures should be initiated or suspended? When our hospital’s total electrical system had to be shut down for an extended period, we found that a P&P was lacking for a task as mundane as shutting down and restarting our PACS components. What is the sequence for the shutdown? Who is responsible for shutting down and restarting? How long can the devices operate on uninteruptible power supplies (UPS)? What components are on emergency power? Should we expect the components to survive the switchover to generator power? Developing this P&P was worth the effort: it made the PACS more fault-tolerant and served as a reference document 3 years later when expansion of our physical plant required two more power outages.
The transition to filmless radiology is a much more formidable task than making the request for proposal to purchase a (Picture Archiving and Communications System) PACS. The Department of Defense and the Veterans Administration have been pioneers in the transformation of medical diagnostic imaging to the electronic environment. Many civilian sites are expected to implement large-scale PACS in the next five to ten years. This presentation will relate the empirical insights gleaned at our institution from a large-scale PACS implementation. Our PACS integration was introduced into a fully operational department (not a new hospital) in which work flow had to continue with minimal impact. Impediments to user acceptance will be addressed. The critical components of this enormous task will be discussed. The topics covered during this session will include issues such as phased implementation, DICOM (digital imaging and communications in medicine) standard-based interaction of devices, hospital information system (HIS)/radiology information system (RIS) interface, user approval, networking, workstation deployment and backup procedures. The presentation will make specific suggestions regarding the implementation team, operating instructions, quality control (QC), training and education. the concept of identifying key functional areas is relevant to transitioning the facility to be entirely on line. Special attention must be paid to specific functional areas such as the operating rooms and trauma rooms where the clinical requirements may not match the PACS capabilities. The printing of films may be necessary for certain circumstances. The integration of teleradiology and remote clinics into a PACS is a salient topic with respect to the overall role of the radiologists providing rapid consultation. A Webbased server allows a clinician to review images and reports on a desk-top (personal) computer and thus reduce the number of dedicated PACS review workstations. This session will focus on effective strategies for a seamless transition. Critical issues involve maintaining a good working relationship with the vendor, cultivating personnel readiness and instituting well-defined support systems. Success depends on the ability to integrate the institutional directives, user expectations and available technologies. A team approach is mandatory for success.
Early picture archiving and communication systems (PACS) were characterized by the use of very expensive hardware devices, cumbersome display stations, duplication of database content, lack of interfaces to other clinical information systems, and immaturity in their understanding of the folder manager concepts and workflow reengineering. They were implemented historically at large academic medical centers by biomedical engineers and imaging informaticists. PACS were nonstandard, home-grown projects with mixed clinical acceptance. However, they clearly showed the great potential for PACS and filmless medical imaging. Filmless radiology is a reality today. The advent of efficient softcopy display of images provides a means for dealing with the ever-increasing number of studies and number of images per study. Computer power has increased, and archival storage cost has decreased to the extent that the economics of PACS is justifiable with respect to film. Network bandwidths have increased to allow large studies of many megabytes to arrive at display stations within seconds of examination completion. PACS vendors have recognized the need for efficient workflow and have built systems with intelligence in the mangement of patient data. Close integration with the hospital information system (HIS)-radiology information system (RIS) is critical for system functionality. Successful implementation of PACS requires integration or interoperation with hospital and radiology information systems. Besides the economic advantages, secure rapid access to all clinical information on patients, including imaging studies, anytime and anywhere, enhances the quality of patient care, although it is difficult to quantify. Medical image management systems are maturing, providing access outside of the radiology department to images and clinical information throughout the hospital or the enterprise via the Internet. Small and medium-sized community hospitals, private practices, and outpatient centers in rural areas will begin realizing the benefits of PACS already realized by the large tertiary care academic medical centers and research institutions. Hand-held devices and the Worldwide Web are going to change the way people communicate and do business. The impact on health care will be huge, including radiology. Computer-aided diagnosis, decision support tools, virtual imaging, and guidance systems will transform our practice as value-added applications utilizing the technologies pushed by PACS development efforts. Outcomes data and the electronic medical record (EMR) will drive our interactions with referring physicians and we expect the radiologist to become the informaticist, a new version of the medical management consultant.
picture archiving and communication systems (PACS); image storage and retrieval; folder manager; workflow manager; radiology information systems; computers; digital radiology
With the increasing prevalence of Picture Archiving and Communication Systems (PACS) in healthcare institutions, there is a growing need to measure their success. However, there is a lack of published literature emphasizing the technical and social factors underlying a successful PACS.
An updated Information Systems Success Model was utilized by radiology technologists (RTs) to evaluate the success of PACS at a large medical center in Taiwan. A survey, consisting of 109 questionnaires, was analyzed by Structural Equation Modeling.
Socio-technical factors (including system quality, information quality, service quality, perceived usefulness, user satisfaction, and PACS dependence) were proven to be effective measures of PACS success. Although the relationship between service quality and perceived usefulness was not significant, other proposed relationships amongst the six measurement parameters of success were all confirmed.
Managers have an obligation to improve the attributes of PACS. At the onset of its deployment, RTs will have formed their own subjective opinions with regards to its quality (system quality, information quality, and service quality). As these personal concepts are either refuted or reinforced based on personal experiences, RTs will become either satisfied or dissatisfied with PACS, based on their perception of its usefulness or lack of usefulness. A satisfied RT may play a pivotal role in the implementation of PACS in the future.
Socio-technical evaluation; Information systems success model; Picture archiving and communication systems (PACS)
In RIS-PACS systems, potential errors occurring during the execution of a radiologic examination can amplify the clinical risks of the patient during subsequent treatments, e.g., of oncologic patients or of those who must do additional treatments based on the initial diagnosis. In Reggio Emilia Province Diagnostic Imaging Department (REDID) we experienced different strategies to reduce clinical risks due to patient reconciliation errors. In 2010, we developed a procedure directly integrated in our RIS-PACS that uses Health Level 7 (HL7) standard messaging, which generates an overlay with the text "under investigation" on the images of the study to be corrected. All the healthcare staff is informed of the meaning of that overlay, and only the radiologist and the emergency services staff can consult these images on PACS. The elimination of image overlay and of any access limitation to PACS was triggered to confirm of the right correction made by RIS-PACS system administrator (SA). The RIS-PACS integrated tool described in this paper allows technologists and radiologists to efficiently highlight patient exam errors and to inform all the users to minimize the overall clinical risks, with a significant savings in costs. Over the years, we have observed a steady decrease in the percentage of reconciled studies. Error reconciliation requires an effective and efficient mechanism. The RIS-PACS integrated tool described in this paper enables technologists and radiologists to quickly and efficiently highlight patient exam errors and inform all the users. Next generation of RIS-PACS could be equipped with similar reconciliation tools.
RIS; PACS; Quality assurance; Patient information reconciliation
Designing and operating a PACS system requires an integrated focus to maintain peak performance of the system from an information technology (IT) perspective and to ensure that all clinical and financial requirements are met. An IT-based picture archiving and communication system (PACS) manager is in the best position to satisfy these sometime conflicting audiences. This report will describe how an institution moving towards PACS can unite radiologists, hospital administrators, and information systems (IS)/IT specialists into one cohesive team to ensure the highest levels of success with their future PACS. There are several keys to success: (1) Designing and selecting PACS requires a dedicated team, with representatives from radiology, as well as IS/IT and administration. (2) Each group needs to thoroughly outline their specific needs, so that the final PACS solution is relevant from all perspectives. This needs assessment needs to be made before issuing a request for proposal (RFP) and interviewing vendors. (3) The team needs to be small to be effective. Each group should have one or at most two representatives that collect input from, and report to, a group of his or her peers. (4) Plans need to be made to determine how to integrate current and future hospital information systems (HIS), in order to ensure a smooth pathway to the electronic medical record. (5) All team members should agree on the overall objectives for PACS and participate in its design and installation. (6) Each team member is charged with motivating, and helping to educate, his or her peers. (7) Training should be tailored to the needs of each audience. Explain how each staff member benefits from the PACS. Training should be ongoing to accommodate the addition of new system features and new users. This report will describe the importance of recognizing PACS as being an IT system with a clinical focus. The importance of designing goals of the PACS system from various perspectives, including clinical, technical, and financial, will be addressed. More importantly, this presentation will high-light the benefits a medical institution will receive if the various groups can work together, while at the same time outlining some pitfalls they can expect to encounter if the groups take an adversarial approach.
The presentation will focus on the implementation and utilization of a central picture archiving and communications system (PACS) network-monitoring tool that allows for enterprise-wide operations management and support of the image distribution network. The MagicWatch (Siemens, Iselin, NJ) PACS/radiology information system (RIS) monitoring station from Siemens has allowed our organization to create a service support structure that has given us proactive control of our environment and has allowed us to meet the service level performance expectations of the users. The Radiology Help Desk has used the MagicWatch PACS monitoring station as an applications support tool that has allowed the group to monitor network activity and individual systems performance at each node. Fast and timely recognition of the effects of single events within the PACS/RIS environment has allowed the group to proactively recognize possible performance issues and resolve problems. The PACS/operations group performs network management control, image storage management, and software distribution management from a single, central point in the enterprise. The MagicWatch station allows for the complete automation of software distribution, installation, and configuration process across all the nodes in the system. The tool has allowed for the standardization of the workstations and provides a central configuration control for the establishment and maintenance of the system standards. This report will describe the PACS management and operation prior to the implementation of the MagicWatch PACS monitoring station and will highlight the operational benefits of a centralized network and system-monitoring tool.
This study was performed to evaluate the changes in workflow and efficiency in various clinical settings in the radiology department after the introduction of a picture archiving and communication system (PACS). Time and motion data were collected when conventional image management was used, and again after the introduction of a PACS. Changes in the elapsed time from examination request until the image dispatch to the radiologist, and from dispatch until report dictation, were evaluated. The relationship between patient volume and throughput was evaluated. The time from examination request until dispatch was significantly longer after the introduction of PACS for examinations taken on patients from the emergency department (ED) (pre-PACS, 20 minutes; post-PACS, 25 minutes;P<.0001), and for examinations taken on patients in the medical intensive care unit (MICU) (pre-PACS, 34 minutes; post-PACS, 42 minutes;P<.0001). The interval from image dispatch until report dictation shortened significantly after the introduction of PACS in the ED (pre-PACS, 38 minutes; post-PACS, 23 minutes;P<.0001) and in the outpatient department (OPD) (pre-PACS, 38 minutes; post-PACS, 20 minutes;P<.0001). Simple least squares regression showed a significant relationship between daily patient volume and the daily median time until report dictation (F=43.42,P<.001). PACS slowed technologists by prolonging the quality-control procedure. Radiologist workflow was shortened or not affected. Efficiency is dependent on patient volume, and workflow improvements are due to a shift from batch to on-line reading that is enabled by the ability of PACS to route enough examinations to keep radiologists fully occupied.
Information technology (IT), long taken for granted in commercial settings, is now being utilized for healthcare applications. Medical imaging has lagged comparatively due to the extremely vast data content of each frame; thus, the requirement for expensive high-end components. Further, IT in radiology has evolved from two distinctly separate camps—information systems, known as RIS (radiology information systems) and PACS (picture archiving and communications systems). Both RIS and PACS applications have migrated to the PC environment, enabling cost-effective implementation, but from two backgrounds: RIS from vendors using conventional information systems platforms and products, and PACS from radiographic film and modality vendors. The radiology department at Texas Tech University has assembled a seamlessly integrated, enterprise-wide RIS/PACS/teleradiology intranet. The design criteria include user-friendliness, flexibility to respond to changing needs, and open modular architecture to assure interoperability, cost-effectiveness, and future-proofing of investment. Since no single venor could provide an integrated system meeting our specifications, we decided to assume the burden of constructing our own system. As the system integrator, we embrace open architecture, thus enabling the incorporation of industry-standard-compliant, COTS (commercially off the shelf) products as modules. Microsoft Windows NT operating system, Visual C++ programming language, TCP/IP (transmission control protocol/internetworking protocol), relational SQL (structured query language) database, ODBC (open database connectivity), HL-7 (health level seven) and DICOM (digital imaging and communications in medicine) interfaces are utilized. The usage of COTS components reduces the cost to very affordable levels. With this approach, any module in our system can be replaced when outmoded, without affecting other modules in our system, making it truly future-proof. Construction and evolution of our system (TECHRAD) is reviewed.
While health care facilities recognize the need for dedicated picture archiving and communication system (PACS) staff at the time of the initial implementation of PACS, they often do not plan accordingly for ongoing or increasing PACS support needs as a PACS matures. This article reviews trends in a health care system’s PACS support data over 4 years to show how PACS support needs evolve over time. PACS support items were logged and categorized over this period and were used by the health care system to become more proactive in system support and adjust staffing levels accordingly. This article details how PACS support needs change over the life of a PACS installation and can be used as a model for health care facilities planning for future PACS support needs.
PACS; digital imaging; support
Despite the increasing use of diagnostic workstations, film reading is still commonplace in most radiology departments all over the world. The purpose of this work is to assess the adoption of image review workstations in a radiology department where the usual primary diagnosis is film-based and cannot be replaced with diagnostic workstations. At our institution, a tertiary care center specialized in diagnostic imaging, a pair of PC-based review workstations running a Digital Imaging and Communications in Medicine (DICOM)-conformant public domain software for image display and analysis were installed in two reading rooms. Studies are automatically routed after acquisition from the picture archiving and communication system (PACS) server to the workstations and remain available for visualization for approximately 15 to 20 days. Data from two radiologists and two technologists collected over a 3-month period were analyzed, including purpose of use, time savings as compared to traditional manual methods, and overall user satisfaction. The results from the analysis presented in this work indicate a high degree of approval from the users, who report significant timesavings in numerous circumstances, in particular when it comes to discussing findings with referring physicians whenever films are not available. It also enriches communication between radiologists, facilitating peer review on the telephone when one of them has questions at the outcome of any given study. One of the main advantages associated with the system is the possibility of using it as a powerful tool for teaching and research. In conclusion, even when primary diagnosis is performed on film, the availability of a PACS for review can be helpful to enhance communication with referring physicians, as well as technologists and radiologists’ efficiency. Our experience shows that it is possible to implement such a system using low-cost or freely available components without compromising ease of use while keeping costs down, which is a major concern in developing countries.
Providing high-quality clinical cases is important for teaching radiology. We developed, implemented and evaluated a program for a university hospital to support this task.
The system was built with Intranet technology and connected to the Picture Archiving and Communications System (PACS). It contains cases for every user group from students to attendants and is structured according to the ACR-code (American College of Radiology) . Each department member was given an individual account, could gather his teaching cases and put the completed cases into the common database.
During 18 months 583 cases containing 4136 images involving all radiological techniques were compiled and 350 cases put into the common case repository. Workflow integration as well as individual interest influenced the personal efforts to participate but an increasing number of cases and minor modifications of the program improved user acceptance continuously. 101 students went through an evaluation which showed a high level of acceptance and a special interest in elaborate documentation.
Electronic access to reference cases for all department members anytime anywhere is feasible. Critical success factors are workflow integration, reliability, efficient retrieval strategies and incentives for case authoring.
The objective of the study was to evaluate current marketplace conditions and strategies employed by major picture archiving and communication systems (PACS) vendors in the creation of alternative financing strategies, to enhance the diffusion of filmless imaging. Data were collected from the major PACS vendors in the forms of survey questionnaires and review of existing leases. Topics evaluated in the survey included current financing options available, foreseeable changes in PACS financing, role of third-party financiers, and creation of risk-sharing arrangements. Generic leases were also reviewed evaluating the presence or absence of several key variables including technology obsolescence protection, hardware/soft-ware upgrades, end-of-term options, determination of fair market value, functionality/acceptance testing, uptime guarantees, and workflow management consulting. Eight of the 10 PACS vendors surveyed participated in the data collection. The vast majority of current PACS implementations (60% to 90%) occur through direct purchase, with conventional leasing (operating or capital) accounting for only 5% to 30% of PACS installations. The majority of respondents view fee-for-lease arrangements and other forms of risk sharing as increasing importance for future PACS financing. The specific targets for such risk-sharing arrangements consist of small hospital and privately owned imaging centers. Leases currently offered range in duration from 3 to 5 years and frequently offer technology obsolescence protection with upgrades, multiple end-of-term options, and some form of acceptance testing. A number of important variables frequently omitted from leases include uptime guarantees, flexibility in changing financing or vendors, and incorporation of expected productivity/operational efficiency gains. As vendors strive to increase the penetration of PACS into the radiology marketplace, there will be a shift from conventional financing (loan or purchase) to leasing. Fee-for-use leasing and other forms of risk sharing have the greatest potential in smaller hospitals, which do not have the financial resources to pursue conventional financing options. Potential PACS customers must be cautious when entering into these alternative financing strategies, to ensure that appropriate safeguards are incorporated, in order to minimize downside risk.
The Department of Diagnostic Imaging at the Hospital for Sick Children (HSC), Toronto, implemented a picture archiving and communication system (PACS) during the last year. This report describes our experience from the point of view of user acceptability. Based on objective data, the following key success factors were identified: user involvement in PACS planning, training, technical support, and rollout of pilot projects. Although technical factors are critical and must be addressed, the main conclusion of our study is that other nontechnical factors need to be recognized and resolved. Recognition of the importance of these factors to user acceptance and clear communication and consultation will help reduce negative user attitudes and increase the chance of a successful PACS implementation.
The PACS implementation process is complicated requiring a tremendous amount of time, resources, and planning. The Department of Defense (DOD) has significant experience in developing and refining PACS acceptance testing (AT) protocols that assure contract compliance, clinical safety, and functionality. The DOD’s AT experience under the initial Medical Diagnostic Imaging Support System contract led to the current Digital Imaging Network–Picture Archiving and Communications Systems (DIN-PACS) contract AT protocol. To identify the most common system and component deficiencies under the current DIN-PACS AT protocol, 14 tri-service sites were evaluated during 1998–2000. Sixteen system deficiency citations with 154 separate types of limitations were noted with problems involving the workstation, interfaces, and the Radiology Information System comprising more than 50% of the citations. Larger PACS deployments were associated with a higher number of deficiencies. The most commonly cited systems deficiencies were among the most expensive components of the PACS.
PACS; acceptance testing; workstation; clinical use determination; monitors; HIS; RIS; DIN-PACS; MDIS
The benefits of an integrated picture archiving and communication system/radiology information system (PACS/RIS) archive built with open source tools and methods are 2-fold. Open source permits an inexpensive development model where interfaces can be updated as needed, and the code is peer reviewed by many eyes (analogous to the scientific model). Integration of PACS/RIS functionality reduces the risk of inconsistent data by reducing interfaces among databases that contain largely redundant information. Also, wide adoption would promote standard data mining tools—reducing user needs to learn multiple methods to perform the same task. A model has been constructed capable of accepting HL7 orders, performing examination and resource scheduling, providing digital imaging and communications in medicine (DICOM) worklist information to modalities, archiving studies, and supporting DICOM query/retrieve from third party viewing software. The multitiered architecture uses a single database communicating via an ODBC bridge to a Linux server with HL7, DICOM, and HTTP connections. Human interaction is supported via a web browser, whereas automated informatics services communicate over the HL7 and DICOM links. The system is still under development, but the primary database schema is complete as well as key pieces of the web user interface. Additional work is needed on the DICOM/HL7 interface broker and completion of the base DICOM service classes.