This contribution focuses on picture archiving and communication systems (PACS) in the Italian National Healthcare System (NHS). It finally aims to test the Chiefs Radiology Department’s perceptions about PACS along the main evaluation dimensions emerging from the literature. First, a brief review of the main literature concerning PACS evaluation leads the authors to classify the different approaches undertaken and highlight the main variables of investigation. Second, the evidence emerging from a survey is presented and discussed in the light of the literature review. The survey aims to: (a) map out the degree of PACSs diffusion and their main features in the Italian NHS; (b) verify whether and how PACS impact the dimensions analyzed in many evaluation studies carried out to date; (c) test the relationship between some measured impacts and specific PACS features.
Cost-benefit analysis; PACS integration; PACS implementation; PACS
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.
As the technology of picture archiving and communications systems (PACS) improves and implementation becomes more widespread, the project management of deploying substantially large, multiple-facility systems becomes an integral part of success. A successful deployment requires project support from the initial planning and surveying to the final acceptance, even encompassing support during active use of the PACS. The sharing of information between project stakeholders of a PACS implementation can be daunting at times, but with the flexibility of the worldwide web, this aspect can be eased. This report speaks to the tools and usuability of the worldwide web to disseminate project management information for planning, implementation, and support of any PACS implementation—anywhere. This sharing of knowledge prepares the end user for what will be available for them when the complete systems is in place, allowing for a smoother migration to PACS.
A picture archiving and communication system (PACS) is an electronic and ideally filmless information system for acquiring, sorting, transporting, storing, and electronically displaying medical images. PACS have developed rapidly and are in operation in a number of hospitals. Before widespread adoption of PACSs can occur, however, their cost-effectiveness must be proven. This article introduces the basic components of a PACS. The current PACS cost-analysis literature is reviewed. Some authors conclude that the PACS would pay for itself, while others find the PACS much more expensive. Explanations for these differences are explored. Almost all of these studies focus on direct costs and ignore indirect costs and benefits. The literature characterizing the indirect costs of PACS is reviewed. The authors conclude that there is a need for uniform, well-defined criteria for the calculation of the costs and savings of PACSs.
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 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.
A picture archiving and communication system (PACS) study was recently performed by KLAS, a national market intelligence firm specializing in monitoring and reporting the performance of HealthCare’s Information Technology (HIT) vendors. Fifteen leading PACS vendors are included in the study, which provides a snapshot of today’s market performance through the eyes of both users and vendors. KLAS interviewed clients from more than 275 sites, and the study incorporates the opinions of over 345 PACS imaging managers, medical directors, radiologists, chief information officers (CIO), department directors, and vendor executives. Results indicate that the PACS vendors are performing well and overall rate above the HIT industry norm; the market is growing and products are maturing; lines between PACS and radiology, information systems are merging; survey respondents are focusing more on functionality, price, and technology for selection; and the most common benefit of PACS is the cost savings from film and storage.
KLAS 2003 PACS Vendor Performance Study
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.
An integrated picture archiving and communication system (PACS) is a large investment in both money and resources. With all of the components and systems contained in the PACS, a methodical set of protocols and procedures must be developed to test all aspects of the PACS within the short time allocated for contract compliance. For the Department of Defense (DoD), acceptance testing (AT) sets the protocols and procedures. Broken down into modules and test procedures that group like components and systems, the AT protocol maximizes the efficiency and thoroughness of testing all aspects of an integrated PACS. A standardized and methodical protocol reduces the probability of functionality or performance limitations being overlooked. The AT protocol allows complete PACS testing within the 30 days allocated by the digital imaging network (DIN)-PACS contract. AT shortcomings identified during the testing phase properly allows for resolution before complete acceptance of the system. This presentation will describe the evolution of the process, the components of the DoD AT protocol, the benefits of the AT process, and its significance to the successful implementation of a PACS.
Strategies for deployment of picture archiving and communications systems (PACS) in new hospitals often involve the establishment of initial PACS operations. Such a strategy is flawed in the sense that the clinical and radiological users must adapt to PACS operations, while being faced with several other new facility learning curves. This increases the complexity and risk of the radiological services. A strategy of implementing PACS operations in the old facility and performing a zero-downtime transition into the new facility offers several advantages to this method. The successful undertaking of such a project will support not only the physical movement of the existing PACS, but the accomplishment of other re-engineering goals associated with the new hospital. This report will describe the strategy used in two successful transitions of PACS into newly constructed hospitals.
Considerable debate within the medical community has focused on the optimal location of information technology (IT) support groups on the organizational chart. The challenge has been to marry local accountability and physician acceptance of IT with the benefits gained by the economies of scale achieved by centralized knowledge and system best practices. In the picture archiving and communication systems (PACS) industry, a slight shift has recently occurred toward centralized control. Radiology departments, however, have begun to realize that no physicians in any other discipline are as dependent on IT as radiologists are on their PACS. The potential strengths and weaknesses of centralized control of the PACS is the topic of discussion for this month’s Point/Counterpoint.
Hospital Information Systems (HIS); information management; PACS; PACS management; radiology department; hospital
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.
The purpose of this study was to measure users’ perceived benefits of a picture archiving and communication system (PACS) upgrade, and compare their responses to those predicted by developers. The Task–Technology Fit (TTF) model served as the theoretical framework to study the relation between TTF, utilization, and perceived benefits. A self-administered survey was distributed to radiologists working in a university hospital undergoing a PACS upgrade. Four variables were measured: impact, utilization, TTF, and perceived net benefits. The radiologists were divided into subgroups according to their utilization profiles. Analysis of variance was performed and the hypotheses were tested with regression analysis. Interviews were conducted with developers involved in the PACS upgrade who were asked to predict impact and TTF. Users identified only a moderate fit between the PACS enhancements and their tasks, while developers predicted a high level of TTF. The combination of a moderate fit and an underestimation of the potential impact of changes in the PACS led to a low score for perceived net benefits. Results varied significantly among user subgroups. Globally, the data support the hypotheses that TTF predicts utilization and perceived net benefits, but not that utilization predicts perceived net benefits. TTF is a valid tool to assess perceived benefits, but it is important to take into account the characteristics of users. In the context of a technology that is rapidly evolving, there needs to be an alignment of what users perceive as a good fit and the functionality developers incorporate into their products.
Picture archiving and communication system (PACS); task–technology fit; radiology information systems; technology assessment; questionnaires; organizational innovation; evaluation research; models; theoretical
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
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.
The development and acceptance of the digital communication in medicine (DICOM) standard has become a basic requirement for the implementation of electronic imaging in radiology. DICOM is now evolving to provide a standard for electronic communication between radiology and other parts of the hospital enterprise. In a completely integrated filmless radiology department, there are 3 core computer systems, the picture archiving and communication system (PACS), the hospital or radiology information system (HIS, RIS), and the acquisition modality. Ideally, each would have bidirectional communication with the other 2 systems. At a minimum, a PACS must be able to receive and acknowledge receipt of image and demographic data from the modalities. Similarly, the modalities must be able to send images and demographic data to the PACS. Now that basic DICOM communication protocols for query or retrieval, storage, and print classes have become established through both conformance statements and intervendor testing, there has been an increase in interest in enhancing the functionality of communication between the 3 computers. Historically, demographic data passed to the PACS have been generated manually at the modality despite the existence of the same data on the HIS or RIS. In more current sophisticated implementations, acquisition modalities are able to receive patient and study-related data from the HIS or RIS. DICOM Modality Worklist is the missing electronic link that transfers this critical information between the acquisition modalities and the HIS or RIS. This report describes the concepts, issues, and impact of DICOM Modality Worklist implementation in a PACS environment.
DICOM; PACS; worklist
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.
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
Picture Archiving and Communication System (PACS) is a key workflow tool in the functioning of radiology departments worldwide, today, and its utilization is rapidly growing in India. The key challenges in PACS implementation are related to vendor and feature selection, integration with the existing HIS, user training, maintenance and scalability to meet increasing demands. Additionally, the networking requirements that PACS imposes on hospital networks are not insignificant. This article attempts to review these issues from the standpoint of what a prospective or new user needs to know.
Computers; networks; picture archiving and communication system; teleradiology
Picture archiving and communication systems (PACS) are being widely adopted in radiology practice. The objective of this study was to find radiologists’ perspective on the relative importance of the required features when selecting or developing a PACS. Important features for PACS were identified based on the literature and consultation/interviews with radiologists. These features were categorized and organized into a logical hierarchy consisting of the main dimensions and sub-dimensions. An online survey was conducted to obtain data from 58 radiologists about their relative preferences. Analytical hierarchy process methodology was used to determine the relative priority weights for different dimensions along with the consistency of responses. System continuity and functionality was found to be the most important dimension, followed by system performance and architecture, user interface for workflow management, user interface for image manipulation, and display quality. Among the sub-dimensions, the top two features were: security, backup, and downtime prevention; and voice recognition, transcription, and reporting. Structured reporting was also given very high priority. The results point to the dimensions that can be critical discriminators between different PACS and highlight the importance of faster integration of the emerging developments in radiology into PACS.
PACS; structured reporting; voice recognition; transcription; RIS; open systems; proprietary systems; display quality; system continuity; security; backup; recovery; downtime prevention; system architecture and performance; user interface for image manipulation; user interface workflow management, worklist
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.
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.
The potential benefits of digital imaging to clinical operations focuses on both quantitative and qualitative improvements. In the future it is postulated that it will totally replace analog imaging, creating the 'filmless' Radiology department. Although this could result in dramatic savings in film costs, realization of this scenario will require continued improvements in the performance and cost of component technologies, acceptance by the medical and legal communities of the reliability of the medium, and changes in the practice and process of radiology. Baltimore VAMC has recently become one of the truly 'filmless' radiology departments through use of a leading commercial Picture Archiving and Communications System (PACS) and DHCP's Digital Imaging System. This document outlines the results of a preliminary assessment of PACS technology as it is installed at Baltimore, and its impact on operations.
This paper presents the design and implementation of a clinical picture archiving and communication system (PACS) module within the radiology department of a 700-bed teaching hospital. The system is composed of an integrated network of digital devices used to electronically acquire, store, manage, and display radiological text and image information. Preliminary evaluation based on formal survey and usage statistics show that the system is rapidly being accepted by radiologists and clinicians for the review and processing of pediatric digital images.
Picture Archiving and Communication System; Digital Radiology; Queueing Networks; Digital Viewing Station
This article outlines the strategy used by our hospital to maximize the knowledge transfer to referring physicians on using a picture archiving and communication system (PACS). We developed an e-learning platform underpinned by the cognitive load theory (CLT) so that in depth knowledge of PACS’ abilities becomes attainable regardless of the user’s prior experience with computers. The application of the techniques proposed by CLT optimizes the learning of the new actions necessary to obtain and manipulate radiological images. The application of cognitive load reducing techniques is explained with several examples. We discuss the need to safeguard the physicians’ main mental processes to keep the patient’s interests in focus. A holistic adoption of CLT techniques both in teaching and in configuration of information systems could be adopted to attain this goal. An overview of the advantages of this instruction method is given both on the individual and organizational level.
Informatics training; computer-assisted instruction; PACS training; clinical image viewing; cognitive load theory; e-learning