Integrating digital systems: commitment and collaboration

One year ago, the radiology department at Ball Memorial Hospital, a 350-bed facility in Muncie, IN, was completely film-based. The need to support a new all-digital, 35-room emergency department (ED) hastened the facility's transition to a digital environment. Today, with the exception of mammography, the hospital's imaging services are now digital. To develop and implement the project, the hospital formed an internal implementation team. An independent consultant was also hired to evaluate the impact of these new technologies and to provide an estimated cost payback. After research, site visits, and vendor demonstrations, the hospital selected a single vendor for its picture archiving and communication system (PACS), digital radiography (DR), computed radiography (CR), and overall project management. The DR system was installed in the ED to provide digital image capture for a full range of trauma exams. The ED also initially began utilizing a Web-based PACS distribution originally implemented for after-hours teleradiology. The majority of the hospital's imaging studies are captured with 2 multi-cassette CR systems that serve 7 exam rooms in the radiology department. The hospital also installed remote operations panels to expedite entry of patient and exam information. Technologists readily embraced both CR and DR systems. The Web distribution system now transmits images to hospital-based computers and to 150 remote referring physicians. The PACS platform automatically e-mails key images and radiology reports to referring physicians. Authorized physicians can also request reports and images on an as-needed basis. The PACS vendor had previously performed multiple integrations with the radiology information system (RIS) vendor; the integration of PACS and RIS was extremely smooth. One of the critical components of a successful conversion is experienced, dedicated management. The hospital retained professional project management services to facilitate implementation and to ensure adequate training for all users.     

Acceptance of PACS utilizing a PACS QI Program

This article describes the quality improvement program that Mercy Hospital (Alegent Health System) initiated after it implemented a picture archiving and communication system (PACS) in November 2003. The radiology department encountered numerous PACS-related issues that directly affected the quality and workflow of patient care. In order to get a better understanding of the situation, the department developed a quality improvement plan for its PACS program. The first step was to dedicate a resource--in this case, a radiology information technology (RIT) support specialist--who would serve as a PACS subject matter expert while dealing with day-to-day PACS-related issues--specifically, errors. The error data were collected and categorized for consistency using statistical process control (SPC) tools. The information gathered was then traced back to the team members responsible for the errors and used as a training tool to further educate them. As a result of this program, the average error rate was reduced from 12% to 4% because the radiology team developed a better understanding of the errors by identifying the root causes and being accountable for eliminating errors within their control. In addition, the radiology staff learned to accept and trust the PACS, resulting in a positive culture change that benefited teamwork and staff morale as well as improve the workflow and the quality of patient care.     

PACS database architecture and design

PACS (Picture Archiving and Communication Systems) database design requires careful understanding of the data and processing needs of radiologists, referring physicians, radiology staff, administrators, and researchers. Due to access requirements, the physical implementation for the management of small text data sets differs from the implementation strategy for large image data sets (centralized vs. distributed storage strategies). In this paper we discuss the database structure, storage architecture, file placement strategies, and administration considerations of the UCLA PACS.     

Installing PACS--lessons learned.

In 1997, Carson-Tahoe Hospital in Carson City, Nev., looked into the possibility of installing its own PACS system. Increased productivity was the main business goal the hospital hoped a PACS system would meet. Only two of three chosen vendors seriously considered the request to bid because of the small number of films produced by the hospital. After installation, the hospital identified the referring physicians who used the most film and then directed its marketing efforts to them. Lessons learned include the tremendous need for training of staff, referring physicians and radiologists. Expect everyone to be slow the first week the new system is running. Map out all processes to prepare for contingencies. Make plans for archiving and be flexible in assigning tasks--next week things may change. Consider bringing in an outside consultant to measure people's expectations and fears. After nearly a year, neither the technologists nor physicians express any regrets about the installation of PACS at Carson-Tahoe.     

From shared data to sharing workflow: Merging PACS and teleradiology

Due to a host of technological, interface, operational and workflow limitations, teleradiology and PACS/RIS were historically developed as separate systems serving different purposes. PACS/RIS handled local radiology storage and workflow management while teleradiology addressed remote access to images. Today advanced PACS/RIS support complete site radiology workflow for attending physicians, whether on-site or remote. In parallel, teleradiology has emerged into a service of providing remote, off-hours, coverage for emergency radiology and to a lesser extent subspecialty reading to subscribing sites and radiology groups.When attending radiologists use teleradiology for remote access to a site, they may share all relevant patient data and participate in the site's workflow like their on-site peers. The operation gets cumbersome and time consuming when these radiologists serve multi-sites, each requiring a different remote access, or when the sites do not employ the same PACS/RIS/Reporting Systems and do not share the same ownership. The least efficient operation is of teleradiology companies engaged in reading for multiple facilities. As these services typically employ non-local radiologists, they are allowed to share some of the available patient data necessary to provide an emergency report but, by enlarge, they do not share the workflow of the sites they serve.Radiology stakeholders usually prefer to have their own radiologists perform all radiology tasks including interpretation of off-hour examinations. It is possible with current technology to create a system that combines the benefits of local radiology services to multiple sites with the advantages offered by adding subspecialty and off-hours emergency services through teleradiology. Such a system increases efficiency for the radiology groups by enabling all users, regardless of location, to work “local” and fully participate in the workflow of every site. We refer to such a system as SuperPACS.     

The current position of cardiac radiology in the United Kingdom

A questionnaire was sent to 39 hospitals, in the United Kingdom, 38 with a cardiosurgical unit and one with a cardiac radiology department. The object was to ascertain the commitment of consultant radiologists to cardiovascular radiology and cardiac radiology in particular and to evaluate training given to non-consultant radiologists in this subspecialty. Thirty-five (90%) departments responded, 33 of which had a cardiac radiology consultant. All but three of the 63 consultant cardiac radiologists report cine angiography. Of the 63, 26 perform one additional imaging technique and 21 perform two or more additional imaging techniques. The remaining 16 consultants only report on cine angiography. Only nine of 21 departments in which some form of cardiac radiology training was given, had a rotation through the subspecialty at registrar or senior registrar level. Twenty-one departments thought that an additional post in cardiac radiology would be sought if trained people were available.     

A case study in developing a radiology information technology (RIT) specialist position for supporting digital imaging

Support services in providing PACS to healthcare facilities are becoming more complex. Imaginative staffing models are imperative to provide a successful PACS program to customers. Choosing the right staffing grid of support staff can be assisted by locations with like volumes or geographic areas. The RIT (radiology information technology) specialist is an excellent asset in a growing PACS environment. RITs can be the crucial liaison between the radiology department and the customer. RITs with different backgrounds can be recruited based on what type of support services your customers need. RITs are a great resource for one-on-one training from physicians to nursing staff. This mobile PACS spokesperson can take the concerns of the customers to the PACS administrator to open dialogue and communication that will win customer loyalty in this ever changing world of technology.     

PACS--and beyond. A journey to the digital promised land

A successful picture archiving and communication system (PACS) integration depends on much more than the technology; marketing also plays a large role. This fact was evident from the inception of the PACS project at Boca Raton Community Hospital (BRCH). Strategic and effective marketing efforts should target technologists, nurses, physicians (including radiologists), administration, and colleagues in other departments. The buy-in of these users is critical to the project's success. BRCH's first marketing effort took place during the initial PACS presentation made to the hospital's board of directors. Once approval was given and a 6-month implementation target was set, a strategic and effective marketing/education plan commenced. Posters, brochures, t-shirts, and promotional items were distributed in a coordinated effort to target hospital staff and referring physician offices. Through its "Got PACS?" branding and other identity materials, BRCH implemented a marketing plan that informed, educated, and engaged PACS users.     

Emergency radiology in Canada: a national survey.

OBJECTIVE: To document the existing radiology services available to emergency physicians in hospitals across Canada and to preview future trends and needs. METHODS: Questionnaires (n = 130) regarding the type, availability and satisfaction with radiology services were distributed to radiologists and emergency physicians at 65 hospitals across Canada. RESULTS: Fifty-three (41%) questionnaires were returned, and 45 (35%) completed questionnaires from 35 hospitals were used for analysis (24 from radiologists and 21 from emergency physicians). Plain radiographs were available in all hospitals at all times. Ultrasonography, intravenous pyleograms and computed tomography (CT) were available in all departments during normal working hours; after hours, CT was unavailable in 1 hospital and ultrasonography was unavailable in 2. Focused assessment with sonography for trauma (FAST) was routinely performed for blunt abdominal trauma in 6 centres, and 10 centres had teleradiology services. Regarding the quality of emergency service, 7 of 45 responded "poor," 4 "average," 14 "good," and 17 of 45 rated service "excellent." Interestingly, most radiologists answered "good" or "excellent," and most of the "poor" responses came from emergency physicians. Regarding staff coverage after 5 pm, 34 hospitals provided CT services, 20 had ultrasonography staff available, and there was radiology nursing coverage in 14 hospitals. Clinical details on requisitions were generally rated "adequate" or "poor." Although most radiograph reports were available within 48 hours, some took longer. Hot-seat reporting was available in 11 centres. During normal working hours, radiologists were the first to read films in 5 of 35 hospitals. After hours, emergency physicians were the first to read films in all hospitals, but only 14 hospitals indicated they were "formally" trained to do so. CONCLUSION: This survey documents the strengths and weaknesses of the radiology services available to emergency physicians. The perceptions of emergency physicians and radiologists of the adequacy those services differ significantly.     

Radiology Design Project Primer

The design of hospital environments is receiving increased attention as an important contributor to patient satisfaction and experience, which have a direct impact on reimbursement. Well-designed health care environments can decrease stress, improve concentration, and contribute to improved patient outcomes and enhanced staff morale. Most radiologists and business directors lack formal training in design and may feel they have little to contribute to design planning, yet creating an optimal environment for patients requires a strong understanding of local demographics and both patient and staff needs, which is a core responsibility of radiology leadership. This article presents practical guidelines for selecting a design partner for an imaging construction project, developing a design theme and design sensibilities, and engaging a multidisciplinary radiology team in working with a designer; the goal is to enable radiology leadership to collaborate with designers to cocreate health care environments that aspire to be integral components of patient-centered care and experience.     

Radiology and the Cancer Services Collaborative--an opportunity awaits

The principles and methodologies used by the Cancer Services Collaborative (CSC) are particularly relevant for radiology departments. A radiology project looking at the provision of barium enema examinations is used to highlight how the principles can be applied to a radiology department. Advice on how to access available CSC literature is offered. The CSC principles and methodologies are an important part of the NHS modernization agenda, and offer an exciting vehicle to improve patient care. It is important that radiologists understand the opportunities offered and the challenges posed by the modernization agenda.     

Globalization of P4 medicine: predictive, personalized, preemptive, and participatory--summary of the proceedings of the Eighth International Symposium of the International Society for Strategic Studies in Radiology, August 27-29, 2009

In August 2009, the International Society for Strategic Studies in Radiology held its eighth biennial meeting. The program focused on the globalization of predictive medicine--or P4 medicine--as it relates to the practice of radiology and radiology research. P4 medicine refers to predictive, personalized, preemptive, and participatory medicine and was the inspiration of Elias Zerhouni, MD, former director of the National Institutes of Health. This article is a summary of some of the key concepts presented at the meeting by an international group of radiologists, imaging scientists, and leaders of industry. In predictive medicine, imaging and imaging-related technologies will likely play an increasing role in the early detection of disease and, thus, the preemption of the development of advanced, hard-to-treat disease. Research into systems biology and molecular imaging promises to personalize medicine, facilitating the provision of the right care to the right patient at the right time. In participatory medicine, increasing interactions with referring physicians and patients will be helpful in raising awareness and recognition of the role of radiologists and will have a positive effect on professionalism. There is also a need to increase awareness of the vital role of radiologists as imaging and radiation safety experts who evaluate the necessity and appropriateness of examinations, monitor performance quality, and are available for postexamination consultations.     

Radiology integration in a multi-hospital system.

In 1989, Salt Lake City's Intermountain Health Care (IHC) began a process to reduce costs and streamline processes. Divided into four geographic regions, IHC consists of 24 hospitals and 100 clinics, a 400-member practitioner-physician group, and a staff of 23,000. IHC determined that three Salt Lake Valley hospitals, part of its Urban Central Region, must become one entity with shared management and a reduced staff to cover operations at all three hospitals. Management of the three radiology departments were charged with creating an integration process for the three hospitals. Two directors were selected to manage radiology and meet the outlined goals. Difficulty arose when one director needed to make changes in a facility managed by the other. The directors found that structuring by modality allowed them to plan for all three facilities, standardize equipment purchases and create integrated rather than departmental programs. As consolidation was taking place in top management, employees worried what the resulting changes meant for their jobs. Many were unfamiliar with the concepts of team structure and continuous quality improvement. Various courses and meetings were held to educate staff members and bring them up to new standards. Most successful were the meetings that allowed staff from different facilities to come together and share ideas. Although travel was an issue, these meetings quickly helped move the integration processes forward as peer relationships were developed. Employees were recruited for cross-training and new staff worked wherever needed. As they began to share data, the three hospitals identified best-practice and internal benchmarks. IHC is now ready to hire a single director to manage the radiology departments at the three Salt Lake Valley hospitals.     

The PACS committee: the all-important human element

The PACS committee plays a crucial role in attaining successful outcomes from a PACS implementation. However, most radiology departments do not organize and manage their PACS committees well. This has resulted in poor outcomes and inability to realize projected benefits and return on investment. Ideally, there are two PACS committees: a high-level strategic committee that aligns the goals for the PACS with institutional initiatives, and an operational PACS committee that makes a hands-on approach to the project and manages the entire PACS program. The chairman of radiology, an assigned radiologist or the radiology administrator heads both PACS committees. The strategic PACS committee consists of senior people from information systems, strategic and operational planning, radiology, physicians, nursing, critical care, and other related departments in the hospital. The operational PACS committee consists of people directly involved in radiology operations including the chief of radiology, radiology administrator, technologists, file room manager and other personnel whose daily routines will be affected by the PACS implementation. The operational PACS committee manages the PACS program from initial planning through the post-installation period. Committee tasks include: developing an implementation plan, establishing goals and objectives, conducting a cost/benefits analysis, developing functional specifications, generating an RFP, managing vendor selection and contracting, preparing the site for installation, performing project management functions, conducting acceptance testing, overseeing training, and evolving the PACS operations to meet predicted outcomes.     

Is terminology used effectively to convey diagnostic certainty in radiology reports?

RATIONALE AND OBJECTIVES: This study was performed to assess the extent of agreement among radiologists and nonradiologists in perception of diagnostic certainty conveyed by words and phrases commonly used in radiology reports. MATERIALS AND METHODS: The study was performed in a large academic radiology department. To determine the commonly used terminology for conveying diagnostic certainty in radiology reports, 12 randomly selected radiologists from six different subspecialties were interviewed. The authors identified the 15 most commonly used words and phrases and included these in random order in a questionnaire sent to all staff radiologists (n = 45) and to 158 referring physicians. Physicians were asked to rank the 15 phrases in order of the diagnostic certainty conveyed by each, from 1 (most certain) to 15 (least certain), using each number only once. The kappa statistic was used to assess agreement in rank order among physicians. RESULTS: The questionnaire response rate was 76% (n = 34) for radiologists and 49% (n = 78) for nonradiologists. There was excellent agreement among radiologists (kappa = 0.95) and nonradiologists (kappa = 0.93) in the rank order for the phrase diagnostic of. Although there was good agreement (kappa = 0.45) among radiologists for the word unlikely, agreement among nonradiologists was poor (kappa = 0.27). There was very poor agreement among all physicians for the rank order of the other 13 phrases. CONCLUSION: Among radiologists and nonradiologists, concordance was poor regarding the diagnostic certainty associated with phrases commonly used in radiology reports. Because poor agreement could lead to suboptimal quality of care, the standardization of terminology would benefit all parties.     

A comparison of the time required by radiologists for the preparation of clinico-radiological meetings when film and PACS are used

The hypothesis was that when a hospital-wide Picture Archive and Communications System (PACS) is used, preparation for clinico-radiological meetings is faster, and more images are available, than when a conventional film system is used. This paper reports a study which compared the preparation time by radiologists when film was used with the time for the same activity when a hospital-wide PACS was used at Hammersmith Hospital for the preparation of the respiratory medicine and hepato-biliary meetings. It was found that when PACS was used the time per patient to prepare for the respiratory medicine session was reduced by 11.1 min and that similarly, 16 min per patient was saved in the preparation of the hepato-biliary sessions. The number of images which were unavailable for the session was reduced when PACS was in operation, but this reduction was not shown to be statistically significant. The introduction of PACS at Hammersmith Hospital has significantly reduced the time spent by radiologists in preparing for the two clinico-radiological sessions studied and, if this is extended to the other numerous sessions held each week, contributes to a considerable saving of staff time within the radiology department. Received: 1 April 1999; Revised: 24 June 1999; Accepted: 9 August 1999     

Proficiency examination of physicians for classifying pneumoconiosis chest films.

An examination has been developed to test the proficiency of physicians classifying chest radiographs with pneumoconiosis in accordance with the classification system promulgated by the International Labor Office in Geneva. The examination, prepared by Johns Hopkins University under contract with the National Institute of Occupational Safety and Health, was commissioned to identify physicians qualified to serve in national pneumoconiosis programs directed both to epidemiological research and to the compensation of coal miners and others who suffer from dust-related illness. The examination, consisting of 125 chest radiographs, includes examples of a broad range of disease extending from normal to far advanced pneumoconiosis. An examinee passes or fails by ability to classify the films, within prescribed limits, in the same manner as an expert panel of radiologists. The examination is open to radiologists, chest physicians, occupational health specialists, and other physicians interested in pneumoconiosis. By the end of 1978, the examination had been given to 202 candidates, including 116 radiologists 30 chest physicians, three candidates certified in preventive medicine, two family practitioners, and 51 others. Of the 202 candidates, 118 (58.4%) passed and 84 (41.6%) failed. Among the candidates taking the examination for the first time, 74 radiologists (63.8%) and 18 chest physicians (60%) received passing grades. Of the remainder, 21 physicians (37.5%) were successful. Early experience indicates the examination is quite successful in meeting its primary objectives, which suggests that this type of examination may be applicable in other situations to separate those who meet certain standards of performance in radiology from those who do not.