Lessons learned from a whole hospital PACS installation. Picture Archiving and Communication System

The Norfolk and Norwich University Hospital has incorporated a fully filmless Picture Archiving and Communication System (PACS) as part of a new hospital provision using PFI funding. The PACS project has been very successful and has met with unanimous acclaim from radiologists and clinicians. A project of this size cannot be achieved without learning some lessons from mistakes and recognising areas where attention to detail resulted in a successful implementation. This paper considers the successes and problems encountered in a large PACS installation.     

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.     

Off-site real-time review of remote ambulatory care obstetric and gynecologic ultrasound examinations: Implications to radiologists for managed care contract negotiations

We present a cost comparison of contracts to provide obstetric and gynecologic ultrasound (US) services to a managed care provider group (MCPG) and discuss the long-term implications of off-site monitoring of US procedures by video/voice technology to radiologists in competing for managed care contracts.During a 19-month period, 1,741 ultrasound examinations were performed for a MCPG in a clinic located 7 miles from our institution. The costs of different arrangements to provide this service and a 5-year cost analysis are provided.Based on the reported obstetric and gynecologic US caseload, annualized first year cost to the MCPG under the current contract was $183,945, compared with $252,000 under a prior contract. Without a contract, the cost would be $325,907.Our analysis shows that the use of the citywide fiberoptic network for remote monitoring of US examinations enables US radiologists to compete for managed care contracts and provides cost savings to payors.     

Helical CT examination of multiple trauma patients in a digitized radiology department

In a newly erected trauma hospital the whole process of diagnostic imaging, image distribution within the hospital, and clinical radiological conferences is managed digitally and in a filmless manner. The system has two main parts: a radiological information system (RIS) and a picture archiving and communication system (PACS). Using helical computed tomography directly adjacent to the shock room, acute management of accident victims with multiple injuries has become highly efficient.     

The benefits of hospital-wide picture archiving and communication systems: a survey of clinical users of radiology services.

This paper describes one element of a broad evaluation of a hospital-wide picture archiving and communication system (PACS): an assessment of the views of users of the radiology service, their major causes of dissatisfaction with the service, the incidence of image unavailability, and the consequences of images being unavailable. The principal research design was a "before and after" comparison at Hammersmith Hospital, as the hospital site introducing PACS. Several other hospitals were included in this survey, for comparison. Questionnaires were distributed several times before PACS was operational at Hammersmith, and on one occasion after. The overall response rate was 54%. The main pre-PACS radiology-related problem areas were: the non-availability of images, the non-availability of written reports when clinically required, and the time devoted by junior staff to image searching. PACS greatly reduced the perceived problem of image non-availability. But Hammersmith's problems with the availability of radiological reports still remained when PACS was operational. The time junior doctors spent in image-searching was dramatically reduced by the introduction of PACS.     

Financing a large-scale picture archival and communication system

RATIONALE AND OBJECTIVES: An attempt to finance a large-scale multi-hospital picture archival and communication system (PACS) solely based on cost savings from current film operations is reported. MATERIALS AND METHODS: A modified Request for Proposal described the technical requirements, PACS architecture, and performance targets. The Request for Proposal was complemented by a set of desired financial goals-the main one being the ability to use film savings to pay for the implementation and operation of the PACS. RESULTS: Financing of the enterprise-wide PACS was completed through an operating lease agreement including all PACS equipment, implementation, service, and support for an 8-year term, much like a complete outsourcing. Equipment refreshes, both hardware and software, are included. Our agreement also linked the management of the digital imaging operation (PACS) and the traditional film printing, shifting the operational risks of continued printing and costs related to implementation delays to the PACS vendor. An additional optimization step provided the elimination of the negative film budget variances in the beginning of the project when PACS costs tend to be higher than film and film-related expenses. CONCLUSION: An enterprise-wide PACS has been adopted to achieve clinical workflow improvements and cost savings. PACS financing was solely based on film savings, which included the entire digital solution (PACS) and any residual film printing. These goals were achieved with simultaneous elimination of any over-budget scenarios providing a non-negative cash flow in each year of an 8-year term.     

Why PACS is no longer a four-letter word

The real value of PACS is not realized until widespread adoption exists among physicians other than interpreting radiologists. Referring physicians at the office level, in the operating room and in other departments must be willing to embrace the reading of images on monitors. That takes time. The payoff for a PACS system is therefore not realized until sometime in the future. Given the huge up-front capital expenditure required of PACS solutions, it is no wonder that the decision has historically been a difficult one to make. Enter the application service provider (ASP). The marriage of the ASP model to PACS seems to be one of the true "killer apps" currently available in the healthcare technology space. An ASP can host and maintain the software inherent in PACS solutions. Images are centrally archived over the short-, medium-, and long-term timeframe, utilizing state-of-art data management facilities. Some ASPs also provide the necessary bandwidth to office sites and the small amount of hardware that is required onsite, such as viewing stations or monitors. Costs for Internet-based image management under the ASP model rely on a pay-as-you-go formula, which may include all software, support, required hardware and bandwidth as part of the service. There may be a minor up-front fee for installation. The ASP pricing model eliminates the huge gamble an organization takes on "big iron" PACS purchases. Those benefits rely on the first rule of finance: a dollar today is worth more than a dollar tomorrow. PACS and ASPs were made for one another. Because the financial benefits of PACS are realized over time, the timing of cash flows is extremely important. Other benefits inherent in the ASP model such as scalability, diminished need for IT personnel, software version integrity and better pricing because of economies of scale are attractive also.     

Trends in PACS image storage and archive.

PACS is widely used in hospitals and is considered a mission critical system for around-the-clock daily clinical operation. Scheduled or unscheduled downtime of the main PACS archive storage or server could potentially cripple the entire PACS operation. This is especially the case in a filmless hospital environment. Therefore, in a downtime event, it is most desirable for users to have only a minimal performance impact without interruption of clinical data flow or loss of data and to have available historical PACS studies. This paper summarizes some of the developments in the design and implementation of a reliable PACS that insures maximum uptime for end users while preserving the integrity of the PACS data and making it available during downtime events. It also details strategy for developing proper clinical workflow contingency procedures when a scheduled downtime event to the main archive storage and server occurs. Specifically, the design and implementation of a fault-tolerant (FT) main archive server, the development of a FT back-up archive using an application service provider (ASP) model, and the clinical experiences while upgrading a main archive server and migrating the stored PACS data to new storage media will be discussed.     

Construction of a quality assurance system for images in general radiography in a filmless environment: construction of an accurate and swift workflow

When medical records went digital at our hospital, we also went filmless. In the general radiography department, we were forced to change the workflow, so we created a new one. We introduced a system of quality assurance for images between consoles and PACS. As our original improvement, we added to the system a function to automatically narrow down patient images and a function to automatically sort images. We divided quality assurance for images into 1st and 2nd quality assurance and defined and managed it. In addition, we measured the time for each process of the workflow with and without film use. We compared 10 cases of chest and abdomen radiographs with 10 cases of bone radiographs. As a result, by using this system of quality assurance for images, we were able to cut three minutes from each examination, leading to quicker work.     

Duplex doppler ultrasound in determination of renal artery stenosis

Twenty-six cases of renal artery stenosis were evaluated with Doppler ultrasound using the pulsatile flow index (PFI). To establish normal values, the PFI in 60 renal arteries in 30 healthy volunteers was obtained. Normal values by PFI ranged between 0.48 and 0.71 (mean ± SD: 0.6 ± 0.06). In renal artery stenosis the PFI range was 0.72–0.79. The normal upper limit was 0.71. The PFI failed in three patients; however, an ultrasound examination showed secondary renal disease (two patients with stenosis on both sides with a shrunken kidney on one side, and one patient with hypernephroma on the opposite side). The PFI was normal (14 of 14 patients) in patients without angiographic evidence of stenosis or after successful dilatation.     

Incorporating electronic media into medical student education: a survey of AMSER members on computer and web use in radiology courses. Alliance of Medical Student Educators in Radiology

RATIONALE AND OBJECTIVES: The purpose of this study was to define the current use of information technology in radiology tutorials for medical students. MATERIALS AND METHODS: The authors conducted a Web-based survey of directors of medical school courses in radiology. The survey dealt with the details of the courses and the use of computers and the Web during the courses. RESULTS: There were 48 responses. Most radiology courses were elective (73%) and were offered monthly. Most institutions (79%) had picture archiving and communication systems (PACS) available or were completely filmless. The teaching case presentations, however, often included film images displayed on a view box or by an overhead projector. Computers dedicated to student use were uncommon (28%). The Web was used infrequently as a teaching resource, and a Web site was not available in most courses. Computer technical support was variable and usually provided by the course director. Course directors at institutions with PACS were more likely to use digital technology for case presentations and more likely to use the Web for teaching purposes. CONCLUSION: Despite the widespread use of digital technology and PACS in the field of radiology, digital technology is underused in radiology courses. However, departments with PACS tend to use digital technology more frequently in education than do departments without PACS.     

基于医学影像存储与传输系统的交互式CT影像教学模块的开发与实践

目的 开发基于医学影像存储与传输（PACS）的交互式CT影像教学模块，满足临床医生和低年资影像诊断医生对CT影像知识进一步继续医学教育的需求。方法 PACS采用100M主干网，10M交换到桌面；在浏览工作站和诊断工作站安装教学模块；教学内容按部位分类，以树枝模式管理；教学文字资料来源于具有一定权威的教科书、专著及期刊；图像资料来源于各部位经病理及临床证实的病例，以数码相机、扫描仪等方式数字化或直接从PACS系统提取，编辑处理后，经医学数字影像通讯标准（DICOM）3.0服务器转换为标准数字图像，以文件形式存放于PACS图像服务器硬盘。结果 CT影像教学模块能够实时调阅最合适病种的CT征象、临床特点、病理、鉴别诊断、典型图像及注释、正常断面解剖等，供教学、诊断和报告参考。结论 基于PACS的CT影像教学模块能提供交互式教学及科研工具，提高CT室工作质量和工作效率。     

A hospital-wide picture archiving and communication system (PACS): the views of users and providers of the radiology service at Hammersmith Hospital

OBJECTIVE: To obtain users' views of the new picture archiving and communication system (PACS) from clinical and radiological staff at Hammersmith Hospital, UK. METHODS: Semi-structured interviews were used to ascertain the views of staff, following an interview schedule which covered aspects of: (1) their use of PACS, (2) facilities available, (3) the perceived quality of images, (4) reporting, (5) image availability, (6) image accessibility, (7) training, and (8) ease of use of PACS. RESULTS: Interviews were carried out with 34 key users and providers of the radiological service at Hammersmith Hospital. Overall, staff were very satisfied with PACS particularly in terms of image availability. All staff said that they preferred PACS to the previous, conventional radiology service. CONCLUSIONS: The key implications of issues raised by staff were: the impact of 'down-time' and the importance of an efficient back-up system, the requirement for sufficient short-term storage to prevent images being off-line during clinical situations, the usefulness of the folder system for management of the images, the need to access images for teaching purposes, the advantage of having a default display protocol to facilitate radiological reporting, and the requirement for flexible, yet effective, training to ensure that the system is utilised to its full potential by users.     

Duplex Doppler ultrasound in determination of renal artery stenosis

Twenty-six cases of renal artery stenosis were evaluated with Doppler ultrasound using the pulsatile flow index (PFI). To establish normal values, the PFI in 60 renal arteries in 30 healthy volunteers was obtained. Normal values by PFI ranged between 0.48 and 0.71 (mean +/- SD: 0.6 +/- 0.06). In renal artery stenosis the PFI range was 0.72-0.79. The normal upper limit was 0.71. The PFI failed in three patients; however, an ultrasound examination showed secondary renal disease (two patients with stenosis on both sides with a shrunken kidney on one side, and one patient with hypernephroma on the opposite side). The PFI was normal (14 of 14 patients) in patients without angiographic evidence of stenosis or after successful dilatation.     

通过工作列表实现数字化网络各系统之间患者信息的一致性

目的 实现图像存储与传输系统(picture archiving and communication system，PACS)、放射学信息系统(radiology information systems，RIS)、影像设备之间患者检查信息的一致性。方法 我院引进GE Signa 1．5T磁共振、数字乳腺，Agfa数字X线摄影、计算机X线摄影及GE CT等数字化医学设备。GE PACS是英文系统，所以前期医院在未解决信息一致性时只通过PACS对检查影像进行保存，通过PACS系统中简单的信息管理工作，并没有真正意义上的worklist。2个月后，我院采用国际上先进的解决方法即通过医学数字成像及通讯(digital imaging and communication in medicine，DICOM)标准的工作列表(worklist)的方法实现信息的一致性。在RIS系统中将患者中文信息转换为英文信息，保存并为worklist提供患者的英文信息。结果 我院在集成PACS和RIS的2年多时间以来，通过worklist来保证RIS与影像设备患者检查信息的一致性，取得了非常好的效果。在所有诊断工作站上，诊断医生通过中文RIS系统，对病人的信息进行编辑、修改、产生。结论 通过worklist实现PACS、RIS、影像设备之间患者检查信息的一致性是可行的。     

PACS需求方案的设计方法和原则

目的结合我们的ＰＡＣＳ设计实践探讨ＰＡＣＳ系统需求方案的设计方法和原则。材料与方法搜集和分析各类ＰＡＣＳ有关的信息和数据,建立对ＰＡＣＳ发展技术和动向的深入理解,基于此确立将构建的ＰＡＣＳ系统的规模、结构和功能方面的实际需求。结果ＰＡＣＳ的ＲＦＰ中主要的组成包括：放射科以及医院状况的概述和对ＰＡＣＳ的一般需求;对新建ＰＡＣＳ及其亚系统的结构和功能需求的细节描述;对ＰＡＣＳ集成／提供商的能力和产品支持的具体要求的描述和说明。结论建立基于放射科和医院实际需求的ＲＦＰ,是完成适用并具较高性价比ＰＡＣＳ设计方案的可靠保证。     

The relationship of managed care to business, professional, and organizational aspects of radiology practices

OBJECTIVE: We sought to determine the extent of managed care involvement among radiology practices of different types, locations, and sizes; the factors associated with differences in involvement; and the impact of managed care on professional, organizational, financial, and hospital-relations aspects of radiology practices. MATERIALS AND METHODS: A survey was mailed in 1999 to a sample of 970 radiology practices; completed, usable surveys were returned by 66% of the practices. Three indicators of managed care were used: a practice's percentage of managed care (HMOs plus preferred provider organizations), local area HMO penetration rate, and self-reported perceived effect of managed care. RESULTS: Percentage of managed care averaged 30% but was 40% for multispecialty groups. It was relatively high in large metropolitan areas, for practices with no hospital activity, and for practices with any owners who were not practice members. The three measures of managed care were only moderately correlated (correlation coefficient, 0.25-0.33). None of the managed care variables had a statistically significant effect on days provided for vacation and continuing medical education, promptness of payment, years required for practice ownership (partnership), and percentage of practice members who were owners. Higher percentage of managed care was associated with higher collection rates, whereas greater perceived impact of managed care had the opposite association. Two thirds of practices belonged to at least one managed care-related organization such as an independent practice association. Most radiology practices reported no involvement in the managed care negotiations of hospitals, which was true even when the hospital's negotiations included the radiologists' fees or when the practice determined its level of involvement. CONCLUSION: Many negative outcomes most feared by radiologists regarding the effect of managed care have not materialized. Perceptions of practices as to the effect of managed care seem to reflect negative aspects of their general situation, not only realities of managed care.     

Making PACS the present, not the future

Why haven't you moved forward with PACS? Have you just procrastinated or does your facility have legitimate reasons? Some say the technology is too confusing or too new, while others say the cost of PACS is too high. Many facilities say they haven't found a satisfactory way to deal with the conflicting opinions of their radiologists, IS department, administration, referring physicians and staff. Take time to compare the technology you do understand with something familiar such as your own PC or perhaps the current networks inside your facility. You'll soon begin to see that PACS is not a new technology, but rather a new methodology. To handle the perceived high cost of PACS, remember that every facility has different needs. Look at your work flow and then the many byproducts of PACS, such as marketing. If you are the first in your area to implement this new technology, you'll gain a marketing advantage in competing for referring physicians and managed care referral business. Follow the process you use to purchase other products, such as CT or MRI, as you investigate the vendors. Finally, make a plan! Determine departmental goals and gather information from vendors. Create a timeline, a financial plan and your marketing strategy. Together, these steps will help move PACS into the present for you.     

Pulsatile flow index for qualitative measurements of blood flow with duplex ultrasound. An experimental study

We determined the accuracy of Doppler blood flow measurements in an experimental investigation using a tissue-simulating phantom, pulsatile flow pumps and heparinized blood. A new index for qualitative assessment of blood flow, the pulsed flow index (PFI) is described. The PFI takes advantage of the area under the flow velocity curve between the true zero line and the diastolic baseline. Under conditions of continuous flow, the PFI ranged from 0.82 to 0.94 (mean value 0.90). The PFI was found to be relatively independent of the transducer/vessel angle (+/- 8%) and the inter/intra-operator variation was small (+/- 7.5%, or +/- 7%, respectively).