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/RIS系统在放射科工作流程优化中的作用

目的:探讨应用医学影像存档与通信系统(picture archiving and communication system,PACS)在医院放射科工作流程优化中的作用。方法:将放射科数字成像设备纳入PACS系统,将传统放射科工作流程与应用PACS后工作流程比较。结果:应用PACS工作流程后减少工作步骤,缩短报告发出时间,降低错误率。结论:应用PACS后明显提高了放射科的工作效率,方便了医疗、教学、科研和会诊,提高了医院的社会效益和经济效益。     

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.     

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.     

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。     

Enterprise-wide PACS: beyond radiology, an architecture to manage all medical images

RATIONALE AND OBJECTIVES: Picture archiving and communication systems (PACS) have the vocation to manage all medical images acquired within the hospital. To address the various situations encountered in the imaging specialties, the traditional architecture used for the radiology department has to evolve. MATERIALS AND METHODS: We present our preliminarily results toward an enterprise-wide PACS intended to support all kind of image production in medicine, from biomolecular images to whole-body pictures. Our solution is based on an existing radiologic PACS system from which images are distributed through an electronic patient record to all care facilities. This platform is enriched with a flexible integration framework supporting digital image communication in medicine (DICOM) and DICOM-XML formats. In addition, a generic workflow engine highly customizable is used to drive work processes. RESULTS: Echocardiology; hematology; ear, nose, and throat; and dermatology, including wounds, follow-up is the first implemented extensions outside of radiology. CONCLUSION: We also propose a global strategy for further developments based on three possible architectures for an enterprise-wide PACS.     

Increased productivity of a digital imaging system: one hospital's experience.

During peak hours of operation, it was not uncommon for the radiology department at St. Luke's Episcopal Hospital in Houston, Texas, to have a backlog of six to ten patients. While some of this was due to competing schedules from the emergency department (ED) and inpatients, the major problem was an inefficient workflow, especially for emergency department patients. Our staff in the radiology department worked with the hospital management to include plans for a new radiology room in an ED renovation project. In designing the new radiology room the most important issues under consideration were the physical location of the room and the type of radiography system to be installed. With plans to implement PACS, we evaluated computed radiography and digital radiography options. At St. Luke's, we had had our first experience with digital radiography after the purchase of a dedicated digital chest system. As a beta test site for the manufacturer, we had an opportunity to test--what was at the time--a new digital radiography system. The powerful impact of digital radiography became most evident by the decreased patient backlog. Even without PACS, workflow became dramatically more efficient. Images now are available for review within seconds after exposure, since there are no films to process. This has reduced our average exam time from ten minutes to one and a half minutes, not including patient transport time. The efficiency demonstrated with the digital chest system provided evidence that digital systems could handle significantly more patients than computed radiography or screen-film systems, without a compromise in image quality. Therefore, we decided to put a digital radiography system in the new ED radiology room. We estimate that the new unit will pay for itself in less than three years.     

Trends in PACS architecture

Radiological Picture Archiving and Communication Systems (PACS) have only relatively recently become abundant. Many hospitals have made the transition to PACS about a decade ago. During that decade requirements and available technology have changed considerably. In this paper we look at factors that influence the design of tomorrow's systems, especially those in larger multidisciplinary hospitals. We discuss their impact on PACS architecture (a technological perspective) as well as their impact on radiology (a management perspective).We emphasize that many of these influencing factors originate outside radiology and that radiology has little impact on these factors. That makes it the more important for managers in radiology to be aware of architectural aspects and it may change cooperation of radiology with, among others, the hospital's central IT department.     

放射科工作流集成的应用实践

探讨综合性大型医院RIS/PACS建设中放射科工作流集成方案。采用I HE radiology工作流相关的4个集成模式,并根据国内需求优化应用,达到改善预定工作流、报告工作流、简化纠错流程、提高工作诊疗效率及质量的要求。重视I HE radiology集成模式应用,兼顾本土化需求,完善数字化医疗影像工作环境。     

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.     

A tale of two CRs: hospital conducts side-by-side test

While we elected to install a digital radiography system in the busiest exam room in emergency room (ER) suite at our 535-bed hospital, we selected computed radiography as the primary platform for digital capture throughout the facility because of its flexibility, productivity and cost-effectiveness. We now use CR systems to handle six exam rooms and portable exams conducted by the radiology department, as well as imaging studies conducted in two ER exam rooms. Before committing to a CR vendor, we conducted an eight-week, side-by-side pilot study with two vendors' systems. One CR system was located in the emergency room and the other unit was located in the main radiology department. Our staff received education and training from both vendors. I led an evaluation team that included representatives from the radiology group, the information services (IS) department, biomedical engineering, staff physicians, ER physicians, pulmonologists and orthopedic specialists. Our team met to design the trial and develop a list of factors that technologists would use to evaluate the two systems. The team met after installation and again after the trial was complete to provide verbal input on each vendor for each category and to review feedback from the technologists' survey. Categories included image quality, interactions with each vendor's sales and service staff, workflow, time studies, durability of cassettes and plates, entry of John Doe patients for ER, and other factors. After the trial, we chose a system by unanimous vote. We learned a lot about CR technology throughout this process. Overall we are extremely satisfied with the platform we selected and with this method of evaluating the two systems prior to making this important decision.     

Changing the face of radiology: redesigning patient-focused care

Mercy Hospital began the redesign of its patient-focused care in 1991. A steering committee composed of members from multiple disciplines was asked to create a seamless, patient-focused environment that would coordinate and align hospital resources in the service of patients and families. The director of diagnostic and clinical services served on that committee and used the committee's operating goals and principles to transform Mercy's radiology department into a diagnostic center. As part of its redesign effort, the radiology department reviewed its outpatient environment. Since so many of its patients came to have at least one of three procedures (EKGs, radiology exams and phlebotomy services) and since they must all register, the department decided to concentrate first on its registration procedure. A meeting with the medical records department resulted in the reception and scheduling staffs learning the registration process. After the two staffs went through an aggressive training program of about three months, it was possible to combine the two positions into one. Training staff members to schedule all modalities in the radiology department was next. With further cross-training, staff members now perform centralized scheduling for radiology, endoscopy and osteoporosis. Physicians can schedule such exams with only one phone call. Could technologists learn to draw blood too? Members of the healthcare team accepted the challenge to become more diversified and expand their skills. The author explains how the technologists became certified phlebotomists. With that success underway, the team accepted volunteers for EKG training. The author presents the benefits of the various steps taken, and looks at possible future opportunities in cross-training at the hospital.     

IT-Systeme in der Radiologie und IT-Systeme für den Radiologen

Radiology plays an important role in introduction and use of information technology (IT) systems in the daily clinical routine. The radiology information system (RIS) and picture archiving and communication system (PACS) are the main systems used in a digital radiology department. In this article the basic principles and functions of these systems and trends in development are described.     

PACS for surgery and interventional radiology: features of a Therapy Imaging and Model Management System (TIMMS)

Appropriate use of information and communication technology (ICT) and mechatronic (MT) systems is viewed by many experts as a means to improve workflow and quality of care in the operating room (OR). This will require a suitable information technology (IT) infrastructure, as well as communication and interface standards, such as specialized extensions of DICOM, to allow data interchange between surgical system components in the OR. A design of such an infrastructure, sometimes referred to as surgical PACS, but better defined as a Therapy Imaging and Model Management System (TIMMS), will be introduced in this article.A TIMMS should support the essential functions that enable and advance image guided therapy, and in the future, a more comprehensive form of patient-model guided therapy. Within this concept, the “image-centric world view” of the classical PACS technology is complemented by an IT “model-centric world view”. Such a view is founded in the special patient modelling needs of an increasing number of modern surgical interventions as compared to the imaging intensive working mode of diagnostic radiology, for which PACS was originally conceptualised and developed. The modelling aspects refer to both patient information and workflow modelling.Standards for creating and integrating information about patients, equipment, and procedures are vitally needed when planning for an efficient OR. The DICOM Working Group 24 (WG-24) has been established to develop DICOM objects and services related to image and model guided surgery. To determine these standards, it is important to define step-by-step surgical workflow practices and create interventional workflow models per procedures or per variable cases.As the boundaries between radiation therapy, surgery and interventional radiology are becoming less well-defined, precise patient models will become the greatest common denominator for all therapeutic disciplines. In addition to imaging, the focus of WG-24 is to serve the therapeutic disciplines by enabling modelling technology to be based on standards.     

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.     

Survey on medical information education for radiologic technologists working at hospitals

Recently, the importance of medical information for radiologic technologists has increased. The purpose of this questionnaire survey was to clarify the method of acquiring skill in medical information for radiologic technologists from the point of view of the managers of radiology departments. The questionnaire was sent to 260 hospitals that had introduced picture archiving and communication systems (PACSs) for the person responsible for medical information in the radiology department. The response rate was 35.4% (92 hospitals). The results of this survey clarified that few hospital have staff for medical information in the radiology department. Nevertheless, the excellent staff who have the skills to troubleshoot and develop systems are earnestly needed in radiology departments. To solve this problem, many technologists should understand the content, work load, and necessity of medical information. In addition, cooperation between radiologic technologist schools and hospitals is important in the field of medical information education.     

Managing a Multisite Academic–Private Radiology Practice Reading Environment: Impact of IT Downtimes on Enterprise Efficiency

PurposeThe aim of this study was to assess whether the complex radiology IT infrastructures needed for large, geographically diversified, radiology practices are inherently stable with respect to system downtimes, and to characterize the nature of the downtimes to better understand their impact on radiology department workflow.MethodsAll radiology IT unplanned downtimes over a 12-month period in a hybrid academic–private practice that performs all interpretations in-house (no commercial “nighthawk” services) for approximately 900,000 studies per year, originating at 6 hospitals, 10 outpatient imaging centers, and multiple low-volume off-hours sites, were logged and characterized using 5 downtime metrics: duration, etiology, failure type, extent, and severity.ResultsIn 12 consecutive months, 117 unplanned downtimes occurred with the following characteristics: duration: median time = 3.5 hours with 34% <1.5 hours and 30% >12 hours; etiology: 87% were due to software malfunctions, and 13% to hardware malfunctions; failure type: 88% were transient component failures, 12% were complete component failures; extent: all sites experienced downtimes, but downtimes were always localized to a subset of sites, and no system-wide downtimes occurred; severity (impact on radiologist workflow): 47% had minimal impact, 50% moderate impact, and 3% severe impact.ConclusionsIn the complex radiology IT system that was studied, downtimes were common; they were usually a result of transient software malfunctions; the geographic extent was always localized rather than system wide; and most often, the impacts on radiologist workflow were modest.     

The Emergency Radiology Dashboard: Facilitating Workflow With Realtime Data

Emergency radiology imaging volume varies widely due to predictable (eg, day of the week) and unpredictable factors. This can lead to inefficient or insufficient staffing of radiologists, suboptimal workflow and poor trainee education. In collaboration with the radiology IT division we created and implemented a 2-tiered real-time dashboard to facilitate operational workflow. This allowed us to track overall emergency department patient census, ordered but not yet performed imaging studies, and performed but unread imaging studies. The capability of clicking to obtain information on specific studies was also incorporated. We describe our experience of how this information has improved our workflow, staffing, and trainee education.