Xtria Healthcare
Just a few years back, only large healthcare providers had made the move to a filmless radiology environment. Now many mid-size facilities are deploying PACS networks with the goal of creating dramatic workflow efficiencies, superior patient care, tighter cost controls, and a stronger competitive position.
There is also a broader strategic imperative. Providers now see PACS as a step toward an integrated digital imaging and information environment in which images from all modalities are tied to associated diagnostic reports. In turn, the images, reports, and other information tie in with integrated patient records.
Authorized users across the organization gain anywhere-anytime access to these records, realizing further efficiencies and competitive advantages. However, there are complexities that threaten to derail the progress.
You can’t just flip the switch
Going filmless -- actually, near-filmless -- is a remarkably complex transition for any provider. It’s not just about technology; you can’t just "flip the PACS switch." If you are planning PACS or preparing to deploy, it’s crucial to take a holistic approach.
Going filmless affects workflow, roles, relationships, and your organization’s culture as a whole, sometimes in unexpected ways. Embracing the full breadth of these changes helps ensure a smoother, more effective transition.
The transition begins in the radiology department, because this is where imaging workflow can be streamlined, and film costs potentially slashed to the bone -- one of the main reasons many providers want PACS now rather than later.
However, clinical departments such as the emergency department (ED), intensive care unit (ICU), and in-patient wards also benefit from PACS efficiencies, including faster diagnoses resulting from not having to wait for film retrieval and delivery, as well as eliminating extra work, cost, and delay when films are lost or misfiled.
Integrated digital imaging offers bright promise to disciplines ranging from cardiology to orthopedics to oncology, and including mammography. Efficiencies abound, and specialists can more readily collaborate with primary care physicians in distant locations to improve treatment and therefore outcomes.
However, unless you prepare your transition with extreme thoroughness, any number of factors can erode its benefits, creating difficult situations for administration, clinical staff, and patients. Clinical, technical, financial, and operational factors come into play. These factors range from film users’ comfort and preparedness with digital imaging to how well the organization manages subtle imaging-display issues affecting quality assurance.
Workflow changes beyond radiology
PACS-driven changes reach far beyond radiology -- and even your organization -- because digital imaging affects the organization’s critical relationships with referring physicians and other professionals such as insurers, managed care administrators, and attorneys. In other words, PACS affects everyone who "touches" film and associated diagnostic reports, including ancillary service providers and outside specialists. All of these players must be equipped and prepared to ensure a smooth transition.
Similarly, your PACS output or "product" consists of more than just digital images. It comprises images, written and/or oral reports, and the confidence of radiologists and clinicians that the images are "right."
The radiology product also includes the availability and usability of those images, accomplished through identifying, tracking, and archiving each image as well as tying it to one or more reports and associating it with a unique patient record and ordering physician. Images must be secured to protect patient privacy and comply with Health Insurance Portability and Accountability Act (HIPAA) rules, and delivered rapidly on-demand to authorized users.
There is also an administrative side. With PACS, you will need the ability to transparently tie digital image capture and review to patient billing along with internal costing, cost allocation, and departmental chargeback systems. Management reporting of staff and facility utilization, as well as revenue production, will need to be performed.
Workflow and relationship changes have cascading effects. In many cases, radiologists no longer need to be located near the x-ray imaging suite, so interactions with radiologic technicians, the medical physicist, and other staff members may change.
With waits for film eliminated, patient flow through radiology will accelerate, increasing the facility’s effective capacity. How will you manage the new pattern of patient traffic? Increased flow? Changes in interactions between patients, technologists, radiologists, and clinicians?
To answer these questions it is crucial to delineate your existing film-based workflow, understand PACS-driven workflow, map every change, and ensure that clinical staff and the facility itself is prepared to accommodate each change.
Workspace characteristics will likely change as well. For example, traditional lightboxes are extremely bright to illuminate film; desktop displays aren’t nearly as luminous. Therefore, readers studying images on desktops need low ambient lighting to discern subtle diagnostic details, as well as sufficient task lighting to operate a keyboard and refer to written notes. These opposing requirements need to be accommodated in a single workspace.
Complex technical issues
Wherever your film used to travel physically, you will now need a broad digital pathway to all these "touch points." And you'll also need a means for viewing, storing, archiving, and tracking every newly captured image.
Technical issues can seriously complicate PACS deployment. For example, DICOM standards are designed to enable modalities and PACS to readily communicate, but today’s reality is far from plug-and-play.
Vendors implement DICOM standards in different ways. And not all DICOM capabilities are implemented in every device. Your CT scanners, for instance, may be DICOM-enabled but don’t provide storage verification. Thus, leveraging PACS benefits may require a CT upgrade to automate archiving.
There are numerous other issues. How much and what type of storage will you need for operations and archiving? How should backup and disaster-recovery storage be configured, and where should it be located? How much traffic will your data network need to carry?
Do you have sufficient carrying capacity to ensure fast response times at clinicians’ desktops during peak demand? Are the wide-area connections to outlying clinics sufficient for digital images to replace film deliveries?
How will you manage other technical issues affecting everything from modality integration to your remaining film processing? How will you ensure smooth coordination between radiology staff managing PACS and the IT staff handling the data network? Transition planning can help find the answers.
Film utilization
In addition to cost savings from film reduction, PACS return on investment (ROI) includes workflow efficiencies, revenue generation, and other competitive benefits. For example, PACS can lead to shorter waiting times for diagnosis and treatment, resulting in increased patient satisfaction. Conveniences and timesavings help keep clinical staff on the roster. And referring physicians may prefer receiving digital images over the Internet or on a CD.
However, ROI expectations also must be grounded in realistic assumptions and a thorough understanding of PACS lifecycle cost, including secondary costs such as PACS management, maintenance, and quality control. Some film utilization will continue, so film costs will remain. How much and to what extent film utilization remains will significantly impact ROI.
One of our clients, the chief information officer (CIO) of a southeastern U.S. medical center, anticipates that his recently deployed PACS installation will generate $2 million in film cost savings over a five-year period. His estimate takes into account film "leaks," and the ongoing use of film in the center’s emerging digital information and imaging environment.
Film leaks arise when film is produced from potential sources such as mammography, scoliosis studies, and some surgical and orthopedic applications. Further, it may not be cost-effective to upgrade or replace aging fluoroscopes or other modalities.
Replacing film processors with computed radiography can be expensive, but deferring this cost results in continuing film utilization. Film also is required when digital systems suffer downtime, and when some referring physicians prefer and/or insist on film.
The impact of film leaks on ROI is magnified because printing dry laser film in digital environments can be double or triple the equivalent cost of traditional film processing. Providers often find that substantial film cost savings accrue only after 50% to 66% of film utilization has been eliminated. The CIO mentioned above eliminated 50% of film usage within two weeks of PACS startup.
Quality control
Maintenance and quality control are sometimes overlooked in transition planning. At stake is the confidence of your radiologists and clinicians that their digital images accurately represent patients’ physical manifestations. Moreover, ensuring accuracy can reduce potential legal liabilities.
Long-term quality assurance begins with acceptance testing, which provides a baseline for all future measurements. To maintain optimal display performance, laser film printers and desktop monitors require periodic evaluation, adjustment, and recalibration. These devices may have "built-in calibration," but still need the attention of a medical physicist to ensure verification against an independent standard for uniform, high-accuracy output.
Quality assurance may also be affected by workflow changes. In traditional film environments, radiologists work in close proximity to radiologic technicians, and when they come upon a question, simply mention it. The continuous interaction helps ensure that even minor variations in image quality can be immediately addressed.
However, such informal feedback mechanisms may not occur naturally in the digital world, where radiologists may be far removed from technicians. A more formal process may be required to maintain robust quality control.
By John MonvilleAuntMinnie.com contributing writer
June 16, 2003
John Monville is a vice president at Xtria Healthcare, a Dallas-based company providing digital imaging management, integration, and implementation solutions and services.
Related Reading
PACS brings benefits, with caveats, May 22, 2003
Small investments in imaging ergonomics yield major gains, May 21, 2003
Separating HIPAA facts from fiction, May 12, 2003
IHE pursues user adoption, product development, IT expansion, May 12, 2003
Web-based integration of PACS and RIS systems improves workflow, patient care, May 12, 2003
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