Keeping your eye on the PACS ball

Sep 29, 2003

By Gregg Cohen, Ph.D.
Xtria Healthcare

Implementing PACS is a process, not an event. The PACS process has a life cycle replete with key decision points, and learning how to handle these events in a holistic fashion can be a crucial factor in the success of a digital image management system.

At each point there’s an opportunity to perform a reality check: Are we asking all the right questions? Are we doing what we need to do? Are we aiming toward a solution that meets enterprise as well as radiology needs? How flexible is our vendor decision? Have we fully addressed transition issues such as training and workflow changes? Are we defining and maintaining consistent imaging quality?

If you discover a critical issue that’s been overlooked or realize that you need to rethink or remediate the PACS process, here are some tips from providers who have tackled and resolved issues in midstream.

Decision points

The process of acquiring and deploying PACS should generally follow a sequence of interlocking stages. However, the real world may serve up something other than a straightforward, linear process. For instance, at some facilities a vendor may be all but selected at the outset (not recommended, but it happens).

At any point, a review may cause your PACS planning team to revisit a previous stage. That said, here is the basic sequence:

Needs assessment and gap analysis.

Request for information (RFI) and cost-benefit analysis.

Request for proposal (RFP) and analysis of vendor responses.

Vendor selection and contract negotiation.

Transition planning.

Implementation management.

Acceptance testing.

System management, support, and quality assurance.

Issues can be resolved even after your PACS is up and running. But as with any process, the earlier you identify and address issues, the quicker, less costly, and less complex the resolution will be.

A holistic and strategic approach to PACS (versus a tactical approach) can help you identify critical issues. Under the tactical approach, PACS is viewed as an expensive and essential tactical shift in technology for the radiology department.

However, a tactical approach often ignores the broader impact of PACS on the healthcare enterprise. Ignoring these effects commonly leads to a transition fraught with problems, with results that don’t live up to PACS’ full promise of raising efficiency, saving costs, and improving competitive position.

Tactical versus strategic approaches

With a tactical approach, workflow issues are often overlooked. PACS isn’t a magic bullet. Insert PACS into a flawed workflow, and you’ll get flawed PACS workflow, with numerous resulting problems. As one CIO puts it, "If you automate a mess, you’ll have an automated mess."

Radiology workflow ripples outward to "customer" departments and referring physicians outside the provider organization. This workflow includes how radiology appointments are set, who retrieves the patient, how patients are managed in radiology with and without film, and how quickly radiology releases patients to other caregivers.

There are many other issues:

How will imaging modalities interact with the PACS network?

How will imaging sessions be identified?

How will notes be associated with images?

How will image display quality be ensured long term so that physicians maintain high confidence in image accuracy?

How will imaging and related data tie to the integrated patient record, now or in the future?

How will you manage physician training and provide ongoing user support from the medical staff’s perspective?

How flexible and scalable will your PACS solution be in the future?

In the old days (i.e., a couple of years ago) providers who sought PACS planning and deployment assistance worked with experts who provided turnkey services. That’s changed.

While such comprehensive services are still widely available, today’s focus is often on reviewing or fine-tuning a particular stage in the overall process. This gives enterprises greater flexibility to pause and reassess at any point, using an internal or external team or a combination.

Decision point: RFP

A hospital system in the northwestern U.S. developed a PACS plan and RFP to integrate digital imaging in two of its more than half-dozen facilities. The in-house team realized that the RFP needed improvement, but wasn't sure what was missing or how to change it.

An outside team was retained to diagnose and improve the RFP. This team found that while the RFP specified requirements for a PACS installation, it didn’t delineate crucial PACS criteria such as modalities, the number of units in each modality, or DICOM compatibility.

In addition, workflow had not been addressed. After studying and documenting radiology workflow and its interactions with other departments and physicians, the consulting team added an appendix to the RFP that included a functional narrative describing PACS workflow in detail. This gave the vendors a clear idea of what the provider expected to accomplish with the installed network.

The RFP had initially specified central storage for image data generated by the two facilities. Although the provider intended to later introduce PACS at other facilities, no provision had been made to scale the storage as these facilities came online, and cardiology imaging data requirements weren’t addressed.

Cardiology generates about twice as much data per image as computed radiography (CR) studies. With all facilities eventually tied into the image data storage system, the provider would need to add dozens of terabytes (tens of thousands of gigabytes) of capacity every year to store the PACS output.

Numerous alerts raised during the RFP improvement process also strengthened the provider’s preparations to manage workflow changes, training, and other issues affecting both radiology and the enterprise as a whole.

Decision point: Contract negotiation

Naturally, radiologists’ views often carry a lot of weight in determining a PACS solution. The challenge is to balance these views with enterprise needs. In another recent case, the chief of radiology had specified the PACS he wanted and requested a proposal from a vendor in whom he had confidence based on an earlier deployment elsewhere.

The vendor presented the provider organization with a contract for signature. However, outside experts collaborating with hospital administrators found critical flaws when reviewing the contract.

For example, there was no PACS performance specification and no training or detailed implementation plan. Progress payments were based only on time, not performance. The maintenance contract did not guarantee any specific service quality or performance level, so dependability remained a question mark.

There were also other pitfalls, both major and minor. The review process led this provider toward a PACS solution that would meet the needs of both the radiologist and the enterprise as a whole.

Decision point: Ongoing management (early stage)

One provider had progressed well into the PACS deployment process with a tactical approach before realizing that no provision had been made for providing PACS training to physicians and other staff members, or for managing workflow changes. Radiologists, radiologic technologists, referring physicians, nurses, aides, and administrative staff members all have unique training requirements.

There were problems in distributing images to some referring physicians who lacked compatible technology for viewing the studies. Outside experts were able to address these deficits, resulting in a highly successful deployment. As a result, substantial film-cost savings were realized from the outset.

Decision point: Ongoing management (latter stage)

Another multifacility healthcare provider faced a different challenge. Over a period of years, the provider’s various radiology units -- CR, CT, ultrasound, and nuclear medicine -- had each installed its own PACS. Each system adequately handled the needs of one imaging specialty and its associated modalities.

However, now the provider was moving toward a strategic enterprise solution embracing all patient data, including imaging. There was no simple, straightforward way to integrate these discrete, proprietary mini-PACS units into an integrated enterprise solution.

The provider now faces the tough task of continuing the PACS functionality of the various radiology departments, while evolving towards an integrated, enterprise-scale imaging and information environment.

A team is currently studying this dilemma. There are two primary alternatives. A system overlay could be developed to integrate mini-PACS into a broader enterprise solution. Or the mini-PACS could be retired, and replaced with a solution designed from the ground up to integrate imaging technology across radiology departments.

Numerous technical and financial factors come into play, and the jury is still out on which approach will better serve this provider.

One thing is certain: it’s easy to see in hindsight that a holistic approach early on could have avoided this dilemma. They key word is hindsight.

Several of these facilities were early adopters of PACS technology. Their achievements were hailed as great steps forward, as indeed they were. Pioneers in any technology gain early benefits, but must also deal with issues that are better understood and avoidable later on. If you are now migrating to PACS, you have the luxury of transforming the hindsight of these pioneers into precious foresight.

Putting it together

Constructive use of key decision points at any stage can deliver significant benefits to patients, radiologists, other staff members, and the healthcare enterprise as a whole. Common to each case discussed above were decision makers who, at first, viewed PACS as a tactical technology solution. Key decision points in the PACS life cycle offered providers the opportunity to review, reassess, and, when necessary, remediate and thus resolve overlooked issues.

The bottom line is that you can’t plan and implement PACS in a tactical manner and expect optimal results. Because PACS affects such a broad spectrum of professionals in numerous ways, it demands a holistic, strategic approach.

Providers who adhere to this basic wisdom will avoid the need for remediation. And those in need of remediation can best do so by honoring the underlying wisdom of a holistic approach, applied at key decision points and throughout the PACS life cycle.

By Gregg Cohen, Ph.D.
AuntMinnie.com contributing writer
September 30, 2003

Greg Cohen is a principal at Xtria Healthcare, a Dallas-based company providing digital imaging management, integration, and implementation solutions and services.