Going digital requires rigorous planning from step one

The transition from hard copy or even partly digitized radiology to a filmless workflow is rife with potential difficulties. Careful project planning and extensive consultation are the keys to success.

The first step is to abandon the notion that acquiring a PACS means simply installing a plug-and-play solution. Pre-PACS negotiation and preparation can take two years, according to Dr. Laurence Sutton, clinical director of Royal Calderdale Hospital in Halifax, U.K. This time is needed to prepare a watertight business case for hospital executives, to ensure that the PACS will meet the needs of all end users, and to conduct training. Gaining the support of hospital staff before the PACS arrives, rather than waiting for complaints later, is essential.

"One of the big issues is managing fears and expectations, because a lot of staff can feel threatened by the prospect of PACS," Sutton said. "People think that putting in an IT solution will result in an automatic clinical benefit. It won't if the staff have not signed up to it."

Royal Calderdale, which performs more than 124,000 examinations per year, opened as a filmless institution in April 2001, following the merger of three local hospitals. A dedicated clinical advocacy group had reviewed plans for the new hospital's PACS long before the doors opened. This group comprised representatives of many medical specialties, some of whom had strong reservations.

"Everybody had an opportunity to have a say, even if it was negative," Sutton said. "We told our main cynic, who didn't want to change from film-based working: 'You need to understand what these changes will mean.' He is now our main advocate of PACS."

Among the first issues to be resolved were job status, employment security, change of responsibilities, fear of the unknown, and an overall lack of computer literacy within the hospital.

"The initial phase was like putting everyone on a climbing wall and taking away the floor. It could have been a freefall, but it worked," Sutton said.

Employees with limited computer skills needed extensive training. Those who failed to demonstrate core keyboard competency were not given a password for the PACS workstation. With the benefit of hindsight, it is clear that more time should also have been spent training radiographers on the new computed radiography equipment, Sutton told delegates during a special focus session at ECR 2005.

"A few people had learned the basics, but they hadn't had much experience. So when we moved into the new building, it was very much an 'all hands on, get going' situation, because we couldn't fail," he said.

PACS planners also failed to consider how digital workflow at Royal Calderdale would affect neighboring institutions. Patients referred to other hospitals were given their digital images on a CD-ROM, but physicians accustomed to films were reluctant to accept the new medium. These initial objections gradually diminished, and the amount of film now produced at Royal Calderdale is minimal. Digital images are also sent to nearby hospitals for multidisciplinary team meetings.

Project leaders overseeing a PACS implementation should expect criticism during the transition, said Prof. Torbjorn Andersson, head of radiology and hospital physics at the University Hospital in Orebro, Sweden.

"There is always frustration when things are changed," he said. "The interesting thing is that when you are through the whole process, you don't find anybody who would like to go back to film."

The transition to digital imaging should be a "family affair"; it should be handled within the hospital, rather than by external consultants with no experience of the hospital's daily routines, Andersson said. Staff questions must be answered honestly, even if the reply is one they do not want to hear.

"You cannot say to your staff, 'This will take two weeks, and we will have no problems,'" he said. "You have to say instead, 'We will reach the point when we will be happier, but the journey might be a little bit painful.'"

Andersson recommends setting a defined end point to the implementation so that the entire staff can celebrate its completion. This reinforces the message that moving to PACS is a genuine team effort.

"Getting everybody onboard is really the hard part. Once people realize that this is a win-win situation, they are eager to make the change. But they have to understand the whole picture. In the end, everyone will benefit from this change," said Prof. Johan Blickman, chair of radiology at University Hospital St. Radoud in Nijmegen, the Netherlands.

The most difficult challenge involves integrating PACS into an existing work environment, according to Dr. Werner Leodolter of the KAGes (Krankenanstaltengesellschaft) in Graz, Austria. Many legal and political issues had to be resolved at his hospital, including quality assurance, organizational aspects, and skills shortages in the local workforce.

KAGes faced the dilemma of an expanding patient base, shrinking storage space, increased staff pressures, and the need to provide top-quality healthcare to the community. Managers decided to build a virtual hospital organization: The hospital information system with a single master patient index served as a stepping stone to an electronic patient record, and this enabled an exchange of telemedical services from regional to local hospitals. PACS improves the transmission of images and acts as a main driver of the virtual hospital organization, Leodolter said.