Implementing PACS requires careful planning but brings long-term re

Healthcare managers have consistently underestimated the impact of implementing a PACS on the work of a hospital radiology department. These installations do not only change the technology used by medical staff, but they also have a fundamental impact on the working culture, and they require careful planning and full staff participation, according to Kent Fridell, head of the radiography teaching programme at the Karolinska Institute in Stockholm.

Fridell has studied the effects of the implementation process of a PACS at Lund University Hospital in southern Sweden. While there have been many published accounts of the technological aspects of a new PACS, he believes his was the first ever academic study of its social impact.

The Lund hospital serves a population of about 1.1 million. The project was designed to allow images to be shared between itself and five smaller district hospitals up to 60 km away. Fridell first visited the main hospital before the new system was introduced in 1999 to carry out detailed interviews with radiologists and radiographers about their working lives and expectations. This was followed up with return visits after one and two years to assess staff attitudes to the new technology and the effects it had had on working practices.

"It is natural that the focus has been on the technical aspects as this is very complicated technology and it is under very rapid development," he explains. "There have also been several studies of the economic effects. Some have shown that there are savings, but others do not show any cost benefits. So in the literature the focus has now changed and there is a much greater emphasis on improvements in efficiency."

Fridell says his study confirmed that there were significant changes in working practices in the department and that these affected both radiologists and radiographers. While some of the changes did increase efficiency, they were not always welcomed by all members of staff. Some people were unhappy because they felt they were now given much more to do.

The changes also blurred the distinctions between the two groups. "It used to be the radiologists' job to have the first look at the images, but in some cases this was now done by radiographers. On the other hand, radiographers used to put up the pictures for the radiologists to look at and now they mostly did this themselves. Overall, the radiographers were more happy about the changes because they had more responsibility, but many radiologists were concerned about the effects on their workload," he comments.

Fridell believes that those responsible for implementing a new PACS should be aware of these effects, explain the changes fully to staff in advance, and set realistic targets. That way they are likely to avoid staff becoming disappointed later.

"If staff do not understand the changes, they can have very negative attitudes," he explains. "They will ask: ?Why have we done this? It has cost a lot of money, time, sweat and blood, and many of the things that it does now we could do very well before'."

A more optimistic assessment of the impact of a new PACS is given by Marianne Selim, head nurse in the radiology department at Örebro University Hospital, in central Sweden, about 200 km west of Stockholm. The main hospital and four other radiology departments within the local authority area ?went digital' in a project completed at the beginning of 1998.

She acknowledges that there were some significant teething problems in the early stages of the project. At first, these were predictable technical problems, but as these were gradually solved, the human problems highlighted by Fridell became more apparent.

"Most of the staff were cautiously interested and coped very well with the new system in spite of its technical idiosyncrasies. Some were true enthusiasts, but others had a more aggressive attitude," she says.

After a longer time working with the new technology, even those who were initially hostile to the changes became more relaxed.

"The radiographers were the first ones to really understand the potential benefits for them and accept the new ways of working," she explains. "Other groups of staff needed a longer time to ?see the light' and find out how to use this new tool to their advantage. Today the digital world is accepted and appreciated by everyone and I do not think that there is anyone who misses the old technology."