Implementing PACS requires careful planning but brings long-term rewards

Healthcare managers have consistently underestimated the impact of a PACS on a hospital radiology department. These installations not only change the technology the medical staff uses but also have a fundamental effect on the working culture. They therefore require careful planning and full staff participation, said Kent Fridell, head of the radiography teaching program at the Karolinska Institute in Stockholm.

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

The Lund hospital serves a population of about 1.1 million. The project was designed to allow the hospital to share images with five smaller district hospitals located up to 60 km away. Fridell visited the main hospital before the system was introduced in 1999 to conduct detailed interviews with radiologists and radiographers about their working lives and expectations. He made return visits one and two years later to assess staff attitudes about the new technology and its effect on work 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 said. "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 the focus in the literature has now changed, and there is a much greater emphasis on improvements in efficiency."

Fridell says his study confirmed that significant changes in working practices occurred in the radiology department, affecting both radiologists and radiographers. Although some of the changes increased efficiency, they were not always welcomed by all staff members. Some were unhappy because they believed that they now had more work to do.

The changes also blurred the distinctions between the two groups.

"It used to be the radiologist's job to have the first look at the images, but in some cases this is 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 do 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," Fridell said.

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, he said.

"If staff do not understand the changes, they can have very negative attitudes," he said. "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.'"

Marianne Selim, head nurse in the radiology department at Örebro University Hospital in Sweden, offered a more optimistic assessment of the impact of a PACS. The main hospital and four other radiology departments within the local authority area converted to digital in a project completed in early 1998.

Some significant teething problems occurred in the early stages of the project, Selim said. As the predictable technical problems were gradually solved, the human problems Fridell mentioned became more apparent.

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

After they became more comfortable with the new technology, even those who were initially hostile to it became more accepting of it.

"The radiographers were the first ones to really understand the potential benefits for them and accept the new ways of working," Selim said. "Other groups of staff needed a longer time to 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."