PACS administration: A user's guide for the uninitiated

Introduction |General Responsibilities |System Architecture |Financial Management |Resources Strategy |Implementation Schedules |Quality Control |Conclusions |Job Description |

Introduction

Whether you have PACS or are planning to implement it, you will need someone to coordinate every aspect of your initiative. From capital budget planning to drafting future systems configurations, an administrator with an array of talents is a critical component of any PACS effort. If such a leader is required, who should fill the role? What types of skills should that person have? What is in involved in managing a PACS? What do PACS administrators do?

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General Responsibilities

Responsibilities of a PACS administrator vary depending on the organizational structure of the department of radiology. In most departments, the PACS manager assumes responsibility for daily systems operations, capital budget preparation, data integrity, modality interfacing, and system maintenance and improvement.

Strategic PACS planning is a key role that is often overlooked or omitted when the scope of this position is defined. The most important factor in a PACS manager's success or failure is the ability to construct a plan, communicate milestones, and achieve implementation deadlines.

The strategic plan becomes the cornerstone of PACS administration, but the development of such a plan is not a one-time event. An annual strategic plan will be required to continue to evaluate system performance and optimize emerging technologies once PACS is fully implemented. At Massachusetts General Hospital, we started our PACS implementation in April 1997, and every year since, we have prepared and continue to prepare a strategic plan that clearly articulates our objectives in the next fiscal year.

Traditionally, our strategic plan has been organized around the following core conceptual areas:

• System architecture;

• Financial management;

• Resources strategy;

• Implementation schedules; and

• Quality control programs.

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System Architecture

For most PACS, the individual image acquisition devices or modalities are connected to network gateways. Gateways perform three primary functions:

• Perform radiology information system (RIS) validation;

• Compress images; and

• Distribute images throughout the system to radiologist workstations, the archive, and the Web server.

The gateway queries the broker or RIS and validates that the new study information that the technologist is sending to PACS is correct by determining that the medical record number, accession number, and patient name all match the demographic data in the RIS. This is a critical component that also constitutes part of the quality control mechanism for PACS. RIS validation ensures that the information you store in PACS matches the data in the RIS and prevents data entry errors from being stored on the system.

The second function of a gateway is compression. This is allows the images to transfer throughout the system with greater speed, thus enhancing performance. Most PACS are compressing either 2:1 or 3:1 at the gateway level. Advances have been made toward 4:1 for certain mini-PACS.

The last core function of a gateway is distribution. The network gateway sends the image to an archive of some kind, with most archives using tape -- digital linear tape (DLT) or advanced intelligent tape (AIT) -- or spinning media. Larger archives typically employ tape for storage because the cost per megabyte stored is less than spinning technology. Because it needs to be available to the referring clinician and/or become part of the electronic medical record, the gateway also routes the study to the radiologist workstation for interpretation. Finally, the images need to be available to the referring clinician, so a copy is also sent to the Web server or attached RAID (redundant array of inexpensive disks) system.

Today, the MGH system architecture consists of 46 networked workstations with plans to expand to over 65 stations in five locations. All workstations have two monitors each, and only three of them are 2K stations. The modalities connected to PACS are CT, MRI, fluoroscopy, ultrasound, angiography, nuclear medicine, and computed radiography (CR). There are 44 terabytes of data storage on the system, with a 40-terabyte tape archive, two 1-terabyte disk archives, and a 1-terabyte Web server.

As part of our downtime contingency plan, we also have a laser printer network. Systems do go down, and the hospital should include a PACS downtime contingency plan in its strategic plan. The contingency plan should include emergency resource contacts, an overview of the goals of the plan, and instructions for four types of downtime: power, RIS, PACS, and network.

By including those elements in a written document, we found that each operational area was able to implement the appropriate next actions depending on the type of interruption. The contingency plan is not a set of guidelines written by the PACS manager. To help structure this document at MGH, a template was created by the PACS manager and circulated among operations managers, who were responsible for completing the plan. All operations managers share the applicable documents with their staff, who also form a communication tree in the event of unexpected problems. The key to successful contingency planning is to have the operations managers themselves determine their course of action in the event of downtime. If guidelines are created by the area that has to use them, they are more likely to be followed.

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Financial Management

From the budget preparation process to financial negotiations for application service provider arrangements, it is important to set financial goals and achieve them. Although a full discussion of financial management and PACS is beyond the scope of this article, a few points are often overlooked in such a plan.

It is just as necessary to have a capital contingency plan as a plan for downtime. The department should always know what it will do if it does not obtain all of the funding that it requested for a particular stage or phase of PACS implementation, and hospital administration should know what it will forgo in film-related cost savings by not funding specific PACS initiatives.

In addition to your capital contingency plan, it is essential to have a asset management plan as well that includes DICOM interfaces, which should also be line items in the capital budget, and any modality replenishment or obsolescence issues.

Your actual management strategy will depend on whether your primary strategy is to produce a return on investment or to implement PACS as a strategic imperative or competitive advantage. At MGH, the PACS administrator is responsible for meeting film savings projections. In addition, a limited-filming team is committed to ensuring that the dollars previously spent on film are removed from the budget. For 2000, the amount of savings given back to the hospital exceeded $450,000.

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Resources Strategy

There are many types of resources to consider when planning for PACS implementation and management. These include human resources, space, and equipment. An important human resource, the PACS manager, needs skills in several areas. This individual should be flexible and should understand that changes will occur in the PACS agenda, time frames, and components. In addition to an ability to roll with the punches, the PACS manager should possess some degree of visionary thinking. He or she should function as an informal leader of the department in order to be successful in this position.

At MGH, we use technical and operational (limited-filming) teams to direct our PACS efforts. The operational team makes sure that budgetary goals are met. The technical team, led by the PACS manager, includes representatives from the information services department, those who work with the RIS, an occasional radiologist who has an interest in the topic of discussion, and many referring and other physicians who have special requests.

Once a PACS is in place, it becomes a hospital initiative, even if it began in radiology. When digital diagnostic data become available, special requests from all clinical services throughout the hospital are received and prioritized. Those designing a resources strategy should remember that one of the great opportunities associated with PACS is the service expansion, and associated revenue, afforded by teleradiology. The opportunity to increase the productivity of the individual radiologist is also enhanced through the efficiencies created by PACS.

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Implementation Schedules

Deciding where to start when you draft an implementation schedule requires strategic planning. This primarily involves consideration of five areas:

• Determining where the most pressing problems exist;

• Determining what areas have a political champion for the PACS project;

• Determining the DICOM capabilities of the institution's existing image acquisition devices;

• Determining the ease of implementation (network ready?, staff prepared?, etc.); and

• Determining the FDA approval. For example, several mammography systems and PET applications have not yet received this approval, so these areas would drop to the bottom of the implementation list.

Your prioritization of the elements for success combined with an assessment of each area weighed against these elements will determine which areas top the list.

The PACS team must also decide whether it will base its implementation steps on organ systems or modalities. The areas most likely to yield rapid returns on investment should be identified as good starting places. The first capital outlays should be made in areas that will produce the most impressive results, if possible. Each fiscal year should have its own PACS implementation schedule, with steps assigned to specific quarters of the year in a logical progression.

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Quality Control

Unfortunately, PACS vendors provide few system performance assessment tools for the PACS administrator. This makes it difficult to truly know at a glance how all components of your system are performing on a given day or for a specific time frame. At MGH, we developed a Web page as part of our PACS STATS initiative to let radiologists know how the system is performing. It is still in the demonstration phase, but we know how long the system took to process a study, when the Web server received it, and when it became available to referring clinicians.

The development of a solid quality control program for PACS involves wrestling with many gray areas: multivendor accountability, intersystem dependency, and the transition phase during which both current digital images and older films are needed (even when substantial archiving of prior studies has been performed). Through our quality control reports, we realized that some bridges were missing between the actual operation of the PACS and the way in which some users wanted it to work. We encountered an example of this problem that was related to the following question:

How do you know that every exam you performed (or completed in the RIS) was received and is archived in PACS?

Although we would prefer a vendor solution to this problem, each morning, we run a homegrown Web exceptions report that displays any study that was completed according to the RIS but for which we have no images on the PACS. We then verify the status of this case, which might have been canceled, for example, and determine whether images need to be sent from the modality.

If we find a case that has not been received, the manager of that modality area receives a list of any cases that did not make it into the system every morning. Most areas have anywhere from no to five cases daily that are not in PACS. The majority of these are related to technologists not sending the case correctly or at all, rather than technical difficulties.

An additional component of any quality control program is a commitment to training and education. This includes training for staff such as film librarians that now help support the system as image service representatives as well as for radiologists and referring clinicians. The importance of training cannot be overemphasized.

We found that the best training model for radiologists is to secure a pilot system or minisystem and designate a workstation as the training unit. We have also found that it was very helpful to connect a PACS workstation to a ceiling-mounted projector to hold an introduction to PACS briefing. We conduct routine briefings on our PACS and Web imaging systems at department town meetings and are in the process of incorporating this type of information into our radiology new employee orientation.

Once the responsibilities of the PACS administrator in planning have been identified, the next step is to determine what specific job duties will be performed and what skills are required. Table 1 is a summary of the PACS administrator job description from MGH that illustrates the general job duties of a PACS administrator and minimum skills required.

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Conclusions

Once you have determined the responsibilities, assigned job duties, and identified the skills required for a successful PACS administrator, the next challenge is to hire one. This has become increasingly difficult. Faced with a lack of available candidates with extensive experience, many organizations look within their own ranks for potential candidates.

The question of whether the administrator needs to be a technologist is a familiar one. In general, most sites typically promote one of two internal resources to the PACS administrator role: department physicists and technologists. Increasingly, engineers, who typically worked on the radiology modalities, are making their way into PACS environment. In PACS deployments in which the system is located outside of the department, the PACS administrator is still usually based out of the department of radiology, with a systems manager counterpart from the information systems team.

Because of the varied backgrounds and job scopes of PACS administrators, the compensation scale varies. True database administrators and some experienced PACS veterans command salaries above $125,000, whereas internally promoted personnel with little or no systems experience may start at $50,000. These figures may vary with geographic location as well.

Whether you are just starting out or are in the middle of an implementation, PACS leadership is essential to your initiative's success. Strong communications abilities, informal leadership, and an outstanding relationship management are some of the most important qualities to look for when hiring. A great sense of humor and a "tough as nails" exterior go without saying! With a leader in place and a well-thought-out and communicated plan, your PACS administration efforts will pay off.

-- By Patricia Whelan, MHA, and Amit Mehta, MD

MS. WHELAN is PACS administrator, department of radiology, and DR. MEHTA is medical director, advanced imaging laboratory, both at Massachusetts General Hospital in Boston.