PACS purchases demand future-proof planning

Installation of a PACS is generally regarded as an important step toward healthcare efficiency. But the long-awaited improvements may not occur if the chosen hardware and software solution does nothing to ease day-to-day workflow bottlenecks.

Hospitals purchasing a PACS should conduct detailed workflow planning before selecting a system, according to Brendan O'Dowd, a radiographer and PACS administrator at the Adelaide and Meath Hospital in Tallaght, Dublin. The 580-bed teaching hospital opened in June 1998, accommodating staff and patients previously housed in two separate city-center hospitals. A hospital-wide PACS implemented on day one was linked to a radiology information system inherited from one of the former hospitals and to connecting modalities supplied by nine medical imaging vendors.

The new system has reduced the time from issuance of a request to availability of the radiological report by a factor of three, O'Dowd said during a European Congress of Radiology session on digital workflow reengineering. In addition, 99% of all radiological studies are reported in the new hospital, compared with a reporting rate of 82% before the move, despite a dramatic increase in workload.

Prior to moving premises and switching to digital imaging, the staff completed a thorough assessment of current and future imaging needs. O'Dowd advises anyone contemplating a PACS purchase to conduct a similar forward-thinking exercise.

"Try to predict the number of examinations you're likely to be carrying out in the future, how many images per examination, how much data that will equate to, and what equipment you'll be using to handle it," he said.

Despite the exhaustive planning, some changes to the workflow were required after the move, as a result of actual experience, improved hardware and software, and increased demand for imaging services. The hospital is now upgrading its storage capacity, for example, to accommodate the surge in data.

Another ECR speaker, Dr. Filip Veldeman, European sales manager for Dictaphone in Diegem, Belgium, agrees that radiological workflow should be analyzed before IT solutions are chosen. Speech-processing software is a case in point, he said, noting the differences between systems in which transcribed text is sent to secretaries for editing, and those that allow radiologists to edit their own dictation on screen. The former package does not fully address the cause of the workflow bottleneck, whereas the latter eliminates delays caused by shuttling reports back and forth.

"The whole process is completed without having to pass work from one person to another and back again. There are no secretarial or administrative staff involved, so five minutes after you have done your dictation, your validated report may be signed off and distributed throughout the hospital," Veldeman said.

A user-friendly system is essential if radiologists are to reap maximum benefit from speech-processing software, he said, but this does not necessarily equate to high-tech, wireless technology. Mobile dictation handsets can easily become too mobile, disappearing from the room where they are needed. Doctors should also look carefully at options included in a PACS to ensure that it meets all their needs.

The Hammersmith Hospital in London is in the process of adding automated speech recognition to its reporting areas, said Dr. Nicola Strickland, a consultant radiologist. Plans are also under way to replace conventional paper-based procedures for requesting imaging examinations with an electronic system.

"Up to now, our aim has been to get a truly digital hospital. But getting our pictures digitally is only a very small part of the solution," Strickland said. "The aim of our PACS environment is to become paperless as well as filmless, and this is really the challenge."

Integrating doctors' referral notes into the hospitalwide digital network will provide access to valuable clinical information at every stage of the radiology workflow. Availability of clinical details prior to image acquisition can help radiographers decide which x-ray views to take or which CT or MRI protocols to choose. Radiologists also benefit from having clinical histories close at hand when producing their final reports.

Several ad hoc arrangements for digitizing this information exist, but none are totally satisfactory. Digitizing paper request forms is a slow process that can disrupt workflow in other departments and inevitably generates debate about who will take on the task. And this option does nothing to make clinicians' writing more legible, nor does it automatically combine the digitized file with the relevant patient images.

Keying the information into the system solves some but not all of these problems, Strickland said. A fully integrated electronic remote requesting system, on the other hand, saves time, removes the possibility of lost paper forms, and avoids duplications or errors caused by mistyping patient information.

Hospitals should consider acquisition of such a system now, regardless of when it will actually be implemented, she said. When the time is right to install the technology, sufficient funding for the upgrade will have been allocated, and the PACS will be configured so that the software can be easily implemented into workflow processes.

"There are many theoretical advantages of introducing an electronic remote requesting system. It greatly improves workflow efficiency and provides you with the opportunity to have a truly paperless hospital," she said. "It is important to plan for this at the stage when you are planning for a PACS."

Radiologists should encourage manufacturers developing digital requesting systems to produce software that suits radiologists. Effective solutions would include "clash alerts," for example, to ensure that clinicians leave sufficient time between certain examinations. An ideal system might include drop-down menus to help clinicians place accurate imaging requests, and it could refuse requests from any doctor who does not leave a contact telephone number.

The electronic remote requesting system being designed for the Hammersmith will be linked to guidelines from the U.K. Royal College of Radiologists to help referring doctors formulate their requests appropriately. Junior doctors working the nightshift who might previously have ordered a complete skull CT series, for example, will see that the RCR recommends only a lateral view, which avoids exposing the patient to unnecessary radiation.

"Become involved as advisors in the design of software if you can," Strickland said. "Make requests and be demanding. We know what we need as radiologists.