"PACS: Planning for ROI", © Jay Mazurowski CRA, Imaging Economics, 12/05

Team planning is necessary if the best possible return on investment is to be achieved for a picture archiving and communications system (PACS). The team (a PACS committee) will have several important roles throughout the implementation of the project, although these will naturally be more demanding at the initiation of the process. The PACS committee must first take charge of assessing the readiness of the institution for PACS and addressing any shortcomings that might affect PACS implementation. Next, the committee will determine which financial strategies should be used to acquire PACS and related technologies, as well as to make them operational. The PACS committee will develop methods for selecting the vendors of all items necessary for the implementation and will choose a process for contracting for the services needed. The committee will also oversee each step involved in the PACS implementation.

The PACS committee should be composed of individuals who are responsible team players and who are able to act as liaisons among the various groups whose interests are affected by PACS implementation. Each of these stakeholder groups must be represented on the committee (Figure 1).

The team's leader should be an enthusiastic person who can motivate others to participate fully in the PACS project. The leader should also be well organized and results oriented in order to manage the many details involved in the project. He or she must be able to anticipate potential problems and resolve them as they arise.

PROJECT MANAGEMENT

Five essential factors are the keys to success in PACS project management. These are:

As a means of ensuring the best chance of success for PACS implementation, the PACS committee should develop a detailed project charter. Naturally, this document should cover the goals and objectives of the project. In addition, it should include a comprehensive statement of work that clarifies the purpose of the PACS implementation; the scope and deliverables of the project (including a quality-assurance program, a disaster plan, and an outline of problem escalation); and the exclusions that the project should not be expected to incorporate. Another section of the project charter should set out the assumptions being made by the committee in constructing the document. This should be followed by a list of all PACS stakeholders whose needs are being considered.

One section of the project charter should contain a complete responsibility assignment, so that there will be no later confusion over whose job a particular task is. Cost estimates should constitute the next section and should be as complete as possible. A work-breakdown section should include a detailed timeline for the entire project. This timeline should take the form of a Gantt chart so that the duration of each task can be seen, not simply when it should begin.

Because even the most careful planners can make some assumptions that may not prove true, the work breakdown should also include a list of alternate (or temporary) methods that could be employed if a planned step cannot be completed as intended. Risk management should be covered next in the charter; this should include an evaluation of probable risk based on the impact of the project and a description of any mitigation measures that should be taken. The final section of the project charter should be a communication plan designed to keep all individuals and departments involved in the PACS project fully informed at all times.

INFRASTRUCTURE ASSESSMENT

Site readiness in key areas must be assessed; this can be thought of as measuring the organization's current reality in preparation for improving it. Gaining a detailed assessment of the state of the PACS infrastructure is of great benefit in later planning, particularly since it can help the PACS committee anticipate future difficulties and expenses. It can also be very helpful in preventing or reducing potential errors in the retrieval of images and other data. The assessment process can be educational for PACS stakeholders, and financial planning can also be made more specific through infrastructure evaluation. After infrastructure assessment, the PACS committee will be more prepared to construct a useful request for proposal for potential vendors (Figure 2).

Assessments should be carried out for the reading areas, modalities, hospital information system (HIS) (Figure 3, below) and radiology information system (RIS), network, and expenses. In the reading area, the assessment should cover lighting, glare, noise, and ergonomic factors. In addition, whether there is sufficient space for the additional hardware needed for PACS should be evaluated (bearing in mind not only space for the system itself, but for added HIS and RIS hardware, voice-recognition systems, and Internet access). Network access for the reading area should be assessed, with attention to whether the necessary number of diagnostic review stations can be supported, both at present and following any predicted future expansion. The reading area's assessment should include any clinician review stations placed outside the main area, such as in the emergency department or intensive care unit (ICU). It is especially important to determine whether existing hardware can be used for clinician review by adding software for PACS access and whether a secure area for soft-copy review can be established.

When infrastructure assessment is applied to imaging modalities, each piece of equipment should be evaluated for compliance with the Digital Imaging and Communications in Medicine (DICOM) standard. Of particular importance is the ability of the modalities to support DICOM Modality Worklist (DMWL), which permits acceptance of admission/discharge/transfer and order information from the HIS. DMWL use increases both efficiency and data integrity because it reduces data-entry errors by eliminating manual data entry at the modality level. The integrity of the electronic database, as protected by DMWL, is vital to efficient workflow and a successful PACS implementation. How legacy systems will connect to PACS must be determined, with the evaluators bearing in mind that DICOM boxes used for this purpose may not support DMWL.

Assessment of the HIS and RIS should begin with evaluation of the links between each piece of imaging equipment and the HIS and RIS. Whether the HIS and RIS will pass Health Level 7 data to the imaging modalities reliably should be determined, as well as whether the two information systems will accept data updates from the PACS and whether an interface between them and future PACS components can be created. The available distribution options for information should be evaluated; for example, it may be possible to gain PACS access through a secure web-based viewer, portal, or electronic medical record product. Vendor support for the PACS, HIS, and RIS should be outlined during this assessment.

A review of campus-wide network drawings should be the starting point for infrastructure assessment of the information network. Bandwidth, speed, and switches should be assessed, and potential slow points should be identified. Teleradiology needs should also be assessed at this time, with attention to delivering the necessary bandwidth to the homes of radiologists.

The assessment of expenses associated with the PACS project should consider the cost of:

IMPLEMENTATION EXPERIENCE

At Concord Hospital, Concord, NH, PACS implementation was undertaken in order to meet several business objectives. Radiology services is comprised of the main hospital radiology department, two busy imaging centers, and a satellite department in a local clinic. A seamless integration was needed to maximize workflow efficiencies between facilities. Film handling was a significant challenge since the lion's share of the film library is located off campus. This slows interpretation turnaround because of the inherent complexities in the film retrieval process.

The organization wanted to provide referring physicians with more immediate access to radiology images. In addition, it needed to absorb annual increases of 6% to 12% in radiology volume without increasing full-time equivalents (FTEs). Other objectives for fiscal year 2005 were to reduce film and chemistry costs by approximately $400,000 and to decrease outsourced film storage and handling costs by about $30,000 (and by $63,000 to $67,000 for 2006). In addition to reducing the incidence of lost films, Concord Hospital wanted to reduce film requests 75% to 80%.

The first implementation target was set for July 2004, when PACS was made active for the radiology department, emergency department, and ICU. Wide-area distribution (via our physician portal) was available by mid August 2004. By September 2004, operations were filmless, with CDs supplied in fulfillment of off-campus film requests.

To support the filmless implementation target, the physician community was informed via letter (sent before filmless operation began). The PACS committee also met with referring physicians to identify the issues that concerned them and educate them regarding the advantages of PACS. The physicians' office staff and practice managers were also visited, and all-day training sessions covering use of the portal-based image-viewing system were held for physicians.

Following PACS implementation, workflows were streamlined. Redesigning the film-retrieval process led to reduced film handling (as well as less film production). Document scanning and electronic templates were employed to reduce paper flow, and template-based (canned) reporting increased efficiency. There was 74% less film traffic after PACS use began. Film costs decreased from roughly $432,000 per year before PACS to $78,000 per year (this reflects the main hospital experience only), and are expected to decrease further when the PACS is extended to the operating room.

Costs for outsourced film handling were reduced dramatically, from $6,000 to $100 per month. Annual volume increases (typically 6% to 12%, and currently 9%) have been absorbed without an FTE increase. In fact, there has been a net reduction of 4.21 clerical FTEs to date.