In The Beginning…

Back in 1980, medical imaging departments attributed most of their problems to their dependence on film. As a result, early PACS were designed as replacement technology for film. Hence the name, Picture Archiving and Communications System.

In the 80’s and 90’s film was much more expensive and many figured they could pay for PACS based on film savings. “Going film-less” became the mantra for both vendors and the market.

Fast Forward 25 Years

We finally have the technology to replace film:
* Interfaces to connect modalities
* High-speed networks for moving massive amounts of image data
* Fail-safe servers for 99.9% availability and reliability
* A variety of standards-based compression schemes (including J-PEG 2000) to improve performance and reduce hardware costs
* Reasonably priced, “off-the-shelf” storage solutions
* High resolution displays that rival the image presentation quality of film

All of this has made it possible to replace the film-based process with an electronic process.

Lessons Learned

Based on our experience, we’ve made some surprising realizations. The first is that the economics of the medical imaging business have changed.

In response to the perceived threat of PACS, the film companies started dropping their prices. Using those lowered film prices, materials and labor savings alone would not produce a break-even or produce an operational profit. In fact, operational deficits with PACS often ran six figures year after year.

Over the past few years, it has dawned on us that film is not the only important piece of information in the film jacket. The other “P” in PACS is for paper. For example:
* Patient/exam history
* Print of the order or requisition
* Any and all clinical notes
* Release forms
* Technologist worksheets/reports
* Radiologist reports

This paper supports the internal workflow of the department that the traditional Radiology Information System (RIS) does not reach. It might also represent the workflow that the PACS will not reach unless the system is properly designed.

In order for the PACS to be successful, the radiology department needs to eliminate all of the study-related documents (1) because there will be no one to move it, nowhere to store it, and no way to find it when the Jacket goes away. That means replacing the paper exchanged between the Emergency Department and Radiology to note preliminary impressions, and the occasional discrepancy or incidental finding. That means eliminating the hardcopy of the requisition, simply because the radiologists use its bar code to open the dictation file. If you stop an d think about it, This means eliminating a lot of paper forms you have invented for good reasons and have gotten very used to using.

Lessons Learned Summary

For a department considering its first PACS, PACS is a zero gain initiative – at best, costs will equal savings. The goal of PACS should be to “go jacketless” rather than “film-less”. And that means developing a new workflow that successfully eliminates the use of paper [1] to announce the readiness of a patient or study, [2] to communicate clinical information to the radiologist, [3] to communicate results to the referring physician.

In the process of determining this new paper-less workflow, it was also discovered that the technologists will have to play a larger role in preparing the study for interpretation. The technologists and not the system administrator will have to take responsibility for study QC. The Technologist must determine if all the clinical information needed by the radiologist for interpretation is present and accurate and attached to the electronic study.

Current Meaning of PACS

The epiphany that there is more to PACS than film clearly lead to a new goal: the delivery of clinical information (images and reports) in the most expeditious and cost-effective manner throughout the healthcare enterprise.

The term PACS has become an anachronism, pictures are no longer the only focus. The market has matured to become more centered on information management.

The advice is simply this, “don’t spend $2 million on a PACS only to realize that you need to spend more money to automate the other half of what’s in the film jacket”.

State of the Art PACS

The ideal PACS today is more than just a PACS. It must manage all forms of data prior to interpretation, enable the creation of multi-media reports and distribute the reports quickly at a cost-effective price. This ideal information system is comprised of:
* PACS as we knew it
* RIS as we know it
* Technologist workstations with PACS and RIS features
* Voice-to-text and multi-media reporting
* Workflow engine that directs operations
* An enterprise oriented data repository and distribution system

New Paradigm, Same Old Name

The next time you are talking to someone about PACS, be sure to find out which PACS they are talking about…

And as you review this web site, know that the PACS I’m talking about is the new PACS, not the old.

How long does it take to do it right?

Proper planning prevents poor performance

The process for mapping out an image and information management plan is rather involved.

It is appropriate to observe the current workflow in radiology and determine what changes will be affected by the PACS. That means observing how the Technologists, Clerical staff and Radiologists do what they do. How is the RIS used today, and how will that change? How should that change? How is study QC done today, and how will that change?

How will paper be used after the PACS, and how will its information be captured and managed by the PACS?

In order to determine the best data storage solution, it is necessary to collect study data and convert it to digital equivalents. What are the daily, weekly, yearly digital equivalents of the new studies, and what are the digital equivalents of the relevant priors? What is your projected growth in each of the imaging areas? What level of compression will you use for new studies, priors, and the legal archive?

How will you role out the digital display technology to the referring physicians? What kind of services will you provide them to help them with this major adaptation to your new system? Discussing the possibilities or pre-selling the intended solution is a necessary and touchy project.

The technology of PACS is still quite complicated, and that technology is constantly changing and evolving. Regardless how many individuals are responsible for selecting the system and the vendor, those making the decisions should have a reasonable level of knowledge on the subject. There are numerous ways to go about gaining this education. Requests For Proposal (RFP) projects have been used by many organizations to learn about PACS technology and to make a vendor selection. Each component of the project has its own Time Line.

Properly done, the process from planning through vendor selection can last 3 to 6 months.
* Planning – 2 months
* RFP – 3 months

That’s assuming of course that you are starting from scratch…that you have done little or no data collection, workflow mapping, physician interviewing, or investigation of the underlying PACS technology. Good preparation can significantly reduce the amount of time and effort required in the formal Planning and Vendor Selection projects.

So it is important to plan early, get started early and schedule the project before time has run out to do the job right.

Buying a PACS can be daunting – there is little room for error in such an expensive undertaking.

Challenges include:
• A working knowledge of rapidly changing technology
• An unbiased insight into the business strategies of potential suppliers
• Incorporating existing equipment
• Considering changes to current operations, especially the role of the radiology technologist
• Accounting for the various skills and apprehensions of a multitude of potential users
• Accommodating complex practice patterns of radiologists and referring physicians, especially in the Emergency Room, Operating Rooms, and Exam Rooms
• Impact of organizational changes within the enterprise
• Impact of changes in the health care industry
• Impact of the emerging PACS-Neutral Archive as a consolidated multi-media archive for he enterprise as well as the data repository for the image-enabled Electronic Medical Record.

Deployment Strategy

There’s an order to the deployment of a Radiology or Cardiology PACS. The expression, “the devil is in the details”, is very true in PACS deployments. Determining the optimal sequence and getting all of the potential users to accept a new way of doing things is the challenge.

A stable and long-lived infrastructure must be designed. This is especially true for the Storage Solution, if that storage will someday be separated from the PACS are reassigned to a PACS-Neutral Archive.

A successful deployment schedule must string “little successes”, simple but effective changes in the operations of the department whose very effectiveness builds acceptance and confidence.

To be successful, the system designer must
• Chose the right solutions to the right problem
• Gently nudge the professional staff just beyond the edge of their experience
• Bring a multi-phase project in under budget.
• Every enterprise is unique. Otherwise, everyone could buy the same thing with equally good results.

Two-Step Process

There is a basic two-step process to buying a PACS, planning and vendor selection.

Planning includes:

• Needs assessment
• Business case analysis
• System design
• Deployment Strategy

Vendor selection includes:

• Review and refine requirements
• Request For Proposal (RFP)
• Finalist’s evaluations via demos and site visits
• Final section and contract negotiation

Planning

Planning is a comprehensive study to make sure you don’t waste money on your PACS. You must consider:
• Organization dynamics
• Existing technology
• Lesson learned from the existing and possibly previous PACS
• Optimization of the new PACS configuration
• Phased implementation plan including the obligatory data migration

The planning process must meet the needs of:
• Imaging department’s customers
• Department professional, technical and clerical staff
• For both immediate needs and future

Planning is based on:
• Operation data and expenses
• User preferences and skill-sets

A resulting plan and system design must accommodate various constraints:
• Technical
• Organizational
• Political
• Operational
• Financial

Getting all the various stakeholders throughout the enterprise to all agree on the plan is also critical.

The Gray Consulting planning and design process includes:
• Current State Analysis
• Impact Study
• System Design and Implementation Strategy
• Cost Estimate
• Payback Analysis

The outcome of the planning process is a roadmap for implementing a new or replacement PACS.

Vendor Selection – Potential Pitfalls

RFPs for a Radiology PACS are very time consuming to prepare. Considerable effort is also required to prepare the PACS team to understand the responses. A good RFP must describe the design strategy and rationale in great detail. This will attract considerable debate and argument from the vendors, who will want to argue their strategy.

Many vendors today will not respond to a complex RFP unless they are already engaged in the selling process with the facility and believe that they have a good chance to win the deal. Since it is not unusual for a prospective PACS buyer to overlook a number of companies and products, the client may never discover just how good their PACS solutions may be, if those companies choose not to respond.

Gray Consulting has simplified the RFP process by creating a template. The RFP Template allows you to build your own comprehensive and precisely written RFP for PACS. The package includes the RFP on CD, Instructional Booklet, and one hour of telephone consultation. The technical section includes section after section of probing questions carefully written to expose the benefits or failures of the system. Asking for detailed information, this RFP template yields a level of detail the team will need to decide which components best fit the expectations of both the department and the enterprise.

All of the major PACS vendors have responded to the Gray Consulting RFP. Since 90% of the document remains the same with each publication (approximately 10% of the questions are new to address changes in technology or requirements), and the question numbering system remains the same, all of the major vendors have continued to respond to the invitation to submit responses. The client will not miss out on an opportunity to discover the best PACS solution.

The RFP is sent to numerous companies that the team believes has the right components. A careful analysis of the vendor Responses will weed out all but the best 2 or 3 finalists.

This RFP process gives the team much greater control over the system design and vendor compliance.

The Gray Consulting vendor selection process includes:
• Design Review of any existing system plan and strategy
• Refinement of System Specs
• Description of required vendor services to support the proposed system
• Development of RFP
• Evaluation and summary of RFP responses
• Site visit preparation
• Vendor or system integrator selection
• Negotiations