review article picture archiving and communication system - rbrs

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weaknesses, an inventory of technologic requirements must be made. This inventory of technologic requirements must include modalities and DICOM readiness, hardware requirements (workstations, servers, archives), network status, implementation timelines, maintenance requirements and upgrade issues. Certainly, these requirements are associated with costs, and these costs must be factored into the project analysis. Equally important are the human resources that are required to implement, maintain and support the project; they will determine its success. The role of the parent organization is important and must be analysed. Is the culture conservative or progressive? What is the current level of technologic sophistication within the organization? What is the organization’s track record with prior information technology projects? External opportunities and threats must also be factored into the analysis and the status of the electronic imaging market must be considered. With respect to environmental issues, project planners must maintain an awareness of increased government scrutiny and regulations. A dedicated vision and mission statement establishes a direction the enterprise will move toward, adequately represents the need of users, and supports enterprise-wide strategic initiatives such as the electronic medical record. A mission statement demonstrates its value by providing the SC with high-level objectives that support the vision statement. A vision and mission statement concerning PACS may include primary goals and longer term goals. The primary goals for PACS implementation are: make images available to any physician who needs to see them, with images and reports to be combined in an integrated solution; increase the volume and decrease the backlog of scheduled exams in the radiology department; increase productivity of physicians and radiologists while retaining the same sized staff to handle a larger volume of exams; increase the reliability of locating exams in archives. Longer-term goals are to reduce, redirect or reeducate staff to work smarter; reduce storage costs of purging records; and eventually, reutilize the space used to store films. Development of strategic plan The extent of PACS implementation or scope must be established as PICTURE ARCHIVING AND COMMUNICATION SYSTEM — DE BACKER et al. 243 early as possible and maintained. Project add-ons that result from new objectives or new programs are best left as complementary implementation phases for new funding allotments (12). The strategic plan becomes the roadmap for the PACS initiative and describes problems, defines needs, and proposes solutions. Key elements in the strategic plan include objective and desired outcome, description of issues, definition of needs, proposed solution, scope of project, resources required ( financial, human, and physical), roles and responsibilities of SC, due-diligence process including time lines, policies, procedures, and strategic guidelines, quality of implementation, Strengths, Weaknesses, Opportunities, Threats (SWOT) relative to PACS, and proposed configuration scheme Collection stage The collection stage documents the current environment and provides the baseline for change. Required-skill sets To successfully complete the collection of data the SC requires diagnostic imaging experience, computer hardware and network knowledge, and expertise with clinical, financial, and hospital systems. External resources, such as new employees or consultants, may be required in situations where the SC is deficient. Workflow analysis PACS may not provide the expected advantages if changes are not instituted in the different processes and workflow of the department at all levels. An exhaustive workflow analysis must be carried out and this may allow the reorganization of a number of processes in the department at the clerical, technical, and medical levels (6). The workflow analysis must provide current and projected examination volumes (e.g., volume of studies per day, peak volume per hour, distance from imaging suites), workflow strengths and weaknesses, and staffing levels. Other important subjects are the cost per examination by modality, the overall operating expenses with film including staff, supplies, and equipment service cost. The current demand to view films (e.g., over the counter, at clinics, external requests); the critical response times (e.g., exam com- pletion to being reported, being reported to being transcribed); the percentage of pull requests filled and unfilled in the film library and the percentage of lost films are evaluated. Special needs obtained from exhaustive workflow analysis will establish unique workflow requirements for each stakeholder. For example, the emergency department setting and intensive care unit probably will instantly have access to the images as they are acquired. The flow of images to the location at which they are needed, at the time they are needed, and displayed in the preferred manner as required by the radiologist to achieve both with efficiency and high diagnostic accuracy requires management of the studies. An intimate understanding of existing workflow patterns will significantly aid in the selection of PACS that will provide workflow that meets today’s requirements and has flexibility for reconfiguration in the future. Training requirements Not only is there a challenge to inform clinicians about the radical changes in practice which PACS brings (no more looking at films against the nearest window) but the impact of training on the hospital, especially if PACS is hospital-wide, should be considered carefully. Not only will all the radiographers and radiologists require several hours of training to use the system at maximum efficiency, but every other user of images will need training, including referring physicians, nurses, physical therapists, etc. Many junior medical staff change appointments at one-year intervals. The minimum PACS training, however computer literature, both hospital-wide and in the radiology department, is provided to produce adept users whilst appreciating that hospital staff, especially busy junior doctors, are loathe to sacrificing time to a training program (13). If PACS is hospital-wide, setting up and maintaining a training program may be advocated. Vendors offer a wide variety of training packages. Some have a service engineer who trains new users for a few hours and then leaves them on their own. Other vendors have a staff of dedicated training specialists who roam the country and provide training wherever they are needed. More and more, vendors are advocating the train-thetrainer concept, where the vendor
244 JBR–BTR, 2004, 87 (5) trains an in-house resource, who then is responsible for training inhouse staff (14). Information system integration It is necessary to determine the requirements and costs of interfacing PACS with existing applications on the current network. Specification of the network communication infrastructure, either existing or new, and inclusion of wide-area network connectivity to clinics and physician offices or homes, based on required transfer times, availability, reliability and cost are other important issues. Furthermore, the make and versions of HIS and RIS and current enterprise security protocols must be known. PACS component requirements report A PACS component requirements report lists the PACS equipment by component and the integration requirements to meet a desired quality of implementation. What are the requirements for each major function? For example, what are the important functions for a workstation: image manipulation and processing, supported “hanging” protocols depending on the application, image quality, number of screens, performance? The same applies for the archive and database management system – what is the required capacity, the access time, workflow support (pre-fetching), and performance standards? Surveying the marketplace will provide current trends and changes in technology that should be included, such as changes in archive long-term storage media. The report outlines the required storage, network, functionality, integration, and network performance requirements and provides the requirements needed to write the request for information (RFI) and request for proposal (RFP). Physical needs Physical layout is often an overlooked aspect of PACS projects. Details of room design, storage, lighting and communications needs have a tremendous impact on effective utilization. A functional analysis of the PACS project with evaluation of the actual layout may help for finalizing design details. Having the proper room design and comparing it to the required functions and work flow will be crucial in enabling the equipment to be properly utilized. Outline business case PACS systems can range from hundreds of thousands to millions of Euros. Developing a realistic budget that is adequate, not only to cover initial installation and start-up costs, but for the life of the system is necessary for successful PACS implementation (5,6,11,15). A successful business case compares the cost of operations in a film environment with the projected costs in a PACS environment. It is important to create a budget based on what is currently spend on film, film processing and handling, full-time equivalents, capital equipment that will need to be replaced if not buying PACS, storage costs/restraints, as well as growth of the department and available capital. Projections should also include all hidden costs, such as facilities remodelling, telephone and modem capability. The costs of capital equipment upgrades, to meet DICOM compliance standards or to enable the creation of modality work lists, must be accounted for. The equipment costs for workstations, servers, brokers, archives, digitizers and viewing stations must be calculated. Network creation and maintenance will also have assigned costs. An oftenignored issue is the human resource allocation that is required to implement, maintain and upgrade the system. Who will cover cost overruns for installation, service or upgrades, if they occur? Three prime areas need to be investigated: cost avoidance, productivity gains, and revenue-generation opportunities. The cost per examination is calculated with the supplies, staff, and service costs in both environments. Unrealistic claims must be avoided regarding improved throughput and reductions in staffing and expenses. Perhaps those could be achieved under ideal conditions elsewhere, but whether or not they can be achieved at your institution is key. Attempt to undersell, or at least conservatively sell, what will be achieved so expectations can be met or exceeded. Overselling has two very serious results. One is that you have doomed the project to failure. The second is that it will be much more difficult for you to gain approval for future requests (15). The scope of the project and capital-financing plan will impact the business case outcome. Consider the following three payment methods: a capital purchase, an operating lease, and an application service provider. The method of payment chosen affects the business plan significantly (6). The business case is critical for senior administration approval to implement PACS. Investigation stage Share information The more information shared between the institution and the potential vendors, the better off everyone will be (14). If a vendor does not know exactly what the objectives are – what the new acquisition needs to achieve and the characteristics of the institution – the proposed system cannot be expected to meet the specified needs. It is essential to share as much information as possible. What is the problem to be solved? The introduction of any RFP should state objectives, such as eliminating film loss, increasing turnaround time, simultaneous access in the intensive care unit, emergency radiology or radiology department to increase efficiency, etc. In addition, one should list hospital characteristics, such as the number of its procedures, images/exams, a complete list of acquisition modalities and its expected growth rate. Further, clinical scenarios, from patient entry through discharge within radiology, are important so that a vendor can match the workflow. The investigation of options is probably the most time-consuming portion of the analysis. It is in this stage that the system architecture is drafted. This draft is both determined and refined by input from multiple individuals and groups. Important contributions must be solicited from the information technology division, radiologists and other physicians, hospital administration and any other service where the use of imaging technology information is required and beneficial. Vendors and consultants may be extremely valuable in generating workflow diagrams, which include imaging acquisition components and imaging display components (11). Request for information A well-designed RFI may be a means to meeting the various needs for successful PACS implementation. A detailed inventory of imaging equipment, imaging equipment
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