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locations and use, imaging equipment DICOM compatibility, imaging equipment upgrade requirements, reading locations and user locations must be obtained and confirmed. The extent and requirements, reading locations and user locations must be obtained and confirmed. The extent and requirements for both the local and wide-area networks must be clearly defined by qualified personnel. Of critical importance are the allocations for growth in imaging information volumes. These are associated with increased efficiency and economies of scale and are also a by-product of increases in data sets related to technologic innovations (for example, multi-slice CT). Imaging volumes must be estimated for each modality in order to determine the most appropriate archiving strategies (11, 16). Implementation alternatives must be factored into the analysis. Will the implementation of the system occur as a single event or will the implementation require multiple phases? Alternatively, should the radiology department outsource its PACS, partially or completely? Finally, financing options must be assessed and factored into the analysis. A RFI proved to be a learning opportunity for the development of questions for the RFP along with knowledge of how vendors respond to various types of questions. It allows the SC to learn how to evaluate proposals and refine their evaluation process prior to evaluating the RFP. Furthermore, it offers the SC the opportunity to increase their understanding of PACS and the offerings of vendors. A RFI may be used to narrow the list of vendors who will receive the RFP, thereby reducing the evaluation costs for both the hospital and vendors (6). With the budgetary costs and information gained from the RFI, the business case may require modifications and an alternative configuration in order to make PACS viable. Request for proposal The strategic plan, business case, and reference documents created in previous stages can be used to obtain the approval of senior administration to proceed to the RFP. Agreeing to proceed with the RFP commits senior administration to fund the PACS initiative once a vendor of choice has been selected. A well-designed RFP becomes the basis for the purchase agree- PICTURE ARCHIVING AND COMMUNICATION SYSTEM — DE BACKER et al. 245 ment. The RFP requests the information required to make an informed decision and can be a refinement of the RFI. It also provides an accurate method for evaluating many proposal responses. Specific objectives defined in the strategic plan should serve as the basis for evaluation criteria in the RFP. A poor or incomplete RFP will end up with much time wasted and inadequate responses from suppliers. Not only at this stage, but also throughout the procurement, the most involved members of the SC have to invest considerable time in the project. An RFP with requirements that are impossible for any vendor to meet, particularly for the price the users are willing or can afford to pay, must be avoided. For vendors, this attitude may be so discouraging they may opt not to bid at all. It is, therefore, important to agree in advance which requirements are true needs, wants or ‘nice-to-have’. It may also help in evaluating responses because a relative rating may be applied to each requirement; for example, using these weighted factors, a matrix may be applied objectively to come up with the proposal that best meets the requirement. Evaluation of proposals Evaluation criteria need to be developed and agreed upon prior to release of the RFP. The criteria must emphasize the primary objectives of the strategic plan. Methodologies and processes for the numerical evaluation of different vendors’ systems, based on measurable specifications and subjective input, must be established. Different vendor response styles and personal preferences or interpretation of information may offer some problems to fairly evaluate all vendors (6, 14). It may be important to get as many references about comparable sites as possible. There are many small things that one will learn only from other users who recently implemented a system. Site visits are important, but be aware that a vendor typically has several “showcase sites” that display the good side of a system, or sites where one will speak only with a satisfied user. Try to speak with users who are unhappy with a system or who have had a hard time adjusting to implementation. There is nothing wrong with asking to speak with dissatisfied users because, typically, these people will teach you the most. Negotiation stage Once a vendor of choice and a decision to purchase is established the negotiating team begins negotiations with final objectives related to operating and capital costs. The negotiation stage is critical to the long-term success of the project. Negotiations will determine the purchase price, as well as other critical ownership details (6, 8). A technical review of the final configuration should confirm all PACS components, functionality, integration requirements, and the resulting workflow. When the RFP is used as the technical specification for functionality and performance, reference to the RFP must be included in the final agreement. Furthermore, ensure that the vendor updates the RFP responses with current deliverable specifications prior to the negotiations. The optimal financing strategy (e.g., purchase versus lease) must be determined during financial negotiations. The optimal financing strategy is based on the intended use of the equipment, the planning horizon of the technology, annual service plan options, the expected lifetime of the equipment, potential changes during the intended lifetime (in the form of upgrade path options or replacements), network upgrades, type and quantity of workstations, furniture requirements, CR versus DR options, archive options and special software packages (e.g., cardiac, etc.). Furthermore, other critical details consisting of penalty clauses, delivery, installation, and implementation timelines, acceptance test plan, application and system administration training, current and future interface and integration costs and performance guarantees must be discussed (12). A managed service may allow for the application of penalties if the supplier fails to provide the service for which they have contracted. The specification should include the standards expected of the service for uptime, system response times (for image transfer to the workstation, for instance), service response times (how quickly an engineer may be expected to respond to a service call, and how long before the acute problem is rectified to re-establish the previous level of functionality extant before the fault developed)(12). If delays in implementation occur there must be some agreed escape route at no cost to
246 JBR–BTR, 2004, 87 (5) the purchaser. Some formula for liquidated damages may be included in the contract. Upgrades and enhancements should be included in the contract to avoid the risk of obsolescence. A hardware refresh at regular agreed intervals may be mandatory for lengthy contracts. It would be unreasonable to expect new hardware to be installed every time that a new computer came on the market, but a replacement of computers and monitors may be expected after 5 years. All training and management costs may be included in the proposed contract reducing the risk of additional costs over time as the system requires modification with further training implications. It is mandatory to agree with the supplier to maintain the system in line with the latest DICOM attributes, which become available during the course of the contract. However, it must be acknowledged that some DICOM developments will have to be matched by software upgrades on modalities or the departmental RIS in order to take advantage of the new DICOM attribute and this may be costly. The risk of cost overruns should be discussed and may be transferred to the supplier in a managed service because a fixed price will be agreed for a clearly defined specification. Performance guarantees must be established. An uptime of 98% is certainly a standard which modern information technology systems should be able to achieve. This is a generous allowance since it equates to 13 hours of downtime in any month. Downtime may be defined as the failure of any component of the core system or the simultaneous failure of three or more workstations (12). The event of any complete system failure and disaster recovery should be discussed and will have to be overcome without financial implication for the purchaser. Contract ‘Get a good lawyer’ was the advice given at one PACS confer- ence (6). Your Trust needs expert legal advice in order to avoid later pitfalls. However, smaller PACS implementations require less supporting documentation. The scope of the project determines if a purchase order or contract finalizes the agreement. Once the terms of an agreement are established, a legal review by attorneys with experience in high-technology system purchase agreements is recommended (6). For example, the contract needs to review definitions of terms, performance, penalties (or lack of) for failure, dispute resolution mechanisms, acceptance test plans with redress for any failure, and software licensing agreements. One of the major costs that incurs after a PACS implementation is that of service and maintenance (9). At the contracting stage it is essential to ensure that adequate service is available. Many suppliers think that 8 h/day 250 days/year is sufficient. They may charge exorbitant sums for more comprehensive cover. This is the time to sort it out. They may provide the cheapest system to install but you may not be able to afford to run it. Conclusion It takes a certain dogged persistence to see a PACS procurement through to a successful conclusion. To successfully integrate PACS into the radiology department or hospital it is critical to outline different stages for a PACS procurement in which critical questions must be formulated and answered, a strategic and financial plan must be established, a timeline created, marked research performed, program design developed, and training programs designed before implementation may be performed of the best PACS solution. References 1. Becker S.H., Arenson R.L.: Cost and benefits of a picture archiving and communication sytem. J Am Med Inform Assoc, 1994, 1: 361-371. 2. Chopra R.M. Why PACS is no longer a four-letter word. Radiol Manage, 2000, 22: 44-48. 3. Seigel E.L.: Economic and clinical impact of filmless operation in a multifacility environment. J Digit Imaging, 1998, 11(Suppl 2): 42-47. 4. Grosskopf E.J. On the road to PACS – confronting the issues. Radiol Manage, 1998, 20: 26-33 . 5. Hunt D.: Making PACS the present, not the future. Radiol Manage, 1998, 20(5): 34-38. 6. vanEssen J., Hough T.: An overview of a picture archiving and communications system procurement. J Digit Imaging, 2001, 14: 34-39. 7. Roberson G.H., Shieh Y.: Radiology Information Systems, Picture Archiving and Communication Systems, Teleradiology – Overview and Design Criteria. J Digit Imaging, 1998, 11 (Suppl 2): 2-7. 8. Reiner B., Siegel E.: Understanding financing options for PACS implementation. J Digit Imaging, 2000, 13: 49-54. 9. Pilling J.: Problems facing the radiologist tendering for a hospital wide PACS system. Eur J Radiol, 1999, 32: 101-105. 10. Strickland N.H.: EuroPACS Newsletter. February, 1997, 10: 1. 11. Ortiz A.O., Luyckx M.P.: Preparing a business justification for going electronic. Radiol Manage, 2002, 24: 14- 21. 12. Pilling J.R.: Establishing a contract for a PACS managed service. Clin Radiol, 2002, 57: 178-183. 13. Strickland N.H.: Review article: some cost-benefit considerations for PACS: a radiological perspective. Br J Radiol, 1996, 69, 1089-1098 . 14. Oosterwijk H.: All you need to know about a PACS RFP you learned in kindergarten. Radiol Manage, 1998, 20: 39-43. 15. Johnson K.C., Dye J.A.: Ten steps to improve your changes for success with PACS. Radiol Manage, 1995, 17: 32-33. 16. Bedel V.: The strategy to be “paperless” via a cost-effective filmless plan. J Digit Imaging, 2002, 15 (Suppl 1): 15-19.
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