(From left) Leonard A. Levine, senior business consultant; Nicole pliner, managing director; Pamela M. Harlem, senior consultant; and Sharon E. Antiles, senior consultant, Radiology Consulting Group, Boston.

Pre-picture archiving and communications (PACS) implementation work-flow analysis is critical to ensuring a smooth transition from a film-based to a digital environment. Through experience and process refinement, the Radiology Consulting Group (RCG) has developed a robust pre-PACS implementation plan that enables our clients to reach their PACS goals.

RCG identifies five key objectives for undergoing a pre-PACS work-flow analysis.

? Guide vendors on operational requirements

? Establish baseline statistics

? Resolve current operational inefficiencies

? Anticipate operational impact of a PACS

? Address enterprise-wide electronic image distribution

The five objectives are discussed in greater detail below. These objectives are incorporated into figure 1, the RCG Methodology for Pre-PACS Implementation Operational Analysis.

Operational Requirements

Operational considerations play into three aspects of PACS implementation: (1) training for front-end users and system administrators, (2) the capture of standard radiographic images, and (3) viewing workstations.

The success of any PACS implementation is highly dependent on well-supported training for all users. An inventory of system users should include radiologists, technologists, film librarians, high-volume referring clinicians, as well as the radiology and hospital information system administrators involved in the implementation and upkeep of PACS. The inventory of front-end users should be further delineated by modality, with the realization that cross-trained staff may need to be trained in more than one new technology. For example, a technologist may primarily work in MRI, but occasionally work in radiography. Training for that technologist will include both modalities.

Training requirements should be shared between the practice and the PACS vendor and can be specified in the Request for Proposal (RFP). The information in the RFP will assist the vendor in customizing the number of manuals required, as well as training days on-site and off-site.

In a full-scale PACS implementation, fundamental operations will change most dramatically in plain film radiographic procedures. The available technologies for capturing digital rather than analog images are computed radiography (CR) or direct radiography (DR). When deciding on technology options, your organization must consider what equipment to purchase and areas for placement. This may be accomplished through analysis of space constraints, peak throughput, technologist work flow, and review of scheduling templates.

The work flow of radiologists and technologists needs to be assessed to determine the quantities, most advantageous locations, and configurations for diagnostic interpretation workstations. In addition, careful consideration should be given to allocating clinical review workstations for referring? physicians. This analysis can be accomplished by interviewing the clinicians, looking at the volume from various clinician sources, the referring clinician’s locations, and the propensity of these clinician’s to utilize the technology. The results of the analysis will facilitate an understanding of how and why film is used in each referring practice. This information will allow you to specify in the RFP the quantity, location, image manipulation tools, and configurations of diagnostic interpretation and clinical review workstations.

Establish Baseline Statistics

Baseline metrics allow the practice to gauge the impact of reengineering efforts and PACS on the overall operation. Problems inevitably arise after implementation, and the institution must be able to determine whether the root cause lies with the technology or the work flow processes.

Figure 1. Operation assessment tools for conducting pre-PACS workflow analysis.

Because PACS impacts many areas, the baseline statistics should reflect the gamut of radiology operations. Metrics for analysis include report turnaround time, examination throughput and capacity, film usage/costs, retrieval of prior images, staffing levels, and length of stay. If your organization already utilizes a dashboard of operational indicators, new PACS-related indicators such as study size, archiving capacity, system downtime, image transmission time, and unread cases may be warranted in your dashboard.

Resolve Operational Inefficiencies

The PACS rollout presents an opportunity to fix existing operational problems, particularly with regard to the misallocation of staffing resources and system failure points. In fact, it would be unwise to implement expensive technology in suboptimal operations. Conducting a work-flow assessment may reveal that technologists spend too much time in peripheral tasks or that radiologists’ assignments in a multisite institution may not maximize work-flow. The following examples illustrate these points.

At one client site using conventional radiography, the technologists worked in a linear process; that is, one technologist performed all functions from greeting through discharging the patient. The client was considering the installation of CR hardware and software. CR is more labor intensive on the front end of the examination in that demographics must be registered on the cassettes prior to imaging. However, time is saved at the end of the examination because patients no longer wait for printed films. Prior to the CR deployment, RCG reviewed the client’s operational processes to determine more efficient methods for managing patient throughput. A new process was devised that would also maximize the new technology. The result of the analysis revealed that a patient care coordinator, in combination with staffing two technologists per examination room, would expedite patient throughput (see figures 2 and 3). The digital systems reduced patient departure time, measured from the time of examination completion to the time the patient left the division, by 82.35% (17 minutes to 3 minutes). In addition, the operational reengineering strategies, unrelated to PACS, decreased pre-examination patient wait times by 54.88% (35.68 minutes to 16.1 minutes).

In the analog environment, radiologists may rotate between sites; for example, interpreting at the beginning of the day at the main hospital and at the affiliated health center or hospital site in the afternoon. Time is lost in travel, and delays/loss of prior studies may occur due to inherent inefficiencies in tracking and manual transferal of films. With PACS, radiologist interpretation and dictation practices may change. Because PACS maps studies and relevant prior studies to multiple sites, radiologists no longer have to travel to the images; instead, images and priors are digitally transferred to the radiologists who may be stationed at one primary site and provide interpretation for all affiliated hospitals and centers. With multiple physicians practicing at one site, new space configurations must be taken into account. Alternatively, if a radiologist’s presence is required at a low-volume site, studies from other, potentially higher-volume sites could be accessed for interpretation. The digital transmission of images maximizes the department’s overall efficiency and provides a new business opportunity.

The ability to access images throughout a network allows the organization to consider innovative practice styles. By stationing radiologists centrally at one clinical site, medical management may determine that radiologists could provide more subspecialized services. Incidentally, subspecialization is a marketing strategy that may lead to a new portal for business.

It further should be noted that in instances where the radiology practice has not yet gained the buy-in of senior management to purchase PACS, the efficiencies gained through a pre-PACS operational assessment may also become quantifiable components of the business case justification for the PACS purchase.

Anticipate Operational Impact

Every PACS implementation presents unique operational challenges. The RCG experience at two client engagements highlights how an individual practice might proactively address some of these changes in the pre-PACS operational analysis.

Figure 2. Pre-computed radiography implementation operational flow chart.

Unread Cases. In an analog environment, hard-copy films serve as a reminder that the study must be brought to the radiologist for dictation. The possible causes for lost cases in an analog system are well known and well documented; the responsibility lies with multiple individuals in the system. With PACS, a new definition of a lost case emerges, termed the unread case. Factors leading to unread cases include miscoding, failure to cancel examinations that were completed in the radiology information system (RIS), incorrectly completed studies, association problems (linking a dictated report to an examination accession number), studies not transmitted from the scanner, and merged studies. At Massachusetts General Hospital recently, the Image Service Team, comprised of film library staff, and RCG focused on an Unread Case Initiative that eliminated the extensive backlog of unread cases.

From this reconciliation process, RCG added two refinements to our pre-PACS assessment and implementation planning for clients. First, new training competencies were identified for technologists (preimplementation) and accountability measures were instituted (postimplementation). Second, the role of the film librarian, already expanded with increased training and competency in computer skills, was expanded to include trouble-shooting the PACS, correcting technologists’ errors, and ensuring that all completed cases reached the PACS. This is an empowering role for the former film librarians, now known as image service representatives.

Data Integrity. A system is only as strong as its weakest link. If a technologist does not network a case into PACS, the radiologist is unable to provide interpretation. How can this happen? In a digital environment, visual cues disappear; the technologist no longer sees a hard-copy film. Oversight occurs and studies may not be networked.

RCG, in conjunction with MGH’s PACS/information technology team, has developed an Operational Information Integrity/Quality Control (QC) Program that uses Web-based tools for ensuring data integrity. The Check PACS Web tool allows the technologist to verify that a study has reached the PACS system (see figure 4, page 8). Similarly, the QC Web page lists, by modality, all studies that were performed that were not networked into PACS (see figure 5, page 8). These tools serve as checkpoints to ensure that all studies are reaching the radiologists. The goal is for each tool to generate data within a 2-second interval.

Figure 3. Post-computed radiography implementation operational flow chart.

Enterprise-Wide Distribution

One of the most tangible benefits of PACS is reducing the amount of film that is printed and distributed throughout the enterprise. Many clients refer to this as a limited filming initiative. Changing work flow both inside and outside of radiology is challenging because it requires greater cooperation among members of the radiology department and between radiology and the other services.

Task Force. RCG recommends forming a limited-filming task force prior to enacting any limited filming initiative. At a minimum, the task force, led by a radiology administrator or designee, should include the operations manager from each modality, the IT/PACS manager, a representative with budgetary responsibilities, an operations re-engineering liaison, and, as needed, representatives from referring clinician practices. This task force has three primary responsibilities:

1. Identify the film-related work flow of referring clinicians who currently depend on printed studies in order to develop strategies to transition them from film to on-line viewing. To accomplish this goal, the work-flow analysis needs to focus on what films are being printed, for whom, and reasons for the requests.

Referring physicians are more likely to accept, and therefore contribute to the success of, a limited filming initiative if the processes for accessing and viewing digital images can be streamlined. Based on the RCG’s experience, we have developed tools that proactively address changes in work flow that will facilitate acceptance and a smooth transition to limited filming. The radiology department can market these tools to the referring practices as additional benefits to enterprise-wide distribution.

For example, Web-based tools have been developed at MGH to enable the referring clinician to page radiology for IT support. The response time is based on a predefined service guarantee. If an older study is not available on the Web server, automated systems can be set up to enable the referring clinicians to pull the study to their PCs without having to call the radiology department. The system can provide updates to the referring clinician on the expected duration for image retrieval and the progress of the retrieval process. These Web-based tools are empowering and relieve the referring clinician from otherwise having to make several follow-up phone calls. These technologies make the referring clinician more efficient and less likely to reject the system in favor of printed film.

2. Assist in the development of equipment plans that will be required to enable a practice to limit its dependence on film. For example, limiting film to a busy orthopedic practice may require the purchase of additional PCs, review stations, and monitors with specific hardware and software requirements. The practice’s work flow will determine the quantity and location of clinical workstations. Negotiations between the referring practice and radiology will determine who will pay for the hardware and software.

3. Ensure that protocols and contingency plans are created for limited filming strategies such as summary series and print-on-demand.

Selecting a summary series, that is, images capturing the focal point of the study, requires defining protocols regarding which images will be captured and who is responsible for the summary series creation. Typically, the creation of a summary series becomes a part of the radiologists’ work flow. If compliance for creating a summary series is low, then either the film librarian or the technologist will need to print the entire study on demand, undermining the limited-filming initiative. Alternatively, the dictating radiologist would need to be located to create a summary series, decreasing the efficiency of the system.

In order to reduce film expense in a limited-filming environment, studies should be printed only on request by a referring clinician or by predefined protocols, a process known as print-on-demand. The task force should define the printing request and fulfillment process. Protocols must be developed that identify triggers for studies that are automatically printed, for example, operating room studies, and those for which requests must be made, and the tool sets required to ensure that referring clinicians are comfortable viewing soft-copy images.

Figure 4. PACS Web tool enables the technologist to verify that a study has reached the PACS.

Figure 5. Quality Control Web page lists all studies performed but not networked into PACS.

Defining contingency plans in case of catastrophic failure of the online image distribution system components is critical in order to maintain high levels of service. If any part of the system fails or compromises the ability to deliver images to the referring clinician’s PC, then the technologist staff and film librarians need to know how and when to go back to printing film without interruptions in work flow.

Because limited or on-demand filming initiatives are typically targets for reducing film expense, the task force will continue to exist even after implementation. At that point, the task force’s goal would be to continually assess the amount of film printed and its variance to budget within each modality in order to identify where the film reduction goals are not being met.


In summary, a proactive approach should be taken when implementing a PACS. By focusing on the five key objectives for a pre-PACS work-flow analysis, your practice should achieve a smooth transition to PACS. However, the work-flow analysis and change required to achieve a successful limited filming initiative are not limited to the preimplementation planning process. Instead, it is a continuous process that must occur periodically over the life cycle of the initiative.

Sharon E. Antiles, is senior consultant; Pamela M. Harlem, is senior consultant; Leonard A. Levine, is senior business consultant; and Nicole Pliner, is managing director of the Radiology Consulting Group, Boston, www.thercg.com.