Most medical facilities aim for a 100% filmless digital imaging environment when they employ a PACS – or a more reasonable 95%. Without the support of their referring physicians, however, an institution might never even realize half that figure.

“Nearly 90 percent of PACS users are outside of the radiology department,” says Mark Reis, communications manager at Stentor Inc (Brisbane, Calif). “If this group rejects the use of PACS and continues to demand film, the investment is worthless, particularly since a mere 10 percent of the PACS cost is for delivery of this service.”

Therefore, it is imperative that referring physicians embrace the technology. How can a facility inspire this group to become advocates rather than detractors? What follows is a list of tips from professionals who have done so successfully.

1. Perform outreach.

Once a facility begins to think about investing in a PACS, it should reach out to all of its potential users, including the referring physicians. “You want to identify these users early and include them so they become advocates of the system,” says S. Ted Treves, MD, vice chairman of radiology information systems and chief of the division of nuclear medicine in the department of radiology at Children’s Hospital Boston and professor of radiology at Harvard Medical School (Boston).

The outreach process is the biggest single determinant of success, according to Skip Kennedy, assistant director of PACS operations at Kaiser Northern California Region (Sacramento, Calif). “We met with every department personally to avoid creating any slighted feelings,” he says.

The outreach can occur in many forms, including newsletters, emails, and focus groups, but in-person meetings generate the most good will. Paul Sylvester, RT, director of radiology at Alpena Regional Medical Center (Alpena, Mich), notes that his facility held a dinner meeting with representatives from its vendor, Eastman Kodak Co (Rochester, NY), to give a presentation on PACS. “Some of the doctors started the presentation with their arms folded, but by the end, they were looking forward to its implementation,” he says.

Marilyn Schultz, administrative director of radiology at Akron General Medical Center (Akron, Ohio), stresses the importance of pointing out the advantages of the system. “You want to educate the physicians as to what the system does and how it will impact them,” she says. “Be sure to let them know the advantages up front.”

2. Conduct an assessment of needs.

Outreach should include some form of needs assessment. It’s important to find out all user needs up front – not only to include them in the process, but also to be sure that the system purchased can meet those needs. Subspecialists, such as orthopedists or surgeons, will have specific demands, some of which – including image use in the operating room – also will be life-critical.

“The needs of a referring physician might be different but are just as demanding as those of a radiologist,” says Matt Long, VP of marketing at Stentor. “The referring doctor is using the data to make a diagnostic decision, and so [he or she] needs the same quality and high performance automatically considered for radiologists.”

3. Create one system with
access to reports and images.

Referring physicians typically will need access to both the images and the radiology report. The content of the report will determine whether or not they look at the images. For example, if a physician is treating a patient complaining of chest pain and the radiology report is normal, the physician will likely skip viewing the images; but if the report indicates an abnormality, he or she will probably want to study the relevant images.

Stentor's iSite Radiology features dedicated diagnostic monitors for image display and interpretation.
Stentor’s iSite Radiology features dedicated diagnostic monitors for image display and interpretation.

Access to these images should be readily available from within the report, just as the report should be readily accessible from the images. Physicians will not be thrilled about having to log on to multiple systems and might just demand film if they feel they have to go through hoops to see the electronic images on the same screen as the report.

“We didn’t realize how important having the images and reports together would be,” says Kennedy, whose institution, in response to physicians’ concerns, is currently integrating two separate applications: Stentor’s PACS and the IT department’s reporting system.

4. Try out systems before buying.

Testing a system before purchasing it can help to identify potential items of concern, such as display. “Facilities should try out the PACS products they are considering to get a true idea of how the associated Web-based system works,” Reis notes. “Doctors will not accept slow transfer times or poor image quality, and a trial run can help to eliminate these concerns.”

Schultz shares that her facility did conduct a test of the Web-based portion of a system they bought, but did not realize its inadequacies. “The system was slow and cumbersome and occasionally shut down the doctors’ computers,” she says. Before acquiring a new Web delivery system from DeJarnette Research Systems (Towson, Md), she tested it with 25 physicians, all of whom loved the Radiance system.

5. Deliver functionality to all.

Physicians, particularly those within subspecialties, might frequently require the same functionality needed by radiologists. These needs include high image quality and manipulation capabilities. “This need has become very exposed in the past few years, and every vendor is talking about providing better tool functionality,” Long says.

6. Select a user-friendly system.

The interface should be intuitive. “The degree to which doctors can get up to speed on a program will influence its success,” Kennedy says. “If, after their first trial, they still have no idea how to use the system, they will find it too difficult and will want film.”

7. Conduct plenty of training.

Even though the system should be user-friendly, institutions will still want to offer training to physicians; and the more formats they use, the better. “We found that group training was difficult because the doctors had such different schedules, so we conducted sessions individually,” says Steve Pluhar, radiology systems coordinator at the Northern Nevada Medical Center (Sparks, Nev), a client of Medweb (San Francisco).

Rik Primo, director of marketing and strategic relationships of Siemens Medical Solutions Image Management?PACS/RIS (Malvern, Pa), suggests that weekly training sessions can help work around this situation when the numbers of physicians are large. “Webcasts are another option,” Primo suggests.

Treves adds, “Even though little training was needed, we offered it to everyone who would use the system. Even now, we have a team who can train anyone at a moment’s notice.”

8. Make IT available to help
physicians set up their systems.

Having trouble with referring physicians not wanting to convert to PACS? Coax them with a reminder that by having images available immediately and on screen, their productivity will increase dramatically.
Having trouble with referring physicians not wanting to convert to PACS? Coax them with a reminder that by having images available immediately and on screen, their productivity will increase dramatically.

Referring physicians do not need to invest in significant equipment to access the Web delivery system from their offices, but they do need computers with adequate speed and memory, as well as a fast Internet connection. Depending on the region and the physician, they might already be equipped; others will need to upgrade.

Sylvester notes that, in choosing a PACS, he avoided systems that required special workstations or on-site access. But still, he says, “One of our biggest challenges was getting the doctors to understand that they might need to upgrade their office equipment.” Staff at Alpena Regional provided physicians with options to ease the transition, explaining what transfer times they would experience with certain computers and connections as well as stressing that they could get a system for less than $1,200. “Once [referring physicians] had the equipment, if they had problems with connectivity, our IT department helped them,” Sylvester notes.

9. Be cognizant of workflow.

SELLING POINTS

If your referring physicians are not jumping on board with your PACS implementation, you might want to offer the following selling points:

  1. The physician will have immediate access to film.
  2. Multiple physicians can view the images simultaneously.
  3. The physician will spend less time retrieving film, either from the file room or from the transport truck – or from the lost and found.
  4. The film can be interactively processed – zoom, for example.
  5. He or she will have the ability to work anywhere or obtain a consult from a physician who is not on-site.
  6. The physician’s productivity will increase.
  7. Patient care will improve with faster turnaround of images and subsequently faster diagnosis.

-RD

“It is not sufficient to announce that PACS is here. One needs to be cognizant of workflow needs,” Treves says. “We spent time with clinical administrators before and after our PACS implementation to determine workflow.” Although this step is true both on- and off-site, it’s particularly relevant on-site.

“Originally, we had workstations in the hall, where the computers had always been, and physicians found themselves walking in and out of rooms to access images,” Kennedy remembers of Kaiser Northern California. The solution was to go through the institution, note where each lightbox was located, determine which ones were actually used, and then place workstations in those spots. “We didn’t want the workflow disrupted to view images,” Kennedy says. “If a lightbox is regularly used, then a computer should be installed there.”

Primo suggests that technologists, nurses, and administrative staff could be trained to have the images ready for viewing, which will save time and keep the physicians happy.

10. Eliminate film.

Facilities shouldn’t expect to be filmless right away – if ever. As Treves points out, it’s difficult to be 100% filmless since occasionally, film does need to be printed. But there are ways to significantly decrease these needs.

Some hospitals choose to offer both film and digital versions of images during the transition, which averages about 18?24 months, according to Long. He states that implementing PACS at the outer layers first (the referring physicians), rather than starting in radiology, can reduce this time to 3?6 months.

But being committed works too. “Abandon completely the use of film,” Primo says. “As long as [film is available to physicians,] the resistance to change will result in its continued use.”

Schultz notes that Akron General charges physicians for film after the first print. “Too often, film is lost. By charging for it, we can reduce this unnecessary expense,” she says. Primo notes that he has heard lost film can account for as much as 15% of what is printed.

Alpena Regional Medical Center installed CR and DR systems as part of its conversion to PACS.
Alpena Regional Medical Center installed CR and DR systems as part of its conversion to PACS.

Alpena Regional has achieved a 95% filmless workflow by informing its physicians that no one would receive film and then sticking to it. “If you give in to one, then you have to provide film for all,” Sylvester says, “and in doing so, never realize the benefits intended when the system was installed.”

Of course, Jeff Mansel, PACS system administrator at Magnolia Regional Health Center (Corinth, Miss), notes that you cannot force-feed PACS to everyone. But by selling referring physicians on the benefits, providing convenient training, and soliciting their feedback, you can turn at least a few detractors into advocates.

Renee DiIulio is a contributing writer for Medical Imaging.