maging procedure volume at Primary Children’s Medical Center in Salt Lake City, Utah, increased 25% since 1997, but turnaround time for those studies decreased by 15% during that same period. What enabled the radiology department at the hospital to more quickly acquire images, interpret them and forward the results to referring physicians despite greater numbers of procedures being performed was the introduction of a picture archiving and communications system (PACS) coupled with redesigned workflow.

(Standing, from left to right:) Phil Anderson, IHC equipment manager; Deanna Welch, IHC director of imaging services; Darin Day, PACS system administrator, Primary Children’s Medical Center; Mike Creason, imaging director, Primary Childrens Medical Center; Dave Young, imaging director, Urban Central Region Hospitals; Dennis Welch, MD, IHC medical director of imaging services; Richard Taylor, imaging director, McKay-Dee Hospital; Mary Gathers, IS system analyst; Troy Dalla, PACS system administrator, McKay-Dee Hospital. (Sitting, left to right) Margaret Farrell, information manager, Urban Central Region Hospitals; Troy Dicou, information manager, Urban Southern Region Hospitals, Siew Lam, MD, medical informaticist, Urban Southern Region Hospitals, Denise Bruno, IHC compliance coordinator, Joe Boyce, MD, medical informaticist, McKay-Dee Hospital.

“PACS alone does not necessarily make you more productive; you also have to re-engineer the way you do things once PACS is in place in order to get the full benefits of being able to move images around electronically,” says Darin Day, application systems and PACS administrator at Primary Children’s. “Take, for example, the way we now handle orders from referring physicians in cardiology. Because of redesigned workflow, we’ve pared approximately five minutes off the time it takes to complete each examination for that department’s patients. Immediately after we have acquired the image or images, those patients return to the cardiology department for a further encounter with their physician. But since we keep the patients for an appreciably shorter time now, the cardiologists are able to accomplish more in the course of a day-either spending more time providing care to those patients or increasing the number of patients they can see.”


Primary Children’s Medical Center is part of Intermountain Health Care (IHC), a not-for-profit integrated delivery system based in Salt Lake City and providing services across Utah and Idaho. Last year, HCI, in a study reported by Modern Healthcare, ranked IHC as “the nation’s leading integrated health-care system” out of 500 networks reviewed.

Figure 1. Comparsion of staffing needs by FTE type before and after PACS implementation.

The IHC system includes a number of regional, community, and academic hospitals. Imaging services are provided at these facilities by multiple independent radiology groups. Together, they perform approximately 830,000 imaging procedures.

In 1995, IHC decided to encourage each of its hospitals to develop a filmless radiology environment. As outlined to the hospitals, they would be free to implement PACS along their own time lines and in accordance with their individual budget strategies. The only stipulation imposed by IHC was that all hospitals would be required to standardize around a single make of PACS. After extensive evaluation, IHC chose Agfa as its PACS vendor.

Figure 2. File room work flow.

Thus far, only one IHC hospital is totally filmless-Primary Children’s. However, by year’s end, IHC expects six others will produce, disseminate and store images in fully electronic fashion. As for IHC’s rural facilities (of which there are about a dozen), planning for PACSs installs in several of these facilities is now taking place, says Deanna Welch, MBA, RT, director of imaging services for IHC.

Meanwhile, IHC is embarking upon a new initiative with regard to PACS. The organization wants to begin integrating the various PACS installations in order to permit enterprise-wide access and distribution of electronic images.

“This will ultimately allow us to put all of our patient records into a single electronic medical record that would be instantly available at whichever facility in the system the patient goes next to receive care,” Welch says. “Regardless of where the patient’s study is performed, the referring physician will have seamless access to the patient medical record, including images. This integration also will allow us to provide electronic imaging across the system at lower cost than would be possible with each facility providing it independently.”

Welch says the integration will entail more than linking all of the PACSs.

“It’s also a work-flow issue,” she contends. “Work flow will have to be addressed both locally and globally. Work-flow redesign at the local level will be the responsibility of each facility and will center around processes. At the global level, the responsibility will be IHC’s and will center around PACS network architecture. How we configure that architecture is a work-flow issue and it will have impact on local work-flow processes, since a good architecture is the key to improving the speed of access to images from multiple locations.”

Welch adds that the architecture configuration will be dependent on the design and execution of the image archives, as well as the design of the core backbone of the PACS system. In many instances we are looking at running multiple facilities from a single PACS core.

“And how we structure those key components will affect the amount of bandwidth we will need,” she continues. “We want to be able to have images available very rapidly. That will be possible only if we can configure our architecture in a way that avoids having to query a long-term central archive or central server every time an image is sought. We are trying to decide if we can accomplish this by installing a sufficient amount of RAID or perhaps a medium-term storage archive, locally. On the other hand, if we have single servers handling multiple facilities, or are putting images in a central long-term archive, we need to predict the traffic patterns and then calculate the impact of those patterns on the network so that we can optimize performance.”


For local-level work-flow process re-engineering, facilities in the IHC system will likely look to Primary Children’s as a model.

Primary Children is IHC’s main pediatric facility, providing coverage to a five-state region. It was the first hospital in Utah with a fully filmless radiology department (and thought to be the first in the nation among pediatric facilities to make such a claim).

The hospital was relocated in 1990 and was designed from the start to host a fully filmless environment. However, because the technology of PACS was not at that time far enough advanced, the hospital opted to postpone running in all-electronic mode. It did not acquire its PACS until 1997, although the radiology department did experiment for several years prior to that time with a three-workstation mini-PACS and a film digitizer in order to get a feel for how work processes might need to be structured in a future filmless environment.

“After bringing aboard the full-blown PACS, we converted to filmless one modality at a time,” Day explains, whose department consists of nine radiologists and 45 clinical and administrative personnel. “In 1998, we discontinued film in our diagnostic radiography, ultrasound, nuclear medicine, CT, and MRI units. One year after that, the department was 100% filmless. And the year after that, the entire hospital was 100% filmless.”

From the beginning of Primary Children’s journey to filmless it was evident that the department needed to consider a redesign of its work flow, Day offers.

“In our film days, we worked very efficiently, but we knew that converting to filmless would represent a major change in the way we did business,” he says.

For that reason, the department decided long before acquiring its PACS to carefully document the way work was performed.

“We wanted to be able to clearly understand the nature and scope of our work-flow issues, and documenting these processes made it a much easier task,” Day explains. “We kept asking ourselves, what are our current work processes as we see them? In the course of answering this, we also kept track of who in the department and in the hospital was being affected by these established, pre-PACS work processes.”

The process of documenting was formal, Day allows: “We maintained detailed diaries and logs, and drew diagrams showing where images move and what people do with them once those images get there. We also kept accurate records of how much time it took to accomplish each task. When completed, we knew exactly how long it took to pull a folder, how long to print an examination.”

Day says the documentation was inputted to a computerized data base through a program written by one of the radiologists.

“Having the documentation data based made it relatively easy later to find ways to eliminate steps from our work flow once we got into PACS,” he says.


The documentation helped the department to uncover numerous opportunities for reengineering as the conversion to an all-electronic environment progressed. Typical was the matter of relevant prior images.

Figure 3. The flow of information in the digital department.

“It amounted to a terrible waste of money to have staffers pull films of relevant priors from the file room and then put them up on a light box immediately adjacent to a PACS workstation so the radiologist could perform comparisons of new images against old,” Day says. “To address this, we made it policy to digitize all relevant prior films. This was a slow and erratic process. So, we surveyed all the radiologists in one fell swoop to determine how old a film could be and still count as relevant. The answer we came up with was two years. Based on that, it was decided to simply go ahead and digitize any hard-copy relevant prior examination 2 years old and under without a word from the radiologist. That caused the digitizing process to be both greatly accelerated and truncated.”

Another example of how the department reengineered processes to its advantage concerns the retrieval of images for conferences.

“We’re a teaching hospital, so we have conferences every week here on neurosurgery, cardiology, you name it,” says Day. “To support these conferences, it used to be that we would assign a file room staffer to the task of pulling all of the films requested by the individual departments. These films then would have to be put into the correct order before they could be delivered for the conference. After the conference, the films would have to be returned to the file room and put away properly.

“This whole cycle sapped a lot of manpower. In our redesign, we deployed PACS workstations in the various departments and developed protocols f to search for and retrieve images on their own, all without having to physically come to our department to do it.”

Redesign may sound easy, but Day assures it is not, mainly because seldom are there clear guideposts showing where and when steps can be eliminated or refined.

“A lot of it is accomplished purely through trial and error,” Day confides. “We’d try a new way of doing things for a week. In that time, we would see what worked and what didn’t. And some of the things we tried were unsuccessful. So then we would try something else until we got it to work. If it worked, we’d incorporate it and move on to the next process in need of re-engineering. And, we had to make sure that whatever we attempted did not adversely impact another process or department, which was always a possibility.”

Day acknowledges that, in many hospital radiology departments around the country, the culture is such that failure to get a redesigned process right the first time would cause those leading the charge to beat a hasty retreat and circle the wagons, almost certainly dooming further efforts to move forward.

“Here at Primary Children’s, we maintained the mindset that, yes, we were going to encounter failure along the way, that we needed to be prepared for that, and that we would not let that discourage us from continuing to try,” Day says. “We also had the mind set that, once we got started on this journey, there would be no turning back. We were determined, absolutely, to make this work.”


A key to success, says Day, entailed making sure there was buy-in among the physicians and staff who would be affected by a redesign of the work flow.

“We had to impart to them our vision, get them to understand the benefits, to understand that we were all in this together and that there would be some pain involved,” he tells. “It helped that we had champions around the hospital.”

The champions included radiologists but also specialists from outside the department. One very important champion was the hospital’s lead neurosurgeon.

“His buy-in was pivotal to our success because of his influence throughout the? hospital,” Day recalls. “We would implement a new method for him and say, OK, let’s try this in your department and see if it improves how you do business. These were actually quite modest proposals. For example, we’d put a workstation in his office and invite him to try it. Then, as he tried it and liked it, we’d build on it from there. Eventually, he and his team would come up on their own with ways to further improve work flow.”

As buy-in among the champions was secured, Day’s department began rolling out the new work-flow blueprint in each of their departments.

“When people would say, oh, this won’t work, the champions would step forward and say, forcefully, ‘It will work, and here is how I am using it,'” Day recalls. “That convinced doubters that they ought to at least give it a try.”

Day says it was not difficult to identify candidates for the role of champion.

“We chose individuals who had stature in the hospital and would therefore command a great deal of respect,” he notes. “They also were individuals who were open to innovation and who were technologically savvy. Most importantly, these were individuals who were our biggest and most frequent users of images. We figured that if our redesign ideas were going to be tested, it would be best to put them through the paces under the most heavy-demand conditions possible. That way, failure would be readily apparent and addressable. By the same token, success would really shine.”

While the champions were experimenting with suggested new ways of working, Day and his team were clocking them.

“I would sit for hours on end doing nothing but watch radiologists hang films,” he shares. “I’d notice things like this radiologist over here likes to hang images from left to right, that one over there likes his images hung another way. I would compare the radiologists to one another in terms of their efficiencies and lack thereof. I realized that if we were all doing the same things consistently, we could make the system successful.”

Day, along with Keith White, MD, the department’s radiologist champion, spearheaded the efforts to redesign workflow. Participating with him was the radiology department director.

“Whenever we had a proposed process change that was going to involve another department, we would include on our team that department’s manager or those individuals most directly impacted,” he says. “The team itself wasn’t big. It was just a few key people who sat down and brainstormed to work out the details of the redesigned processes.”


A mistake Day regrets through the course of developing re-engineered processes is his team’s failure to communicate fully with those individuals and departments destined to be impacted by changes in work flow. Ironically, the team used all the right methods of communication-memorandums, newsletters, presentations at committee meetings. It just did not use them frequently enough, it seems.

Figure 4. Impact of PACS on radiology department staffing levels.

“You have to over-communicate, over-saturate with information,” Day advises. “Everyone was made aware of what we were planning. But as we implemented things, and they arrived in each department, a lot of people in those departments acted as if they were hearing about all of it for the first time. So, I think it would have been helpful to have kept people informed of coming changes, not just in big-picture terms but in terms of nuts-and-bolts, day-to-day detail.”

Day also says he should have had in place for every redesigned work process a contingency plan to fall back upon in the event things went wrong-which, of course, they did. Day learned this the hard way when both of his CR devices malfunctioned within minutes of one another late at night. He directed the technologists to switch to film-capture mode as a temporary fix.

“They gave me this deer-in-the-headlights look,” he muses. “They were familiar only with electronic image acquisition. They had forgotten how to use film. In retrospect it would have been very smart for our work-flow redesign to have included training in how to work with film in case of an event like this.”

Welch says there have been lessons gleaned as well from the entire system’s experiences with PACS.

“We’ve discovered that, if you are going to address work flow at the global level, it is perhaps best to not take a piecemeal approach to investing in PACS,” she says. “You end up with only a partial solution that is insufficient to deliver the cost savings needed to justify the commitment of capital. Also, if you’re a health-care system, establish standards and consistency between installations: the systemwide benefits of PACS cannot be realized without a strong, centrally administered initiative to ensure that every facility installs the same system, configured uniformly. In our situation, we had to take the decentralized approach because of capital funding requirements at the local level and because IHC does not have in place a structure to permit centralized radiology budgeting. Even with a central budget, it is probably not fiscally or operationally feasible to drop PACS systems into 22 hospitals simultaneously. But as a result of our approach, each facility must budget and cost-justify its upgrade of PACS to bring it to the level required for a seamless, systemwide integration. This has complicated our efforts to achieve systemwide integration. We are hoping to address some of these issues through a comprehensive enterprise PACS strategic plan. With this plan, each facility and hospital division will understand how they fit into the whole and will be better able to plan for acquiring the capital needed for executing the plan.

“We will eventually work it all out. When we do, we’ll have an excellent system and very smoothly functioning work flow processes. Of that I’m confident.”

Rich Smith is a contributing writer for Decisions in Axis Imaging News.