Bruce Reiner, MD,

“It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity.”

Charles Dickens – A Tale of Two Cities

The above quote sums up the collective experience for most medical imaging professionals in today’s fast-paced, frenetic, high-anxiety, high-tech imaging environment. For years we have been told by the industry that transitioning from film-based to filmless operation would bring new productivity gains, never before realized, yet most practitioners operating in a filmless medical imaging department have not realized the anticipated operational efficiency and productivity gains. We simply transferred one set of problems for another, only this time it comes at a higher price. Was this because we were not implementing the technology to its full extent, or were the vendors’ promises overly optimistic? To answer this question, we need to review the scientific literature and investigate why some PACS facilities report unprecedented success, while others report no gains at all. The answer can be found in two simple words: work-flow optimization.


In order to best improve productivity within the imaging department, it is important to understand the basics of the science of work-flow analysis, which evaluates the individual steps that occur during a single event such as the performance of a chest radiographic examination. Whereas the industrial engineering literature has devoted significant time and resources to process analysis, little to date has been published about it in the radiology literature. Without a basic understanding of work flow, productivity and operational efficiency gains within the medical imaging department will not be realized.

Eliot Siegel, MD

Work-flow redesign initiatives are commonly achieved through the bundling of jobs, consolidation of individual tasks, and employee empowerment.1 One must realize, however, that work-flow redesign must be customized to the unique and idiosyncratic nature of each individual organization. While automation and task consolidation remain the cornerstone of work-flow optimization, a number of extraneous factors must be considered including the stochastic nature of the workload, availability of human resources, and the specific technologies being employed. The end goal is to improve productivity while reducing cycle time. This can take on a number of forms within a medical enterprise including examination acquisition, report turnaround, examination backlog, or length of hospital stay. The end goal is the delivery of information and data in a more timely fashion, so that decision-making can occur expeditiously, with the objective to improve patient care and outcomes.

When assessing work flow within the imaging department, one can focus on the responsibilities of the technologist or radiologist, each with his or her own unique perspective and goals. For this article, our primary focus will be on technologist work flow, specifically in the acquisition of general radiographic examinations. This can take the form of screen-film radiography in film-based operation or digital radiography in filmless operation. The two commonly employed digital radiographic techniques to achieve filmless operation are computed radiography (CR) and direct radiography (DR), each of which has its own unique advantages and disadvantages. A number of individual technologist tasks make up the collective process of performing a general radiographic examination, and these include examination scheduling, patient transportation, patient preparation, data access, examination acquisition, image processing, retrieval of historical comparison studies, image duplication, and repeat examinations due to technical factors or loss.

Given that the primary function of the technologist is to produce medical images, we have chosen the percentage of time devoted to examination acquisition (as opposed to clerical and other tasks) as our index of technologist work-flow efficiency. Therefore, optimization of technologist work-flow efficiency would increase the percentage of time spent in image acquisition (ie, optimized work flow = 100% of time spent in image acquisition). In a recently published nationwide survey evaluating technologist productivity and work flow, only 65% of technologist time was spent in image acquisition.2 Alternatively stated, technologists spend approximately one-third of their total working time performing a mixture of clerical and ancillary tasks. This wasted technologist time is the target of work-flow optimization through automation, task consolidation, and reallocation (to less expensive and less well trained staff).

With implementation of an integrated HIS/RIS, many of the clerical functions currently being performed by technologists such as data entry, examination scheduling, and accessing data can be significantly reduced or eliminated. Implementation of filmless imaging using PACS and CR/DR will in turn reduce or eliminate technologist time spent in image processing, retrieval of comparison studies, and image duplication. At the same time, technologist time spent in repeating examinations (due to loss and technical factors) will be reduced, by the addition of an electronic archive, because of the improved dynamic range of CR/DR, and the radiologist’s ability to actively manipulate the image using a computer workstation.


A formal work-flow analysis was performed at the Baltimore Veterans Affairs Medical Center (BVAMC),3 which evaluated the individual steps involved in the ordering, acquisition, and reporting of a diagnostic imaging examination (ie, chest radiograph). During film/paper-based operation, process analysis identified 59 individual steps for this entire process (Figure 1), which began with the physician order and ended with the report available in the patient’s chart for review. Following implementation of a filmless/paperless imaging department with CR, PACS, and a fully integrated HIS/RIS, process analysis revealed the same process required only nine individual steps (Figure 2). This improved work flow resulted in 50 fewer steps performed by seven fewer staff members.

An additional time-motion study was performed at the BVAMC, specifically evaluating work flow and time requirements for technologists to perform general radiographic examinations, comparing filmless (using CR) and film-based operations.4 Time-savings of 31% to 58% were observed with filmless operation, when compared with film-based operations at two other facilities. In this study, 7 to 14 additional steps were required for film-based diagnostic technologists, depending on the individual department’s technology (conventional versus daylight processor), work flow, and ancillary staffing.

The improvement in productivity experienced at the BVAMC has not been consistently observed or reported by other filmless facilities, which raises the question as to why other filmless facilities have not achieved similar operational efficiency gains. One of the most common mistakes made by facilities implementing PACS has been to underestimate the potential major role PACS can play in the redesign of departmental and enterprise-wide work flow. Without proper integration of PACS, information systems, and the individual imaging modalities, potential gains in productivity will not be realized.

To this end, many PACS adopters have operated their filmless imaging departments in a manner similar to their preexisting film-based departments, with few changes in departmental work flow. Examinations are still being ordered using paper requisitions that require manual reentry of patient and examination information (by clerical staff) into the RIS. This paper-based information is subsequently printed out and given to the imaging technologist who in turn manually retypes patient and study information into his or her modality acquisition workstations. These operational inefficiencies translate into inefficient use of technologist time, even after transition to filmless operation. With proper work-flow optimization after PACS implementation, one would expect further reduction in time allocations for these tasks, with more time spent in image acquisition and less time performing clerical and ancillary tasks.


A number of work-flow optimization software enhancements are available to further augment technologist productivity and work flow by increasing system functionality and operational efficiency. One of these work-flow enhancers is modality worklist, which allows for orders residing in the information system (RIS or HIS) to be automatically distributed to and from various imaging modalities. In interfaced systems, the patient metadata from the information system automatically populates the relevant demographics fields within the modality’s computer. After images are acquired at the local modality and reviewed for quality assurance, they are automatically transferred to the enterprise-wide PACS. An additional software function, referred to as modality performed procedure step (MPPS), electronically notifies the information system (RIS or HIS) that image acquisition has been completed. This can avoid the additional time-consuming steps required for examination verification on the part of the technologist.

The concepts of functionality and system performance are frequently overlooked yet important contributors to work-flow optimization. Until system integration is entirely seamless, there will be further complicating factors when attempting to integrate different technologies from different vendors. The end result is that each individual institution has its own inherent “system functionality,” which significantly impacts productivity and work flow. In order to facilitate system integration, several standards have been developed including Digital Imaging and Communications in Medicine (DICOM) and Health Level Seven (HL-7). In spite of the near universal support for DICOM among modality vendors, many HIS/RIS vendors have provided limited DICOM support in their systems. As a result, many imaging providers (ie, technologists) have been unable to take full advantage of the work-flow savings made possible by the implementation of the DICOM modality worklist function and MPPS. A recent initiative of the Radiological Society of North America (RSNA) and the Healthcare Information Management Systems Society (HIMSS) has focused on increasing connectivity and systems integration, by bringing together imaging and HIS/RIS vendors. The Integrating the Healthcare Enterprise (IHE) initiative has already resulted in the creation of a consensus among multiple vendors on the use of DICOM and HL-7 to communicate information among modalities, information systems, and PACS. The IHE initiative is likely to also facilitate communication of information systems between different enterprises, which should allow improved collaboration and sharing of resources among multiple facilities or different delivery networks. These ongoing efforts should provide improved system functionality and performance, resulting in improved productivity within the imaging department.


In order to optimize work flow, one must begin by performing a detailed work-flow analysis, both in and outside of the imaging department. One must remember that as filmless operation transcends the entire medical enterprise, work-flow analysis must follow suit. Begin by identifying all the individual steps that go into the ordering, scheduling, acquisition, distribution, and reporting of a medical imaging examination. Identify all of the individual staff members who play a role in the overall process and identify existing frustrations, inefficiencies, and bottlenecks. This process should be multidisciplinary, with representation from clerical staff, technologists, nursing, administration, the IT department, radiologists, and referring clinicians. If you are currently filmless (or near filmless), include your PACS and HIS/RIS vendors in this analysis, because they will play a pivotal role in the analysis and problem solving. Many of the major vendors have in-house expertise and/or consulting teams that have been through this process before and can offer both experience and expertise in a number of pertinent areas, including IHE and HIPAA. At the same time, they will be aware of ongoing work-flow related research and development efforts within their companies that need to be considered in the overall analysis and planning processes.

When evaluating the important, yet overlooked topic of system functionality, a number of factors need to be considered. These include (but are not limited to) support for DICOM service classes, systems integration and redundancy, archival strategy, network topology, work-flow optimization software, and workstation number, type, and distribution. In addition to vendor technical support and product development, in-house IT service and support is a necessary and critical component in the optimization of enterprise-wide work flow. This takes on even greater importance as many new PACS customers adopt a “software only” strategy for PACS implementation.

As work-flow-enhancing software developments and systems integration coalesce into a fully functional electronic medical record, productivity and work flow will continue to improve throughout the digital medical enterprise. However, in order to take full advantage of the technological advancements, a proactive approach is necessary with continuing education and process analysis. The same team-oriented strategy used during the PACS implementation phase should be continued, in order to take advantage of the unique perspectives and expertise of the many different professionals within the enterprise.

Many of us experience the same frustrations in the workplace as Jack Nicholson’s obsessive-compulsive character in As Good As It Gets. He walks into his psychiatrist’s office during one of his exasperated moments and asks, “What if this really is as good as it gets?” Although you and your staff may be currently working at a frenetic pace and think this might be as good as it can get, a well-thought-out and creative work-flow redesign will undoubtedly allow you to make things a little bit (or maybe a lot) better.

Bruce Reiner, MD, is director of research, VA Maryland Health Care System, Baltimore

Eliot Siegel, MD, is chief of imaging, VA Maryland Health Care System, amd vice chairman of information systems for the Diagnstic Radiology Department at the University of Maryland School of Medicine, Baltimore.


  2. Reiner BI, Siegel EL, Carrino JA. Workflow optimization: current trends and future directions. J Digit Imaging. 2003. In press.
  3. Siegel E, Reiner B. Work flow redesign: the key to success when using PACS. AJR Am J Roentgenol. 2002;178:563-566.
  4. Reiner BI, Siegel EL. Technologists productivity when using PACS: comparison of film-based versus filmless radiography. AJR. 2002;179:33-37.