The introduction of PACS at Primary Children’s Medical Center in Salt Lake City allowed the radiology department there to dramatically redesign work flow in many ways. Here are a few examples of precisely how:

?Procedures for film tracing have been jettisoned. In the days before PACS, a clinician desiring to see a particular image or set of images was obliged to walk to the image file room and submit a request to the clerks. One of those clerks would then be dispatched to retrieve from storage the folder containing the requested image or images. If it happened that the folder could not be found, the clerk would initiate a search beyond the confines of the file room.

“The first place the clerk would start looking would be at the modality,” says Darin Day, BS, RT, application systems and PACS administrator. “From there, she would look in the reading room. And after that, she would search all of the other most likely places the folder could be, such as the operating room.”

The entire process of tracing might be concluded within a few minutes or, if the folder were particularly elusive, after several long hours. During that time, however, the clerk would be prevented from taking care of requests from other clinicians, thereby hindered in their work. A ripple effect could develop, causing a cascade of workflow interruptions elsewhere throughout the department and hospital.

As a pre-PACS solution, the department introduced a bar-coded film-tracking system. But this only helped a little.

The arrival of PACS eliminated these rituals. Now, images are stored electronically and are accessible almost instantly on command from any connected or linked workstation or monitor.

?Radiologists now can count on comparison examinations being readily available. In the days before PACS, supplying comparison examinations required first that a file-room clerk consult an index file to locate the encounter card for the patient in question. After retrieving all such folders, she then carried them to the modality where a new study would presently be performed.

The technologist performed the new study and attached the examination along with the requisition and previous study to the folder. Next, the folder was carried to the reading room for review and interpretation by the radiologist.

“We do things differently now that PACS is here,” says Day. “What happens instead is the clerk a day in advance of a scheduled examination reviews the RIS for relevant prior studies. If there are relevant priors that are not electronic, they are digitized by the clerk and loaded into the PACS. When the new study is taken, the image goes into the PACS, which then automatically combines it with the prior studies, and they are all immediately available in electronic format at the radiologist’s workstation. The film folder never leaves the file room: as soon as the contents are digitized, back it goes into it’s proper place and is marked as having been digitized.”

?Studies cannot go unread. Until PACS was implemented, the radiology department attempted to ensure that every study was read with reasonable promptness. It did this by producing from the RIS a list of studies that had not been finalized within 72 hours of creation.

“When we found non-finalized studies- that is, examinations that weren’t yet read and transcribed-we produced a new requisition for the existing order and sent out a clerk to track down the films. Once located, we brought the films back to the radiologist and reminded him of the need to read them.

“Now, with PACS, the clerk still must query RIS for a list of studies and their status, and she creates a new requisition as a reminder for those remaining unread after 72 hours. However, there is no longer any need to manually hunt for the images.”

If at first you don’t succeed…

Not every process that was redesigned worked according to plan. To wit:

?An alphabetized sorter system of organizing requisition paperwork at the PACS workstation in the reading room proved inefficient.

“An alphabetized sorter is a portable file holder, hinged to accommodate page after page of requisitions,” says Day. “Leafed between the pages are alphabetized, tabbed dividers. The sorter sat on the tabletop and was positioned right alongside the radiologist’s workstation. When an examination was completed, the technologist would take the requisition and file it in the alphabetized leaf of the sorter.

“This system worked, but it proved inefficient because it required the radiologist to remove his hands from the keyboard to access the requisition. Moreover, the technologist who would deposit the requisition did not alphabetize beyond the first letter of the last name. That meant the radiologist had to expend time wading through the S section to find that requisition for Smith instead of being able to quickly page right to it.”

This problem was ameliorated by eliminating the sorter and revamping the content of the worklist so that the radiologist could obtain key information from the requisition directly on screen, according to Day.

?Routing multiple images to PACS in real-time rather than batch mode confused radiologists at the workstation in the reading room. “What would happen is we’d produce a ‘scout’ image at the start of the study and this would immediately pop up on the radiologist’s workstation monitor,” says Day. “Then, several minutes would go by. The radiologist would wonder if this was the only image he was supposed to get or if something had gone wrong with the system. He’d then call the modality to find out the answer. Of course, everything was fine with the system since the examination was still underway. But by the radiologist having to stop and make that phone call, his workflow was disrupted.

“We realized it was better to just wait until all images in the study had been taken before sending them across the network.”

?Customizing work flow and systems for each radiologist turned out to be excessively time-consuming. Day offered individual customization as a way to obtain fuller and faster PACS buy-in from the radiologists.

“To solve this, the radiologists and I mutually agreed on a common, standardized approach to workflow,” Day says.

“Once the standards were in place, if an adjustment to the system was required, I could implement it one time and take care of everyone.”?