(From left to right) Briant Redmond, radiology information and PACS administrator, Jeff Fete, MD, chief of radiology, and Mike Morateck, chief ultrasound technologist and PACS co-administrator.

When Waukesha Memorial Hospital (WMH) in Waukesha, Wis, implemented a picture archiving and communications system (PACS) 3 years ago, the radiology department took particular care in drawing up a work-flow redesign plan.

Briant Redmond, radiology information and PACS administrator, devised the plan himself, tapping his expertise as a former technologist. But additionally, he gathered input from radiologists, technologists, and support team members who would be directly impacted by any changes-a very astute move, Redmond acknowledges in retrospect.

“I’ve held positions throughout this department, so I knew how things flowed and generally what we could expect in the way of work-flow changes from PACS,” Redmond explains. “When we created the work-flow redesign plan, we did not have any models to follow. We had acquired our PACS from Agfa, but, at that time, the Agfa users’ group had not yet been launched-it would have been a great resource to take advantage of.

“So, instead, we went to the department staffers and asked them how they wanted things to work. We asked questions such as: what do you want to happen once PACS is in place; how do you want to be able to see images; where do you think we can save you some steps with this technology?

“With the input they supplied, we structured the work-flow plan accordingly. Then, once the plan was readied, we invited the staff to review it carefully. We asked them to call to my attention any areas where we might have overlooked anything. In other words, we were asking them to bulletproof the plan. And, we figured, that if anyone could help me do exactly that, it would be the people whom the plan would affect, since they’re the ones doing the job and know best how to do it easier.”

Collecting staff input in designing the reengineered work flow served another purpose as well. It promoted immediate buy-in, says Redmond.

“The staff believed they had an ownership stake in the success of the redesign plan, since it was at least to some extent the product of their ideas and input,” he notes. “Consequently, the department was spared the need to later invest significant time and energy in attempts at convincing people to cooperate with the plan as it was being implemented. They knew ahead of time that changes were coming, because they had a hand in setting those changes in motion. They didn’t have to be warned to get on board or be left behind at the station.”


Waukesha Memorial is a community hospital located in the center of Waukesha, a city of about 500,000 adjacent to Milwaukee.

The hospital is accredited for 400 beds, but currently has 225. More bed capacity will become available after 2002 when the hospital opens a new six-story wing, currently under construction.

The radiology department is staffed by 15 radiologists who also provide coverage at a second hospital in the area-Oconomowoc Memorial Hospital-which not long ago merged with Waukesha Memorial. The staff at WMH includes 115 full- and part-time technologists and clerks. Modalities include MRI, digital mammography, computed radiography (CR), CT, ultrasound, bone densitometry, nuclear medicine, and angiography. The department performs roughly 100,000 imaging studies in the course of a year.

Waukesha Memorial offers medical services at 10 satellite locations. The radiology department provides ultrasound at about half of them. One of the satellites is a women’s center; it is equipped with nuclear, ultrasound, and digital mammography, although images produced there are transmitted to and stored within the WMH department’s PACS, where they are read by department radiologists.

Today, WMH is about 95% filmless and should reach 100% filmless soon, according to Redmond. Still awaiting conversion to filmless is the hospital’s surgery section.

“The surgery area is being remodeled? right now and rooms are being added,” says Redmond. “We took advantage of this construction activity to install PACS network jacks in the middle and at all four corners of each room. These jacks will provide connections for mobile, intranet-Web PCs that will be placed on carts in each room. Surgeons and the operating room teams will be able to use these PCs to tie into our PACS and view images from any place that is convenient for them within the room. Each one of the PCs has a 19-inch LCD monitor for viewing the images. In test runs, these Web-enabled PCs have worked very well.”

It was in 1995 that WMH first considered adopting a filmless approach to capturing, handling, and storing radiologic images.

“Our basement file room was in serious need of expansion,” Redmond recalls. “We needed a lot of extra square footage, in part because we were seeing an increase in examination volume and in part because new regulations regarding the number of years that images of various types had to be retained were soon to take effect.

“But the cost of constructing the envisioned additional space for that file room was going to be substantial. We looked into the possibility of leasing existing space off-site, but the projected costs again were going to be quite high-plus in a lease arrangement we would be expending capital without gaining material value in return.”

At about this time, decision-makers in the department had become aware of PACS technology and the promise it held for the digital future.

“For the amount of money it would cost us to acquire space for an enlarged file room, we could instead invest it in a PACS and thereby solve our storage space problems while at the same time positioning ourselves for achieving huge new efficiencies,” says Redmond.

The department’s radiologists, too, saw merit in the idea of introducing PACS. One of those eager to bring it aboard was Jeff Fete, MD.

“We support a busy medical oncology service, and it is not unusual to have long CT examinations to include head-neck, chest, abdomen and, in some cases, pelvis,” says Fete. “To take film and do a new-and-old comparison or to compare a new study to two old studies is a complicated and tedious process. However, to do these same comparisons on PACS is far more efficient. That was just one of the many appeals PACS held for us.”

With consensus in the department favoring acquisition of a PACS, the next step was to choose a vendor. WMH decided to go with Agfa.

“Agfa’s PACS solution was the only one with the capabilities we needed,” says Redmond. “The alternative was to buy bits and pieces from just about every other vendor and attempt to somehow string them all together in order to come up with a PACS able to do all the things we had in mind. Agfa, unlike the other vendors, was way out in front with its thinking about what PACS could and should be.”


Once the purchase was completed, the radiology department crafted a three-phase PACS rollout strategy.

“In Phase One, we connected all modalities that fell into the category of soft imaging, which included CT, nuclear medicine, ultrasound, and MRI,” says Redmond. “We started with these on the dual premise that they would be the easiest to hook up and that they would not be images looked at by referring physicians-at the time we were still contemplating what to do with image display for the referring physicians, since even the lower-end display unit then was pricey.

“Among the modalities in our Phase One implementation, ultrasound was the first we tackled. We hooked it up and spent about a month debugging the connections. After that was squared away, we moved on to the next modality-CT-and so on until all modalities in the soft-imaging category were hooked up.

“In Phase Two, we addressed distribution of images. For this, we deployed review stations in the ICU, emergency department, and any other area that needed imaging. At this point we also started up our intranet Web display capability. In Phase Three, we hooked up CR.”

Prior to the rollout, radiologists rotated through the handful of modality-equipped WMH satellites to perform reads there. After PACS was implemented, all images were piped into the radiology department for interpretation in a centralized reading room.

But with this there had to be the redesign of work flow. As with the rollout of PACS, the work-flow plan was implemented in steps.

“It was an evolutionary process,” says Fete. “We didn’t flip a switch and suddenly everybody was working in ways to which they were unaccustomed. That would have been a disaster. Instead, we go live with PACS in one modality and give the radiologists and staff time to become accustomed to being filmless in that area before adding the next modality and implementing the next set of work-flow changes.”

Redmond says that the most pronounced change in work flow for the support staff was the elimination of report filing and the corresponding need to create or maintain jackets for images. This had the effect of making superfluous the roles played by some employees.

“We found other tasks for them to perform,” says Redmond. “One of their jobs now is to print films for outside sources, such as patients who want to have a copy of their images to take to a physician who isn’t affiliated with WMH. The staff now also generates the paperwork that goes along with the films they print.”

Another task to which these staffers have been reassigned involves assisting WMH referring physicians who visit the department to look at images.

“In the past, because our manpower was limited, the help our staff was able to give to referring physicians was very limited,” says Fete. “Today, referring physicians no longer must come to the department to view images. They can see them from any number of remote terminals throughout the hospital. Still, though, there are some referring physicians who want to continue coming to the radiology department and see images here.”

Sometimes, those visiting physicians desire to interact with the radiologists rather than with clerical staff. No problem, Fete assures.

“It is not considered a disruption of work flow for referring physicians to engage the radiologists in this manner,” he says. “We see this as an essential part of providing good service to our customers. Customer satisfaction is way up as a result, and that is what we’re seeking.”

Importantly, none of the department staff was laid off as a result of PACS and workflow redesign-nor were any such layoffs ever contemplated, a fact emphasized by Redmond in his dealings with the staff during the work-flow redesign process. That, he indicates, was critical for maintaining good morale throughout.

However, the number of employees in the department was permitted to shrink through normal attrition after PACS was in place.

“As staffers left, we did not hire replacements for them,” says Redmond. “But we have had to begin hiring additional people recently to keep pace with our greater volume of imaging studies. When we started with PACS, we were at about 70,000 examinations per year. Now, we’re doing 30,000 more than that.

“But just to illustrate how much more efficient we are now, another hospital in the area is doing about 40,000 examinations per year and has the same number of staffers in its radiology department as we have in ours, even though we’re doing 100,000 examinations a year.”


A lesson learned in the course of all this, Redmond notes, is that work-flow redesign calls for thorough training of those who will see their routines changed.

“You must instruct staff in how to use the system first of all,” he says. “That includes how to pull up images, how to print, how to window-level for a CT, what type of window level to print for a CT, and so forth. But then you have to delve into the ins-and-outs of how these capabilities help each person be more efficient, and what your plan is for taking advantage of these efficiencies. Then, you have to be prepared for a lengthy learning curve. It takes at least a solid month of training before the staff is comfortable with its new duties and work methodologies. In some cases, it can take as long as 3 months to get them properly trained.”

Fete asserts that training should be extended to include referring physicians as well.

“We observed that many referring physicians have trepidations about giving up film, and for a variety of reasons,” he says. “Therefore, it is essential that they also receive training in PACS operation and in new work processes.”

Managing Expectations

An aspect of work-flow redesign that is sometimes overlooked or given short shrift is the need to manage expectations. In the case of WMH, Fete says that he and his colleagues came to believe that PACS and the re-engineered departmental processes the technology permitted would quickly yield substantive gains in radiologist efficiency.

“The efficiencies we expected did come about, but not nearly as rapidly as we thought,” he says. “This was a bit disappointing.”

However, the champions of the system helped buck up their colleagues and rebuild enthusiasm. Left unchecked, flagging enthusiasm could have undermined efforts to implement the redesigned work-flow plan, which would in turn have caused enthusiasm to dip lower still.

Of course, some expectations are hard to dampen, considering all that a good PACS promises to do to lighten the burden of daily chores around a radiology department. At WMH, the file room staff was ecstatic upon learning that they no longer would have to trot up and down stairs for folders.

“In our facility, the file room was one flight of stairs down from the radiology examination rooms; the clerks used to jog downstairs, pull folders, load them onto the dumbwaiter, send them up and then hustle back upstairs to continue their routine,” says Redmond. “Everyone was happy to see this method end.”

Taking such lessons to heart will be key in the near future, for WMH is gearing up already for further reengineering of its work flow. This will occur as a result of the hospital’s plan to convert to an electronic medical record system.

“We’re just in the initial stages of this,” says Redmond. “But it will require acquisition of a new mainframe computer system for our RIS to be able to interface with what the hospital is planning.”

In a related development, WMH recently converted its PACS platform from a Unix-based system to Windows NT. Running on that system is Agfa’s Impax version 4.0 software, to which the radiology department upgraded after having started with Impax 3.0 and later advancing to version 3.5. Included with the upgrade was on-site applications support.

“Agfa supplied a technician to work with the clerical staff during the upgrade to demonstrate new procedures, such as how the printing processes would be changed,” says Redmond. “That was very beneficial to us. It made things so much simpler as we went about the task of implementing the upgrade-and, naturally, the work-flow modifications that went along with it.”


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