(Left to right) Jeff Albert, PACS coordinator, David Simms, MD, radiologist, and Larry Leopold, manager of radiology

To David A. Simms, MD, a staff radiologist at Wichita Clinic in Wichita, Kan, work flow represents an organized system of tasks that must be redesigned when picture archiving and communications (PACS) is introduced-otherwise, productivity-boosting efficiencies will prove elusive.

“A radiology department that continues employing the same work processes as in the days before implementing PACS will not realize for itself the full set of benefits that PACS can make possible,” Simms says.

His point is amply illustrated by what Wichita Clinic’s 7-radiologist imaging department accomplished through a makeover of ultrasound work flow following the 1998 arrival of PACS at the 160-physician, multispecialty group practice.

Wichita Clinic-which logs more than 500,000 patient visits and nearly 100,000 imaging procedures annually-operates 10 satellite facilities across greater Wichita. Three of these are equipped with ultrasound units. After linking those sites to the PACS, the radiology department reengineered the way paperwork for each examination would reach the radiologists back at the main facility.

“Before PACS, the technologists would scan throughout the morning and complete necessary documentation; then, at some point in the afternoon, they would gather the day’s images and documentation and hand-carry them to the radiologists, and wait around in case the radiologists wanted to discuss particular examinations,” Simms says. “Once PACS was in place, the technologists were permitted to send images over the phone lines as soon as they were completed and then bring in the documentation by hand as before at the end of the day. When it was observed that the radiologists seldom thereafter found occasion to talk to the waiting technologists, the work flow process was refined to permit documentation to be sent to the radiologists by fax, thereby eliminating the need for technologists to travel to the main office.

“If a radiologist needed to talk to a technologist about an examination, he could do so by picking up the phone and calling over to the branch where the technologist was based. The technologists, since they could remain at their own locations all day, were given additional ultrasound examinations to perform to fill that free time. Thus, we were able to increase the number of ultrasound examinations performed at the branches each day by as many as two per technologist.”


Work-flow redesign involving ultrasound and other imaging modalities did not occur overnight at Wichita Clinic. In fact, the endeavor moved forward at a slow, deliberate and methodical pace-and to this moment remains in progress.

“The reason we haven’t hurried this along is because our physician base wants to see incremental success,” explains Larry Leopold, manager of radiology. “They feel that, since they have a vested financial stake in our success, the least risky way to proceed is to start small and cautiously, and be able to demonstrate that PACS and any changes in work flow really has improved productivity and lowered costs. Only then can we proceed with wider PACS deployment and more work-flow reengineering.”

Leopold says the radiology department began with a small-scale PACS server and two workstations.

“Our first real test was to convert ultrasound from film to totally filmless,” he recalls. “When the new equipment was in place, the system fully readied, the work flow redesigned and the staff trained, we shut off film and in one day switched over completely to digital. We didn’t even announce to the physician base that they would no longer have ultrasound film. We just made the conversion one day and that was that. Fortunately, it worked.”

Eventually, though, some of the group’s surgeons requested ultrasound film be made available once again so that they could more comfortably reference malignancies of their breast cases while performing biopsies in the operating room, says Leopold.

“To accommodate those surgeons,” he says, “we established a rule that anytime the main building technologists were going to ultrasound a breast-be it for a surgeon or a family practice physician-they were to scan the patient and archive the image to the PACS, but also at the same time print it as a film. To help get the technologists accustomed to doing this each and every time, we would highlight on the daily schedule every procedure involving a breast-a reminder. We further reinforced this by asking our radiologists to make sure every ultrasound breast image available on their monitor screen in the reading room was accompanied by a jacketed film of that same image-and if there wasn’t, to immediately call the technologists and direct them to print one.”

The necessity of making such an accommodation was apparent as soon as the surgeons made their request. However, in a few instances, the necessity was not so evident.

“We had one surgeon who continued to insist on having film in the operating room for thoracic procedures,” Leopold offers. “We couldn’t conceive of why he needed film for that type of surgery-until we asked him why. He told us it was for only one reason, and that was so he could confirm before walking over to the operating table whether the lesion he was about to remove was on the left or the right.

“Our solution-which we will soon implement-is to deploy in every operating room within our ambulatory surgery center PCs connected to an intranet Web browser and allow the nurses there to bring up the image so the surgeons can see which is left and which is right without film.”


That intranet Web browser already is in place, albeit for other uses at the moment. It runs on a server that can accommodate 255 users. The department recently upgraded to this high-horsepower product after wiping out its fatally undersized original browser.

“We first entered the intranet Web arena in mid-1999,” Leopold says. “Back then, we thought we would have perhaps five to 10 users online at any given moment. We assumed a small-sized browser would be more than adequate. However, we burned it up, that’s how heavy the data-flow demand on it ended up being. It was clear that we erred in choosing a browser size based on the type and amount of information that would be going out, not on what would be going in. We did not give consideration to how that would affect the inner workings of the browser.

“As we discovered, it doesn’t take a Web server a lot of energy to supply a client with images. However, the amount of raw digital data embodied by radiologic images requires an enormous amount of system energy to be able to compress them into a wavelet format, store them in the different areas of the Web server and quickly transmit them across the intranet so that they therefore can be very accessible by the physicians.”

Another mistake related to browser sizing had to do with user traffic. The Wichita Clinic is open Monday through Friday from 8 AM to 6 PM and the radiology department operates in tandem with those hours. “We pack a lot of examination taking and reading into a short period,” Leopold says. “But our browser size calculation was based on the number of images generated in a day as though our business day were 24 hours long rather than the 10 hours it actually is. It is one thing to say you’re going to move 300 to 400 images through your network connections in the span of 24 hours; it is something entirely different to say you’re going to move 300 or 400 images across it in 10 hours. On a moment-by-moment basis, 400 images in 10 hours creates much greater traffic congestion than does 400 images in 24 hours.”

A similar problem arose with regard to network architecture, a problem that was solved not by means of a change in hardware and software, but by a further reengineering of work flow. In the first redesigned work-flow scheme, technologists operating computed radiography (CR) units at satellite facilities would wait until after scanning a full set of images before transmitting them to the radiologists back at the main facility. It was more efficient that way. But if a study consisted of 10 images, it could take several long minutes for the compressed file to finish crossing the network, even though connections were made via high-speed T-1 data lines, according to Jeff Albert, RT, PACS coordinator.

“It turned out it was better to take three or four of the images, stop there, transmit those across the network, then resume taking images,” says Albert. “By the time you collected another three or four and stopped to send those over, the first set of images would have finished arriving at the main facility. You would send those, then go back to the CR unit and finish the study. By the time you went to transmit those remaining images, the previous set too would have finished arriving.

“This approach may have added some steps in one part of the process, but it ensured that images would be received faster, which would have the effect of improving work flow at that end. Taken as a whole, the improvements in workflow at the receiving end more than offset the need for added steps at the point of origin.”


Wichita Clinic’s radiology department began linking its various modalities to PACS beginning in May, 1999.

“CT was the first,” says Albert. “Then ultrasound and nuclear medicine in April, 1999. MRI was live in August, 1999. After that was R/F in March, 2000, and CR two months later.”

Currently, about 60% of the main facility is filmless. It is expected to reach the 95% mark later this year, Leopold indicates.

“Our largest branch office is the only one of the satellites that is 100% filmless,” he says. “The other nine still produce film, which they deliver to our centralized reading room via courier. Once those films arrive at the main facility, they are distributed by hand to the radiologists.

“We’re hoping at some point this summer to expand our intranet browsing capabilities to include the Internet and so enable physicians who are not part of the Wichita Clinic to also have access to images.”

Interestingly, it was Wichita Clinic’s desire for a better deal on film pricing and support services that prompted it to even consider conversion to a filmless environment.

“In 1997, our film contract, which we had previously awarded to Agfa, was up for renewal,” Leopold remembers. “To ensure that we would receive the fairest shake possible, we sent out a request for proposal to a number of vendors in addition to Agfa. We specified that we wanted to see a lot of creativity in coming up with a cost-and-time saving solution. Agfa proposed that-because of the image volume we were seeing and the structure of the work flow-we ought to leave film and adopt PACS.”

Over the next four months, an intrigued Wichita Clinic explored with Agfa a variety of scenarios by which PACS could be utilized. It was clear to Leopold and other decision-makers that PACS was a pivotal technology for the future and that the group needed to embrace it.

Once the decision to acquire a PACS was reached, Wichita Clinic then invited other PACS vendors to make proposals, too.

“We didn’t have the capital necessary to permit adoption of some of the other vendor solutions shown to us,” says Leopold. “But Agfa’s solution was, in contrast, very inventive and very workable for us.”

After the PACS was installed, productivity gains quickly materialized, Leopold reports.

“Our ultrasound technicians, for instance, no longer had to stand around at the processor, waiting for films to come out,” he says. “They also didn’t have to stand outside the doctor’s office, waiting to show the films. We estimated that the elimination of these steps saved approximately 15 minutes per ultrasound examination.”

Leopold adds that the time savings turned out to be as much a benefit to patients as they were to the enterprise.

“We do a lot of OB scans,” he explains. “The patients have very full bladders and are uncomfortable the entire time, so getting them through the test at least 15 minutes sooner makes for improved customer satisfaction.

“The time savings also relieves pressure at the front desk where the patients arrive; the techs are now almost always able to keep up with the schedule of appointments. In the days before PACS, having to pay ultrasound technologists significant overtime was the norm-from five to 10 hours per pay period per technologist. But now, technologists routinely complete each day’s examinations by the close of normal business hours. If there is any overtime now, it is down to about 30 to 45 minutes per technologist per pay period.”


In the course of redesigning work flow, Wichita Clinic discovered that it is worthwhile to have funds available in the budget to cover contingencies, such as the need for an additional workstation above and beyond the number planned, says Albert.

“You do have to be prepared for contingencies,” he asserts. “It almost seems that when you make one change in work flow, it triggers the need for another somewhere else down the line. Some of the changes that are triggered can be anticipated, but for others there is just no way. You need to have some means of addressing them, and often that will entail a need for more capital.”

Albert suggests a way to minimize unexpected consequences of redesigned work flow is to participate in a users’ group, such as the one sponsored by Agfa.

“In the users’ group we’re in, the members have the opportunity to talk about the work-flow problems they are encountering,” he says. “Everyone who is there can offer suggestions on how to solve those problems. Some of the advice is made by users who’ve been there and done that, so what they suggest is usually very helpful.”

Radiologist Simms cautions that, while the term work-flow redesign connotes an effort strategically planned from on high within an enterprise, periodically it can be a spontaneous, bottom-up exercise.

“Some reengineering occurs by happenstance and entirely at the initiative of individual rank-and-file members of the department,” he says. “It is almost inevitable that, after you have received training in how to use the PACS and in how to perform tasks in a work flow-redesigned environment, you will find ways on your own to make further improvements. As you gain competency in the new processes, you may realize that by doing this or that step slightly differently you can get the task done faster or smarter. This encourages you to experiment. Before you know it, you have found a number of ways to improve the process and so you adopt those into your work routine.

“I know that in my own case, the way I work today with PACS is appreciably different from how I worked with it a year ago, which is different from how I worked with it when it first was implemented here-all because I discovered new techniques here and there in the course of day-to-day use. One illustration of this would be the way I read CT scans. Before, I would have a set of new CT images on one screen and a set of relevant prior CT images on the other. After a while, I realized I was really only looking at one new and one old image at a time.

“So, now I no longer pull up multiple images on each screen. Instead, it’s just a single new one on the first and a single old one on the second, and the two are synchronized so that as I pull up the next new one, the next old one automatically comes up on the other screen. I find this makes me a lot more efficient. But, that, of course, is the ultimate aim of PACS and work-flow redesign-to optimize efficiency and productivity.”


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