For most radiology departments and imaging centers, successful adoption of a PACS requires a fundamental cultural change, and preparing the team for success in the new culture requires careful preparation. With 12 weeks or 12 months to go before going live with PACS, an implementation plan is critical for success. The following are 10 tips to ensure the entire team hits the ground running.
1. Have a communications plan.
A successful PACS implementation necessitates strong collaboration between unlikely and possibly heretofore unrelated departments and operational areas. Key constituents include referring physicians and their offices, radiologists, frontline radiology staff, the hospital information systems (IS) department, and all other hospital staff, as well as patients. The best way to ensure that communications are clearly conveyed to all constituents in an appropriate, timely manner is to have communications as part of the PACS project plan.
Each milestone of the project needs a commensurate message to the key constituents, and each constituent base will likely require different information and means and frequency of communication. The communications plan should closely follow the project timeline and provide advance notice of all milestones (see Table 1).
|Table 1. Template for designing communications with all PACS constituents.
2. Design an organizational structure.
To prepare for PACS, critically access existing staff resources to determine what skill sets are on hand, which are needed, and who will be responsible for each aspect of the new technology and operations in a PACS environment. Furthermore, PACS will blur the lines of responsibility between information technology (IT) and radiology, calling for more creative reporting relationships than may currently characterize an organization.
PACS Implementation Team: The PACS implementation team will have primary responsibility for the rollout. All constituents need representation in the PACS implementation team. Some constituents, such as referring physicians, will serve temporarily as advisors to the team during phases critical to their interests. Others, such as the IS department, will have ongoing participation as core members of the team. The project plan will reflect involvement of all constituents, as tasks cross over operational areas and are assigned to multiple team members for completion.
New Positions: If a PACS administrator has not been hired, now is the time. Whether that person resides in radiology or in the IS department will depend on an institution’s unique situation. Depending on the size of the institution and time frame for implementation, other positions may need to be created for PACS support, such as those for training, quality assurance, and user support.
Role Expansion: Hospital-based radiology departments will most likely require 24/7 support, so even if there is only one official PACS full-time equivalent (FTE), additional support, perhaps through the hospital’s IS department, will be needed.
Redefined Roles: Rather than eliminate FTEs, PACS is more likely to redefine the skills and roles of existing staff positions. Skills in information technology, project management, and more sophisticated operational management/tracking will be required for many in the department. Nowhere is this more apparent than in the film library, where “film librarians” acquire skills and a broader understanding of radiology operations to become “image service representatives.”
3. Train prior to implementation.
Training prior to implementation of PACS includes both knowledge-based training on the vendor’s system as well as more generic training in computers (some staff may need to learn how to operate a mouse and navigate Windows-based software programs). Each position, both existing and new, needs to be evaluated and the skill sets required must be identified. Then, each staff member should be assessed for training needs. Radiologists and key referring physicians need to be included in this training assessment. Some knowledge/skill deficits can wait until after initial implementation; most cannot.
4. Vendor(s) expectations.
Know Thyself: Your vendor’s expectations can be no clearer than your own expectations of uptime, support, and training. Rather than rely on the vendor to tell you what you need, do your homework to develop your own expectations in addition to the commitments put forth by the vendor. You are investing substantial and valuable resources; frequent communications and meetings are the only way to be sure that the project proceeds on target.
Know Thy Vendor: One hopes that time was spent visiting installed sites of a few vendors, including those of the chosen vendor. If not, have the vendor arrange such visits immediately. While visiting a site, request time alone with the facility’s PACS administrator and other key participants in the implementation to get their perspective on what went well and what could have gone better with additional planning.
|Table 2. Pros and cons for centralized and decentralized quality control.
Vendors Should Know Each Other: The PACS installation will require coordination among multiple vendors and specialists within the institution. The planners and the PACS vendor need to have a clear plan for who is accountable and how coordination takes place. Areas in which multiple vendors and site specialists may find themselves cooperating to bring PACS live include:
- PACS Installation: Involves PACS vendor, on-site network specialist
- RIS/PACS Integration: Involves RIS vendor, PACS vendor, RIS applications manager
- Modality Integration: Involves modality vendor, PACS vendor, network specialist
- CR/DR Integration: Involves computed radiography/digital radiography vendor, PACS vendor, network specialist
5. Do not forget the contingency plan.
A well-developed contingency plan will mitigate disruptions to your operations in the event of technology failure. The following points should be addressed in the plan:
- Problem: Define potential symptoms of the problem
- Point of Detection: Identify the point of detection and responsibility. Typically this would be the person most likely to notice the problem first.
- Automation: Where possible, the systems should include self-monitoring tools that can examine system loads, delays, and other problems that might affect performance. These features are typically found in the vendor’s response to the Request for Proposal.
- Communications/Broadcasts: Protocols to disseminate the nature of the problem to the end users should be developed in advance. The responsible person for problem detection should be trained on how to execute the protocol. Leveraging pager systems, email, and intranet broadcast messages is an effective way to get the message out. The communication should include performance expectations during the disruption.
- Actions/Roles: Everyone who interacts with the system should understand their roles and actions in the event that a contingency plan is executed. This includes technologists, radiologists, and support staff.
6. Handle all modality integration issues prior to implementation.
Prior to PACS implementation, all modalities that are not already DICOM compliant need to be upgraded. DICOM compliance includes DICOM Store, DICOM Modality Worklist Management, DICOM Perform Procedure Step, and DICOM Print. DICOM Store is a requirement for PACS. Modality Worklist Management and Perform Procedure Step are important for accurate data entry and the realization of the potential for technologist productivity improvement.
PACS implementation requires that all imaging modalities and associated equipment (eg, workstations and DICOM printers) be connected to the hospital network infrastructure. If this is not already in place, it can be a significant project in and of itself and should be undertaken prior to PACS implementation.
Planning for integration of imaging modalities needs to occur both when bringing existing equipment online with PACS and when purchasing and installing new equipment. In either case, the modality vendor, PACS vendor, and on-site network specialist will need to cooperate extensively.
New Equipment: All equipment purchases that will occur post-PACS implementation must be integrated with the PACS. Alert the modality vendor of this need, and have the vendor take ownership for testing and documenting compatibility prior to any signed purchase agreement. In addition, have the radiologists and technologists who work in that modality review and sign off on the compatibility documentation.
7. Before implementing, put in place a quality control (QC) program.
To maximize the effectiveness of the PACS, it is important to be confident that every examination performed and completed in the RIS was received and archived in PACS. After a study has entered the PACS, it must appear on the radiologist’s worklist to be interpreted in a timely manner. Rigorous QC measures are needed for each modality.
No matter the size of the organization, QC is a fact of life with PACS. Before one sends images to the PACS, a QC process must be in place. The primary preimplementation decision is to determine whether QC will be a centralized responsibility in the department or a decentralized, modality-level responsibility. There are pros and cons to each configuration:
Remember that your PACS vendor will need to assist in training/trouble-shooting for the person(s) responsible for QC.
8. Provide some level of enterprise distribution support.
Because of the impact of reducing the film budget, enterprise-wide distribution of images electronically is a key milestone in PACS implementation. Yet it is also the most difficult milestone to achieve, in large part because of the heterogeneity of the referring physician population.
If referring clinicians are expected to use their own PCs for viewing and, as is advisable, film printing is to be limited by strict protocols, the radiology and IT departments should collaborate to provide preimplementation assistance to referring physicians to advise them on the suitability of their hardware and, if necessary, recommend minimum requirements and a preferred vendor.
9. Develop film-printing protocols.
The need to print film in a digital department will diminish but not disappear. To accelerate the transition to a film-limited environment, develop printing protocols and printing guidelines and place them in a readily accessible manual.
Protocols: Developing protocols for printing is a responsibility that falls largely on the radiologists. The Printing Protocol and Procedures Manual should include:
- Format of the printed study
- Window and leveling settings
Limiting the demand for printed film sometimes requires limiting the circumstances under which film can be printed for a digital examination. The radiologists will therefore also guide technologists and image librarians on the guidelines for printing. The radiologists are providing a tool by which the technologists and image librarians, as image gatekeepers, can enforce the move to a digital department.
The Printing Protocol Manual should also include:
- Studies that can be printed
- Approval levels: Can the study be printed upon request, or is supervisor approval needed?
Although the manual will evolve over time as barriers to viewing or using electronic images are eliminated, its very existence implies that certain requests for film will be denied. Remember, though, that denying access to film can occur only when referring physicians have adequate, reliable digital viewing capability.
Printers: Printers are no less critical to the operation of a digital department than to that of an analog department. Determine demand for printed studies as you transition, and translate that volume into:
- Capacity: the total films per hour that will need to be printed (consider peak periods in your calculations)
- Deployment: the appropriate locations for your printers, eg, convenient to the image librarians who will print the studies
10. Invest in facilities and infrastructure preparation.
The devil is in the details. Be sure to address the following:
Furniture: Design the reading room to initially accommodate both workstations and alternators or workstation “carts” with overhead lightboxes.
Delivery: Determine a location to store the system between its arrival and deployment.
Data Center: Verify that the allotted space and environment are sufficient (eg, power, uninterruptible power supply, air conditioning, networking) for the PACS core.
Network Infrastructure: Any required upgrades to the network infrastructure (eg, installation of new switches and routers, upgrades to wide area network connections) to accommodate PACS bandwidth requirements must be completed prior to the PACS implementation.
Electrical Outlets/Network Connections: Install sufficient number of outlets and network connections and ensure they are livened.
These tips seem simple in many ways, and are by no means exhaustive for PACS implementation planning. But failure to follow them could leave the planner with sophisticated, expensive equipment ready to go, while he or she scrambles to finalize preparations. Plan, plan, plan.
Pamela Harlem, MBA, is manager, consulting service.
Len Levine, MSIE, is senior business systems consultant.
icole Pliner, MHSA, is managing director, Radiology Consulting Group, Boston.
Maryann Tateosian, RT(R), is PACS technical project manager, Massachusetts General Physicians Organization, Boston.