|The team responsible for implementing PACS at Peace River Community Health Center, Peace River, Alberta, Canada, are (from left) Darlene Meston, Shawn Wall, Harry Nath, MD, and Krystal Kolenich.|
Picture archiving and communications systems (PACS) are rapidly emerging as the method of choice for centralizing images and data within radiological environments. Up until now, however, this digital trend in health care has been the province of academic and luminary hospitals and clinics with a wealth of resources. The addition of PACS in smaller or rural facilities has been hindered both by the expense of going digital and the implied need for a large network of people to implement the system.
The example of one rural Canadian radiology department could alter the thinking on community hospital-based PACS. Peace River Community Health Center, part of the Peace Health Region in Alberta, Canada, went live in June 2001 with the first completely filmless department in western Canada. The system is set up in a center that serves a population of 6,500, but most surprising is that Peace River’s PACS was developed and implemented by a team of four dedicated professionals.
“A lot of facilities think PACS is just for big sites, but it really is essential for smaller communities because of their remote locations,” says Krystal Kolenich, regional diagnostic imaging coordinator for Peace River. “We want to demonstrate how important it is for remote communities to embark on implementing PACS to improve the service they are offering their patients. However, to make it work, everyone has to be committed to it and excited about it. There has to be motivation throughout the facility, and like any computer system, what you put in is what you get out of it.”
What Peace River put into the plan was shaped most of all by the vision and enthusiasm of project leader Harry Nath, MD, a fellow of the Royal College of Radiologists. In 1987, Nath was recruited to Saskatchewan, Canada, a 5,000-person community served by a 70-bed hospital that had what he calls “an extremely antiquated” radiology department. Under Nath’s tutelage, the department was modernized and its capability increased to include ultrasound and myelography. Though Nath dreamed of creating a totally filmless department, it was not until 1998 that the opportunity presented itself in the form of Peace River, which was building a new hospital.
Cues from Air Traffic Control
Peace River’s visionary Harry Nath, MD, not only applied his proactive manner to developing PACS, he also used it to address the matter of redesigning his reading room to accommodate the new system at the hospital. Using basic ergonomic principles and taking design tips from the local air traffic control tower, Nath designed a unique and much-photographed reading room that helps avoid the issues of neck and back strain.
“In most reading rooms, radiologists are required to look up to read the viewbox, and that means craning the neck uncomfortably,” Nath says. “I went to Houston, Milwaukee, Baltimore, and saw universally that the monitors are too high. They also have strong, heavy bases and even if they are on regular tabletops, the keypad comes out further.”
Nath kept those things in mind as he designed his room, which houses a work station with a diagnostic monitor, a computer monitor on the left with Internet capability, four small ultrasound monitors, a VCR for viewing cardiograms, a monitor connected to the digital fluoroscopy unit, and a viewbox for those sites still sending in films. The whole table goes descends in two-inch increments and all the monitors are slanted and recessed so that they sit lower than the table.
“Incorporating an adjustable shelf gives him the ability to move the monitors, which are quite big, up and down to help with visualization,” says Krystal Kolenich. “They also are inset at an angle.
“He put a lot of work into designing the reading room, which is all about understanding that you can’t replace a viewbox with a monitor,” she adds. “These are not interchangeable, and the design can affect the reading.”
“I did not initially have the buy-in from the radiologists, because this was different, but I quickly got over that hurdle,” Nath says. “And the end result is that I have no neck strain because I am looking down at the monitors.” n
Putting PACS at Peace River
“There were two things I wanted to do at Peace River,” Nath says. “I wanted to create a digital department, and I wanted to change the fact that there were few CT scanners in Canada. In general, the health system felt that small community hospitals didn’t need such equipment and could not afford them. Peace River was a little hinky-dinky place, that had a different radiologist flying in each week from Edmonton, so there also was no continuity of care.”
Changing the administration’s mindset to ally with his own was a challenge, but Nath had a plan. Shortly after presenting his vision to the board, Nath took one of the administrators to RSNA in 1998. After spending a whole day roaming among the vendor booths, Nath asked the administrator if he had noticed anyone selling film.
“No one was selling film there, and that was my whole reason for taking him,” Nath says. “So when the filmless dialogue came up with the board, the administrator was on my side. Lack of space for storage was another selling point to the board for going filmless, and digital archives are getting cheaper by the day. All that helped make the decision.”
Once the administration was on his side, Nath had to cope with the even larger hurdle of financing the project. The Canadian system has very little money for health care, according to Nath, so doing a whole department with top-notch machinery and a CT scanner was very difficult. His method was to approach three of the largest PACS manufacturers and propose to become a show site.
Further complicating Nath’s goals were the board members’ insistence that consultants be involved. Contrarily, Nath felt the hospital would be wasting money on such outside commentary, and that PACS should be a radiologist-led project. Consultants were brought in for a brief period, but Nath says they had a mindset that Peace River should have second-grade machinery. Because of the difference in vision, they soon parted ways.
“Needless to say, once we started deciding on machinery, we had a parting of the ways,” Nath says.
|Harry Nath, MD, took cues from air traffic control to design a reading room with monitors placed below eye level.|
Nath eventually forged an agreement with a major manufacturer for both top-of -the-line equipment and an ongoing service contract. He also managed to convince the board that the CT scanner was a necessary part of the PACS bargaining. However, while the scanner was purchased, there was no budget for its operating expenses.
“This was quite a crisis, so I went to community for the money,” Nath says. “After talking with lots of people, I found two wealthy who were willing to pay the operating expenses for the CT for two years.”
Subsequently, Nath points out that the CT has generated some major cost savings for the hospital system by cutting down on the ambulance costs that used to be incurred transporting patients to Grand Prairie or the University of Alberta in Edmonton for diagnostic work.
Today, Peace River’s diagnostic capabilities include a single slice helical CT, a digital fluroscopy unit, a digital mammography unit, a general purpose radiographic system, an ultrasound mainly used for breast scans, and two ultrasound systems. The Peace River location sees 1,000 patients per month but serves a total of 40,000 from the three surrounding regions.
The initial phase in Peace River’s PACS implementation focused on going digital and training the staff, and creating the network for access to images and reports at Peace Health Region’s other community health centers in Grimshaw, Manning, and McLennan. Keeping the sole radiologist on site more and reducing his travel throughout the region was a focal issue as well in the primary phase. The second phase involves adding voice recognition to create a smoother information flow to PACS and the information system, while the third phase will add teleultrasound, get Peace Health Regions’ three other sites online with digital imaging, and connect Peace River to larger facilities and other facilities outside of the region.
The People Factor
Even with the support of the board and the financial assistance from the community, Nath says the greatest challenge was adding personnel-without whom the plan would never work. Nath labored for a year to bring in Kolenich from Saskatchewan, and she finally came online in September 1999. Soon after, Darlene Mestin came aboard as regional information systems coordinator and Shawn Wall was hired as the network analyst. Although Nath had great faith in each one of them, Kolenich, Mestin, and Wall knew little about PACS.
“It was an education from the start,” Nath says. “But everyone worked extremely hard on this project, and it was a real labor of love. The learning curve was so steep and we are so remote that we basically learned it on our own or over the phone with the service personnel.”
“Everyone had to do their own background work and use whatever resources they had to find out what we needed on our side,” Kolenich says. “Luckily our team was really dedicated, so the initiative was there. But we didn’t know exactly what this would take.”
“At first I spent a lot of time figuring out exactly what PACS was, because I had never seen it, and I had no idea what they were trying to accomplish,” Wall says. “Then I was trying to bridge the gap between IT and the health care workers. As involved as they were, they didn’t have the very basic concepts of IT, so we had to do a knowledge transfer that worked both ways.”
|Harry Nath, MD, and Mona Diebert, CT technician, in the CT suite, included in the PACS proposal.|
Although the job was certainly daunting, Kolenich says she feels PACS is easier to implement with a small committee because it simplifies the decision-making process.
“We were lucky to have just four people doing this,” Kolenich says. “Some would consider that unfortunate, but it gets rid of a lot of delays. We didn’t have people on our team who didn’t belong there. A lot of facilities get a group together to do PACS and they think it needs to be big enough to include everyone. But if you have 14 people on a team, the decisions never come about. It really benefited us to have close, direct communication between the group members.”
Granted, Kolenich concedes that staff members most likely will have to take on other roles. Hopefully the facility is committed enough to the project that they will understand the need for job requirements to change. Kolenich, for instance, added the job of PACS administrator to her duties as radiology manager. Daily interaction with IS is required, as well as oversight of daily quality control checks.
“This process takes a lot of dedication and a lot of your own time, including weekends and evenings. We were lucky to have people dedicated enough to make this work,” Kolenich says. “We took time off when we needed it, but when we were expected to be there, even at 2 AM on a Saturday, we did what we needed to do.”
Once the four got up to speed on the new system, their next challenge was to train the entire staff-both in-house and within the region-not only on PACS, but also on the hospital information system (HIS) being implemented at the same time. Though the hospital was not even looking into HIS when it was planning its expansion, that changed when the PACS plan began coming together .
“Initially, Peace Health River had contracted with a very small company to build a small RIS,” Nath says. “By the time 1999 came around and the board was thinking more in terms of an electronic hospital, they started looking into HIS.”
Wall worked closely to integrate the RIS with the HIS, which turned out to be a huge endeavor.
|The PACS at the Peace River Community Health Center, first in the province, is intended to facilitate the delivery of imaging services throughout the region, according to Krystal Kolenich, regional diagnostic imaging coordinator for Peace Health Region, Alberta, Canada.|
“They were also building a brand new hospital, so everyone felt that was a good time to bring on a new HIS and RIS system,” Wall says. “Tackling all that at the same time was very difficult. I’m not sure if there was a lot of wisdom in doing that, although if you’re going to make changes I guess you might as well go all the way.”
Nath felt it was not the time to go all the way in terms of making Peace Health Region’s other locations digital, however.
“I realized early on we would not have the money to make the outlying locations digital, although hopefully that will be part of phase two and phase three,” Nath says. “Since a large portion of patients and films at the other locations are still referred out, it would be foolhardy to go digital and then have to print everything anyway. However, the outlying locations will be able to digitize urgent films and send them to Peace River for viewing with this system.”
Peace River also is looking into setting up private networks to its tertiary care center, the University of Alberta in Edmonton. The trouble at this stage is that the university is not yet PACS-based, forcing Peace River to print film to send out.
“That’s kind of a retrogressive step for us,” Nath says.
A portable ultrasound enables Nath to go to Peace Health Regions’ other locations, though within two months, the clinics will be adding ultrasound with real-time capability. Once that link is in-house, voice dictation will be added as well to free up administrative time.
“One of the major benefits is that when the physician phones me up from a local clinic, we can be connected online and look at the image together,” Nath says. “When the outlying physicians phone me, I don’t have to wait for someone to dig the films out. Some of them don’t yet understand what we have here and they wonder how we can access the films so quickly when we are on the phone with them.”
Getting It Online
The process of going digital for a community hospital is certainly both unique and challenging. For instance, while there was a request for proposal concerning the PACS, Kolenich says it was “very cookie cutter” because of a lack of knowledge about what specifically was needed at Peace River.
“We used a basic RFP to get it out there, but it wasn’t programmed for our site specifically,” Kolenich says. “A lot of improvisions came afterwards when we were talking with the vendors. However, a generic RFP is a good idea because it gives you something to compare apples and apples and get the basic questions out. For the end result, that does not do it, however. It’s best if you have people involved who have done PACS before, in order to find out exactly what you want out of the PACS.
“Nath gave us a vision of what we were going to do,” Kolenich adds. “How it was rolled out came on a needs basis, because there were not a lot of other sites to refer to.”
Ingenuity and dedication from the staff is the real cornerstone to going digital for a smaller facility. Wall, Nath, and Kolenich all stress the teamwork that occurred on the part of the implementation team, and its major contribution to the success of Peace River’s PACS.
“You really need to have good rapport and teamwork to pull this off,” Wall says. “Also, if you let a vendor come in and just drop a system in your environment, it won’t work.”
“It’s important to do what works for your facility,” Kolenich says. “People are just trying to sell you stuff, so you need to determine what you require to make a hospital run. We didn’t have a full idea of what we would need until we went on a site visit to a place that was our size. While it may be a little difficult to change, it is well worth it.”
What is key, says Nath, is that radiology, not information services or consultants, lead the project. “IT needs to be involved, but it has very little idea of what radiology needs. IT should not lead. If it is radiology-led, you will get a more practical and purposeful department.”
Elizabeth Finch is a contributing writer for Decisions in Axis Imaging News.