|John Couris, Morton Plant Mease Health Care, Clearwater, Fla.|
A picture archiving and communications system (PACS) fundamentally changes the way the medical imaging product line is delivered to the marketplace for health systems. The deployment of PACS has a profound impact on service, outcome, and cost. In the medical imaging industry we hear a great deal about the implementation, training, and measurable sustainment of the technology; what is equally important is the strategic decisions that go into the conceptualization of what PACS will mean for a specific health system and the community it services. The following will attempt to outline how PACS might be strategically planned and the considerations necessary when selecting, implementing, and sustaining a PACS deployment.
Health care organizations are facing challenges to reduce cost and increase service across the continuum of care for patients. With imaging becoming a greater part of the care patients receive, it is important for radiology, cardiology, and pathology leaders to find creative ways to manage both the growth and cost of services provided. Medical imaging organizations within health care need to quickly create a process to address the increasing needs of referring physicians and patients when it comes to providing clinical information to help aid in the diagnosis and treatment of disease. PACS will not only increase the ability to provide care, it will also set the stage for the health system to better utilize imaging modalities resulting in the system’s ability to identify unnecessary tests/procedures and to free up capacity for appropriate studies.
Developing Needs Assessment
Once an organization has determined what PACS will do for the health system and community, a needs assessment of current operations is required. The Radiology Consulting Group (RCG) from Boston has developed a tool that Morton Plant Mease used with great success. The tool focused on creating clear objectives for the project, practical process improvement techniques, financial modeling, and measurement focused on pre-implementation so when the PACS is deployed the organization can measure quantitatively the improvements focused on service, outcome, and cost.
When an organization begins the business needs assessment, clear objectives and ground rules are extremely important. The objectives should focus on the creation of a high level blueprint of the organization’s operational and technical workflow and the formation of a PACS steering committee. Once an organization has begun to lay the foundation financial indicators are extremely important from both a capital and operating perspective. One of the major pitfalls of any type of large multiyear deployment is the lack of baseline information to measure the improvements and plan for the future of the technology. Some ground rules that should be considered are 1) develop solutions/recommendations that are realistic, results oriented, and sustainable, and 2) align the goals and objectives of the radiology practice(s), the hospital, and the referring physicians.
Process tools for a business assessment is the next cornerstone to helping conceptualize an organization’s approach. Some of the tools recommended are: flow-charting, failure point analysis, stakeholder interviews, unit cost analysis, and incremental revenue projections. Operational flow charting along with failure point analysis is one of the most powerful tools in helping assess current operations and future states of operation as the technology is deployed. Failure point analysis is an attempt to identify the bottlenecks or points within the system that may be adversely impacted by the new technology. This allows the team to proactively plan and anticipate where the issues and/or opportunities could be. When evaluating why a PACS is successful, failure is often in the processes that have not been adequately planned for. When the PACS goes into operation, if it is not being optimized, it often adds to the total cost of the project and can adversely impact the return on investment.
The stakeholder interviews are crucial to receiving organizational buy-in and support. As a leader, you must apply a systems thinking approach to the PACS deployment. The PACS implementation will impact almost every aspect of the organization. The team needs to meet with the CEO, COO, vice presidents of nursing, CIOs, vice presidents of ambulatory care, and other clinical leaders such as the vice presidents of medical affairs. The PACS team also needs to meet with referring physicians, hospital-based physicians, nurses, technologists, and other users of the technology. It is really important to remember that this technology will change the way health care workers receive and interpret clinical information.
Determining Cost and Revenue
The next phase of the business case and organizational profiling is focused on cost and revenue. The first step is to understand the current cost of performing medical imaging in an analog environment and how the cost algorithm changes as PACS is deployed. Using the RCG cost approach, a health system must focus on the following elements: variable and fixed costs. Examples of variable costs are staff, film expense, chemicals. The fixed costs focus primarily on overhead related activity such as the lease of the space for films, equipment maintenance, utilities, and alternators. This activity is crucial to the ultimate success of the program. PACS is often scrutinized because health systems struggle with the return on investment, and this is partially to blame on the lack of baseline analysis on the cost side of the equation when planning for PACS. As you analyze and identify current costs and how they will be impacted by PACS, the revenue side of the equation needs to be addressed. As the organization deploys PACS and a critical mass of the technology materializes, the organization will be able to increase profitable volumes by providing the product anywhere at anytime, the walls of medical imaging come down, and a concept called mass customization begins to take over. Mass customization refers to the ability to be all things to all people; if the customer wants film, they can theoretically have film, if they perform digital on-line images at their office, they can call the images up via the Internet or a direct connection to the hospital. If patients or referring physicians want the clinical data on disk, they can have the information on disk. All of these mediums add to the value of the medical imaging product line and help maintain and grow market share.
An organization should balance cost and revenue because inevitably at the beginning stages of a PACS deployment the cost will increase as the organization will work within both an analog environment and a digital environment. The team implementing must have not only a strong understanding of baseline and incremental costs but also increased revenue that will help offset some of the temporary increases in expense.
Designing a Dashboard
The final assessment piece is an organization’s dashboard of key indicators that will drive improvement focused on service, outcome, and cost. For example, an organization, when focusing on these three areas, might want to consider the following (note that these are actual high level indictors selected for phase two of the Morton Plant Mease Health Care PACS deployment):
- Clinicians will have access to any image, anytime, anywhere. Web-based technology will allow instantaneous access to images from any PC in the Morton Plant Mease Health System and referring physician offices.
- The PACS technology will allow a radiologist to cover multiple sites from a single location increasing capacity and access through increased efficiency.
- PACS will decrease turnaround time by 30% for emergency department/stat cases. Morton Plant emergency department (ED) physicians now have digital images available within 2 to 5 minutes from the time the examination is completed.
- Images will be available for distribution on multiple mediums. The digital images can be printed on paper or film, viewed digitally on workstations, sent via email, or transferred to a compact disk or DVD. (The key to the service indicators, once the team agrees to them, is to find a way to take the qualitative to the quantitative.)
B. Outcome. (example describes a PACS deployment in the Morton Plant Hospital newly built ED).
- Another benefit to using digital imaging is a reduction in the number of retakes. In the past, with a poor quality study, the technologists would need to retake the study. Digital radiology and computed radiography (DR/CR) allow for a wider margin of image manipulation, and are not as sensitive to technique. Technologists at MPMHC estimate digital imaging will reduce the repeat rate from 5% to 1%.
- In the ED, we estimate that there will be a cumulative savings of 3 hours per day ( equal to $16,425 annually) because of efficiencies gained by the PACS. The time saved can be used to maximize resource capacity. In October 2001, compared to the previous year, we were able to complete 103 more computed tomography (CT) examinations (from 627 to 730 examinations = 14% increase), and 205 more diagnostic examinations (from 2,339 to 2,544 examinations = 8% increase). If we extrapolate this annually, CT examinations will grow from 8,187 to 9,333, an increase of 1,146 examinations. Diagnostic examinations will go from 27,986 to 30,225, an additional 2,239 examinations. We estimate that the additional volume would have required one Technologist FTE at $33,000, one Tech Assistant at $20,000, and two Film Library FTEs at $20,000. This will result in a cost avoidance of $73,000 annually.
- PACS will eliminate lost films. Films transported to physician’s offices, clinics, or inpatient units are vulnerable to being misplaced.
- Focus on operating expense (supplies, courier, depreciation, storage, and salary).
- Incremental revenue analysis by modality.
As an administrator responsible for overseeing a PACS implementation, it is imperative to first conceptualize what PACS will mean to the health system. The business needs assessment is a key tool in aiding in that activity. Remember to focus on clear, realistic, and practical objectives, process improvement tools focused on analyzing current operating infrastructure, financial indicators that focus on both incremental savings and revenue, and finally the creation of a dashboard of indicators that emphasize service, outcome, and cost.
John Couris is Vice President, Ambulatory Care and Medical Imaging Morton Plant Mease Health Care, Bay Care Health Systems, Clearwater, Fla, [email protected]