"How can my department successfully implement and operate a
PACS?" is a question I frequently come in contact with. The obvious
answer is to first develop a set of guidelines or policies for the
implementation and operation of the PACS, setting the parameters,
expectations, and expenditures for the system. Hence, it is fair to
say that what is truly being inquired about in the above question
is not so much the method employed in the implementation and
operation of PACS but the methodology employed in developing
guidelines for recommendations issued for the purpose of
influencing decisions about health intervention. As Eddy states,
these guidelines are similar to the process of making a clinical
decision.1 Just as any clinical decision making process must
identify the health outcomes that are the goal of the treatment,
the probabilistic nature of the outcomes, and the risks involved in
each treatment used to reach that outcome, the guidelines for the
selection of technology in the case of PACS must address similar
issues. Because hospital departments are generally accustomed to
developing practice policies or guidelines for clinical
applications and most likely have developed systematic procedures
to go about setting such policies, their clinical processes are
capable of serving as a valuable model for guideline development
for a PACS.
The aim of a PACS is to solve the problems of acquiring,
transmitting, archiving, and displaying digital radiographic
images. Developing a guideline for implementing and operating PACS
requires dealing with uncertainty. A way of eliminating a measure
of this uncertainty is to analyze as many different PACS systems as
possible in relation to your specific departmental and
enterprise-wide needs. Make estimates of their outcomes in your
department and then provide this information to your hospital
administration.
The first step in developing a guideline is to assemble a
guideline group, one that represents the staff interested in
acquiring and operating a PACS. Once the group is assembled, they
should address the following issues and concerns:
1. Authors of the guideline: All authors should be clearly
identified, and any conflicts of interest among them should be
identified.
2. Summary of guideline: This should be a one to three line
statement that concisely, clearly, and specifically delineates the
intended use for the guidelines. For example, the statement "This
is a guideline for filmless image management in the ICUs and ER"
would be an appropriate starting point.
3. Background of guideline: This should be a concise statement
that clearly explains why the guideline is being written. For
example, the PACS guideline may be written to implement soft-copy
reading of CTs and MRIs as an initial step in moving towards
filmless radiology management. The background should describe the
broad acceptance of soft-copy reading of CT images, and the areas
of difficulty in reading MRIs, such as in spinal images, and should
correlate pulse sequences, anatomy, and prior studies.
4. The problem to be solved: This should succinctly define the
parameters that the guideline will cover. For example, "This
guideline is being applied to the use of PACS for patients in the
ER."
5. Health and economic outcomes: This statement should cover the
health outcomes and economic costs that were considered in the
design of the implementation plan. There are several studies that
have been conducted on PACS health and economic outcomes.2,3
6. Evidence: State any evidence and examples used in support of
the tenets of the proposed guideline. Include sites visited,
conferences and seminars attended, and seminars presented at your
site.
7. Effects on health and economic outcomes: This provides
quantitative estimates of the magnitude of the health and economic
outcomes. In other words, describe the expected results regarding
these issues if the PACS system is implemented.
8. Calculation methodology: Describe the methods used to derive
the stated estimates of health and economic outcomes.
9. Preference judgements: Describe the judgements made about the
desirability of the outcomes. Make a study of the benefits of PACS
compared to continuing the current method of managing film. These
are sometimes judgments of impressions held by the staff and
hospital administrators.
10. Instructions for using the guideline: List and describe any
factors that should be considered when applying the guideline to
implementation of a specific system. For example, the guideline may
lay out a 3-year implementation. In this case, certain elements of
the infrastructure of the PACS must be ironed out before proceeding
to later parts of the plan, such as the location and number of
workstations, or the centralized archiving system and the
database.
11. Conflicts with other guidelines: Explain conflicts and/or
disagreements with any other guidelines that purport to address the
same issue. Often, the issue of networks for images requires
different parameters than networks for medical text data.
Enterprise type networks must handle the traffic of both images and
text.
12. Comparisons: Guidelines should be evaluated within the
context of other interventions that address the same issues as they
do. Hence, it is necessary to compare the merits of competing
technologies or solutions. Explain why your approach is superior or
should be used as opposed to a competing alternative. For example,
comparisons should be made between the current film-based
management systems and those of filmless operation. For soft-copy
readings, it can be mentioned that the display protocols have been
developed to the point that spatial resolution is not a strong
issue for radiologists.
13. Miscellaneous: Describe any expected technical developments
that could modify your selection decisions and suggest dates for
reviewing the guideline. For example, "Web technology used for
intranet distribution of medical images in the hospital"--Review in
February, 1999.
This guideline will provide an important tool in support of the
implementation of a PACS. Patients, practitioners, and individuals
working in hospital management will all be affected by it, and it
will be much easier to reach your goals, within your limitations,
if everyone involved can clearly understand exactly what they are.
The guideline will provide the estimated cost for a phase-in
implementation, state the benefits and cost savings to be realized,
and provide a management plan.
References
1. Eddy DM: Clinical Decision Making. Sadbury, Jones and
Bartlett, 1996.
2. Pratt HM, Langlotz CP, Feingold ER, et al: Incremental cost
of department-wide implementation of a picture archiving and
communication system and computed radiography. Radiology
206:245-252, 1998.
3. Reiner BI, Siegel EL, Hooper FJ, Glasser P: Effect on
film-based versus filmless operation on the productivity of CT
technologists. Radiology 207:481-485, 1998.
Dr. Dwyer is a Professor in the Department of Radiology at the
University of Virginia Health Sciences Center in Charlottesville,
VA. He is also a member of the editorial advisory board of this
journal.