Dr. Reiner is the Director of Radiology Research at the VA Maryland Healthcare System (VAMHCS) and an Associate Professor at the University of Maryland School of Medicine; Dr. Siegel is the Director of Imaging at VAMHCS and an Associate Professor at the University of Maryland School of Medicine, Baltimore, MD.

Despite excellent documentation of the myriad benefits associated with implementation of digital imaging in the radiology literature, the rate of adoption of PACS (picture archival and communication systems) remains surprisingly low. Currently, less than 5% of U.S. hospitals have an enterprise-wide PACS. There are a number of theoretical causes to explain this delayed diffusion of PACS (Table 1), which include both technical and economic factors. At the same time, however, psychological factors must also be considered to explain this phenomenon of the slow diffusion of PACS. By understanding these psychological factors and the barriers they can create, the potential PACS customer can develop a successful implementation plan more effectively.

Two scientists, Ryan and Gross, ¹ who were studying the adoption of hybrid seed corn among Iowa farmers, first introduced the concept of the "diffusion of innovation" in 1943. They observed five categories of adopting groups among the farmers (Table 2), with each group defined by its own personality and socioeconomic characteristics.

The fastest adopting group was categorized as "innovators," and these were an extremely small subset who were characterized as adventuresome, extremely risk tolerant, and socially disconnected. It was the interaction between the innovators and the second group, the "early adopters," that allowed these new technologies to become assimilated into the populace at large. The early adopters served as opinion leaders, who learned from the socially wayward innovators, and then shared this vital information with their colleagues, largely by means of their well-formed social connections. In turn, the third and fourth groups, labeled the "early and late majority," incorporated these new technologies into their business practices. Before adopting these technologies, however, they required a sense of personal trust due to their relative distrust of strangers and scientific theory. These majority groups utilized local learning channels for education and tended to be risk averse, due to their conservative mindset and limited economic means. The fifth and final group was classified as the "traditionalists," and was far and away the last group to adopt new technologies. The traditionalists' reference point was largely in the past and they served to remind their peers of past failures and the economic losses that resulted from "untested technologies."

For the individual who wants to become the local "PACS champion," it is important to keep this technology personality profile in mind. In order to use this to its fullest advantage, one should try to categorize the most influential thought leaders at your host institution. In turn, try to create a balanced PACS planning committee, with representatives of each of the five technology adoption groups. For example, if your CEO is a member of the late majority, try to identify senior members of the medical staff whose mindset is in keeping with that of an early adopter. By providing these medical staff early adopters with information and access to innovators in the field, the PACS champion can help educate other committee members about the effects of PACS and other information management technologies on medical care delivery. At the same time, a balanced committee should also contain a traditionalist, who plays the important role of ensuring that the committee members consider all perspectives and the potential negative impact of new technology implementation on the organization. This traditionalistic approach will not only provide balance to the planning process but also serve to keep the vendors in line, for they often make promises that are not always in keeping with reality. It is this balanced approach that allows all viewpoints to be considered, ultimately leads to greater acceptance of newer technologies, and increases the overall success of implementation.

Many of us who have tried to convince a department chairman, hospital administrator, or finance officer of the merits of newer technologies, such as PACS, have personally encountered real-life examples of these five adopting groups. If we want to be successful in making an argument for filmless implementation, we must consider not only scientific and economic factors, but psychological factors as well.

Below is a list of recommendations to help in this quest. These have been adapted from a plenary address given by Donald Berwick, MD, CEO of the Institute for Healthcare Improvement. ² It is essential to remember that PACS is just one of several pieces in the overall information management paradigm. In order to implement digital technologies successfully, the commitment to information technology must be on an organizational, not departmental level. This will require the solicitation of multiple technology "champions," across departmental and professional lines.

Rule 1: Identify innovators

While medical communities tend to be local in their orientation (and dominated by early and late majority groups), a search for innovators is a necessary first step. This is usually accomplished by searching for information from scientific journals and meetings. Table 3 lists a number of excellent online societal resources for PACS, including the Society for Computer Applications in Radiology (SCAR), Healthcare Information and Management Systems Society (HIMSS), the International Society for Optical Engineering (SPIE, formerly known as the Society of Photo-optical Instrumentation Engineers) and the Radiological Society of North America (RSNA).

Rule 2: Support innovators

One must realize that administrators often seek answers to local problems from outside the organization. This explains the outsourcing of problem solving to highly paid consultants, who serve as conduits of information, rather than initiators of it. Leadership needs to value organizational "scouts," and provide them with the necessary resources to support innovation.

Rule 3: Invest in early adopters

If you want to spread innovation, then you must change the culture that focuses on "compliance by everyone." Invest in the curiosity of a few early adopters, which may take the form of underwriting a scientific meeting or site visit. The switch from compliance to support is essential if the diffusion of new technologies is going to be successful.

Rule 4: Make the activities of early adopters observable

In order for the early and late majority groups to learn of new technologies, they must be able to see them firsthand. This requires an active interface between early adopters and their majority counterparts. Remember the adage, "seeing is believing."

Rule 5: Trust and enable reinvention

In order for an outside idea to be implemented successfully, it will probably require local change, based on the unique needs and idiosyncrasies of the parent institution. Reinvention is a relatively slow and laborious process; it takes time, energy, money, and patience.

Rule 6: Lead by example

Leaders who want to invoke change must change themselves. There are no shortcuts or free lunches. The true strength of an organization is the spirit of its people, and this is the greatest source of untapped energy. A true leader is one who understands and respects the diversity in change.

In addition to the aforementioned psychological factors, a number of unique attributes must be considered when contemplating PACS implementation. Unlike traditional radiology equipment, PACS is a system, not a device. Modalities such as CT or MRI are stand-alone devices, which operate in relative isolation. PACS, on the other hand, is an enterprise-wide system, which goes beyond the imaging department. Its operational impact is felt throughout the enterprise, and can extend into neighboring hospitals, outpatient facilities, and physicians' offices and homes. Web-based technologies are beginning to allow patients to access selected portions of their medical imaging data.

While medical technologies as a whole tend to have finite life spans, PACS is a particularly rapidly evolving technology. This leads to legitimate concerns for technology obsolescence, which can serve as a deterrent to its adoption. A PACS that is purchased today potentially could become obsolete in 5 years, leaving the unsuspecting customer with a multi-million dollar dud. This uncertainty with regard to technology obsolescence and predictability of future developments has led to the adoption of alternative PACS financing strategies, such as leasing and application service providers (ASPs). By choosing to defer ownership of the equipment, the PACS customer may have more protection from technology obsolescence. This is particularly important in today's marketplace, where no after-market exists for a used PACS.

The PACS vendor-customer relationship is unique as well, because it requires a long-term relationship that goes well beyond the delivery of the equipment. Traditional modality vendors and their customers typically have a short-term relationship, which ends after equipment delivery and applications. PACS, on the other hand, requires a long-term commitment between customer and vendor, which has been likened to a marriage. Both parties are dependent upon the other for successful implementation, and this can even evolve into a formal risk-sharing relationship. In this scenario, payments to the vendor are typically based on utilization of imaging services, where the vendor receives payment for each exam acquired or archived. In return, the vendor provides the customer with "downside risk protection" at a price typically higher than encountered in a purchase or lease arrangement.

Conclusion

One must realize that economic justification alone is not the "end all" when contemplating PACS implementation. It is important to maintain a bit of a visionary perspective that goes beyond the return on investment. The core business of healthcare information management is focused on patient care. While advanced information management technologies are important, they alone do not affect patient care. It is the successful application of these technologies by the end-users (healthcare workers) that translate into improved patient care. By better understanding the real and significant psychological factors that affect these interactions, we can better prepare for the ultimate paradigm shift to the filmless, paperless medical practice. AR