In order to remain competitive in today's dynamic, cost-conscious healthcare marketplace, hospitals and health systems will need to integrate picture archiving and communication system (PACS) technology into their radiology practice. Indeed, trend reports forecast that by the year 2000, 66% of hospitals will use some level

of PACS.1

Concurrent with this desire to install their PACS systems, vendors continue to offer technical innovations that permit widespread use as the digital hospital becomes a reality. While increased productivity and efficiency are commonly listed among the major benefits of PACS, the socioeconomic benefits and the impact on patient care are only starting to be discussed.

Experience with the most recent generation of PACS indicates that the

benefits of new technology will pay dividends in improved patient care as radiologists and clinicians become comfortable with soft-copy interpretation and as medical images are copied electronically for simultaneous viewing by the multitude of medical personnel that must access these images.

Socioeconomics of PACS innovation

Continuous improvements in PACS have brought the technology to a broader level of acceptance by clinicians. Initially, workstations were rather clumsy and tended to reflect a lack of experience and understanding of radiologists' work habits. However, system architecture has improved as many manufacturers actively involve practicing radiologists in the design process, resulting in the development of user-friendly workstations that mirror radiology departments; these workstations now utilize film-based workflows with the potential to increase productivity.

Until the DICOM standard was introduced to provide a protocol by which radiology devices could communicate, the devices often were tied to stand-alone systems. As the DICOM standard continues to evolve, PACS will become more of a plug-and-play technology. Until that day arrives, however, it is important for facilities to have clinical DICOM validation performed by their PACS vendors. Most vendors perform a DICOM validation to ensure that communication channels between devices are compatible. However, some vendors also perform a clinical validation to ensure that the most accurate clinical information is passed along.

Although issues in communication between systems have largely been resolved, gaining radiology staff acceptance of PACS for everyday use remains a hurdle for most practices. Institutions that install PACS in phases ensure that the technological changes don't overshadow the way the radiology staff functions. We prefer small, gradual installation steps over larger, more sweeping changes that risk failure. This method also allows the facility to determine which parts of the practice require the most attention as the PACS is implemented. Common problem issues such as high rates of unavailable priors and slow report turnaround times create logical entry points for PACS. By identifying exactly where problem areas are, the phased installation approach helps the radiology staff to gain confidence in PACS technology, resulting in better long-term acceptance and justifying the initial installations. Additionally, a phased installation approach allows the radiology staff to become familiar with the new equipment and to adjust to the inherent change of workflow.

Before starting a phased installation, a facility needs to determine whether the current technology meets its needs. For example, Yale-New Haven Hospital began exploring PACS in 1993. However, the decision to move forward wasn't reached until 1996 when it was determined that off-the-shelf performance of PACS was able to meet the technology needs of a large institution. Currently, the facility is phasing in an enterprise-wide Imation PACS solution.

A threshold for workstations today might be the 10-foot pole test.2 A good quality workstation would be one that a radiologist who wouldn't touch a computer with a 10-foot-pole is asked to evaluate and he or she comes away saying, "I could work this way," or even better, "I want this."At Yale-New Haven Hospital, where 240,000 films are generated and examined each year, radiologists who were initially resistant to soft-copy reading are finding that continuous advancements in PACS workstations are making reading more efficient. Hanging protocols, a software feature that positions studies on a viewing station in the layout preferred by individual users, allow radiologists to conduct their studies in a visually familiar manner. Collaborative workflows provide the radiology staff with the online capability of tracking which studies have been read, prioritized, and marked for sharing. This ensures that the entire system is communicating efficiently and removes the redundant tasks involved in a film-based workflow.

Socioeconomics of patient care

Quality in patient care typically is measured by the stakeholder. The referring physician is, perhaps, the best able to determine whether and how quality

is achieved. When radiologists and clinicians become comfortable with PACS, the true benefits to the patient start to emerge.

One major improvement brought on by the proliferation of PACS is more timely patient care. Using PACS, the report turn around time to the referring physician is reduced substantially, permitting clinicians to make decisions more quickly. This improves patient care and reduces the average length of hospital stays. Also, referring physicians can prescribe treatment more quickly, providing patients with more effective treatment.

Another way that PACS improves patient care is by making radiologists available for diagnostic interpretation virtually anytime and anywhere through teleradiology. This benefit is noticed in many trauma rooms, for example, where radiologists become part of the front line of the trauma team and provide expert reads on images taken in the ECU.

The reduction of lost films also improves patient care in a way similar to the trauma model. At many hospitals, 2 to 20% of films are unavailable to the radiologists when they are needed. Often, these missing films are lost when clinicians take them to clinical wards during situations requiring emergent or critical care. In some cases, this occurs before the radiologist has a chance to interpret the film and make a report. In this scenario, the patient has lost the opportunity for an expert interpretation. Also, lost films are not available for future comparative studies. PACS make it possible for radiologists and clinicians to have 100 percent access to images and patient data, thereby increasing diagnostic efficiency in situations when a prior film might have been lost.

The improved archiving capabilities of PACS also provides diagnostic benefits. Some systems, for example, intelligently collect, store, and distribute current and prior examinations using pre-determined, site-specific rules. This allows for all relevant radiology examinations to be routed to appropriate viewing stations in a ready-to-read format. Patients' complete radiological histories can thus be reviewed simply by hanging current and prior studies in an interactive side-by-side manner. Similarly, teaching files containing studies of patients with the same diseases can be easily compiled, compared, and analyzed.

Conclusion

PACS has reached the point technologically that makes it a competitive tool in the managed care environment. It provides the flexibility necessary to meet the service demands required by today's healthcare systems.

At some point, in order to remain competitive, hospitals and health care systems must make a decision to implement PACS. The decision can be likened to the decision to buy a personal computer.2 Tomorrow's model will always be faster, cheaper, and better; from the cost standpoint it is always better to wait. But to keep waiting means you will never own a computer and, more importantly, never realize the benefits of using that computer. A point of equilibrium is reached when an evaluation of the future benefits of the technology outweigh the current costs. The question then becomes: What determines the "bandwagon" point for computers and technology? The answer is when standard technology adequately meets the application's needs without compromise.2 If the need is improved patient care, PACS technology's time has come. AR

References

1. Drew PG, et al: Concord Consulting Group: PACS opportunities, 1997-2007. November 1997.

2. Swett HA, Mutalik PG: PACS et Veritas. Presented at the American Roentgen Ray Society Annual Meeting, Boston, May 7, 1998.

Dr. Brink, Dr. Neklesa, Dr. Mutalik, and Dr. Forman are in the Diagnostic Radiology Department at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, CT.