Running head: PACS SYSTEMS FINAL PROJECT

PACS Systems Final Project

Laurence Weinreich
Siena Heights University
Information Systems Management
LDR 620
Dr. Schoenbart
October 19, 2016
PACS Systems Final Project
Introduction
A PACS (Picture Archive Communication System) system is stage three in the
components of an EHR (Electronic Medical Record). A PACS system will capture and store
medical images such as x-ray images, CT (computerized tomography) scans, MRI (magnetic
resonance imaging) scans, and other medical diagnostic images (Glandon, Smaltz, & Slovensky,
2014, p. 262).
According to Hynes, Stevenson, & Nahmias, 1997:
It is an odd fact that radiologists are willing to spend
at least a minute pulling films from a film bag,

orienting them, and putting them on a viewing box but

refuse to use a computer that takes 10 or 20 seconds to
accomplish the same task while we twiddle our thumbs. (p. 659)

According to Shullman, 2009, back when we used film, a radiologist could read
approximately 50 cases a day. Today, many of them are reading 100 to 125 cases a day, because
all of the data is instantly available (p. 13). PACS has been a huge improvement, but physician
resistance to the new medium and un-user friendly equipment, coupled with high cost of
systems, caused a delay in the use of PACS, nonetheless, radiology departments were pioneers in
early hospital IT software (Gillespie, 2001). A big advantage to the use of PACS are images
which are no longer lost, which happened all the time in the age of hard copy film, We simply
do not lose films anymore. With a manual film process, hospitals have to deal with the possibility
of lost film. But with an electronic system, lost films are just a memory (Rogoski, 2004, p. 16).
Moving into a PACS world
PACS did not take hold on radiology departments right away- in fact it took about 30
years for PACS to become fully accepted. Early systems were high in cost and the equipment
took up lots of space, were slow, and did not store many images. When looking at film x-rays
only a very bright light can change some density of the image while reading. When using a
PACS system images can be darkened or lightened, depending on physician preference, and what
disease process the physician is seeking out (Hynes, Stevenson, & Nahmias, 1997). In the new
digital world, a physician can immediately access the images of a trauma victim saving valuable
time and saving more lives. When using film other problems were present, with conventional
film, only one physician can view X-rays at any given time. With digital radiological images,

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physicians in different locations can simultaneously view the same images (Gillespie, 2001, p.
55). With film, comparison films could be hard to find or unable to locate at all. The radiologist
would have to search through a film jacket, and then locate the correct film, and date by hand, all
of that before he hung the films by hand on a view box. Using a new PACS workflow, patients
can be scheduled without asking redundant questions, because their patient information is
already online. This improvement extends over to the A/R side of the house with updated
systems billing and an increase in collections. Bills are processed and sent out much faster than
in the past, usually within 24 hours. This faster and better structured system has resulted in less
denials, and an increase in profits (Shullman, 2009).
One of the benefits of a PACS system is enhanced work-flow. Less steps and less time is
spent on the same job. Which increases productivity and can decrease manpower, which will
save the organization money. There are work practice changes which enhance workflow and are
realized because of the use of PACS, as stated by Yu & Hilton, 2005, these changes are:

Better access to films: In the film-based practice, doctors or nurses had to go to

the Radiology Department to obtain the hard-copy films, or wait until the
radiology porter delivered them. With PACS, the images were readily available to
authorized users at multiple locations once radiographers had processed them and
checked their quality.

Increased speed of access to X-ray images in multiple locations, including the

radiologists home through broadband connection.

Different medium for viewing X-ray images: The viewing medium changed from
hard-copy film to digital image on a screen. The user loses the freedom of moving
X-ray images easily from one location to another.

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The possible change of indicator that an X-ray image is waiting to be reviewed.

The users comfort of using user name and password to log on to the PACS.

The workflow change from film to digital image cuts out a lot of steps and streamlines
the technicians steps, and the patients experience. An example of both of those workflows is
used when setting up a new PACS process.
A Film based workflow according to Lander, Courtney, Emick, Srihari, & Rivero, 2006
consists of 14 steps:
1. Patient registration
2.

Enter order in RIS

3. Retrieval of previous images (if any)

4.

Patient examination

5.

Films printed/developed

6. Old studies combined with current

7.

Films delivered to radiologist reading room

8. Films taken from stack and hung for radiologist analysis

9.

Radiologist interpretation/dictation

10. Films returned to storage

11. Report transcription
12. Radiologist reviews and signs off report
13. Report printed and delivered to referring clinician
14. Copy of report filed in storage with patient folder.
When compared to the Filmless Workflow there are only 9 steps:
1. Patient registration

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2.

Order entered in RIS

3.

Patient examination

4.

Digital images available via PACS workstation

5.

Radiologist interpretation/dictation

6.

Report transcription

7. Radiologist reviews and signs off report

8. Report archived digitally
9.

Online report available to referring clinician (p. 2).

The experience of the user, known as user satisfaction is a great influence in the success
of any PACS system. Those users who were the happiest with the system were the
stronger supporters of the system. Par, Lepanto, Aubry, & Sicotte, 2005 found that user
satisfaction might be interpreted as a response to three types of user aspirations for a
system: system quality, information quality, and service quality (p.477). Four
perceptions of system quality were found to influence satisfaction

PACS reliability was found to influence both radiologists and technologists

satisfaction with the system. Radiologists satisfaction was also influenced by the
ease of use of the system.

Contrary to expectations, neither perceived information or image quality as an

influencer. This is because images of excellent quality are the norm.

Satisfaction was positively associated with PACS technical service quality.

Satisfaction with PACS was also predicted by users confirmation of the

realization of expectations in relation to PACS usage (Par, Lepanto, Aubry, &
Sicotte,2005, p. 477).

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Implementing PACS is a challenge, but there are ways of achieving success during
the install. Up front planning and loads of training for all users will help take the edge
off of the install. A successful system has to be operated in each section of the
organization. All physicians must be able to access their images, no matter where they
are at the time they need to view those images. Just keying in on the cost of the
system is not the winning factor, providing those images in real-time, all the time is
the service that physicians expect (Rogoski,2004).
Runy, 2007, has offered 10 tips for Successful PACS Implementation (p.30), which
should help guide any organization through the process of moving from film to
PACS:
1. Conduct a thorough analysis of current workflow patterns. When
implemented correctly, PACS should streamline workflow and improve
patient care.
2. Opt for enterprise wide solutions that will facilitate clinical integration.
3. Collaborate with clinicians from the beginning. Their input will enable a
smoother transition.
4. Provide redundant storage so access to images is always available.
5. Solicit executive support. Senior leaders involvement can help move the
project forward.
6. Increase digital storage space. New diagnostic imaging technologies will
demand greater storage needs in the future.
7. Start now: Film-based systems lack flexibility and are more costly.

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8. Create a protocol for what needs to be stored. The entire MRI or CT scan
may not need storage.
9. Dont give in to demands for access to high-resolution images in every
location. Not every department needs the most expensive equipment.
10. Recognize the importance of education and training, and allow for
different forms of training to meet the individual needs of your staff
(Runy, 2007, p. 30).
Another factor to consider when building a PACS system, future storage needs.
Knowledge about storage volume for particular images is helpful in estimating the
storage needs of your department. It is also suggested that an organization look at a
one and five-year plan for increasing storage to keep up with future image storage
needs. A 64 slice CT scanner will contribute more images to the system than a 16
slice scanner. So special attention should be placed on looking at the current and
future equipment needs of the imaging department. While costs are going down for
storage, it is best to increase your fiscal budget a bit to allow for adjustments in
pricing. When updating the PACS system, attention should also be placed on the
infrastructure of the computer systems, and not just the PACS system software
upgrade. The bandwidth must also be considered because of an increase in users and
equipment using the wireless (Runy, 2007).
Transcription is another piece of the PACS puzzle which has had to change, and
update to keep up with the new technology. Hospitals were looking for new ways to
cut costs, and the high cost of transcription made them a target. Speech recognition is

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now on the forefront of the PACS movement to help solve that dilemma. Speech
recognition is expected to surge in part because of two reasons:

Physicians will recognize that the more detailed accurate documentation that
comes from using speech recognition can help them better defend the
diagnostic codes they use for payment purposes.

Organizations will conclude that the technology, whether used on the front
end or back end, can slash astronomical transcription costs (Anderson,2007,
p.34).

Physicians are able to edit a report much faster as they dictate it, rather than waiting
hours or even days in some cases, for a transcriber to return the recording in typed
form to the physician for editing. This saves on patient treatment time and directly
increases patient satisfaction rates (Anderson,2007).
Another new trend which goes hand in hand with PACS are VNAs (Vendor- neutral
archive) which can store images in a format that is readable and viewable along all
service lines. This will help cut down on image storage costs as medical images
account for up to 80 percent of data volume in electronic records and support 60
percent of all patient diagnoses (Maluf, & Rajendran,2012). As stated by
Rogoski,2004 CDs created on a proprietary system used by one organization may
not work with the system used by a second organization (p.14). This is where a VNA
comes into play. A cloud based VNA can save costs while acting as translators to
convert image information for transmission between the archive and proprietary
PACS (Maluf, & Rajendran,2012, p. 79).

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There are many benefits of having a VNA. It allows the archival images in PACS to
be kept long term. A VNA has a universal viewer, which allows viewing of images
from across the PACS spectrum, without building more interfaces to allow viewing.
Another feature is bidirectional mapping and normalization of information, which is
key to the archives vendor neutrality (Maluf, & Rajendran,2012, p. 80). A key
feature is the ability to move images to cheaper storage to save money as images
storied, build up on servers. VNAs will save the physician time by allowing one
viewer in which to view all images- in-house or from outside the facility.
VNAs are not the end all-do all of the computer storage world. There are problem
areas that one should consider before purchasing one. The initial film migration is the
same as any movement from one PACS to another, except that once this movement of
images is complete, the organization is not locked into any single vendor. The upfront
costs are high, but on the back-end a savings is realized down the road.
As found by Maluf, & Rajendran,2012, Deployment of a cloud-based VNA can help
providers decrease costs and spur interoperability, which is a requirement both for
ACOs and for meeting the meaningful use requirements under the Health Information
Technology for Economic and Clinical Health Act (p.82).
Conclusion
Years ago errors were common in billing, and hard copy films were lost on a daily
basis. Radiologists could only read a few studies each day, and technologists had to
deal with finding empty cassettes when running films in the darkroom, and film jams
in processors. Transcription was slow and expensive, with patients sometimes waiting
weeks for results of routine common exams. With the advent of PACS, Speech

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Recognition, and VNAs we have moved into a new era. The era of increased
patient services, and access to almost unlimited patient data, which is accessible from
multiple electronic devices. The time of lost films and lost reports is over, and the
new era of speedy service with limited malfunctions is upon us, If a study is ordered
stat, our staff or radiologist is on the phone with the referring doctor before the patient
even walks out our door and that doctor can also view our images online
(Shullman,2009, p.24). A patient can also walk out of an imaging center, CD in
hand with the images of not only their current exam, but also any and all previous
exams. As we move from film to a new digital world, the only limitations are our
imaginations.

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References

Anderson, H. J. (2007). GIVING TRANSCRIPTION A TRIM. Health Data Management, 15(9),

32-32, 34, 36 passim. Retrieved from http://search.proquest.com/docview/219552822?
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Gillespie, G. (2001). Filmless radiology brightens its image. Health Data Management, 9(11),
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Glandon, G. L., Smaltz, D. H., & Slovensky, D. J. (2014). (8th ed.). Chicago, Ill: Health
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Hynes, D. M., Stevenson, G., & Nahmias, C. (1997). Towards filmless and distance radiology.
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Lander, R., Courtney, A. K., Emick, F., Srihari, K., P., & Rivero, R. (2006). ANALYZING THE
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Par, G., Lepanto, L., Aubry, D., & Sicotte, C. (2005). Toward a multidimensional assessment of
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