Judson Moore, MD, and Chris Hughes, PACS coordinator, review the system.
Courtesy of Milt Wood

AAOS Now

Published 12/1/2008
|
Milt Wood

Taking the road to PACS

Converting to computed radiography: a step-by-step process with inspiring results

Southern Bone & Joint Specialists is a 20-physician orthopaedic practice with four offices in southeast Alabama. The physicians see more than 400 patients a day and order approximately 45,000 radiographs each year.

The practice more than doubled in size during the past 10 years. As the chief executive officer, I realized that to take advantage of efficiencies of scale, we would need to adopt new technologies to increase productivity and reduce redundancies in operations. We also needed to find a way to open up floor space occupied by more than 500,000 medical records and radiographs.

Picture Archiving and Communication Systems (PACS) provided an opportunity to springboard the practice into the digital world of technology. By taking a step-by-step approach, we implemented PACS over a 2-year period.

Step 1: Get agreement.
The initial presentation focused on the concept of digital imaging. Specific case studies of other clinics our size provided documented proof that PACS would increase efficiencies. Support staff would no longer have to look for lost radio­graphs, pull radiographs for patient visits, or copy films for surgery. The number of retakes would be reduced.

More importantly, digital technology would enable the surgeons to adjust the window and level of an image to improve resolution. Digital images could be enlarged or inverted with a click of a mouse.

A cost analysis detailed the savings from the elimination of film, jackets, chemicals, and processor service as well as time savings for the staff. Because the technology for digital radiographs is expensive, the shift to PACS should be seen as an opportunity to use digital technology to advance the ability of physicians to diagnose and treat their patients. The benefits of making the investment in digital radiology are long-term, rather than immediate.

With the endorsement of the executive committee, the project went to the full board for review, consideration, and final approval. I provided an estimated cost, as well as a decision and installation time line, and requested a physician-partner to work on the project on an as-needed basis.

Step 2: Assemble a team.
The radiographic department supervisor served as our PACS project coordinator. Regular communication with the clinic’s directors and all employees helped ensure their enthusiastic support. Discussions with the local hospitals revealed their interest in PACS; one hospital actually provided their PACS administrator to help us develop a strategy and vendor request for proposal (RFP). There was no turning back now!

We conducted vendor interviews and made site visits to gain an understanding of patient flow. Both my physician-partner and I attended conference sessions to learn about the technology. We also researched computed radiography (CR) and digital radiology technology. After a careful analysis—including developing time-motion and financial models—we elected to purchase all CRs.

We also added our information technology vendor to the project team. He and his staff began to investigate the networking and communication needed to link the four facilities, both hospitals, and an outpatient surgery center.

Step 3: Select a vendor.
As year 2 of the project began, we set a 6-to-8 month implementation goal. We developed an RFP and sent it to our selected potential vendors. We met and interviewed six PACS vendors and four CR vendors.

We received detailed responses to our PACS RFP from three vendors. After reviewing the results, the project team chose two vendors and requested detailed proposals on implementation and costs. Final negotiations covered topics such as extended warranties, offsite data storage costs, and additional on-site training. One vendor even provided an “added-value” proposal to integrate the proposed PACS with an electronic medical record (EMR) system. Although we had not included an EMR system in the initial project, it certainly added value and reinforced our vendor selection.

We recommend making site visits to view the systems in operation, particularly in an orthopaedic setting. If feasible, an additional site visit to the vendor’s home office is also beneficial.

Step 4: Keep everyone in the loop.
Throughout the process, I met frequently with the physician liaison and provided updates to the executive committee, the medical staff, and the radiology staff. We made every effort to communicate with all employees to secure their cooperation and endorsement. Without the staff “onboard,” a successful implementation would be difficult, at best.

At 4 months prior to installation, we began preliminary on-line training and installed a wireless network. Physicians and medical staff would use wireless tablets to view the images. The foundation was prepared and the framing of the project was starting.

Step 5: Have a backup plan.
Before the “go-live” date, we put backup systems in place to address any unforeseen problems. The CRs were installed the week before the conversion date and the radiology staff was trained on the new equipment. Wireless tablets were distributed to all the physicians and medical staff 10 days prior to implementation.

For the first week, we scaled back appointments about 10 per­cent. On the first day, the PACS and CR vendors provided trainers and technicians in all three locations to help the physicians and staff. The initial conversion went smoothly with few problems.

As with any major system conversion or equipment implementation, you should hope for the best and expect (and plan for) the worst. The PACS system and the transferring of images from one location to another created a data bottleneck. Processing speed became an issue. Fortunately, we were able to quickly install a fiber optic ring, twin T-1s, and high-speed cable backups.

Once the communication network was installed, the system worked with speed and efficiency. We learned this lesson the hard way: Make sure your transmission highway is big enough for the data traffic, and allow for extra capacity.

Step 6. Enjoy the results.
After 3 years, the benefits of our decision to implement PACS are apparent. Gone are the rows of old X-ray jackets, giving the clinic room to expand. Radiograph and support service staff hours have been reduced by 3.5 full-time employees; consumable costs for film and chemicals have been eliminated.

Physicians report that patients are favorably impressed with the state-of-the-art technology. Most important, the physicians are better able to use their skills to better diagnose and treat patients.

Milt Wood is chief executive officer of Southern Bone & Joint Specialists in Dothan, Alabama. He can be reached at miltw@southernbone.com