Published 1/1/2008
Craig R. Mahoney, MD; Kevin Ward

Do you get the picture?

Get the most from digital radiographs and PACS

Today’s sophisticated technologies are changing the way radiographs are treated and stored. Nearly all hospital systems across the United States now use picture archiving and communication systems (PACS). A recent audit in our practice found that 95 percent of outside referrals to the practice were accompanied by digital radiographs, often placed on a CD-ROM.

As the push for healthcare providers to adopt electronic systems continues to strengthen, more office-based practices will adopt PACS technology, particularly as costs decline and the need for efficiency increases. Based on our experience, adopting a PACS has both advantages and disadvantages.

What’s not to like?
The advantages of introducing a PACS into your office seem readily apparent (
Table 1), particularly because most orthopaedists are familiar with the benefits from their hospital PACS experiences. Images can be obtained, viewed, and sent from one office to another quickly. Reductions in personnel, materials, and storage costs generate overall long-term savings relative to film radiographs.

On the other hand, adopting any new system or technology can place a strain on your practice. Incorporating a PACS into the office environment requires adopting new technologies, changing office procedures and workflows, and overcoming the PACS learning curve, to say nothing of the initial start-up costs. For the technologically paranoid, a PACS also creates a hypothetical single point of failure, given its reliance on computer technology.

Business and convenience reasons support PACS
One of the main reasons for adopting a PACS system is the increased speed with which images can be obtained, transported, and used. Radiographs can be developed in a fraction of the time required with traditional methods. Images can be viewed by the ordering physician while the patient is still on the table, eliminating the need for “reshoots” at a later time

A PACS also makes it easier to locate and transport previous radiographs. Physicians can quickly call up prior studies for review and comparison. Studies can be indexed by patient name (including maiden and current names), date of birth, date of study, or other demographic metrics. In sum, images are easily available with a minimum of effort on the part of the physician and practice employees.

Another reason to adopt a PACS is the improvement in workflow that comes with higher levels of efficiency, and the resultant reductions in costs for materials and personnel. Physicians can see more patients in a given amount of time, thus increasing gross revenue to the practice. According to one sample orthopaedic facility workflow we reviewed, a PACS can save more than 5 minutes per exam. If your office does approximately 100 exams per day, that time savings equals the cost of one full-time radiology technician.

The transition to digital format also reduces raw material usage, eliminating costs for film, development hardware, chemicals, packaging, storage, and disposal traditionally associated with plain-film radiographs. Although computer memory does cost money, it is a one-time sunk cost that makes computer memory much cheaper in the long run.

In addition to these business reasons, multiple clinical and physician-convenience reasons support the use of digital imaging. A PACS offers the immediate advantage of portability. Images can be obtained at multiple clinic sites, promoting closer collaboration among physicians. Physicians can view the images securely over the Internet while at home, in an outlying office, or out of town. If the physician has questions, he or she can view the images with a second physician, in real time, to make the diagnosis.

The image-enhancement tools that come with the PACS software can also be helpful. For example, the image can be magnified or the exposure changed to assist in interpretation; physicians can also calculate length measurements and angular relationships.

Purchasing additional software that provides prosthesis/implant-specific geometry will enable physicians to prepare and save surgical templates electronically and in multiple versions for future reference. The image templates can also be sent to and viewed on any hospital computer with an Internet connection or sent directly to the hospital PACS.

Overcoming the obstacles
Minimizing the disadvantages of a PACS is key in making a successful transition to digital imaging. Initially, some physicians—especially those with limited computer background—may resist adopting PACS technology. Allowing them to become familiar with the system and reinforcing the business advantages of using a PACS will gradually overcome their objections. Start-up costs can also be daunting; a disciplined contract negotiating strategy can help manage these costs.

Other issues associated with clinic workflow and learning curve can be overcome if staff is involved early on. This enables the practice to develop training plans, obtain buy-in, and minimize disruption to patient flow as it plans the implementation.

In our experience (see “4 years, 2 vendors, 1 success story,” page 25), four issues must be addressed with vendors. If you are considering a PACS system or are replacing one, remember the following precepts:

  • No vendor or PACS is perfect. Vendors want you to buy, so they will present themselves, their systems, and their support in the best possible light.
  • Get a service level agreement, with financial penalties, as part of the contract. This ensures that you will get the support you need, when you need it.
  • Check references first, last, and always. Don’t just check references supplied by the vendor; ask other orthopaedists what they use.
  • Make sure the vendor understands your business process and that the system can support it.

Craig R. Mahoney, MD, is a contributor to the AAOS Practice Management Committee. He can be reached at iowamahoneymd@aol.com Kevin Ward is chief executive officer of the Iowa Orthopaedic Center. He can be reached at kward@iowaorthopaediccenter.com Brent Hood, medical student at Des Moines University, also contributed to this article.