Putting PACS in Place

It’s a little like buying a car: The easy part is deciding to make a purchase, then the real work begins. Facilities eager to bring a picture archiving and communications system (PACS) onboard need to thoroughly prepare for it, and most form a committee to help swath the path toward PACS success.

 PACS images are viewed on workstations that provide the power to manipulate images for improved diagnosis.

For CEs and BMETs working in a hospital, this process presents a unique challenge. PACS is a clinical system used in real time, for the diagnosis and treatment of patients, that depends on technology to operate. This overlap is often the source of friction between the biomedical and information technology (IT) departments, but it is something that must be overcome. One way to avoid conflict is to set parameters early in the process.

“It’s a good opportunity for collaboration, and who works on what depends a lot on the type and size of the facility,” says Mark Freeman, CBET, CRES, president of Biomed Supplyline (Virginia Beach, Va), who notes that a perfect solution for one location would be a disaster in another. “It’s something that is going to depend on the structure of different facilities and even the politics within the organization,” he says.

Bringing a Wealth of Experience
Clearly defining what tasks IT is responsible for and which will be managed by the biomedical department can go a long way toward improving relations between the biomed and IT departments. The exact balance is impossible to prescribe, as it must be set by each individual health care entity. But without a doubt, biomedical and clinical engineers are uniquely qualified to handle much of the PACS preparation.

“Clinical engineering folks understand not only the life-support equipment, but we also know a great deal about computers, networks, TCP/IP [transmission control protocol/ Internet protocol], IHE [Integrating the Healthcare Enterprise] settings, ports, all those components of programming in a network,” says Gordon Lawson, vice president of operations, Technology in Medicine Inc (Holliston, Mass). “We bring a lot of value in that respect.”

With existing vendor relationships, BMETs and CEs can also provide great insight into a specific manufacturer’s offerings, allowing selection committees to compare apples to apples.

“Most biomed departments have someone who is more qualified than anybody else in the hospital would be to analyze service contracts and service terms, as well as the overall management of technology,” Freeman says.

Ideally, someone from the biomedical department should be included from the very beginning of the PACS selection process, because he or she is equipped to address connectivity issues and is better able to foresee areas where communication problems could arise.

Into the Pressure Cooker
One of the first tasks for the PACS committee is to designate a PACS administrator (PA).

“It’s best to seek out experienced resources, because that old adage, ‘You don’t know what you don’t,’ really does hold true,” advises Eric Pearce, manager, Americas marketing, GE Healthcare Imaging Solutions (Barrington, Ill). Many facilities seek out the experience professional PACS consultants can provide, a solution that is ideal for many facilities new to the process. “PACS really is a new paradigm, and it’s very hard to anticipate what that is going to feel like unless you’ve lived it,” Pearce adds.

The decision about whether to bring on a consultant can also depend on how much staff a facility has, along with the knowledge base available.

“It depends on the size of the hospital, because in smaller community hospitals they often don’t have in-house clinical engineers, and in many cases their IT departments are not as robust, so it’s best to call in a consultant,” Lawson says. “But for facilities with over 150 or 200 beds, they generally have a lot of resources with IT, clinical engineers, and their own x-ray staff, and they have enough know-how to make wise decisions without spending the extra money.”

Some facilities rely heavily on those internal resources, using specialized consultants only to address areas where the in-house team is unfamiliar. One such example would be for modalities that require a secondary capture before images can be delivered to the PACS.

Recruit From Within
PAs often come from existing team members, in particular those with experience in the radiology department.

“Most of the PAs hired internally are the savvy radiology folks who understand equipment and who enjoy working with computers,” Lawson says, counseling that whoever takes on the task should be aware of what he or she is getting into. “It’s a stressful position, because not only do they deal with IT and clinical engineers, they also have to deal with the doctors and the vendors.”

Regardless of where a facility recruits the PACS administrator, there are certain qualities the PA should definitely possess, including project-management and conflict-resolution skills.

“It’s not required that they physically know how to do everything, but they need to be able to coordinate it all, such as scheduling which vendors and contractors do what and when they do it,” Freeman says. “The PACS administrator also has to deal with disputes, because certain things need to be done on a timetable, and it may require wielding the hammer to get things completed.”

The ideal PA would also be on-site every day so that he or she could easily coordinate activities and be available to promptly deal with any issues. He or she should also know the hardware and software, and at the very least be familiar with the basics of medical imaging technology and process.

Know What You Are Getting Into
A smooth, successful PACS installation can generally be attributed to one thing: preparation. The first step for many BMETs and CEs is to get a bird’s-eye view on the role PACS plays as part of the IHE initiative.

For almost a decade, IHE has offered a framework for information sharing designed to optimize clinical workflow. The organization promotes the use of established standards such as Digital Imaging and Communications in Medicine (DICOM) and Health Level Seven, which enable care providers to effectively use and share medical information.

“It is important for clinical engineering to understand the bigger picture; not just PACS but the whole integration of the health care enterprise, which includes things like the hospital information systems and radiology information systems,” Lawson says, adding that there is roughly a four-to-one ratio of clinical equipment to IT devices that could be in the enterprise. “While PACS is a significant component, it’s knowing what’s going on in areas outside of radiology—in the lab, in cardiology—that strengthens the biomedical engineers and clinical engineers,” he says.

Attending to Details
Once BMETs and CEs are familiar with the big picture, their attention should be turned to the specifics of the process.

“My advice is to look at it as an educational opportunity and try to get involved as early as you can,” Freeman says. “Taking a DICOM class would be good, for example, because it will help you understand the communication between the modalities and the PACS; do your homework, and try and learn as much as you can.”

In addition, the biomedical team is also an ideal source for the detailed outline of the imaging workflow required to successfully convert to a digital system. While the workflow is being recorded, a complete list of every modality that will be attached to the PACS should be made as well, detailing where the item is located and the volume that each device is expected to process.

“The clinical engineering and IT departments should put their heads together to make sure they have a solid, accurate list of all the devices in all of their settings, because you’ve got different places where that equipment is located—radiology, computed tomography, magnetic resonance, down in the emergency room—to ensure there is no duplication,” Lawson says. “I would also recommend they consider the interconnectivity between the computed radiography (CR) workstations and the thermal or laser printers, because while it’s strictly transmitting ethernet data to the PACS, if the two pieces of equipment have different vendors, there can sometimes be issues.”

Be Prepared to Accommodate
New hardware must also be taken into consideration. In some facilities, the addition of viewing stations and dry printers will require the construction of an additional workroom for the physician to read images, or perhaps some simple modifications to an existing reading room.

Facilities also need to plan for connectivity. Even if a network exists, it needs to be determined if it is capable of handling every modality and if it will be able to withstand the strain a PACS—and its huge files—will place on it. These are vital questions that are better addressed before the vendor shows up and starts to unload boxes.

“One of the advantages of setting up the network first is you can have most of your network problems worked out by the time you get the PACS,” Freeman says. “With the network in place, you have a whole lot less to deal with while you are involved with the actual installation.”

This evaluation process can also be used to determine how the CR system will meet—or fall short of—the facility’s expectations.

“For the most part, a server is a server,” Lawson says. “They are capturing and storing the data and backing it up—it’s pretty straightforward. The features of the CR are more important, because between vendors there are big differences in the type of plates used and how many machines it can handle at one time, for example, and those questions need to be answered to make sure the system will work as intended.”

Preparing the Masses
It is impossible to bring a PACS system into a facility without disrupting the status quo. A new and improved workflow is one of its upsides, but such monumental changes require a coordinated approach.

The PA is generally tasked with not only the responsibility of overseeing all the systems and deployment issues, but for keeping everyone involved in the process—BMETs, CEs, radiologists, cardiologists, technologists, administrators—informed and on the same page.

Obtaining support from high-level executives can be the difference between whether the installation process hits speed bumps or road blocks.

“Having high-level buy-in makes a huge difference, because if there is a lot of indecision about switching everyone over, it sometimes leads to messy or troublesome implementations,” Pearce says. “Having agreement among the stakeholders involved in the purchase is incredibly important, but when tough decisions need to be made about the change, high-level support is invaluable.”

Beyond internal departments, consideration must be given to the external users of the PACS, primarily the referring physicians. While many will be comfortable viewing their images on CDs or via the Internet, others will demand that film continue to be produced for them. Meeting their needs must be considered in terms of both funding and equipment.

Uncovering Hidden Costs
In addition to the obvious costs of converting to a PACS, one of the biggest assets the biomedical team brings to the PACS process is their knowledge of issues related to servicing an enterprise-wide system of software and hardware. Having an employee alert to these possibilities at the beginning can save a lot of money.

Such topics include learning the amount of available training, either from the vendor or through a third party; figuring the cost of licensing fees, including any charges incurred if new modalities are incorporated with the PACS in the future; and determining which components of the system are proprietary and which can be purchased off the shelf, as well as the terms of the warranty. For example, does the biomedical department determine service options, or does the vendor?

Software upgrades are another potential area for ongoing expense.

“You have to find out how the company handles software issues. What is their policy on software upgrades? How much will it cost?” Freeman says. Policies are as varied as vendors, with some charging an annual fee encompassing all software support, and others requiring companies to purchase software piecemeal. It is also important for facilities to determine their access to backup software. “If a piece of hardware goes down or a hard drive crashes, will the vendor supply the software for you again? Or do you have to pay them to give you a copy if you don’t have one?”

Installation Day
Assuming that all the homework has been done properly, the actual PACS installation should progress smoothly, handled largely by the chosen vendor. That does not, however, mean that in-house staff should clear the area. On the contrary. Spending time with and around the vendor representatives as they get the PACS in place and online can be an extremely beneficial learning experience.

“The vendors bring the equipment in, install it, and input all the settings. So it’s good for us to stand by and see that those things are accurate, there is no duplication in title, in TCP/IP ports, and those types of things,” Lawson says. “By being involved during installation, clinical engineering can play a role in solving any interconnectivity problems that occur after the vendor leaves.”

Once online, the PACS system should not alter whatever preventive maintenance requirements are needed for existing modalities.

Foster Relationships
No matter how much preparation is done and how diligently the process is studied and learned, it could all fall apart in an instant if there is a breakdown in communication between the professionals involved.

“The clinical engineers and the biomedical equipment technicians have to build relationships with people, and gain their confidence, and they’ll find themselves in the driver’s seat,” Lawson says. “Clinical engineers have always taken the lead, whether it’s in identifying operator user error or locating the source of problems that cannot be duplicated. Patient safety is our overarching mandate, and we are really driven by a life-critical mode of operation.” 24×7

For an introduction to PACS, see our March cover story at www.24x7mag.com.
Dana Hinesly is a contributing writer for 24×7.