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  1. 1. Appendix 3 Post Implementation Review PACS Author: Ian Willis Version: 0.03 Issue Date: Last Saved On: 07/09/05 /mnt/temp/unoconv/20150129095758/attached-63156.doc
  2. 2. Post Implementation Review of PACS/RIS Document Control Document Owner Owning Team Author(s) Document Preparation Date Version Contributor Role Comment 18/08/05 0.01 Ian Willis Business Analyst First Draft 22/08/05 0.02 Joanne Dewar Director of Information Second Draft 24/08/05 0.03 Ingrid Walker Divisional Manager Radiology Third Draft 24/08/05 0.03 Michelle Harrison PACS System Manager Third Draft Document Review/QA Date Version Reviewer Role Comment/Status 24/08/05 0.03 Ingrid Walker Divisional Manager Radiology 24/08/05 0.03 Michelle Harrison PACS System Manager 24/08/05 0.03 Dr Kevin Clifford Consultant Radiologist 24/08/05 0.03 Joanne Dewar Director of Information Document Approval Date Version Reviewer Role Approval Document Circulation Date Version Reviewer Role Page 2 of 20
  3. 3. Post Implementation Review of PACS/RIS Table of Contents 1 Executive Summary...............................................................................................................4 1.1 Introduction........................................................................................................................4 1.2 Summary............................................................................................................................4 2 Achievement of Expected Results........................................................................................6 2.1 Business Goals..................................................................................................................6 2.2 Benefits Review.................................................................................................................9 3 Additional Benefits...............................................................................................................12 3.1 Additional Benefits ..........................................................................................................12 4 Problems...............................................................................................................................13 5 User Reaction.......................................................................................................................14 5.1 Key Messages..................................................................................................................14 5.2 System Use/Functionality................................................................................................14 5.3 Patient Care.....................................................................................................................15 5.4 Image Sharing/Remote Access........................................................................................15 5.5 Theatres...........................................................................................................................15 6 System Appraisal.................................................................................................................17 7 Plans for further Improvements..........................................................................................18 7.1 Implementation of the Theatre solution...........................................................................18 7.2 Extended use of voice recognition...................................................................................18 7.3 PACS into the community and GP surgeries...................................................................18 7.4 Remote access.................................................................................................................19 7.5 Service redesign and benefits realisation in clinical areas outside Radiology.................19 7.6 Other considerations........................................................................................................19 Page 3 of 20
  4. 4. Post Implementation Review of PACS/RIS 1 Executive Summary 1.1 Introduction The Picture Archive and Communication System (PACS) was implemented in South Tees as a Radiology capital project in James Cook University Hospital (JCUH) and community in April 2004 and Friarage (FHN) in September 2004. The Radiology Information System (RIS) was implemented as an ICT capital project in JCUH and community in March 2004 and FHN in July 2004. The RIS provides patient administration, clinical reporting and performance reporting for the Radiology Division, Neuroradiology, Women and Children ultrasound service and nuclear medicine. The PACS comprises of several integrated systems providing an image service workflow. The major components are Impax, providing diagnostic image storage and retrieval used by Radiologist, Neuroradiologists and reporting Radiographers, and Web1000 providing review image storage and retrieval for the trust clinicians and staff who require access to images for patient management. This document summarises the findings of a post implementation review conducted through May and June 2005 of the PACS, but does not include the RIS, although elements of the RIS are touched upon in this document due to its integration with PACS. It includes a review of performance against the business objectives and benefits realisation plan set out in the initial business case, identification of unexpected benefits and problems, the user perspective, consideration of performance of the supplier against the agreed contract and any further plans for continuous improvement following implementation. 1.2 Summary 1.2.1 Approach The review was conducted in several ways. The potential and expected benefits were identified in the original business case. A user questionnaire was issued to over 1,000 users, although the complete analysis of this survey is not available for this review. Additionally a number of key users were interviewed to illicit views on the approach to implementation and software functionality. The author acknowledges the input of all those who took time to contribute to the review. 1.2.2 Findings and Conclusions It is fair to conclude that PACS is a well-liked, well-used and highly respected system. All of the users interviewed for this review stated that they would not go back to traditional films. Although many users have experienced some problems with the system, without exception each said that returning to film would now be a retrograde step. The key outcomes from the implementation of the PACS are: • The project has been delivered within the original project budget. • The system should exceed the original predicted financial benefits over the lifetime of the system, with a renegotiated contract and improved savings in staffing. • Additional costs have been avoided such as the need to transport films across sites between James Cook (JCUH) and the Friarage Hospital (FHN). • The system has met nearly all of the original predicted non-financial benefits. The two main areas that are still to be addressed are a solution in all theatres to eliminate the requirement to print film, and access to images and reports in the community. • Further process redesign and innovative use of additional resources such as wireless networks could also realise additional financial and non-financial benefits. • PACS as a system is extremely stable and robust, however its integration with RIS, which is not as stable, and because it is delivered as part of the overall trust infrastructure, it can appear to be unstable to users. Page 4 of 20
  5. 5. Post Implementation Review of PACS/RIS • Take up for training on PACS was poor with only 25% of all the available training slots being used. Users are not fully exploiting all of the functionality that is available within the system. • Speed of access to the system at FHN, particularly when first logging into the system is an issue for a number of users this appears to be a network issue. • Further recommendations for improvements are made in Plans for further improvements (section 7). Page 5 of 20
  6. 6. Post Implementation Review of PACS/RIS 2 Achievement of Expected Results 2.1 Business Goals 2.1.1.1 National Results The investment in PACS will support the Government’s vision for filmless diagnostic services. Advances in digital technologies, particularly in the fields of computing, imaging and in communication, have progressed to the point that it is now possible to acquire medical images in digital form, archive them on computer systems and display them in a diagnostic quality. The display monitor used to present the images can be near or distant to the original point from where the image was acquired. There can be multiple monitors at multiple locations. PACS is not solely a radiology tool and is utilised by many clinicians across an organisation. A proven technology, it has found high levels of application through realised clinical benefits, improved patient flows and improvements to productivity wherever it has been implemented. The installation of a PACS gives the opportunity to re-evaluate the workflow within the radiology department. Rather than merely mimicking an existing, paper-based system, a carefully planned PACS implementation can provide improved workflow, i.e. the more efficient flow of information, images and patients through the department. When the original business case for the PACS was written and the procurement process begun, PACS was not high on the agenda for the National Programme for IT (NPfIT). Since then a National PACS solution has become a key component of the National Programme and as such, the implementation of PACS at the Trust has put it in a strategically advantageous position. 2.1.1.2 Organisation goals The corporate IS/IT Strategy was developed in 2001 and subsequently updated in March 2005. The objectives of the Strategy, which were identified as key to the achievement of the Trust’s business goals, are as follows:  Support patient care by providing staff with effective tools to access clinical information that is easy to use, wherever and whenever it is needed  As a direct by-product of clinical care, provide high quality information  Enable informed decision-making, operational monitoring and performance management through the provision of extensive data analysis tools  Administrative and clinical data is entered once, close to the point of data capture, and immediately available elsewhere  Investment in ICT provides realisable benefits to the organisation 2.1.1.3 Specific Objectives of the Investment The single site development at the JCUH along with the underpinning IM&T strategy above, offered the opportunity for the Trust to reconsider the method of management of clinical images in a manner consistent with patient centred care. This would deliver benefits to patient care for referrals from all specialties, both from within the trust and from primary care and facilitate further use of diagnostic services in the community. Page 6 of 20
  7. 7. Post Implementation Review of PACS/RIS From the original business case, the key strategic driver for the introduction of PACS was the trust’s intent to improve patient flows and streamline diagnostic decision making, by making radiology images rapidly available to clinicians on wards, in departments and in primary care. This would enable increased patient throughput and contribute to the Trust’s aim to reduce waiting times for inpatients and outpatients, in accordance with the NHS National Plan. The original business case for the PACS was written 2002/2003 and with hindsight, there are objectives within it that were too ambitious to be achieved within the timescales and budget, particularly around access in general practice surgeries. Additionally, PACS would reduce the amount of space required to store medical images releasing accommodation for direct clinical care. The business objectives from the original business case for the radiology service is: • To provide accurate and timely diagnoses using imaging to assist and facilitate the appropriate clinical management of patients • To make the results of these images rapidly and readily available to referring specialties in wards, departments and GP practices. • To provide advice and guidance to referring clinicians on the results of imaging. • To maintain an archive to ensure the future availability of images for any future patient interventions. The role of radiology extends not only to providing high quality examinations and interventions but also to ensuring that the diagnostic information obtained is available thereafter wherever and whenever it is needed. With traditional film, nationally and locally, up to 10% of images are permanently lost and as many as 50% of x-ray images are not available when required. It has been estimated that 30% of administrative and clerical staff time within radiology and throughout the hospital is wasted searching for missing or mislaid films. In an audit carried out before PACS was introduced, it was estimated that approximately 1,700 films went missing each year. As well as JCUH, other imaging facilities are provided by the trust at: • Stead Memorial Hospital, Redcar • East Cleveland Hospital, Brotton • Guisborough General Hospital • The Friarage Hospital Northallerton • The Friary Hospital Films from the first three of these sites were physically transported to JCUH for reporting. A key benefit of introducing PACS was to eliminate delays in transportation and facilitate prompt reporting by electronically transferred images. Images would also be transferred from and between The Friarage and The Friary electronically with reporting on any site. The implementation of the PACS would therefore make a major contribution to: • Clinical Governance – easy access to information including who accessed what information when. • Risk Management – through improved security of information (reports and images) and the reduction of lost information. • Partnerships with PCT – it will be possible to provide an increased level of service to Primary Care by providing both reports and images direct to practices via the NHS net and within community hospitals. PACS also provides a platform for the future expansion of radiology services into the community in accordance with PCT strategies Page 7 of 20
  8. 8. Post Implementation Review of PACS/RIS and the emphasis in the National Plan of providing greater access to diagnostic facilities. • Financial and Service Regime of the Trust – PACS is the most cost effective way of storing and distributing images in that it reduces the need for: o Film and Film storage space o Film processing equipment and silver recovery costs o Paper-based reports o Portering o Film library clerks o Radiology clerical staff o Ward clerks • Single Site – Patient centred care on one single state-of-the-art hospital • The merger of the management of clinic services with FHN – PACS enables greater clinical flexibility across sites within the Trust, including the ability to report on images without the need to physically transport images between sites. • Develop further HR strategies – act as an incentive for recruitment and retention of staff in a range of specialties and enabling re-profiling of human resources in accordance with agenda for change. In summary, the PACS implementation was to provide: Functional Capability Critical Success Factors Met Reason for variance A robust image archive and communication system for South Tees Hospitals NHS Trust, which rapidly delivers radiology images to users throughout the Trust and accommodates increasing demand for image storage. Yes The facility to provide images to clinicians within the Trust and to GPs working in primary care. Partially Met Images are not available within GP surgeries. As mentioned above, this was an ambitious objective within the project budget and timescale. A common image archive system to cover all hospitals within the Trust and associated community hospitals as listed above. Yes Table 1: Functional capability Page 8 of 20
  9. 9. Post Implementation Review of PACS/RIS 2.2 Benefits Review 2.2.1 Financial Benefits Below are the total expected savings over the lifetime of the system, i.e. over the 8-year lease of the managed service. A full breakdown of the year on year costs and savings is attached in Appendix A. Benefit criteria Original Expected Saving (£) Forecast Saving (£) Variance Saving (£) Reason for Variance Reduced staffing costs 432,200 799,193 366,993 Additional staff savings have been found with a reduction in radiology clerks Reduction in film/chemical costs 4,670,500 4,473,312 197,188 Full savings from 2005/2006 have not been realised due to film printing costs Reduced processor maintenance 592,000 592,000 - Reduced off-site storage costs 21,000 21,000 - TOTAL VALUE 5,715,700 5,885,505 169,805 Table 2: Summary of financial benefits These savings show that additional financial benefits have been achieved beyond those that had been predicted in the original business case. These additional savings have come mainly from additional staff savings. Savings have also been made with a renegotiated contract with Agfa. The original prediction for the total cost of the managed service was £7,571,116. This has been renegotiated and is now £5,719,950. Therefore, there is a saving of £1,851,166 over the lifetime of the project. This has enabled Radiology to give back to the trust approximately £450,000 to date. 2.2.2 Non-financial Benefits Benefit criteria Expected Outcom e Reason for Variance To improve the quality of patient care through more rapid and reliable access to clinical images, with increased accountability • Improved safety and compliance with clinical governance • Reduced diagnostic radiation dose to the patient population through fewer repeated exposures • Improved speed of diagnosis and clinical decision making by ensuring that the correct and relevant clinical images are available in a timely fashion on wards and in departments Met Met Met To improve patient confidentiality, data protection and security • Improved security and confidentiality of images and reports Met To enhance partnerships with • Improved level of Partially Met Although PACS has improved the service Page 9 of 20
  10. 10. Post Implementation Review of PACS/RIS other services. To benefit other services, by improved exchange of requests and results service to primary care by providing access to both reports and images offered to Primary care, e.g. improved turnaround times for GPs receiving reports, the Trust has yet to offer access to images or reports in GP surgeries or other community-based settings as described above. To improve the effectiveness and efficiency of patient care by better use of resources • Reduction in overall resource requirements for image management. • Increased proportion of resources devoted to patient care Met Met More effective use of clinical images through speedier reference to images and reports and by maximising information from images • Improvement in patient throughput • Reduced diagnostic radiation dose to the patient population through fewer repeat exposures Met Met To support the Trust model of patient centred care • Remote and rapid access to all patient images and associated reports, increased speed of access • Increased possible diagnostic information from clinical images • Making clinical images available at the time and place required to support patient focussed care Met Met Partially Met Images are available everywhere except neurosurgery theatres To enhance the Trust’s Human Resources Strategy, by attracting and retaining key staff • Enhanced recruitment potential through well considered working process and resources Partially Met This has been met for radiographers with an improved potential for recruitment. The potential is not as great for radiologists. To benefit other services, through better education and training • Improved teaching and research facilities Met The reduction of environment hazard and danger to staff • Reduction of load handling risks • Reduction in the use of hazardous processing chemicals • Reduced risk from storage and disposal of toxic wastes Met Met Met To advance the implementation of the Trust IM&T • Improved security and confidentiality of images and reports. Met The PACS project implemented 360 PCs, numerous PC upgrades Page 10 of 20
  11. 11. Post Implementation Review of PACS/RIS strategy and towards the National Programme for IT targets • Increased accessibility of diagnostic images (within and between sites) • Remote and rapid access to all patient images Met Met and the associated infrastructure across the Trust. This includes a number of wireless trolley PCs in A&E and Trauma outpatients and the wireless network. Page 11 of 20
  12. 12. Post Implementation Review of PACS/RIS 3 Additional Benefits 3.1 Additional Benefits All of the financial benefits estimated in the business case were based around improvements and efficiencies only within the Division of Radiology, e.g. savings in film costs, savings in staffing costs within Radiology only. The introduction of the PACS enables efficiency savings across most departments within the hospital. For example, before PACS was implemented, many consultant secretaries would spend time chasing film packets or chasing radiology reports. Secretaries should no longer have to do this, releasing this time for other duties. In part, due to the limited amount of process redesign that was completed in divisions outside of radiology and Neuroradiology before the PACS going live, these savings have yet to be formally identified. So far, only the Division of Neurology has commented that the introduction of PACS has allowed them to lose one part time clerical post because of the efficiencies that the system creates. It is therefore recommended as part of this report that further investigation is made into the additional benefits that PACS has delivered outside of the Division of Radiology. With the introduction of the PACS, there have been a number of additional benefits due to the virtual elimination of the films. These include radiology staff no longer having to lift and carry heavy film packets and spend valuable time sifting through them. Space has been freed up on ward trolleys, which can now be used for extra sets of notes where previously there was not enough room. In addition, before PACS was introduced, for legal cases where copies of films would be required, hard copy films would be produced. Now all relevant images can be copied onto one single CD. It is estimated that before PACS this would cost the trust approximately £1,400 per year. With PACS CDs now cost approximately £200 per year. With the introduction of an integrated PACS and RIS which in turn is integrated to the PAS, patient demographics details are automatically passed to the RIS and PACS. As the RIS is also integrated to the machines that acquire the images, this means that work lists are automatically produced that transfer the full patient demographics. Before PAC/RIS, this information would have to be re-keyed into the machines by radiographers. Additionally, no longer having to print films saves radiographer time. Together this improves the efficiency of the patient pathway. Without PACS, the ability to electronically transfer images between FHN and JCUH would not exist and this would mean that film packets would have to be physically transported across sites. The introduction of the PACS has avoided this quite considerable cost. To do this the trust had to implement a gigabit network link between FHN and JCUH, where a 2-megabit microwave link only existed. This has helped meet the trust objective of bringing together services at JCUH and FHN. Again, any additional financial savings have been given up to the trust or helped radiology meet cost improvement plans. Page 12 of 20
  13. 13. Post Implementation Review of PACS/RIS 4 Problems One of the major benefits with the PACS is that images can be manipulated electronically, using the image manipulation tools. This means for example if the original image is not perfect, then it can be manipulated in order to make it clinically useful. This in turn means that further x-rays are not needed, saving time and resources and preventing the patient having further exposure. However, with traditional x-ray films, a badly exposed film would have to be discarded and discarded films could be counted and audited, indicating either a wrongly calibrated x-ray machine, or perhaps a radiographer who needs additional training on a piece of x-ray equipment. This is known as reject analysis. With the new PACS, this auditing is no longer possible; this could mean that patients are receiving higher radiation doses with each x- ray. However, a newly designed reject analysis module as part of the Computerised Radiography (CR) has recently been introduced on the 1st July. Another problem that was mentioned by a number of users is the process by which clinicians are made aware that images have been taken and reported against with the PACS system. With traditional film, the “trigger” to the consultant that the images had been taken and that a report was available would be when they were physically handed a packet of film. With the PACS, this “trigger” to the consultant has now been lost. To compensate for this, Radiology is continuing to print hardcopy reports, which are sent to the consultant and secretaries. This process needs to be reviewed, as this is a waste of resources in terms of cost and time. An issue mentioned by a number of users interviewed is that PACS is quite often down. However, as mentioned below, there are a number of reasons why this may be thought. These include, user Internet settings, lack of roaming profiles on PCs and power. In addition, web1000 requires additional Java programs, which cannot be installed by a standard user. Because of this issue being raised during the implementation of the PACS, all new trust PCs have the Java programs and the PACS icon installed, but there may still be a number of old PCs that do not have the Java programs installed. This review would not be complete without mentioning the training for the PACS. Before the system went live at JCUH, there were over 3,052 training slots available for users to book into. Training was offered between 9am until 8pm. The Trust tried to enforce a policy of no training, no login. However, the take up for training was extremely poor with only 25% of the 3,052 slots used for training. This means there are users using PACS without any formal training. The full functionality of the PACS is not being utilised and consequently the full benefits are not being realised. A simple example is a consultant who was interviewed for user feedback. The consultant had worked with the PACS at Darlington and commented on the zoom facility for multiply slices. With the Darlington PACS, it is possible to zoom into an image slice and then page through subsequent slices keeping the same position and zoom level. The South Tees PACS was criticised for not having this functionality. However, this functionality is available if the images are first linked together. Page 13 of 20
  14. 14. Post Implementation Review of PACS/RIS 5 User Reaction In total, 15 key users were interviewed as part of this post implementation view. Additionally approximately 1,000 users across the Trust were sent user questionnaires. The results of these questionnaires have yet to be collated and are not available at the time of completing this report. 5.1 Key Messages All 15 users who were interviewed stated that they would not go back to film. Even users who have experienced some problems with the PACS agreed that going back to film would now be a retrograde step. Without exception, each interviewee cited the major benefits of the system as: • The speed at which images are available for viewing, compared to traditional images. • The availability of images, no more film packets that have to be chased or that can be lost or locked away in offices. • The ability to share images with colleagues at the same time, in physically different parts of the hospital, allowing for real time collaboration. The majority of users also commented on the ability to save images onto a separate PC, CD or as most of the consultants interviewed are using, to a separate USB Memory “pen”. The images can then be taken to other sites shared with other colleagues or used for training and educational purposes. Images can be imported into PowerPoint, which is useful for presentations and teaching. One of the key messages that came through from interviewing the clinical users was that there was initially a poor understanding and lack of buy-in into the PACS. Statistics on training session attendance confirms that, although many different sessions were offered at various times of the day, attendance on training courses was poor. Many Divisions and departments did not take the opportunity of the introduction of the PACS to examine current processes around images and image reporting and consider redesigning those processes to improve patient care and/or improve efficiencies. 5.2 System Use/Functionality The majority of the users interviewed felt that the system overall was easy to use. Most commented that the image manipulation tools, such as altering the contrast and zooming on images are extremely useful. One of the major problems that most users interviewed commented on was that of speed of the system. This appears to be a particular problem when first logging into the system. However, this appears to be intermittent with users commenting that at times it can take up to five minutes and at other times of the day it can take only seconds. Once in the system, the speed is much better, with just two people commenting that the speed was slow for viewing images. In terms of speed, it appears that the CT scans take the longest, which is to be expected due to the number of images in a CT scan. The other big issue from all users interviewed was the amount of downtime that the system has suffered, although this has greatly improved over the last few months (see below). The majority of the users interviewed use the Web1000 system and most said that the quality of the images through the Web1000 system is very good or excellent. A number of users commented that the quality of the chest x-rays was not as good as traditional films due to the size of the PC screens, i.e. traditional chest x-rays are large images. It was felt that the images are worse on the wireless tablet PCs, which are used on a number of wards, with one user commenting that the screens need to be at least 17’’. Page 14 of 20
  15. 15. Post Implementation Review of PACS/RIS A number of interviewees commented on the searching facilities on the Web1000 system, pointing out that the system does not allow patients to be searched for on date of birth. Additionally, as with most systems in the trust, patients on the system can have multiple numbers, (i.e. J, F and D numbers) and it is only possible to search for one number at a time. This is a problem across a number of systems within the trust as is currently being investigated. Two users commented that to be able to search for images by referring physician requires the name to be typed in the search box, rather than being a drop down list like other search options. One user commented that the icon used to start up Web1000 is an Internet Explorer icon and that it can be difficult sometimes to distinguish it from other Internet Explorer icons. As Web1000 is web based, another problem is that if another web based system is started, e.g. Web ICE, while using Web1000, then the other application “takes over” the Internet Explorer window, cancelling the Web1000. This makes it difficult for users to switch between applications. The Radiologists using the speech recognition functionality of the RIS find this to be an excellent tool and saves a great deal of time. The system understands quite natural speech and can quickly learn and adapt to individual users. 5.3 Patient Care The majority of clinicians interviewed commented on the fact that they believe that PACS has improved patient care. A number commented that having PACS available for example in outpatient clinics, allows images to be shared with patients. Patients are impressed with the “hi-tech” system and feel involved in their care. However, where the images are not able to be shared with the patient, e.g. on ward rounds, the opposite has happened; with clinicians stating that with PACS, they have lost the ability to show patients their x-rays at the bedside. A number of people interviewed commented that sometimes they struggle to access images, particularly on wards where PCs have to be shared with other users and other applications. 5.4 Image Sharing/Remote Access Some Doctors feel than an area of functionality that is not being fully exploited by the introduction of the PACS is that of sharing images across organisations and enabling access from home. As a major tertiary hospital in the region, consultants see patients referred from hospitals such as North Tees and Durham. Durham also has a PACS but it is not possible to transfer images direct from the Durham PACS to the South Tees PACS. If images are transferred between sites, they have to be copied to CD. Similarly, a number of Consultants who were interviewed stated that they would like to have access to images from home, for example, when they are on-call. This would save valuable time and could avoid a Consultant having to travel from home. 5.5 Theatres A number of surgeons were interviewed and they each had a unique view of the system. Concerns over speed, easy of use and reliability of the system are obviously heightened when a surgeon is in the middle of an operation. A number of theatres have within them trolley based viewing PCs, which can be moved within the theatre. However, these trolleys are not wireless like those used in A&E and trauma and are restricted by the physical cable length. Some surgeons do not like the trolleys being mobile, see them as a hazard and prefer to keep them stationary, whereas others like the fact they can be moved. When the trolley is static and at the far side of a theatre, there are concerns over the size of the viewing screens, although additional larger “slave” screens are to be installed. When these PCs were first installed, a problem that cased major frustrations for the surgeons was that the screen-saver on the PCs would start-up in the middle of a case. This meant that a Page 15 of 20
  16. 16. Post Implementation Review of PACS/RIS password had to be entered to clear the screen-saver. There were occasions when the last person logged onto the computer was not present in theatre and the password was unknown, i.e. the PC was now locked. This problem has now been solved and the screen-savers removed from the PCs. Almost every surgeon commented on how difficult they find the mouse on the trolley PCs to use. They incorporate an integrated touch-pad mouse as part of the keyboard, similar to a laptop, to allow the whole keyboard to be wiped clean. These are difficult to use particularly while wearing theatre gloves. This means they often rely on somebody else to control the system, which can lead to obvious frustrations. A number of surgeons commented on the inability to view a number of different images on the screen at once with the system. In neurosurgery theatres, a conscious decision was made to continue to print films until there is a suitable solution that can display more than one modality at the same time. Page 16 of 20
  17. 17. Post Implementation Review of PACS/RIS 6 System Appraisal Since the PACS/RIS went live there have been 535 fault calls placed with the Agfa help desk. Of these only still 13 remain open, 7 of which are RIS problems, and 3 problems with the Diagnostic Workstations. The breakdown of faults is as follows: System No of Calls Overall Percentage of Calls Broker 1 0% Computerised Radiography Equipment 43 8% Diagnostic Workstations 15 3% Laser film printer 6 1% Network 4 1% PACS 15 3% PAXPORT (DICOM converter for non-DICOM machines) 16 3% RIS 212 40% WEB PACS 11 2% RIS Set up (i.e. problems during system installation prior to go live) 164 31% Other e.g. queries about functionality of the system 48 9% It can be seen that the majority of problems caused by the system, since go-live are RIS. In fact taking the RIS set up problems out of the total number of calls RIS accounts for 57% of all calls to the help desk. Downtime has been recorded separately for RIS and PACS and shows a similar picture. Since go live of the system, there has been 130 hours of downtime of the RIS, whereas there has only been 44 hours of downtime attributed to the PACS alone. At FHN, the downtime of the PACS has only been 8.5 hours. It must be stated that PACS as a system is extremely stable and extremely resilient. The only major downtime with the PACS was a failure in a communication channel between the PACS server and the storage system, which meant the system was down for 31.5 hours with one failure, i.e. 72% of all the downtime experienced by the PACS was one failure. During generator tests, the PACS and RIS are on essential power and are available. However, a number of PCs around the trust that access them are not on essential power, which again can be misinterpreted as the PACS being down. Fault calls have not consistently had the time taken for the problem to be solved recorded and therefore it is difficult to give metrics on the efficiency of Agfa to solve problems. However, when the system first went live helpdesk calls to the PACS and RIS had to be logged with two separate helpdesks, one UK based for PACS and one based in Belgium for RIS. In September 2004, it became possible for all calls to be routed through the one helpdesk in the UK. Anecdotal evidence suggests that calls since then have been responded to quicker. Page 17 of 20
  18. 18. Post Implementation Review of PACS/RIS 7 Plans for further Improvements The further roll out of PACS within the organisation can be categorised as: • Implementation of the neurosurgery theatre solution • Extended use of voice recognition • PACS into the community and GP surgeries • Remote access including sharing images across sites and access from home • Service redesign and further benefits realisation in clinical areas outside radiology Other improvements that also need to be considered are: • Better access with patients i.e. at patient bedsides • Multiple hospital numbers • System performance • Report printing and report “trigger” • Implementation of electronic radiological requesting by clinicians 7.1 Implementation of the Theatre solution The next phase of the PACS implementation is to complete the roll out of a solution into neurosurgery theatres. Given the feedback from surgeons and theatre staff, this solution will need careful planning. Finding a solution that suits all has been difficult. The solution that has been implemented in the Cardiothoracic theatres is 42’’ plasma screens. These are used to display images from the Cardio Prosolv Imaging system and it is hoped that this will eventually interface with the PACS allowing all images to be displayed. Neurosurgery has agreed to this solution and two 42’’ plasma screen PCs have been ordered. However, the theatre walls will require strengthening and this has been ordered through Sovereign. In the next year, the trust must endeavour to move away from printing films for theatres and move towards a completely filmless solution (or at least filmlite solution). This will require a solution that is agreed and accepted by all parties and robust enough to have the confidence of all surgeons. One possible solution to this may be to have images that are required for a procedure, copied to a local device within the theatre. In this way, if the PACS is unavailable for whatever reason while in the middle of a procedure, images will still be available. 7.2 Extended use of voice recognition The voice recognition has proved to be a very valuable tool for Radiologist reporting on images. It streamlines the process of reporting on images removing the need for dictated reports to be typed up by secretaries. It is now due to be implemented in Neuroradiology in mid September 2005. 7.3 PACS into the community and GP surgeries As detailed before the ability to view images and reports in the community and GP surgeries is a major element of the original business case, and was too ambitious for timescale and budget. However, discussions have begun to progress this further. With the building of the Linthorpe Halls, due to be completed in November 2005, the trust will be providing diagnostic facility and access to images and reports in a PCT/community setting. Page 18 of 20
  19. 19. Post Implementation Review of PACS/RIS 7.4 Remote access Mentioned by the majority of users who were interviewed, the ability to view images from the PACS remotely particularly at home would be a major advantage and could deliver a number of financial and non-financial benefits. Similarly, the ability to view images from other sites PACS would improve patient care and deliver a number of benefits. The trust is currently looking at this functionality and hopes to have a solution available in the very near future. 7.5 Service redesign and benefits realisation in clinical areas outside Radiology The implementation of a PACS is only truly beneficial along with the appropriate service redesign. As PACS was introduced, this service redesign was implemented in a number of areas, such as A&E, but it did not take place across the whole Trust. When PACS was initially introduced, partially due to budget limitations, there was a policy of replacing light boxes with PCs on wards with a one for one replacement. There is for example an opportunity now, with the majority of the hospital wireless networked enabled to redesign services delivery and patient care by considering different and better ways of working with the PACS. PACS offers the opportunity for radiology reporting to be done remotely, utilising telemedicine and potentially facilitating much more flexible working of Radiologists who will be able to access images on a 24-hour, seven day a week basis. It challenges the traditional radiology reporting structures and encourages organisational review and reconfiguration of imaging services for maximum efficiency. Used to its maximum potential, PACS will be pivotal in all imaging to delivering the objective set out in the NHS plan, a maximum of 18 weeks from the point of referral to the start of treatment. With the enabling of imaging services in primary care, PACS also underpins the concept of choice in imaging services. 7.6 Other considerations 7.6.1 Better access with patients, point of care access The hospital at night project (H@N) has wireless enabled the majority of the hospital wards and corridors. Due to the nature of the H@N team, this network is only used between 8pm and 8am, meaning the network is very much under utilised during the day. By making wireless laptops or tablet PCs available on wards, this would enable PACS to be delivered at the patient bedside or indeed anywhere on the move within the hospital that is wireless enabled. There are plans to put such devices onto all wards as part of the roll out of the electronic prescribing project. However, consideration must be made to screen size on the tablets, given users comments on the quality of chest x-rays viewed on smaller screens. 7.6.2 Multiple hospital numbers The problem of multiple patients with multiple numbers is a problem within a number of information systems across the trust. A solution to this problem is currently being investigated. Consideration should be made to implementing a bi-directional interface between PAS and RIS, which would further improve the quality of data and searching for patients. 7.6.3 System performance The problems with system performance, mainly when users first log into the system, appear to be intermittent and previous investigations on network capacity and performance have been inconclusive. Further investigation of this problem is therefore recommended. 7.6.4 Report printing The practice of printing reports from the system is clearly resource hungry in terms of paper and time. It is recommended that an investigation be made into a better process that will Page 19 of 20
  20. 20. Post Implementation Review of PACS/RIS remove the need for reports to be physically printed from the system. Further consideration will have to be made on the legality of an electronic report. 7.6.5 Implementation of electronic radiological requesting by clinicians By implementing electronic request ordering within the trust, this would further improve the efficiency of the patient pathway and patient experience. This would also help achieve a paperless or paperlite environment within the trust. Page 20 of 20

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