User Centred Design and Implementation of Useful Picture Archiving and Communication Systems for Effective Radiological Workflows in Public Health Facilities in Zambia

User Centred Design and Implementation of
Useful Picture Archiving and Communication
Systems for Eﬀective Radiological Workﬂows in
Public Health Facilities in Zambia
1
DataLab Research Group, University of Zambia, ZAMBIA
2
Adult Hospital, University Teaching Hospitals, ZAMBIA
Brighton Mwaba1
· John Mwanza1
· Wilkins Sikazwe1
Andrew Shawa1
· Ernest Obbie Zulu2
· Elijah Chileshe1
Lighton Phiri1
4th
African Human Computer Interaction Conference (AfriCHI 2023)
November 27– December 1, 2023 | East London, South Africa

2/25
November 29, 2023 4th
Outline
● About the DataLab Research Group
● About the Enterprise Medical Imaging Project
● Radiological Workﬂow
● Medical Imaging Workﬂow Challenges
● Methodological Approach
● Results and Discussion
● Conclusions, Ongoing Work and Future Work
● Acknowledgments

3/25
About the DataLab Research Group at The
University of Zambia
● The DataLab research group at
The University of Zambia is
composed of faculty staﬀ and
students—undergraduate and
postgraduate—working in three
main areas
○ Data Mining
○ Digital Libraries
○ Technology-Enhanced Learning
https://datalab.unza.zm

4/25
About the Enterprise Medical Imaging in
Zambia Project
https://emi.org.zm

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Radiological Workﬂows: Acquisition,
Examination and Interpretation (1/2)

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● Radiological workﬂows
involve a series of cadres
○ Referring Physicians, Data
Entry Clerks,
Radiographers and
Radiologists
● Medical images are utilised
at various stages of
radiological workﬂows

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● Radiological workﬂows
involve a series of cadres
○ Referring Physicians, Data
Entry Clerks,
Radiographers and
Radiologists
● Medical images are utilised
at various stages of
radiological workﬂows

8/25
Efficient and Effective Workflows Using
Enterprise Medical Imaging Strategies
https://wiki.ihe.net

9/25
Efficient and Effective Workflows Using
Enterprise Medical Imaging Strategies
https://wiki.ihe.net

10/25
Methodological Approach
The main objective of this work was to investigate the
feasibility of designing and implementing a useful, usable,
user-friendly and interoperable Picture Archiving and
Communication System (PACS) that will be used for efficient
and effective storage of medical images that are produced in
public health facilities in Zambia
1. Understand medical imaging workflows
2. Evaluation of Free and Open Source PACS platforms
3. Usability evaluation of PACS platform

11/25
Methodology: Understanding Medical
Imaging Workﬂows
● Study setting
○ Two (2) large referral hospitals in Zambia: University Teaching
Hospitals and Levy Mwanawasa University Teaching Hospital
● Target population and sampling technique
○ Two (2) cadres involved in the study: Radiologists and
Radiographers
○ Convenience sampling was used to identify potential study
participants
● Procedure
○ Guided interviews were conducted to determine how images are
stored, managed and accessed

12/25
Methodology: Design and Implementation of
PACS Platform (1/4)
● Desk review
○ Document analysis of PACS FOSS platform document was
conducted
● Selection criteria
○ Active FOSS PACS projects were used as a basis to identify tools to
include in the analysis
● Procedure
○ Evaluation matrix was devised to enable an objective selection of
appropriate FOSS PACS platforms
○ Factors utilised involved development-centric aspects and
subjective aspects

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PACS Platform (2/4)
Dicoogle DCM4CHEE EasyPACS ClearCanvas Orthanc
Base Language Java Java Java C# C++
Extensibility High High High Medium High
Extensibility
Language
Java Java Java · Python ·
Ruby
C++ · VB.NET C++ · Python
Operating
System Support
Windows ·
Linux · MacOS
Windows ·
Linux · MacOS
Windows ·
Linux · MacOS
Windows ·
Linux · MacOS
Windows ·
Linux · MacOS
Database
Support
NoSQL Apache Derby ·
PostgreSQL ·
MySQL · Oracle
MySQL PostgreSQL NoSQL
Search Searving Lucene Lucene Lucene PostgreSQL SQLite
Authentication
Support
Local Auth LDAP LDAP · SSO ·
2FA
OAuth 2.0 Local Auth

14/25
PACS Platform (3/4)
Dicoogle DCM4CHEE EasyPACS ClearCanvas Orthanc
DICOM
Compliance
Yes Yes Yes Yes Yes
DICOM Modality
Worklist
Yes Yes Yes Yes Yes
API Support RESTful RESTful RESTful .NET RESTful
Scalability High High High Low High
Relative
Adoption
Low High Medium Low High
Community
Support
Yes Yes Yes No Yes

15/25
PACS Platform (4/4)

16/25
Methodology: Usability Evaluation PACS
Platform
● Controlled experiment conducted to assess potential of PACS
platform being adopted into public health facilities in Zambia
● Study setting
○ University Teaching Hospitals
● Target population and sampling
○ Radiology Registrars were recruited using convenience sampling
● Procedure
○ Participants were required to search for a DICOM ﬁle in PACS
○ TAM 2 post-experiment questionnaire used to assess Perceived
Usefulness and Perceived Ease of Use of PACS platform

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Results: Understanding Medical Imaging
Workﬂows
Experience Storage Medium Image
Formats
Challenges
Radiographer 1 UTHs 5+ Years Hard Drive ·
Basement
Analog · Digital Retrieval
challenges
Radiographer 2 UTHs 5+ Years Imaging Machine ·
Storeroom
Analog · Digital Retrieval on
patient request
Radiographer 3 UTHs 5+ Years Hard Drive · Films ·
Patients
Analog · Digital Storage capacity
challenges
Radiographer 4 UTHs 7+ Years Compact Discs ·
Film
Analog · Digital Accessibility
challenges
Radiologist 1 LMUTH 11+ Years — Analog · Digital Image
preservation
Radiologist 2 UTHs 4+ Years — Analog · Digital Limited space ·
Image retention

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Results: Design and Implementation of PACS
Platform

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Results: Evaluation of Free and Open Source
PACS Platforms (1/2)

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“Integration to an online patient clinical records would
signiﬁcantly enhance patient care” [Participant 1]
“Suggestions are that it should be a multimodality platform and
should have a provision for reporting
images” [Participant 3]
“Incorporating a DICOM viewer(digital imaging and
communication in medicine) would help to large data
sets(CT scans and MRI Scans)” [Participant 4]

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“There is supposed to be free access to the internet in the
department.” [Participant 5]
“IT WOULD ADD A LOT OF VALUE IF IMAGES WERE EXPORTABLE.”
[Participant 6]
“Order of metadata should prioritise patient pertinent details as
opposed to technical lingo” [Participant 8]
“It's a step in the right direction” [Participant 2]

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Conclusion and Future Work
● Work conducted to demonstrate the feasibility of designing
and implementing potentially cost-effective, useful and easy
to use PACS platforms for use in public health facilities in
Zambia
○ Exploration of challenges with medical imaging workflows
○ Evaluation of FOSS PACS platforms
○ Usability evaluation of PACS platform
● Ongoing work focused on implementing production-quality
PACS platforms
○ Base infrastructure required to explore the use of Artificial
Intelligence in addressing challenges with radiological workflows

23/25
Acknowledgements
● This study was conducted as part of a much larger Enterprise
Medical Imaging in Zambia project. The project is funded
through generous grants from Google Research, Data Science
Africa and The University of Zambia. We are very
appreciative of this funding.

24/25
Q & A Session
● Comments, concerns and complaints?

[1] Zulu, E.O., and Phiri, L. (2022). Enterprise Medical Imaging in the
Global South: Challenges and Opportunities. In Proceedings of
2022 IST-Africa Conference (IST-Africa 2022).
[2] Zulu, E.O. and Phiri, L. (2021). Enterprise Medical Imaging for
Streamlined Radiological Diagnosis in Zambian Public Health
Facilities. The University of Zambia.
[3] C. J. Roth, L. M. Lannum, and K. R. Persons, ‘A Foundation for
Enterprise Imaging: HIMSS-SIIM Collaborative White Paper’, J.
Digit. Imaging, vol. 29, no. 5, pp. 530–538, Oct. 2016, doi:
10.1007/s10278-016-9882-0. [Online]. Available:
https://doi.org/10.1007/s10278-016-9882-0
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User Centred Design and Implementation of Useful Picture Archiving and Communication Systems for Effective Radiological Workflows in Public Health Facilities in Zambia

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