This paper describes a study of the adoption of Picture Archiving and Communication Systems(PACS). The objective of this study is threefold. First, the adoption rate of PACS by European hospitals is described in relation to the use of other medical information systems. From this, a Medical Information Systems Maturity Scale (MISIS) for hospitals is statistically constructed. The second objective is to identify the key determinants of a hospitals’ score on MISIS, i.e. analyzing the situationality of the scale. The final objective of the paper is to explain and the variation in Medical Information System Maturity among hospitals in Europe. Using the results of this empirical analysis we set out general guidelines for the evolution of PACS maturity [1] within hospitals, based on principals of strategic alignment and situational growth.

1. 1
From PACS Adoption to PACS Maturity:
guidelines for strategic alignment and
situational growth
Rogier van de Wetering1, Ronald Batenburg1 and Reeva Lederman2
1Dept. of Information and Computing Sciences, Utrecht University,
The Netherlands
2Department of Information Systems, University of Melbourne,
Australia
Geneva, June 24, 2010

2. 2
Outline
 Introduction
 Methods
 Results
 General improvement guidelines
 Conclusion and further research
 Questions & discussion

3. 3
Introduction
 Picture Archiving and Communication Systems (PACS) have
seen gradual adoption in European hospitals
 Focussed analysis on determinants of adoption of PACS and
related Medical Information Systems and Information
Technology (IS/IT) is lacking
 This study focussed on key determinants of adoption of
Medical IS/IT
 Study objectives:
 Construct a Medical Information Systems Maturity Scale (MISIS)
 Identify the key determinants of a hospitals’ score on MISIS
 Provide general guidelines for PACS maturity and improvement

4. 4
Methods
Data collection
 Data collected through the e-Business W@tch survey (’06)
 Telephone (CATI) interviews with IT managers at firms from 15 different
sectors
 Field work executed by national market research organizations
 Samples from “acknowledged business directories and databases” and
stratified by economic activity (Eurostat/NACE-defined economic
sectors)
 A total of 834 hospitals participated from 18 different EU-
countries
Methods
 Scale analysis
 Multivariate statistical analysis

5. 5
Hospital descriptives
Country # in sample
France 80
Germany 101
Italy 40
Poland 97
Spain 37
UK 34
Belgium 22
Czech Republic 50
Finland 32
Greece 16
Hungary 60
Latvia 55
Lithuania 58
Netherlands 8
Norway 9
Portugal 50
Sweden 10
Turkey 75
Total 834
# beds Hospitals
1-100 344
101-250 226
251-750 155
> 750 49
DK/NA 60
Total 834
Table 1. Overview hospitals in the E-Business W@tch
dataset 2006 (N=834)

6. 6
MISIS construction process
Yes No Don’t
know
Factor
1. “Does your hospital use the following
departmental systems? - Patient Administration
system”
79.3 18.7 2.0 ,627
2. “Does your hospital use the following
departmental systems? - Radiology Information
Systems (RIS)?”
41.1 54.9 3.9 ,742
3. “Does your hospital use the following
departmental systems? - Picture Archiving
Systems (PACS) and medical image
transmission?”
32.4 65.0 2.6 ,620
4. “Does your hospital use the following
departmental systems? - Pharmacy
management system?”
57.3 40.5 2.2 ,655
5. “Does your hospital use the following
departmental systems? - Electronic transmission
of prescriptions?”
20.3 76.7 3.0 ,443
6. “Does your hospital use the following
departmental systems? - Computerized
Physician Order Entry (CPOE)”
32.1 60.9 7.0 ,607
7. “Do you use for managing information in the
hospital – a Medical Records system?”
66.7 30.1 3.3 ,587
Eigen value of the factor 2.67
Table 2. Original questions, answers and frequencies of IS/IT adoption items by hospitals

7. 7
MISIS construction process
 Inter-correlations are positive and significant on a 1% level
(CA = 0.73)
 Common criteria for reliability of constructing a one-dimensional scale
(Nunnally 1979; Peter 1979)
 Medical Information System Integration Scale (MISIS)
 High inter-correlations of factors
 Ranging from 1 to 7 (as sum up the maximum range of each factor)
 Explore variables that are related to MISIS
 A-priori construct variables - particularly based on the work of Galliers and
Sutherland (1991) and Nolan (1979) are used to extract those variables
from the e-business watch questionnaire that are relevant in addressing our
research questions

8. 8
Results (1-2)
 32.4% of surveyed hospitals used PACS exclusively in 2006
 Most commonly, PACS is used in combination with
 Patient Administration Systems
 Radiology Information Systems
 CPOE and
 Pharmacy Management Systems
 Finnish and Norwegian hospitals widely adopted PACS (over
65%) in 2006, French and Polish hospitals lagged behind
(around 10%)*
* NOTE: Results are based on 2006 datasets. PACS adoption rate has increased in recent years

9. 9
Results (2-2)
 Determinants on MISIS are of a both technical and
organizational nature
 Important drivers include:
 Perceived positive attitude towards IS/IT impact (e.g., efficiency, work,
quality)
 Adoption of the Health level 7 (HL7) standard
 Impact on the business functions (management, R&D, logistics, etc.)
 Investments in IT training
 growth (turnover and employee increase)
 Not significant in this study:
 Important influence on organisational aspects (e.g., structure, task/job
description, education and training employees)
 Type of hospital (vs. scale effects)
 Outsourcing IT-services

10. 10
Guidelines for PACS improvement
Source: Van de Wetering, R., R. Batenburg, and R. Lederman, Evolutionistic or revolutionary paths? A PACS maturity model
for strategic situational planning. Int J Comput Assist Radiol Surg., 2010. 5(4): p. 401-409. Epub 2010 Apr 9.

11. 11
Conclusions
 Hospitals with high MISIS score, significantly perceive more IT
added value
 Generic instruments to improve medical IS/IT Maturity
 Strategically plan for MISIS level to:
 Development of competitive and long-term strategy
 Select strategic direction, by taking the business or the IT domain of the
hospital as the anchor point
 Decide how to achieve this goal, given hospital resources and competences
 Desired PACS and medical IS/IT maturity level cannot be
achieved without conscientious governance and by addressing
a clear strategic direction

12. 12
Further research
 Construction of alignment framework for PACS
 Relating “alignment” and “maturity” construct with PACS
performance (previous presentation)
 Construct validity / factor reliability
 Goodness-of-fit of model
 Structural equation modelling (SEM)
 Mechanisms in achieving PACS performance
 Empirical validation of framework
 All Dutch Hospital
 Ambition towards several countries in Europe / U.S.

13. 13
Contact
drs. R. (Rogier) van de Wetering
Email: R.vandeWetering@cs.uu.nl
Office: CGN-B129
Secretary: +31 (30) 253 9251
Group: Organization and information
section: Information and software
systems
Website: www.pacsmaturity.com