PACS/RIS

LEARNING FROM SALISBURY’S PACS/RIS IMPLEMENTATION

Dr Shaun G McGeeConsultant Radiologist and Lead Clinician

Clinical Lead PACS/RIS Project Board

PACS/RIS

PACS/RIS

SALISBURY DISTRICT HOSPITAL

•medium-sized acute trust•3* trust, Foundation Trust status applied for•637 beds•regional plastics/maxillo-facial services•supra-regional spinal injuries/rehabilitation, burns, cleft lip/palate

PACS/RIS

Department of Clinical RadiologyPre PACS/RIS

• 10 established Consultants (9.3WTE) from 5/05• 120-130,000 examinations pa• 80-85% reporting coverage• All modalities except PET-CT• Office- or modality-based reporting• Report authorisation/verification in CT/MRI only• Kodak CR/mini PACS : Spinal Unit 1998• Satellite GP plain film facilities Fordingbridge/Shaftesbury

PACS/RIS

Department of Clinical RadiologyPre PACS/RIS : challenges

• Workflow

• Efficiency

• Clinical Governance

• Accommodation

PACS/RIS

Workflow

• Flexibility to adapt to changing patterns of demand

• Effect culture change : take Mohammed to the Mountain

PACS/RIS

Efficiency

• Reporting turnaround times often slow

• Timeliness of clinical reporting

• Relevance of clinical reporting

• Inefficiency = ↑ clinical risk

• Improvement essential for 31/62 day and 18 week targets

PACS/RIS

Clinical Governance

• Inherent risk in with slow reporting turnaround

• Large risk associated with unverified reports

PACS/RIS

Accommodation

• Shortage of office accommodation for 10 established consultants

• Opportunity to separate reporting process from specific office location

• Optimize use of available space

PACS/RIS

PACS/RIS as a driver for change

PACS/RIS

Preparation

• Enterprise-wide objective• Early involvement of key stakeholders• High-level PMB representation• Partnership : Radiology/IT/LSP• Key Appointments

– Project manager August 2004– PACS manager April 2005

PACS/RIS

Preparation

• Construction of dedicated 100GByte LAN (completed Jan 2005)

• Raising Awareness Programme(started Dec 2004)

• Scoping local hardware requirements

PACS/RIS

Raising Awareness : Objectives

• Give warning of imminent change

• Impart knowledge of new technologies

• Begin process of consultation and engagement

• Stimulate users to start to think about process changes necessary in PACS environment

PACS/RIS

Raising Awareness

• Multifaceted strategy– Talks/Lectures– Grand Round– Divisional/Department meetings– Q&A sessions– E-mail updates– Posters– Hands-on workshops

PACS/RIS

Raising Awareness

the old believe everything

the middle aged suspect everything

the young know everything

Oscar Wilde 1894

PACS/RIS

“Go Live”

• Originally planned for Mar 2005

• Deferred to May 2005

• Occurred 16th July 2005

Did we have any concerns?

PACS/RIS

Concerns prior to “go-live”

• Equipment still being delivered and configured in final 48 hours

• No dummy system in place – were we adequately trained?

• Separate trainers for RIS and PACS with no one individual for training on the integrated product

• Central data storage not ready : local RIS server required (provided by LSP)

• N3 links to satellite units …..etc

PACS/RIS

“Go-live” – Saturday 16th July 2005

Were all our ducks in a row? – we weren’t sure

PACS/RIS

“Go Live” – what happened next ?

“Fat man in a canoe”

PACS/RIS

“Go Live” – what happened next ?

• ↑ plain film workload• ↓ efficiency• myriad process issues• request forms not scanned• often no images in PACS• images on worklists when no report required• felt like meltdown just around the corner

PACS/RIS

Issues emerging after “go-live”

• Business processes/continuity/development

• Training

too little, too late, not “joined-up”

• Technical

loss of extend from RIS to PACS

PACS/RIS

Then what happened ?

• All day visit from FJA/GE/HSS

• Action plan to address technical/support/process/training issues

• Slow steady improvement now being seen

• Clinical benefits within department beginning to be realised

PACS/RIS

Clinical Reporting Pre-PACS/RIS

• Attendance registered on RIS• Hardcopy film from current examination• Old films retrieved and matched• Films and request form to Consultant for

tape reporting• Transcription and typed report production• Printed report despatched to referrer

PACS/RIS

Clinical Reporting post-PACS/RIS

• Reporting driven by worklists created in RIS• Worklists may be

generic/modality-specific/named/other• Request Card scanned into RIS when

examination booked in.• Images open in PACS and scanned request form

is simultaneously visible in RIS• Lost film/request forms no longer a problem

PACS/RIS

Benefits• Increased productivity in plain film reporting

sessions• Improved report turnaround times• More timely/relevant clinical reporting• More efficient clinico-radiological consultation• Improved running of MDT’s• Reduced clinical risk• Increased professional satisfaction

PACS/RIS

Accommodation : Changes

• Created dedicated reporting room from 2 existing Consultant offices

• 4 screened-off reporting workstations• Air-conditioned• Blacked-out• Quiet• ↓ coefficient of interruption

PACS/RIS

Workflow : changes

• Developing Duty Radiologist to deal with general enquiries/troubleshooting

• Separate this role from plain film reporting function to maximize governance/productivity benefits

• Flexible rostering of consultant time to match capacity and demand better

PACS/RIS

Where do we go from here?

• Build on existing achievements

• Introduction of voice recognition technology

• Work towards paperless imaging service

(Ordercomms planned for Autumn 2006)

PACS/RIS

Salisbury District Hospital : 4 months on

• Basically sound technology but still suffering regular loss of extend from RIS to PACS

• Local RIS data storage

• Still dependent on CD for image transfer between SDH and satellite units

• Issues around image transfer to tertiary care

PACS/RIS

If we had to do it all again……

NATIONAL PROGRAMME ISSUES

• seek clearer understanding of the contract, both in terms of equipment and business development support

• better training : ours has been inadequate with no single agent responsible for the integrated PACS/RIS product

• central RIS data storage: will it be achieved

PACS/RIS

If we had to do it all again……

NATIONAL PROGRAMME ISSUES

• Helpdesk support : cumbersome for non-technical issues

• N3

• Information Governance strategy

• Are the suppliers up to it on a national scale?

PACS/RIS

If we had to do it all again…….

LOCALITY ISSUES(1)

• Implement RIS first followed by PACS 2-3 months later

• Have a dummy PACS/RIS system for training at least 1 month before go-live

• If not available under contract, should have Business Process Re-engineering advisors for Radiology and other clinical areas

PACS/RIS

If we had to do it all again…….

LOCALITY ISSUES(2)

• Consider every aspect of life without the brown packet, including image transfer to/from other organisations

• Sufficient resources/time for training

• Realistic assessment of how much time all this requires, esp clinical leads

PACS/RIS

Where is the lifeWe have lost in living?Where is the wisdomWe have lost in knowledge?Where is the knowledge We have lost in information?

TS EliotChoruses form “The Rock”