Steve Walter, Saints Memorial Hospital, Lowell, Mass.

The benefits of picture archiving and communications systems (PACS) are unquestioned, but until recently, they were available only to large teaching hospitals. Can community hospitals obtain them also? Decisions in Imaging Economics talked to representatives at three hospitals that have made the move to PACS, each by its own route. Saints Memorial Hospital in Lowell, Mass, provides comprehensive inpatient and outpatient care as well as occupational and preventive services to businesses and health care centers at two high schools. Unable to afford a PACS initially, the hospital bought computed radiography (CR) more than a year ago and is now installing PACS. Hurley Medical Center in Flint, Mich, is a 463-bed teaching hospital that provides acute and tertiary care to a five-county region and has education affiliations with three medical schools. Hurley is the regional children's medical center and houses a level I trauma department. It purchased and installed a full-blown PACS in what it calls the "Big Bang." St Margaret's Hospital, a 220-bed facility, is part of the University of Pittsburgh Medical Center (UPMC) system. The UPMC had already decided to install PACS, and, in what might be called "trickle-down PACS," St Margaret's is implementing its system in partnership with the University.

CR: INTRODUCTION TO PACS

Saints Memorial began its digital transition when it was faced with replacing an old wet processing system for its ageing radiography technology.

"We had three old x-ray systems interfaced with wet processors that had to be replaced," explains Steve Walter, RT, director of diagnostic imaging at Saints Memorial. "New wet technology certainly would have been less expensive, but it is a technological dead end. Also, we were faced with the need to spend several thousand dollars to update our electrolytic and catalytic recovery to satisfy the local waste water authority. We decided instead to invest in three dry lasers. For about 2.5 to 3 times the price of the traditional technology, we were able to integrate CR." PACS was a logical next step.

Saints Memorial Hospital installed a CR DICOM network 18 months ago and gradually incorporated all of its other digital modalitiesCT, ultrasound, nuclear medicine, angiography, and fluoroscopy. Every modality has a primary laser printer, but if that printer is down, the modality can print to one of the others. With the establishment of a digital and DICOM environment, the hospital had ready entrée to the next step: PACS.

The PACS at Saints Memorial was installed in early July. It includes a 5-terabyte RAID archive without storage to disk. There are six dual flat-panel reading stations for the radiologists and 12 clinical review stations for the referring physicians. The latter workstations have slightly lower, but still diagnostic quality, resolution. In addition, there is a complete web server with viewing software. The target go-live date is the first week in August.

Saints Memorial Hospital is benefiting from an unusual financing mechanism. "Instead of buying the PACS outright, we pay to use it on a capitated per-procedure basis. The charge is about what we would pay for film and film handling for the same study," Walter explains. "Our PACS represents more than $1 million in equipment, and we could not make a capital expenditure of that size. We are budgeting PACS as a break-even. If it increases revenue, it will only be because the referring physicians want to send more patients to us."

The hospital has realized savings by purchasing two types of workstations. The six to be used for primary interpretation are more sophisticated than the 12 clinical review stations placed throughout the rest of the hospital, which are high-quality flat-panel PC monitors. They permit image manipulation, but they have slightly lower, although diagnostic quality, resolution.

View boxes are small; PACS workstations are not. Moreover, workstations have extensive requirements for cabling and cooling and present important security and privacy issues. In space-starved small hospitals, the questions of where to site and how to protect PACS equipment become serious concerns. When Saints Memorial purchased its first CT scanner a decade ago, the computers were large. The computer for its present scanner is about one fifth the size of the first, which has freed up space to serve as the central processing area for the PACS. A great advantage of this approach is that the room already had the necessary security and air conditioning, so the only additional infrastructure costs will be for shelving and cabling.

At Saints Memorial, previous films are retrieved, "but we need to do this less often the longer we have CR. At present, if a patient is going from one facility to another in our system, and there is a critical set of films, we probably would digitize them rather than package them up, send them off, and then try to get them back."

THE BIG BANG APPROACH

Helping to drive the decision at Hurley Medical Center was the fact that one of its competitors had PACS, and the hospital felt the need to catch up. Another important motivator was the promise of no more lost films. As Apparao Mukkamala, MD, Radiology Department Chairman, put it, "I have been a radiologist for 37 years and I got tired of the grief when people could not find films! If we can get rid of this problem, PACS is worth it."

Carole Carpenter, RT, RIS/PACS specialist at Hurley, explains why the hospital chose to install PACS all at once.

Apparao Mukkamala, MD, radiology chairman, Hurley Medical Center, got tired of dealing with the repercussions of lost film.

"We saw many sites trying to phase in PACS and getting stuck, so they were still printing almost as much film as they had been before. We decided that if we did not do it all at once, we were never going to realize the available savings."

In 1999, a consultant looked at the operation at Hurley and told them the payback time for a PACS would be 5 to 6 years. Since then, however, storage has become cheaper, CR and the workstations have improved, and the network technology has become much more robust, so the hospital decided to take another look. They did some shopping at the RSNA conference and talked to staff members at other PACS-equipped sites. They then prepared a two-page list of their requirements.

"We spent about 2 months writing those two pages," recalls Carpenter. "We avoided an RFP [request for proposal], which can create problems because you cannot anticipate all the situations you will face. Moreover, the equipment changes so quickly that your RFP can be outdated by the time you finish it."

With the requirements in hand, they approached three vendors, made site visits, and tested equipment. For side-to-side comparisons of each vendor's software, Hurley brought workstations on-site from multiple vendors at the same time, to which their CT images were sent. They also did blind comparison tests of the CR images that were imported from different CR vendors. "We picked up on subtle differences that may not have been noticeable if they were not side-by-side comparisons," Carpenter notes.

Their final choice was influenced by the vendor's ability to integrate the PACS with the already-installed RIS. The system includes three dual 1.6K and two dual 2K radiologist workstations. Dual 1.6K workstations also were installed in the ICU and orthopedics and dual 1K view stations were installed in the nurses' station and trauma room of the emergency department. Single 1K view stations were placed in the coronary care unit, the neonatal intensive care unit, the pediatric ICU, and neurology. The entire network is web enabled with integrated transcription capability. The dry laser printers are capable of printing two sizes of film. Five multiple plate readers, three single plate readers, and nine remote ID stations also were acquired.

Hurley had to remodel its reading room to accommodate the increased heat and the change in workflow. In some of the viewing areas around the hospital, it was necessary to modify the lighting to make the workstations easy to view.

Although considerable attention has been paid in the radiology literature to digitization of film libraries when PACS is installed, the three hospitals were unanimous that this is not a good use of time and resources.

"Most of those images will never be looked at again," Mukkamala points out. "We have view boxes near the workstations where we can hang the old films. The only films we digitize are those that will be needed for a conference."

A TRICKLE-DOWN INSTALLATION

St Margaret's, Pittsburgh, is one of six community hospitals in the UPMC system, where the web-based PACS software based on the streaming technology developed at UPMC by Paul Chang, MD, began to be implemented approximately 5 years ago.

Three years ago, St Margaret's was networked into the UPMC health system's network and began sending DICOM studies, namely CT and MRI, directly to UPMC for subspecialty interpretation.

The hospital purchased an archive about 9 months ago and started to build a database of the CT and MR studies. Radiology leadership then began to consider the modalities that were or could become PACS-ready. The hospital was already in the process of purchasing new ultrasound equipment, which it made sure was DICOM-ready. Capturing nuclear medicine images was more difficult, because the equipment was old. The solution was a broker that converts analog information to digital and then to DICOM information.

Six months ago the decision was made at St Margaret's to move to a soft-copy reading environment within the hospital and to extend access to digital images to other departments within St Margaret's. In order to do that, St Margaret's purchased CR equipment and updated the hospital server to provide speed for image transmission. The hospital had the network backbone, but additional network drops needed to be placed within radiology. It also had to evaluate whether the existing PCs were up to the minimal standards for running the viewing software. Some floors needed new PCs, but the cost was minimal.

"We now have five diagnostic x-ray rooms, including one dedicated chest room, with CR, and all of our portable studies are done on CR," reports Bill Simmons, radiology director, St Margaret's. "We are still transferring the images both to film and to PACS, but film is being phased out.

"Our reading area was small, so our radiologists read a lot of cases in their offices," Simmons recalls. "Lacking the space to make a large soft-copy reading area, we reconfigured the radiologists' offices so they can have both a view box and a monitor. We also have a main reading area where a couple of radiologists can work."

All of the community hospitals contacted reported special infrastructure issues as they attempt to install PACS in their operating rooms. The experience at St Margaret's is typical.

"Our four new operating rooms all have monitors over the tables for viewing soft-copy images, but the other four rooms still need to be equipped," Simmons says. "We probably will use mobile stands that can be moved into place or shoved out of the way quickly. It is a tough sell when you tell the surgeons, We are going to make things better for you,' but then you say you are going to add equipment. Space in the OR is already tight, and they wonder whether there is going to be any room for them.

"The UPMC believes that the benefits and efficiencies of PACS are cost-effective," Simmons reports. "But it is extremely important that you not try to cost-justify a PACS through radiology savings, because you can't. Yes, you have to look at the cost of film, chemicals, handling, and staffing. We expect to reduce our film costs next year by about $200,000. Also, if you have been storing films on-site, you may be able to convert that space to some revenue-producing activity. But PACS is a campus-wide initiative to improve services for patients and physicians that is capital intensive on the front end. You may not fully realize the operational benefits and savings for 5 years. So you need to get a philosophical acceptance of the fact that we are entering a digital world, and your hospital needs to be part of it."

With financial people, it is difficult to sell a philosophical viewpoint. Simmons suggests calling their attention to the time savings and efficiency that PACS provides for the physicians who order imaging procedures.

"It is hard to put a figure on it," he says. "But consider a resident making 10 to 12 trips at night to the radiology department. What does that equate to in hours, and what could that resident be doing instead?"

St Margaret's has already seen a clear benefit in the throughput of its emergency department in the 6 weeks since it installed PACS. In the past, during the day, a radiologist interpreted the films and then sent them to the ED, which caused delays if the radiologists were busy.

"Now, the radiologist and the ED physician can look at images simultaneously and collaborate with a phone call," Simmons says.

GENERAL ADVICE

Bill Simmons, radiology director, St Margaret's Hospital, Pittsburgh.

"Each piece of equipment is unique, and even if a company says it is DICOM compatible, you have to examine the DICOM conformance statement," he says. "Some equipment is DICOM-send, some is DICOM-ready, and some is DICOM-print but it cannot send."

"There is a huge learning curve in changing to CR," Carpenter cautions. "I highly recommend that if you are going with the Big Bang for your PACS, you have CR up and running 6 months ahead of time. Also, we tried to put in as much redundancy as possible, especially in the emergency department. We tried to think of every possible thing that could break and have at least one or, better, two plans for getting around it."

Carpenter stresses the importance of involving the information systems (IS) department from the beginning.

"Many hospitals start working on PACS with the idea that it is a radiology project that needs a little bit of help from IS. That is the wrong approach," Carpenter states. "PACS is computers and networks. The rest of it is software and teaching the physicians how to use it. It must be an IS and a radiology project.

"It helps to have a PACS administrator involved from the inception of the project," Carpenter continues. "It kept me busy full time just planning the PACS project: doing the remodeling in the rooms, coordinating the vendors, taking bids, developing contingency plans."

Mukkamala cautions that the first 3 months of the transition to PACS are "very painful. Our output went down 25% to 30%, and we all spent long hours in the hospital just getting the work done and getting to know the system. But 6 months into it, we are back to our original productivity level."

The future will be filmless. That is a fact. "Sometimes people want to wait for the next technology before they make a move, but if you do that, you could be standing at the station for many years," Simmons says. "You have to get on that train, or it is going to pass you by."

PACS is no longer an unrealistic goal for smaller hospitals. As the experience of these three centers demonstrates, community hospitals that formerly could only dream about PACS are finding that it is achievable.

Judith Gunn Bronson, MS, is a contributing writer for Decisions in Imaging Economics.