Paul Nagy, PhD

Physicians today suffer from illnesses of the digital agechange toxicity and information overload. A critical factor determining the level of physician acceptance of a new information system lies in how well the system will be supported by the technical staff.¹ Support provides physicians with a comfort level and safety net, allowing them to make mistakes without having to panic. This in turn leads to a faster transition through the learning curve. Radiology in particular lies in the crossroads of an area of medicine besieged by information technology from all quarters; digital modality acquisition, radiology information system (RIS), picture archiving and communications systems (PACS), dictation, and voice recognition. It takes strong leadership, communication, and support to help convert the masses to the benefits of information technology and especially PACS. We have developed a decision support system called Radtracker at the Medical College of Wisconsin to institute excellent system support for the radiology department for PACS and all of our information systems.²

Effective problem management consists of detecting problems quickly, accurately notifying the correct resources to solve the problems, and managing the problems to resolution.³ Our goals to achieve effective problem management were a single point of access, ease of use for the submitter and the support staff, building a knowledge base, and ensuring adequate communication feedback. We have solved more than 500 issues with this tool over the last 12 months and learned many valuable lessons on how to run an effective support system for the radiology department. The issues have spanned the gamut from PACS and RIS to dictation, alternators, PC support, application support, and modalities. Effective system support helps not only the users but also the support staff themselves. Proactive support helps them identify and quantify recurring problems and communicate their impact on productivity to the leadership of the department. This puts them in a more proactive role where they can build on their knowledge base and climb out of a reactive firefighting role. By quantifying their role, support staff can better defend their role and even obtain additional resources if it can be shown to provide cost benefits. This article will discuss key take-aways we have identified as most important in building and maintaining a support team.

Radtracker was built with a web-based front end and a database back end. It was written in the PHP scripting language, and ran on an Apache web server with My-SQL database. The server was running Red Hat Linux. The entire system was running on freely available open-source programs. We used open-source applications because of their robustness as well as the rapid application development environment they provided.

The first take-away is that the only way to support mission-critical applications is to have immediate and automatic notification of the problem to the right people. Once submitted, the issue is emailed to all the support staff that subscribes to the category. The right problem gets sent to the right support person. Different support people can support different systems without having to see each other's traffic. If the issue is submitted as a high priority, then an email is also sent to the alphanumeric pagers of the support staff for instant notification. We have found this to be very useful in resolving any problem that affects patient delivery. We have allowed the user to select the priority and automatically page the staff if necessary. This proved very effective in our department as it put trust in the users that they would not cry wolf for issues that might not be deemed as high priority. Very rarely did the users pull the fire alarm and hit the support staff pagers' for an issue that we deemed was not appropriate.

SINGLE POINT OF ACCESS

Another take-away is to have a single point of access for all issues within the department. When a system is down, users do not want to hunt around for phone numbers of the person who is responsible for the issue and to find out if they are on call or not. It is important to make access to the support system as simple as possible so that problems can be entered as they occur. One phone number to call or one web page to access for all problems is an effective alternative to sticky notes with multiple phone numbers attached to consoles.

With this in mind, we developed a web page with a pull-down list including all of the issues where support is necessary. The user writes a couple of sentences describing the problem. They then assign it a category and a severity level and submit it. When the support person sees the issue and takes action upon it, each action is then entered into the system and emailed back to the user to keep them in the loop.

Radtracker helped transform the support team from a purely reactive firefighter role to an engineering role. It can better identify recurring problems and develop policies and tools to resolve them faster. As more and more issues get assembled for each category, an organic knowledge base emerges that the support staff can refer to. Having detailed logs provides valuable feedback to the vendors on the practical issues with their systems in a clinical environment. The support staff can also sift through these logs and build triage sheets of the most common problems. When a member of the support staff leaves, their knowledge can be retained through the support knowledge base. This also helps in bringing new staff up to speed faster. There is a great benefit in showing trending and quantifying the role of support to the leadership and administration of the department. Support more often than not gets negative visibility because the leadership gets involved only when there is a failure that has been brought to their attention. By tracking issues and the actions required to resolve them, the administration will have evidence of the support necessary to maintain a system, helpful in the event that additional resources are called for.

All actions taken are automatically emailed back to users so they can be aware of the effort and attention the support staff has expended on their problem. This also lets them know when the problem is resolved, and they can then verify that. The benefits of an effective problem management tool include increased productivity of the support staff, a reduction in the time it takes to solve problems through use of an accessible knowledge base to recognize repeating problems, and increased satisfaction from the user base.⁴ The entire process can be reviewed periodically to recognize recurring issues and this review can be used to communicate feedback to vendors to redesign the process and help minimize the impact of the problem or eliminate that failure mode entirely. Today's evolving dependency on technology in the radiology department requires a professional means for supporting the growing needs of the user base.

Determining the right system support per user staffing ratio is not easy. It depends on many variables, such as the complexity of the programs used, the level of sophistication of the user base, the degree to which the computers are locked down, and the tools employed to support the users. The computer industry as a whole reports staffing ratios anywhere from 8:1 to a whopping 240:1.⁵ Radtracker provides a means by which to find the right ratio through feedback from the users. If unresolved issues are piling up and if the users are frustrated with the length of time it takes to resolve issues, a department should consider adding support staff. If users do not feel comfortable with the support they are receiving, expect them to resist any information system-based initiatives like PACS. System support should be handled professionally, and not as an afterthought, to help propel radiology into the information age.

Editor's Note: Radtracker is a free, open-source server web site. It can be downloaded at: http://sourceforge.net/. It is necessary to set up a web server to run the program.

Paul Nagy, PhD, is director, Radiology Informatics Laboratory, Medical College of Wisconsin, Milwaukee.

References:

1. Trester N. Physician Acceptance of New Medical Information Systems: The Field of Dreams (1999). Available at: http://www.cio.com/research/healthcare/field_of_dreams.html.
2. Nagy P, Warnock M, Daly M, Rehm J, Ehlers K. Radtracker: a Web-based open-source issue tracking tool. J Digit Imaging. 2002;15(Suppl 1):114-119.
3. Piedad F, Hawkins M. High Availability: Design, Techniques, and Process. Upper Saddle River, NJ: Prentice Hall PTR; 2001:49-58.
4. Schiesser R. IT Systems Management. Upper Saddle River, NJ: Prentice Hall PTR; 2002:193-214.
5. Transition study results: end-user support (1998). Gartner Research Note. Developing the right end-user/IT support ratio. Available at: www.techrepublic.com