Gregory Hodgman, MD, medical director of radiology services at Bronson Methodist Hospital, reviews images on an eMed PACS workstation.

In early 2000, Bronson Methodist Hospital, Kalamazoo, Mich, seemed fully prepared as it moved toward a picture archiving and communications system (PACS) installation that administrators and information technologists had been planning for months. Bronson Methodist Hospital had one significant advantage that most hospitals implementing PACS do not have. It had a new 348-bed hospital in which to deploy the PACS. The hospital was unoccupied, since it had not yet opened. It was due to accept its first admissions in December 2000, and purchasing the PACS had been part of a $181-million medical campus renovation project, of which the new hospital was the centerpiece. The building, with sweeping curved lines, gardens, atria, acres of glass, and private rooms for all inpatients, was already on the must-visit lists of medical architects. PACS planners had spent months poring over blueprints, confirming workstation locations as well as image-transmission and access details. The inpatient and outpatient radiology suites had been designed to separate the two patient populations, yet centralize the work. The radiology department was so modern that little space had been allocated for a film room, and no plumbing had been included for film-processing chemicals. With few exceptions (largely in mammography), imaging was to be filmless from the start.

Jess Conrad, RT(R), was Bronson Methodist Hospital's radiology information system (RIS) director at the time. He is now the PACS administrator. He remembers the excitement as the PACS-installation date drew near. He explains that the original plan had been to begin using the system with the digital modalities on the old hospital campus in order to give the staff a chance to become familiar with PACS before the new hospital opened (and the switch to completely electronic imaging began). The old hospital is located across the street from the new. The decision to build an entirely new hospital, Conrad says, had been predicated on an analysis indicating that it would cost $40 million more to raise ceilings, widen hallways, and reconfigure the old building than it would cost to build a new hospital. In November 1999, the PACS installation date was drawing near. The system was expected to function by March 2000, not allowing much lead time for the planned April 2000 opening of the new hospital's outpatient wing, but in more than enough time for the new hospital's December 2000 inpatient opening. Then, the best laid plans went awry.

"The PACS vendor was supposed to show up on a Monday," Conrad says, "but called the previous radiology director at his home that Friday night to tell him that the company couldn't get its PACS to work. It had essentially sold the hospital vaporware."

Conrad says that PACS recovery in the next month, during which Bronson Methodist Hospital administrators and staff scrambled for a solution, was conducted "in a serious emergency mode." eMed Technologies was one of several PACS vendors with a system similar enough to the proposed PACS of the failed vendor to be substituted. After a brief review, the decision was made. "eMed brought in what it had and quickly got it to work," Conrad says.

Brook Ward, RT(R), is director of radiology for Bronson Methodist Hospital. He was not there for the failed installation by the original vendor because he was not hired until mid 2001, but he has helped pick up many of the pieces from the failed venture's collapse as eMed's replacement PACS installation has progressed. "The previous radiology director had done a lot of preparatory work and planning, but when the original vendor bailed, everything went from a planned event to a critical situation," Ward says. "The director had done a lot of analysis up front. We just got caught in a situation where we were stuck when it got close to a go-live date."

Under an agreement made with the original vendor, that vendor paid eMed to install an eMed PACS, Ward says. "The vendor went out, with our cooperation, and hired eMed to install a system."

eMed became Bronson Methodist Hospital's PACS vendor and has remained its vendor. Has the PACS added enough value to make the sizable investment worthwhile? The answer appears to be yes (see "The PACS Payoff," this page). For a few months after Bronson Methodist Hospital put in the PACS, Ward says, those referring physicians in Kalamazoo who were wary of electronic images and inexperienced with them sent more of their business to a competing outpatient radiology center that delivered film. As more referring physicians see the patient-care advantages of quick image and report access, however, that trend has been reversed; the competing clinic, which still lacks PACS, is now losing referrals to Bronson Methodist Hospital, Ward says. Overall, and for a variety of reasons, Bronson Methodist Hospital's imaging volumes have nearly doubled since the new hospital opened, Ward adds. The PACS, he says, is responsible for a large part of that increase.

Picking up the pieces

According to Ward, because of the arrangements that were made between the original PACS vendor and eMed in the beginning, the eMed PACS was a smaller version of what had originally been planned. "We had some issues with redundancy and with fail-safe because the system that was installed was smaller. Everything went pretty much as planned with the installation, except for some hardware on the back end. It wasn't as robust as if we had bought it from eMed to begin with, and that's where we spent a lot of time beefing up things. We never had to worry about the workstations, but we had to make sure that, if we had a support server go down, things would go on as normal and the user wouldn't see any difference," he says.

Despite vendor problems, Ward says, much of the planning for the PACS installation that was done by his predecessor and the information-technology department still fit the installation that eMed completed. Previous administrators did an analysis of the hospital network that was going to be installed. "They looked at how the PACS would affect the radiologists' work flow and how it would be made accessible to the physicians. They made sure the new building could handle it. They looked at the facility design to determine where the equipment would be. They looked at the equipment configuration to make sure whatever they installed would fit users' requirements," Ward says.

As the PACS is now configured, radiologists have 12 workstations (each in a separate room) where they read images using mostly a four-monitor configuration. Four of those workstations are on the outpatient side and three are on the inpatient side of the facility. The eighth radiology workstation is for special interpretations. Each workstation has a computer next to it for calling up patient information from the hospital's electronic medical record (EMR) system, Ward and Conrad explain.

In addition to the radiologists' workstations, there are other sites throughout the hospital where images can be accessed and viewed by referring physicians. Any physician with clearance, anywhere in the world, can also access the images over the Internet. The early planners designed conference rooms with PACS access, as well as access for surgeons who needed to see electronic images on monitors in the operating rooms.

Despite this ease of access, any physician who demands film can still get it. It will be laser printed from the digital images, although, Ward says, "We push them to use the electronic versions." As for the physical aspects of the PACS installation, planning paid off despite the vendor switch. Equipment placements and back-end architecture required no changes. Ward says, "We transitioned the planning into implementation and moved forward. We had identified where the technologists would work and where to put a PACS workstation so that the trauma surgeons could view images immediately. We installed all that, despite the vendor switch."

Adapting plans

Many adjustments, however, had to be made in the original plans. This might be expected for any complex equipment installation, but for Bronson Methodist Hospital, the vendor switch made it more crucial. Conrad notes that if he could warn PACS buyers of any single hazard, it would be the need, before any data are stored, to install a PACS broker capable of translating information from modalities and other data sources for the PACS servers, so that what is stored in the archive is correct for each patient and is easily retrievable. The alternative is to rely on hand entry of patient data and identification numbers more than once, and that repeated hand entry creates serious problems. "Even with medical record numbers, some departments omit leading zeros and some use them," he says. "If we'd had a PACS broker and the ability to use that information in combination with a study/modality worklist, it would have alleviated those problems. Our PACS broker was ready as soon as we could get it done."

Conrad says that one of the true payoffs of a PACS is that film loaned to anxious clinicians before it is read by radiologists is not misplaced or discarded, but he says that it is untrue that digital images cannot be lost. With human error, they can be lost easily, and they can be as hard to track down as lost film. Conrad reminds his technical staff constantly of how important it is to enter data correctly as orders are filled and images come from the modalities. "If the technologist goes to the modality worklist, but selects the wrong name by mistake, it becomes very hard to find that examination. You have to go through every patient seen that day. If a patient was cancelled and didn't have an examination that day and we happened to use that name, it wouldn't stick out, either. It would look as though the patient had the procedure, and you wouldn't think anything about it. For these mistakes, it can take two hours to resolve the problem. The key is ownership and responsibility among the technologists, and that's what we preach," Conrad says.

In addition to building redundancy into its PACS, Bronson Methodist Hospital has spent time and lots of money expanding the original system. Computed radiography units have been added to general radiography at the hospital, at a smaller sister hospital, and at Bronson Methodist Hospital's outpatient sites to create electronic images. Now, except for mammography (which is still expensive and difficult to digitize), virtually all of Bronson Methodist Hospital's imaging is electronic. Paper documents are routinely scanned to create electronic copies, and the paper is then discarded.

The effort is being made to build an EMR and a filmless radiology operation at the same time. In mid 2003, Bronson Methodist Hospital installed a CD burner, and it is now delivering images to referring physicians on CDs. Earlier, web-based technology was installed to allow Internet access to PACS data. Ward and Conrad are now working to create an interface to bring radiology reports onto the PACS. Because of configuration problems, radiology orders originate on the RIS, but the radiologists' reports do not go to the RIS. Instead, they are sent to a separate computer and must, at present, be retrieved separately. This is a step that Bronson Methodist Hospital is understandably eager to eliminate.

Since the original planning, the number of full-time equivalents in PACS support has expanded from two to four. Two of those positions are assigned to the information-technology department, but the individuals holding them work full time with the PACS, Conrad says. Cutbacks in staff that were once expected upon the elimination of a film library have turned into staff reassignments instead. "We felt we might have gotten rid of the file-room staff, but we have actually re-educated those people, and they now spend more time on quality-control work on the PACS, making sure the documentation is scanned properly, making sure the images are labeled correctly, and making sure the images are being read in the proper time frame," Conrad says.

One of the tasks that the former file-room employees must perform came as a surprise to the PACS planners. It involves differences in the Digital Imaging and Communications in Medicine (DICOM) formats used from one modality to another. DICOM is meant to be a standard that creates uniformity in digitally transmitted data, but there are variations in DICOM compliance that are not apparent until transmission snarls. "Although equipment manufacturers say they are DICOM compliant," Conrad says, "you may get one modality that transmits data in one DICOM format, and you may have another modality from the same company that will send you data in a totally different format." Faced with DICOM problems, Bronson Methodist Hospital has done all it could, Conrad says. It first appealed to vendors for help, and has obtained some upgrades. It has also been forced to handle some data-entry tasks manually. "We have some modalities in place that can't send a study description," Conrad says, "so somebody goes out there every day and edits and adds those descriptions to the database. Until that equipment gets upgraded, we'll be doing that."

Hardwired Transmission Lines

Bronson Methodist Hospital's PACS staff has learned several lessons. Having a PACS broker operating from the start was one. Another was that a PACS should have its own hardwired transmission lines within the facility. "We have a segmented backbone," Conrad says. "We have our own virtual local area network. That means a certain set of Internet Protocol addresses are used for imaging only. It's a separate lane on the highway, but not a separate highway. We wanted our own hardwired system for inherent redundancy."

Conrad states that whenever a PACS component is installed, it amounts to a wake-up call concerning how indispensable the new EMR system suddenly is. "The project we were doing here in radiology was the single largest critical-system change this hospital had ever witnessed," Conrad says. "A conduit connector was hit with a mop, and we lost the archive for 3 days. We never jeopardized patient care. If we lose the data center, we can always route directly from the modalities to the workstations, but we have rethought and rewired the system, especially the emergency department's part, so that the show can go on."

Ward reports that one lesson confirmed is how important it is to have committees organized to deal with a PACS installation. These include not only a PACS users' committee to keep clinicians informed of upgrades, but a physicians' computer-utilization committee that encourages physician leaders to interact with the information-technology department. Bronson Methodist Hospital also has a committee for its training center and education department that oversees training technical staff and physicians, as well as a PACS steering committee that plans for PACS expansions and upgrades. Ward notes that the next big step for the hospital will be the installation of a voice-recognition report-transcription system to reduce report turnaround time by eliminating the typing that now goes into finishing a dictated report. "We're also expanding our archive to take more data and to add disaster-preparation capacity," Ward says.

For all the difficulties that Bronson Methodist Hospital faced in making its PACS operational, the PACS and the EMR have been a huge improvement over the previous film-and-paper environment, Ward says. "Reports used to take 7 days. Now, the referring physicians get final reports in under 2 days in outpatient areas. For inpatients, the final reports are on the charts within 12 hours, and all our examinations are read in under two hours." Bronson Methodist Hospital's new hospital has won several design awards. The radiology department has also become an important stop on many professional tours. "We have at least two tours a month," Ward says.

George Wiley is a contributing writer for Decisions in Imaging Economics.