Transcript A Successful PACS Implementation - Dartmouth

Obtaining a Digital Image for
PACS
AHRA Electronic Imaging Conference
April 23, 2005
Tampa, FL
Monte Clinton, CRA
Dartmouth-Hitchcock Medical Center
Disclaimer
This presentation is about a conversion from film to
CR and DR at one facility. It is being given as an
example of a successful digital conversion.
DHMC does not endorse any vendor’s
products or services
The Goal is PACS
Picture Archive and Communications System
PACS Requires a Digital Image
• CT, MR, NM and Ultrasound – Digital Now
• Routine Radiography Must be Digital
• Install all at Once or Phased in Over Time
• The Mixed Environment – Film and Digital
Electronic Communication
• A Common Language
• DICOM
• HL7
• An Electronic Network
• Ethernet
• 100 Mb
• 10 Mb
• 1 Gb
Radiology’s DR/CR Partners
• Information Systems
• Purchasing
• Equipment Vendors
• Radiology Staff
• Referring Clinicians
• Administration
Information Systems
• Partner with Information Systems Dept.
• Your implementation schedule must fit with their
availability
• Do they have the technical expertise
• Do it yourself
• You must build the expertise and infrastructure
• Ongoing support is costly and labor intensive
• A good relationship with IS is essential
Purchasing Department
• Institutional Requirement
• Good Business Practice
• Price Comparison
• Payment Options
• Protect Your Investment
DR-CR Equipment Vendors
• Take Advantage of Vendor Experience
• Benefit from Vendor Competition
• Compare Products and Services
• Must be a Good Long Term Relationship
• This Must be a Win – Win Endeavor
DR-CR and the Radiology Staff
• Radiology Admin. Staff - Implementation
• Technologists – Critically important buy-in
• Support Staff – Minimal involvement
• Radiologists – Minimal involvement
Referring Clinicians
• Minimal involvement in DR/CR decisions
• Loss of film a concern for – Ortho -OR
• Let them participate in PACS decisions
• Let them champion the need for PACS
Administration
• Requires a good business plan
• Demonstrate the impact on finances
• Compatibility with the Strategic Plan
• Huge investment in time and money
• Stress positive impact on customers
Benefits of DR/CR
• DR-CR is the Road to PACS
• Increase technologist productivity
• Increase imaging room capacity
• Utilize existing space better
• Decrease patient waiting time
Why DHMC Went Digital
Electronic Image Distribution
• Accommodate hospital’s expansion
• Facilitate Radiology’s expansion
• Improve reimbursement
• Reduce medico-legal risk
• Reduce MD and Patient travel time
Digital Equipment: Benefits for
the Patient and Clinician
Improved Radiology service
• PACS images are always available
• Eliminate technique-related repeats
• Minimize waiting and treatment delays
• Faster service with quicker examinations
The Options When Going from
Film to Digital
The three choices:
CR – Computed Radiography $$ $$
DR – Digital Radiography $$$$ $$$$$$
Digitize Film $
Cost
Payback
Going Digital with CR
• Advantages
• Inexpensive way to get to digital
• Currently required for cross-table and
portable studies
• Disadvantages
• Slow as film – minimal productivity gains
• Requires technologists to handle cassettes
Going Digital with DR
• Advantages:
•
•
•
•
Productivity increase for techs – less hard labor
Technologist does not leave room during exam
Productivity increases for imaging rooms
Enables smooth PACS integration
• Disadvantages:
• The equipment is more expensive then film or CR
• Requires CR for cross-table and portable studies
DR Options
• Dual detector
• Single table or wall detector
• Dual purpose single detector
• Portable DR detector
Dual Detector
Dual Detector DR
Trolley Used with Upright DR
Cross Table Using Upright DR
Single Multi Purpose Detector
Single Multi Purpose Detector
Cross Table Projection
Portable DR Detector
Going Digital by Digitizing Film
Digitize Film
Advantages
• Least costly way to get into digital imaging
Disadvantages
• Slower then film, CR or DR
• No productivity gains for tech or room
• All the costs of film plus added labor/cost
Process Map
MD OFFICE
CALLS
SCHEDULING TO
MAKE APPT &/
FAXES ORDER
SCHEDULING
OBTAINS PT.'s
DEMOGRAPHICS
SCHEDULES
APPT. FOR MR
REVIEWS
SAFETY
SCREENING
NURSING UNIT
CALLS TO
SCHEDULE APPT
PT. ARRIVES AT
FRONT DESK ON
DAY OF APPT.
REGISTERED
IN HIS
RECEPTION
TAKES
FACESHEET &
ORDER IF
AVAILABLE
SCHEDULING
CONTACTS PT.
PRIOR TO APPT.
TO REMIND OF
APPT, REVIEW
PREP, FOR MR:
REVIEW SAFETY
SCREENING
RECPT ASKS PT
TO WAIT IN
WAITING ROOM
TECH ASST
FOR CT: CHECKS W/
ORAL PREP PTS ON
PREP PROGRESS
FOR MR; CHECKS
SAFETY SCREENING
END FOR
PT
PROCESS
END OF
STUDY
DOES RAD
DEVELOP
SPECIAL
PROTOCOL
YES
ORDER SENT TO
RADIOLOGIST
END FOR
PRE PT
ARRIVAL
PROCESS
NO
RECPT NOTIFIES TECHS
OF PT ARRIVAL. SENDS
ORDER & LABELS TO
PRINT IN TECH WORK AREA
SPECIAL
PROTOCOL
SENT TO ___
TECH TAKES ORDER
OFF & GETS PREPULLED MASTER
JACKET
IP BROUGHT TO
EXAM ROOM BY
TRANSPORT(OR
NURSE IF ICU,
PEDS, TRAUMA)
TECH ASST
PICKS UP PT
FROM WAITING,
ESCORTS TO
DRSG RM
TECH ASST ESCORTS PT. TO
DRESSING RM; PT LEAVES
ON OWN FROM THERE
IPTAKEN BACK TO NURSING UNIT
BY TRANSPORT(OR NURSE IF ICU,
PEDS, TRAUMA)
STUDY
INTERPRETED &
DICTATED
FACESHEET
GOES IN TRAY
WITH ORDER &
FORWARDED
TO MED REC
YES
IS AN IV
REQUIRED?
TECH ASST
TAKES PT TO
PREP RM FOR
IV START
NURSE
STARTS
IV
TECH ASST
TAKES PT TO
EXAM RM
TECH
SCOUTS PT
TECH
POSITIONS
PT ON
TABLE,
NO
TECH/TECH
ASST
MOVES PT
FROM
EXAM
ROOM
TECH HAND
CARRIES CASE
TO RADIOLOGIST
FILMS GO IN STACK
TO GO TO READING
ROOM, SOMETIMES
RADIOLOGISTS PICK
UP CASES
TECH
REMOVES
IV FROM PT
YES
NO
TECH PERFORM
EXAM ACCORDING
TO PROTOCOL
AUTO FILMS WHILE
SCANNINGAND
MONITORING PT
IS THIS CASE A
QUICK READ?
TECH
ASSEMBLES
CASE
DR/CR – Getting Started
• Assess your needs
• Volume analysis and a 3 year projection
• Talk to your colleagues
• Attend conference such as this one
• Form an evaluation team
•
•
•
•
Administrator
Clinical Operations Manage
Asset Manager
Technologist
Request for Information (RFI)
The RFI – first step in technology
assessment
• RFI only to companies you can work with
• Purchasing can help with the RFI
• Template available DHMC.org website
• Evaluate the RFI and select 2 to 4 vendors
Site Visits to See DR/CR Equipment
• Visit the vendors you can work with
• Select sites comparable to your own
• Spend some time alone with host
• Look for functionality, technologist
acceptance, downtime, were goals
achieved, vendor responsiveness
Request for Proposal (RFP)
Spell out exactly what is required
• The amount of equipment
• What it will be expected to do
• How will it be expected to perform
• When you want the equipment
• Installation and applications details
RFP (Continued)
Spell out exactly what is required
• Networking requirements for PACS
• Post warranty service agreement
• Value added products and services
• Require vendor to reply in your format
Vendor’s RFP Response
• Must be in the exact format of the RFP to
facilitate comparison between vendors
• Options and post-warranty service
• The vendor’s RFP response will be a legally
binding document of what they will do
• Let Purchasing negotiate price and terms
• Purchase order is based on the RFP
RFP Evaluation
Evaluate on a point system
•
•
•
•
•
•
•
Image Quality
Reliability and Service
Price
Features
Upgradeability
Company Stability
Value Added
Weighted Selection Criteria
Participant's Weights by %
AVE
CRITERIA
P1
P2
P3
P4
Wt.
#1
Reliability &
Service
20%
40%
20%
20%
25%
#2
Image Quality
25%
10%
20%
25%
20%
#3
Price
20%
20%
20%
20%
20%
#4
Features
15%
10%
10%
15%
12.5
#5
Upgradeability
10%
10%
10%
10%
10%
#6
Company-stability
5%
10%
10%
5%
7.5%
#7
Value Added
5%
0%
10%
5%
5%
100%
100%
100%
100%
100%
Weighted Selection Criteria
COMPANY 1
AVE
AVE
CRITERIA
P1
P2
P3
P4
Score
Wt.
#1
Reliability &
Service
8
7
8
6
7.25
25%
#2
Image Quality
7
8
6
7
7
20%
#3
Price
10
10
10
10
10
20%
#4
Features
5
6
7
6
6
12.5
#5
Upgradeability
7
7
6
8
7
10%
#6
Company-stability
9
10
8
10
9.25
7.5%
#7
Value Added
4
3
3
4
3.5
5%
50
100%
Weighted Selection Criteria
COMPANY 2
AVE
AVE
CRITERIA
P1
P2
P3
P4
Score
Wt.
#1
Reliability &
Service
8
7
8
6
7.25
25%
#2
Image Quality
7
8
6
7
7
20%
#3
Price
5
6
4
5
5
20%
#4
Features
5
6
7
6
6
12.5
#5
Upgradeability
7
7
6
8
7
10%
#6
Company-stability
9
10
8
10
9.25
7.5%
#7
Value Added
4
3
3
4
3.5
5%
45
100%
Weighted Selection Criteria
COMPARITIVE SCORE
CRITERIA
AVE
C1
C1
C2
C2
Wt.
#1
Reliability &
Service
4
1
7.25
1.8
25%
#2
Image Quality
3
.6
7
1.4
20%
#3
Price
10
2
5
1
20%
#4
Features
5
,6
6
.75
12.5
#5
Upgradeability
5
,5
7
.75
10%
#6
Company-stability
6
.4
9.25
.7
7.5%
#7
Value Added
3
.15
3.5
.18
5%
36
5.25
45
6.53
100%
Awarding the Contract
• Careful review of the equipment,
options, service and guarantees
• Purchasing Department
completes the negotiation
• The purchase order is awarded
• Plan for installation
Preparing the Installation
• Room size and layout is determined
• Electrical, shielding and HVAC
• Construction plan is developed
• Contractor selected
• Time lines established
Partnering with the Vendor
Agreement with the vendor on the
timeline and implementation phases
Appoint key staff from each stakeholder
This must be a win – win endeavor
Radiology Equipment 2003/4
DHMC Case Study
Existing
3
MR + 1 Mobile
3
CT
3
VIR + 1 PICC
8
DX
3
R/F
5
US
3
NM + PET/CT
5
Mammo
New in 2003 Replace in 2004
1 CT in new ED
1 CT/Angio
1 Angio OR compatible
6 DR-- 4 CR
1 DR/CR in ED + 1 CR trauma
1 DR/Fluoro
2 US in new building
1 NM + Fixed PET/CT
2 DR – Mammo new building
Digital Imaging: Benefits for
the Technologist
• Advantages
•
•
•
•
Eliminate handling of cassettes
Increased imaging equipment options
Faster study times - less waiting
Eliminate technique-related repeats
• Disadvantages
• It’s a change in the way of doing work
Digital Imaging: Benefits
for the Radiology Director
Save money – Increase reimbursement
Increase Productivity - Reduce Risk
• Eliminate film and processing costs
• Reduce Film Library staff - space
• Improve productivity
• Improve billing collections
• Reduce medico-legal exposure
Productivity Benefits of DR
Source: Philips Medical System
Patient
Positioning
13%
Tube Position
5%
Film Handling
43%
Patient Transport
11%
Exposure
4%
Other
16%
Cassette
Handling
8%
DHMC Productivity Gains
• TUCK Review of 46,000 Studies
• 36% Productivity Gain
• Technologist
• Capacity
• Reduced Waiting Time <12 Minutes
• Significantly Better Turn Around Time
• Fewer Imaging Rooms
Dartmouth Hitchcock Medical Center
Imagecast™ RISv9.8/PACS
CT
Rad/Onc
CT/Body Read
Area (3)
Fiber
Image Archive
CT GE - 3
10/100 MB
Display
Stations
100MB
Imagecast
PACS database
Imaging Suite
Neuro Read
Area (3)
MR GE- 4
MR Mobile
RF Siemens
3
DR Philips –6
• Dual DICOM Processors (~3
weeks)
U/S Read
Area (2)
• netCache (~6 months)
• Persistent Store (scalable life)
CR Philips - 3
DX Read Area (5)
ConnectRv4.0
IDXRad
Offsite Disaster Recovery v9.8
ICU
US – 7 HDI Acuson
Film
Digitizer
2
Onsite Disaster Recovery
HC
5
DVD Server
10/100 MB
Speare – Plymouth NH
MR Mobile
T-1
US – HDI 2
CT
Picker
10 MB
U/S Kodak
MiniPACS
(priors only)
10/100 MB
Kodak
Drylaser
Printer - 5
T-1
Enterprise
Access via CIS
LAN-10/100 Lebanon DHMC
Campus
WAN/DSL/Cable
Any Image, Anywhere, Anytime
Dated 05/05/03
Keep The Staff Informed
• Involve technologists
• Have a tech rep. on selection team
• Keep everyone informed of progress
• Train key technologists
• Get ideas for improvement
• Change is hard for many people
Contingency Plans
• Referring clinicians demanding film
• Acceptance of CDs by other facilities
• Urgent results reporting
• Special requests
• System failure – power failure - virus
What DHMC Did Right
• Kept an open mind
• Goal Oriented – PACS & Productivity
• Diverse Selection Team
• Director, Operations Mgr, Asset Mgr, RT
• DR all at once -- Summer 2003
• Partnered with vendor
Thank you
Monte Clinton, CRA
Dartmouth-Hitchcock Medical Center
[email protected]
www.dhmc.org/dept/radiology
Questions?