Transcript A Successful PACS Implementation - Dartmouth

Making the Move to PACS
Monte Clinton, CRA
Dartmouth-Hitchcock Medical Center
Disclaimer
This presentation is about a PACS implementation at
one facility (DHMC) with one vendor (IDX) and is
being given as an example of a successful PACS
implementation
Other facilities and vendors can do a similar PACS
implementation using this partnering program and
methodology
DHMC does not endorse IDX or any other vendor’s
products and services
Radiology Equipment 2004
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 2004 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
Why Install a PACS?
• Expansion to Provide New Space for:
• Mammography
• Nuclear Medicine
• Vascular Interventional
• Offices and conference space
• New Outpatient Clinical Building to:
• Eliminate over crowding
• Add new MDs and exam rooms
• Bring imaging to the patient
• Minimize radiologist travel
Why Install a PACS?
Save money – Increase reimbursement
Reduce medico-legal risk
• Eliminate Film and processing costs
• Reduce Film Library staff and space
• Improve billing collections
• Reduce medico-legal exposure
Why Install a PACS?
Improve staff and imaging room productivity
• Increased staff productivity
• Reduction in the number of staff
• Increased imaging room productivity
• Eliminate imaging rooms
Why Install a PACS?
Improve service to your customers
• Single set of film images limits collaboration
• Minimize lost studies and revenue
• Minimize treatment delays
• Speed service to referring clinician and patient
DHMC’s Steps to Justify PACS
Internal justification – The major players
• Large capital or operating cost impact
requires multiple levels of approval – at
DHMC this was:
– Radiology
– Information Systems
DHMC’s Steps to Justify PACS
Internal justification – Institutional leadership
– Administrative leadership
– Finance Committee
– Board of Trustees – final go or no go
PACS: Getting Started
Outside experts – PACS consultants
Institutional experts
• Radiology
• Information Systems
PACS: Getting Started
Educate yourself about PACS
Ask your colleagues about their experiences
Attend meetings such as this one
Vendor discussions and demonstrations at
trade shows - AHRA, RSNA, SCAR
Understand your own environment and needs
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
PACS: Getting Started
Request for Information (RFI)
• Invite selected vendors to respond to RFI
• Get a list of their customers to contact
• How would their system fit into your facility
• RIS and PACS compatibility
Interface or Integrate
The critical relationship between the RIS and
the PACS
Have the RIS and the PACS vendors worked
together before?
Which vendor has primary responsibility or are
you expected to do problem triage?
PACS: Getting Started
Request for proposal (RFP)
• Invite a limited number of vendors to bid
• Vendor clarification meetings
• RFP review and analysis
• Site visits at working clinical sites
• Final negotiation – Purchasing and Vendors
Paying for a PACS
Capital Purchase or Operating Expense
• Capital purchase
– Major capital expense – compete for funding
– Cost to upgrade and remain technologically
current
– Ongoing service and maintenance cost
• Application Service Provider (ASP)
– Costs are an operating expense
– Always kept technologically current
– All inclusive - charges fluctuate with activity
The PACS Timeline
Develop a realistic implementation timeline
with buy-in from all affected stakeholders
Radiology – all levels
Information Systems
Institutional Leadership
Referring Clinicians
PACS Vendor
DHMC’s PACS Timeline
• Phase 1
• 1-2003
• 4-2003
Archiving started in CT, MR, US
Live in CT, MR and US – stop film
• Phase 2
• 9-2003
• 12-2003
Archiving started in DX
Live in DX – stop printing film
• Phase 3
• 8-2004
• 1-2005
Archiving started in Angio and NM
Angio and NM after IDXrad V10
Partnering with the PACS Vendor
Agreement with the vendor on the timeline and
implementation phases
Appoint key staff from each stakeholder
This must be a win – win endeavor
Planning the Implementation
Weekly meetings of the
PACS Working Group
•
•
•
•
•
•
Radiology Director
Radiology PACS Administrator
Radiology Clinical Operations Manager
Radiology Asset Manager
IS Director
IS Liaison
Guiding the Implementation
PACS Implementation Team
bi-monthly meetings
• Chairman of Radiology
• Chief Information Officer
• Vice President of Clinical Operations
• The Six Working Group Members
Before and After Implementation
Ongoing follow-up
• Weekly calls - Radiology and vendor
• Updates to the clinical departments
• Regular updates to the Board of Trustees
• Monthly updates to the Radiology faculty
• Weekly updates to the Radiology staff
Selecting the Hardware
Involve the end user in equipment selection
• Radiologists given a choice of monitors
• Referring clinicians given a choice of monitors
Specialty sections given choice of monitors
• OR selected from 5 large flat panel monitors
• ED selected the best monitor for their use
Reading Room Design
Radiologists given a choice of layout
• DHMC rejected the modular systems
• Radiologists preferred two image monitors
• Room lighting critical
• Calculate room temperature requirements
• Gradual phase out of alternators
Dealing with Prior Studies
• DHMC chose not to digitize prior studies
• Prior studies are available if needed
• After six months there was very little need for
prior studies
• Some studies are digitized so they can be
used for comparison – joint replacements
The Archive
DHMC’s PACS Archive
• In-house dual servers maintained and
remotely monitored 24/7 by vendor
• External archive backed up daily to
vendor’s San Diego archive facility
• DHMC’s failsafe back-up archive -- DVDs
burned daily and stored at DHMC
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
Training the Radiology
Technologists and Support Staff
• Modality integration in advance – Imaging Suite
• Super users identified - trained in each section
• On-line training with vendor for super users
• Make the process exciting and rewarding
Training of the Radiologists
Vendor provided 1 to 2 hours of one on one
training 2 to 3 days before activation
• Return visits after activation for more
training if needed
• Give them all the time and training they want
• Ask radiologists and residents to offer
suggestions for enhancements
Keep Your Staff Informed
• Being upfront about what is happening and when it
will impact the lives of staff will head off rumors
• Publish a PACS phase in plan – DHMC 1 year
• Stop hiring permanent full time Film Library
\employees a year before implementation
• Work with HR to find jobs for displaced staff
Contingency Plans
• Referring clinicians demanding film
• Acceptance of CD copies by other facilities
• Urgent results reporting
• Special requests
• System failure – power failure, virus, etc.
Partner With Your Vendor
• Clear objectives spelled out in the contract
• Agree on timeline, payment and penalties
• Clearly define facility - vendor responsibilities
• Track progress with regular reports
Make the PACS implementation a win – win
program for both your facility and the vendor
What DHMC Did Right
• Developed and used a workflow analysis
• Piloted PACS with 15 referring clinicians
• Had a close relationship with the PACS vendor
• Integrated modalities in advance
• Integrated RIS/PACS with electronic medical
record
A Chairman’s Perspective
“ Never in my 29 years as a chairman
have I made a decision that has
received such universal acceptance
from both the radiologists and the
referring clinicians”
Peter Spiegel, MD
Chairman – Radiology
A Director’s Perspective
Contact Information
Monte Clinton, CRA
Dartmouth-Hitchcock Medical Center
[email protected]
www.dhmc.org/dept/radiology