PACS implementation demands realistic expectations

While the cost of PACS has declined in the last decade, the system is still a major investment that requires careful planning, implementation, and follow-up, according to speakers on Sunday, the last day of the Society for Imaging Informatics in Medicine meeting in Providence.

A number of metrics can measure the performance of a PACS, including cost savings, increased revenue, improved test turnaround times, and physician and patient satisfaction. It's especially important to document expected gains.

"Document your current environment and be prepared for surprises," said James Oakes, a principal with Health Care Information Consultants in Baltimore. "Customers are almost always stunned to see the breadth of applications and the lack of their interoperability."

It's not unusual to underestimate expenses and cost savings when implementing a PACS, said George H. Bowers, also a principal with Health Care Information Consultants. It's important to include in the planning the annual PACS maintenance fee, for example, which can add up to 25%. The hiring of PACS administrators and any reconfiguration of the facility needed to accommodate the installation are other lurking expenses.

The cost savings from a reduction in film and chemicals are usually less than expected, because it's difficult to totally eliminate film, Bowers said. But real savings can come from the use of fewer film librarians, although those benefits tend to accumulate slowly.

Productivity is a measurable metric. Studies have shown that technologists' productivity increases up to 30% with the implementation of computed radiography and PACS and up to 70% with digital radiography and PACS.

Radiologists' productivity also increases. This can be seen in an increase in revenue, especially if the radiologists are employees earning a salary or owners of an independent imaging center, Bowers said.

PACS can yield a positive return on investment, but only if it is one component in an overall strategy that addresses workflow, imaging equipment, and the facility.

As an example, Bowers presented a case study of a very busy medical office complex built in the 1970s. Over time, it had added CT, mammography, and MRI, essentially chopping up the existing footprint. Because of some poorly designed workflow issues that resulted in two-hour waits for x-rays, in-house physicians began to send patients to an outside center. Before long they also sent CT and MRI patients outside.

The solution involved creating three new dressing rooms adjacent to the waiting room, hiring two technologist aides to help patients, and implementing a PACS with a DICOM modality work list. While the volume of the center increased by 15%, total wait time dropped to under 15 minutes. Radiologists no longer had to immediately check the films, as they could assess them later off the PACS workstation. One FTE technologist was eliminated.

Another case study involved the consolidation of two small imaging centers into one filmless environment. Along with the implementation of PACS, five general imaging rooms were reduced to one and six technologists reduced to three. A greater volume of imaging was performed on one new multislice CT than on the previous two older scanners.

A final case study highlighted Beth Israel Deaconess's effort to implement a PACS. At five years out, officials realized their projected savings of $2.9 million had been overestimated, and they wanted to know why. Planners had not anticipated the cost of additional IT staff and equipment, and the cost savings from using less film and chemicals were not realized quickly enough, Bowers said.

"The lessons learned: Document your expected savings up front and manage the implementation process closely," Bowers said. "Don't wait five years for the first audit."

Oakes agreed.

"Good governance won't guarantee a successful project, but poor governance will almost certainly guarantee a poor outcome," he said.