Transcript Implementing a PACS

Implementing a PACS
By
Ginny Poulin RN, MS
&
Shelly Fisher
Agenda
 Preparing for a PACS
 PACS Components
Data acquisition, Servers, Workstations
 Disaster Recovery and Business Continuity
 Workflow / Integration
 Cost Justification
 Summary and Questions
OBJECTIVES
 Identify all the key components of a
successful PACS Implementation
 Design a successful PACs model
 Identify the cost justification components
necessary to present and win approval for
PACS implementation
PACS Environments - Complex
 PACS – not a single “product”
 Highly integrated
 Requires time to get it all right
 Takes using it to get it right
 Takes customer involvement, too
Preparing for Your PACS
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Start with the end in mind – what is your
perfect environment?
Where does data originate, who needs to see it –
and where
 Some items you learn with experience – be
flexible
 PACS vendor will have different concept of
workflow
 PACS is a highly integrated environment –
standards are key
 Purchase items with standards in advance
Modalities - buy with DICOM Store, MWL,
MPPS
Workstations – support for IHE presentation
states, key object notes
Servers – support for all the above and HL-7
interfaces
PACS Parts / Environment
PACS Parts
DICOM
Archive
Reports
images
RIS
HL-7
messages
HL-7
Interface
DICOM
MWL
DICOM
Server
Workflow
Engine
Web Server
images
images
images
Work
stations
Dictation
system
images
images
PACS
Environment
modalities
printer
Preparing for Your PACS
 Transition plan – comparison studies, training plan, etc.
 Cultural Issues
Dealing with Change
Who will promote the system / will someone turn film printing off?
Relationship between doctors
 Communication and Education Plan
 Networks – internal and external
 Security requirements
 Business Associates Agreements
 Working with existing environments – such as EM
PREPARING THE
PHYSICIANS
 Teleradiology
 E-Signature
 Access from home
 ????? Ask Skip???
What Every PACS Vendor will
Need to Know
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Exam Volumes and Mix
Peak Days?
Modality inventory – type and DICOM capabilities
Where will exams be viewed
Approximate number of users of different types
What type of workstations and where will they be located
Existing network information / network contact name
RIS – whose and HL-7 capabilities / IS contact name
EMR – whose and CCOW capabilities
- CCOW is standard for integrating the desktop
 Shared resource plan (SAN, tape system, disaster recovery site, etc)
 Security requirements
What to do with existing, nonDICOM modalities?
 Digital modalities must be upgraded to
DICOM Store or images frame grabbed.
 Upgrade is preference, but may not be
available or cost effective
 CR and/ or DR implemented
 Need plan for comparison studies
- digitize films? Hang them?
Modality Connectivity
 Connect via fastest connection supported
 Modality Worklist Services
queries supported – name, ID, date, push?
 DICOM Store Services
information transmitted – birth date, accession #, etc.
missing anything, like series description, or anything odd
 Modality Performed Procedure Step
Informs RIS / PACS that exam is complete
WORK STATIONS
 Types of users:
Radiologists, ER, ICU, orthopedics, pulmonologists, other specialists
Requirements vary by users, location, environment
 Sample Workstation Configurations
Only requirement by ACR for radiologist: 50 ftl = aprox. 160 nits
1 MP
5 MP
$1500
$80,000
Increasing quality/complexity and cost
WORK STATIONS
Design Points for various users
Ease of use, run on any hardware, limit tools and cost
Average clinical user
More complexity, hardware restrictions, more tools
Power clinical user
Efficiency, speed, stability, tools, specialty hardware
Radiologist
DICOM Server/Archive
 Broad DICOM Services – Service Object Pairs
 Support for standards in the backend
CAN YOU GET ORIGINAL DATA BACK
OUT?????
 Architecture – Hardware / Software
Data integrity, stability/reliability, redundancy,
speed, growth, supportability and manageability,
maturity (not a place for brand new technology)
DICOM Server/Archive
 Broad DICOM Services – Service Object Pairs
 Support for standards in the backend
CAN YOU GET ORIGINAL DATA BACK
OUT?????
 Architecture – Hardware / Software
Data integrity, stability/reliability, redundancy,
speed, growth, supportability and manageability,
maturity (not a place for brand new technology)
HL-7 Integration
Driving Factors for Integration
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Staff Efficiency
Data Integrity
Improved Tracking
Limiting User Accesses
Auto-routing exams to where they would
most likely be needed
 Reduced cost / complexity of storage
environment (shared SAN)
Let’s Start with Workflow
 We’ll need some volunteers!
 What we’ve just shown is how data is moved
through the department and what we are
doing with it.
HL-7 Integration
Alice in Workflow goes here
Items we would have noticed, if
we’d been paying attention
 How many times was the patient name
entered into the system?
Hint: it’s a number less than 2
Items we would have noticed, if
we’d been paying attention
 Who enters the information?
Hint: it is someone who knows how to type
reasonably well
Items we would have noticed, if
we’d been paying attention
 Does the PACS create image data or report
data?
Hint: No, it just stores it and provides access to
the appropriate users
Items we would have noticed, if
we’d been paying attention
 This exam identifier, called the accession #,
is pretty key to the tracking process.
Other items of note
 The transfers between different RIS / PACS/
Modalities is handled by STANDARD Methods:
HL-7 & These DICOM Services:
Modality Worklist &
DICOM Store
Make sure all new Modality orders include these –
Also ask for Modality Performed Procedure Step
(MPPS)
What to expect in the integration
process
 Meditech to PACS
First, it is a process, an expensive one and it takes time – so
get started as early as possible
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Interface Vendor is KEY and effects the BOTTOM Line
BIG TIME
Meditech requires additional hardware
Vendors need to understand each other’s language, as
well as site’s workflow
Then, they need to map one ‘s Terminology to the other’s
ADT, reports and orders matching them to test
Meditech to PACS (continued)
 Sample mapping issues:
What is used for key patient identifier and what is it called – Patient ID,
MR#, etc.
How many physician types come across in an order and what are their
types?
Do we get information on patient location?
How many characters in exam ID (DICOM has a limitation)
For Distributed Environment, site identifiers can be concatenated to
patient and exam IDs.
Meditech to PACS (continued)
 Testing Phase:
Once mappings done, test messages.
Everything being transferred to PACS database as expected?
Are messages consistent?
Test in abnormal conditions
for example, with HL-7 link down, do messages queue properly?
Resolve all issues, then, test with production system, real data
 Once tested with production system, real data,
ready to deploy
Meditech to PACS (continued)
 Can purchase interface from Meditech or
other party
 Heywood Hospital selected Iatric’s Engine
 Reasons 
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>50% savings
Accommodated our schedule
One on One help – A team approach
Weekly conference calls and then some
Why do interface early
 Data integrity
Any PACS worth its salt tests data before storing – won’t
allow for duplicate patient IDs.
First patient name with ID stored in system is assumed to be
correct, so later, the right one could get rejected.
Early studies may just for telerad, but bad data will live – if
you store data permanently
Want to store data early to build up comparison studies in
system for doctors
Of course, won’t find the comps if they are under the wrong
patient ID
Why do interface early
 Get DICOM integration done early
Large part of complexity of PACS is with
modality integration – and they are all a bit different
Examples: some Ultrasounds won’t take birthdates,
Some want to change key data – even against IHE specs,
for example, some insert their own study instance UID
Once integration is done, you can concentrate on training the
users!
Improved Tracking
 PACS always knows the status of the
exam
 PACS can assist finding and repairing
“broken” studies
BRIT’s Exam Loop
Order Arrived at
RF
Study Reported
Patient Arrives at
Department
Study Read
Order
Canceled
Study arrives, but
no order!
Study arrives
at server
Limiting User Access
 PACS can limit the patient access to just
those patients with known relationship
 Information come from order
(but PACS can enhance it with “groups”)
Sharing SAN / Archive Resources
 RIS and PACS must have support for same
SAN / Disk vendor
 Meditech has limited support, EMC is
certified
 Cost of SAN server, archive and support can
be shared
PACS installed, integrated and
tested. Now - Training
 Determine skills sets early – and get
additional training for users before system
deployed – example – everyone should know
how to use a mouse
 Bring on additional staff, work additional
hours or reduce workload during training
 Assign a trainer – new users will be around
all the time
Cost Justification
Hard savings and Soft savings
Hard savings you can readily measure
Soft savings may be by far the greater saving,
but they are much harder to measure
These will differ from site to site
Note: it’s a hard saving if your CFO says it is
Hard and Soft Savings
Hard savings
Soft savings
•Reduced film, chemical and folder cost
•Reduce off-site storage cost
•Reduced cost of processor maintenance
•Reduced retakes
•No repeat studies due to lost exams
•More efficient use of personne
Technologists, radiologists, others
•More efficient use of equipment
•Reduced space requirements
•Reduced Liability
•Improved exam tracking
What does a film-based system
cost?
Mayo Medical Center Study:
Film-based costs = $15-$20 for
Films (average of 3.5 films / exam): $6.25
Chemicals, jackets, space: $1.46
Personnel within Radiology for film management: $5.91
Personnel outside Radiology for film management: $2.20
And we know that things cost more in small hospitals!
What are typical savings with
PACS
Hard to measure because more items change in environment
Baltimore VA Analysis of Cost and Benefits of
Filmless Radiology*:
40% increase in productivity of
radiologists,
technicians and equipment
reduced cost of $12-$13 / exam
return on investment of 16%-20%
* study done in 1997 by John Hopkins School of Public Health
Estimate of Current Costs
That can be avoided
Cost of Film
Cost of film material
processing/ chemicals & equip.
processing salary
film tracking
archival space
archival salary
Total cost of film
Yearly Savings from Film
Number of exams/year
Number of flms/exam
Number of films/year
Total yearly savings from film
1.84
0.62
0.24
0.34
0.50
0.50
4.04
Yearly savings from reduced
retakes & Lost studies
Cost of film and chemicals alone
- Cost per study (this is an average we've
7.00
seen and is not the same as film and chemical cost above)
Note: cost of film /chemicals alone:
$70,000
10000
3.5
35000
$141,400
Cost of Retakes
% of retakes
Savings from retakes
8.70
15.00
$13,050
Lost studies - costs
% lost studies
Savings from lost studies
60.00
5
$30,000
Liability Savings *
Total yearly savings / film
$50,000
$234,450
* Government gives $120k credit per year for their smallest sites
Estimate of Savings from
Increased Personnel
Efficiencies
Cost of Film Distribution
Hours spent by technologists
looking for films/ handling film / day
Hours per year
burden rate
yearly costs
(7 days a week)
Cost of hanging film
Time per study / hours
Burdne rate
Total Cost
Cost of personnel outside radiology
Percentage of costs withing Radiology
Cost
-% comes from Mayo Study
Total Cost of film distribution
- yearly
3.00
936.00
28.00
$26,208
0.08
15.00
$12,500
37%
$16,172
$54,880
Doctors' time
(USE ONLY IF THEY ARE PAID BY HOSPITAL)
Radiologists - concurrently
time spent handling films/
looking for films - hours/day
burdened rate
yearly cost
(5 days / week)
Doctors - non-radiologists
hours spent looking for film/
going to library each day
burdened rate
yearly cost
(6 days / week)
0
1
85
$0
0
0.25
85
$0
Estimate of Savings from
Increased Room Efficiencies
Improved room efficiency
- use only if you have the volume to do more studies
Number of CT's performed / year
700
Increased efficiency
0.15
Reimbursement / CT
300
Number of additional CTs
105
Increased revenue
$31,500
Number of MRI's performed
Increased efficiency
Reimbursement / MRI
Number of additional MRIs
Increased revenue
400
0.15
$400
60
$24,000
Savings from increased efficiencies
$75,500
Number of Ultrasounds
Increased efficiency
Reimbursement / US
Number of additional US's
Increased revenue
1000
0.20
100
200
$20,000
Note that we use very low room efficiency numbers You can put in higher numbers, if you have the volume
STORAGE
 SAN vs NAS vs Modality storage
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Other data to be stored?
Protecting the data for 30 yrs
Meeting future needs
Total Savings and Analysis
Tot al Est imat ed Savings f rom PACS
Yearly - f ilm
Film dist ribut ion / handling
room ef f iciency
Tot al yearly saving
$234,450
$54,880
$75,500
$364,830
# of years f or anaylsis
Savings over years
5
$1,824,150
Cost of PACS - Quick Analysis
Quick Cost Est imat es f or PACS
Num ber of st udies over years
Cost per st udy
Tot al syst em cost - incl. Service
Est imat e on PACS personnel
Percent age of syst em cost
Cost of personnel over 5 years
Tot al cost of syst em
Tot al cost + 15% cont ingency
50000
9.51
$475,500
Savings using cost + cont ingency
Savings over years - just f ilm/archive
Savings over years - all it em s
$297,330
$949,230
0.12
$285,300
$760,800
$874,920
Determine what you / your CFO will "allow"
Get estimates of costs from vendors
- include extended maintenance for 5 years &
some amount for upgrades
Paying for your PACS
 Straight Payment
 Leases, with delayed payments
 Off balance sheet leases
- one expense replaces another expense
- include technology upgrades in out years
 Price per exam models
 This year, aggressive government write-offs for capital
LET’S TALK
Questions