PACS A difficult implementation Richard Miles MRCP FRCR Derriford Hospital Plymouth

Commercial and In Confidence Introduction Scope of the implementation Resources What went well What went badly Complications Recovery

Commercial and In Confidence Scope of implementation Derriford Hospital

Commercial and In Confidence Scope of implementation

Commercial and In Confidence Pre LSP PACS Situation Limited PACS -Agfa –CT, Ultrasound, Some Plain X-Ray Inadequate Viewing Facilities Obsolete Radiology Information System

Commercial and In Confidence Health Community connectivity Data store & RIS

Commercial and In Confidence

Examinations & staff Derriford & community hospitals 300,000 examinations per year Radiologists 25 SPR 47 Radiographers 80

Commercial and In Confidence Community Hospitals X 6 Modalities with direct connection Modalities using plates CR reader X 10 Plates Reporting workstations X 41 Web PACS (PC) Other Workstations Radiology Academy Workstations RIS terminal (PC) PACS RIS Remote data store Local data store N3 connection 2 x printers

Commercial and In Confidence Modalities Include: 16 CR plate readers 3 CT scanners 2 MRI scanners 25 ultrasound scanners 4 gamma cameras 4 angio suites 10 fluoro rooms In all over 130 modalities and workstations-costs excessive for some modalities

Commercial and In Confidence Key milestones Academy Go Live Hospital Go Live Nov 05Sept 05Jan 06Mar 06May 06Jul 06 Sept 06 Nov 06Jul 05 CRIS Update Trust Board approval RIS migration & Optimisation visit Project Completion

Commercial and In Confidence Training Ris- 300 main users- ended up as 800 Web Pacs e-learning/presentations Pacs – 50+

Commercial and In Confidence Challenges Large implementation Data migration Critical clinical implications Change management challenge Challenges related to the contract

Commercial and In Confidence Internal Audit Management structure Trust Board ISIG Project Board Project team meetings PlymPfiT Clinical User Group PARB

Commercial and In Confidence Project work structure

Commercial and In Confidence Core resources PACS Project board Project Team Project lead Project technical lead Clinical Lead Admin support Radiology IT 1 specialist IT radiographer 0.6 deputy 1 admin support

Commercial and In Confidence What went well Project roll out to schedule despite tight time scale Project delivered within budget Phased roll out maintaining imaging capacity Dedicated implementation team Support from, networks, estates, and hospital IT Equipment scoping close to requirements WebPACS is well liked and trouble free

Commercial and In Confidence What also went well Migration of data from old RAD/Agfa system But at a cost 12 weeks of the project technical lead’s time Significant planning resource Forced big bang deployment of CRIS and PACS

Commercial and In Confidence What went badly CRIS referrer list seriously deficient CRIS Rollout labour and time intensive Resource mapping was made more complex by our system design

Commercial and In Confidence Training and technical support Suppliers unprepared for a hospital of this size and complexity Inadequate system training from supplier –No integrated training on the whole system prior to implementation led to many problems particularly related to workflows and generation of unspecified and split examinations –Training given was much too long before go live date Inadequate system support from supplier after implementation- little activity until we really shouted –No provision for support in contract –Fujitsu Help desk extremely time consuming and frustrating

Commercial and In Confidence CRIS a beta release? Slow speed of system due to CRIS –Log in times averaged 10mins Audited 7th Sept with community log in times of 45mins –Reporting Initially much slower than old Agfa PACS system, reporting efficiency reduced by approximately 30%.

Commercial and In Confidence CRIS login times

Commercial and In Confidence Internal difficulties Size of Radiology IT team much too small –Overwhelmed by technical problems and requests for training/support following implementation –CRIS roll out much more time consuming than expected Lack of understanding of size and complexity of PACS project –Level of support from clinicians outside radiology variable during the difficult early days following roll out, expectations perhaps unrealistic –Needed more contribution from users inside and outside radiology Workflows inadequately thought through –Due in part to lack of integrated training –Should have done more work on this ‘in house’ before go live

Commercial and In Confidence More issues Lack of sharing of problems and solutions with other hospitals Problems with connecting peripheral sites to Derriford Image sharing with other hospitals

Commercial and In Confidence Complications Real clinical risk Serious impact on reporting throughput Split studies in CT and ultrasound Workstations incorrectly setup not automatically displaying doppler ultrasound images

Commercial and In Confidence Ultrasound and CT Audit 50 sonographer ultrasounds all 2nd reported by Radiologist reviewed –35 had split studies –4 had radiologist reports that were incomplete –3 no clinical impact 1 possible clinical impact

Commercial and In Confidence CT Audit 50 unspecified CT examinations reviewed –All 50 had split examinations –49 reports were regarded as complete, with radiologists clearly having sought out the additional images –1 study which had pelvic images in a separate file was deficient

Commercial and In Confidence Recovery Weekly Clinical Governance meeting with CE and Medical Director Galvanised assistance from suppliers –Resolution of numerous technical issues –Fujitsu operational analysis July 30th Reallocated internal resources –Increased reporting capacity –Strengthen the Radiology IT team

Commercial and In Confidence GP Film reporting status

Commercial and In Confidence LSP optimisation visit 18 th -21 st Sept GE/Kodak/HSS representatives Workplace training throughout the directorate Kodak assessment of dose and process issues Resolution of many outstanding system integration problems

Commercial and In Confidence Unresolved issues Image sharing- unresourced –WebPACS sharing Truro/Torbay/Exeter/Barnstaple/Bristol Non NHS image sharing?

Any questions?

Commercial and In Confidence Programme Estates work Networking installtest Delivery JANMARFEBMAYAPR User training Planning “PACS ready” Migrate data Develop processes Prepare training User training Train trainers RIS / WebPACS rollout on wards Rollout complete Academy Initial Phased area rollout XRAY W XRAY E A&E

Commercial and In Confidence Recovery

Commercial and In Confidence