1. Implementing a PACS By Ginny Poulin RN, MS & Shelly Fisher

2. Agenda  Preparing for a PACS  PACS Components Data acquisition, Servers, Workstations  Disaster Recovery and Business Continuity  Workflow / Integration  Cost Justification  Summary and Questions

3. 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

4. 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

5. Preparing for Your PACS  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

6. PACS Parts / Environment RIS HL-7 Interface HL-7 messages DICOM Server DICOM MWL images Web Server Workflow Engine DICOM Archive images Work stations modalities printer images Dictation system Reports PACS Environment PACS Parts

7. 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

8. PREPARING THE PHYSICIANS  Teleradiology  E-Signature  Access from home  ????? Ask Skip???

9. What Every PACS Vendor will Need to Know  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

10. What to do with existing, non- DICOM 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?

11. 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

12. 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 Increasing quality/complexity and cost 1 MP 5 MP $1500 $80,000

13. WORK STATIONS Design Points for various users Ease of use, run on any hardware, limit tools and cost Average clinical user Efficiency, speed, stability, tools, specialty hardware Radiologist Power clinical user More complexity, hardware restrictions, more tools

14. 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)

15. 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)

16. HL-7 Integration

17. Driving Factors for Integration  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)

18. 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.

19. HL-7 Integration Alice in Workflow goes here

20. 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

21. 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

22. 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

23. Items we would have noticed, if we’d been paying attention  This exam identifier, called the accession #, is pretty key to the tracking process.

24. 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)

25. 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 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

26. 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.

27. 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

28. Meditech to PACS (continued)  Can purchase interface from Meditech or other party  Heywood Hospital selected Iatric’s Engine  Reasons - >50% savings Accommodated our schedule One on One help – A team approach Weekly conference calls and then some

29. 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

30. 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!

31. Improved Tracking  PACS always knows the status of the exam  PACS can assist finding and repairing “broken” studies

32. Order Arrived at RF Patient Arrives at Department Study arrives, but no order! Study arrives at server Study Read Study Reported Order Canceled BRIT’s Exam Loop

33. 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”)

34. 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

36. 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

37. 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

38. Hard and 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 Hard savings Soft savings More efficient use of personne Technologists, radiologists, others More efficient use of equipment Reduced space requirements Reduced Liability Improved exam tracking

39. What does a film-based system cost? And we know that things cost more in small hospitals!

40. What are typical savings with PACS Hard to measure because more items change in environment

44. STORAGE  SAN vs NAS vs Modality storage Other data to be stored? Protecting the data for 30 yrs Meeting future needs

45. Total Savings and Analysis

46. 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

47. LET’S TALK  Questions