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Implementing a PACS Ris by MikeJenny


Implementing a PACS Ris

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									Implementing a PACS

  Ginny Poulin RN, MS
      Shelly Fisher

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

 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
  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
 PACS vendor will have different concept of
 PACS is a highly integrated environment –
   standards are key
 Purchase items with standards in advance
   Modalities - buy with DICOM Store, MWL,
  Workstations – support for IHE presentation
   states, key object notes
  Servers – support for all the above and HL-7
            PACS Parts / Environment

      Reports                  DICOM                     PACS Parts

        HL-7                   Server
                                         Workflow     images    Work
RIS                  HL-7                Engine
        messages   Interface                          images   stations
                                         Web Server
                   DICOM          images                  images

                        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
 Teleradiology
 E-Signature
 Access from home
 ????? Ask Skip???
          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
      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?
              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
            DICOM Server/Archive

 Broad DICOM Services – Service Object Pairs
 Support for standards in the backend
 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
 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

 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

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
       What to expect in the integration
 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
      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
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 -
     >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
           Improved Tracking
 PACS always knows the status of the
 PACS can assist finding and repairing
  “broken” studies
        BRIT‟s Exam Loop

                                           Order Arrived at
        Study Reported

                                                      Patient Arrives at
Study Read                                              Department

    Order                                               Study arrives, but
   Canceled                                                 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
 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

               •Reduced film, chemical and folder cost
                    •Reduce off-site storage cost
               •Reduced cost of processor maintenance
                          •Reduced retakes
Hard savings     •No repeat studies due to lost exams
Soft savings       •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

     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
Hard to measure because more items change in environment
             Baltimore VA Analysis of Cost and Benefits of
             Filmless Radiology*:
                  40% increase in productivity of
                        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                                                           Yearly Savings from Film
                                                                       Number of exams/year                         10000
                      Cost of film material        1.84                Number of flms/exam                             3.5
            processing/ chemicals & equip.         0.62                Number of films/year                         35000
                         processing salary         0.24                Total yearly savings from film            $141,400
                              film tracking        0.34
                            archival space         0.50
                            archival salary        0.50                Yearly savings from reduced
Total cost of film                                 4.04                retakes & Lost studies

                                                                       Cost of Retakes                               8.70
                                                                       % of retakes                                 15.00
                                                                       Savings from retakes                       $13,050

                                                                       Lost studies - costs                         60.00
Cost of film and chemicals alone                                       % lost studies                                    5
- Cost per study (this is an average we've          7.00               Savings from lost studies                  $30,000
seen and is not the same as film and chemical cost above)
                                                                       Liability Savings *                        $50,000
Note: cost of film /chemicals alone:           $70,000                 Total yearly savings / film               $234,450

                                                            * Government gives $120k credit per year for their smallest sites
                                          Estimate of Savings from
                                               Increased Personnel

Cost of Film Distribution
Hours spent by technologists                         Doctors' time
 looking for films/ handling film / day       3.00   (USE ONLY IF THEY ARE PAID BY HOSPITAL)
Hours per year                              936.00   Radiologists - concurrently                 0
burden rate                                  28.00    time spent handling films/
yearly costs                               $26,208   looking for films - hours/day                1
(7 days a week)                                        burdened rate                             85
                                                     yearly cost                                $0
Cost of hanging film                                  (5 days / week)
Time per study / hours                        0.08
Burdne rate                                  15.00   Doctors - non-radiologists                  0
Total Cost                                 $12,500   hours spent looking for film/
                                                     going to library each day                 0.25
Cost of personnel outside radiology                  burdened rate                               85
Percentage of costs withing Radiology          37%   yearly cost                                $0
Cost                                       $16,172   (6 days / week)
-% comes from Mayo Study
Total Cost of film distribution            $54,880
 - yearly
                                          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    Number of Ultrasounds          1000
 Increased efficiency                                  0.15   Increased efficiency            0.20
 Reimbursement / CT                                    300    Reimbursement / US               100
 Number of additional CTs                               105   Number of additional US's        200
 Increased revenue                                 $31,500    Increased revenue           $20,000

 Number of MRI's performed                            400
 Increased efficiency                                0.15
 Reimbursement / MRI                                $400
 Number of additional MRIs                              60
 Increased revenue                                $24,000

 Savings from increased efficiencies              $75,500

Note that we use very low room efficiency numbers -
You can put in higher numbers, if you have the volume

 SAN vs NAS vs Modality storage
     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                           $234,450
Film dist ribut ion / handling             $54,880
 room ef f iciency                         $75,500        # of years f or anaylsis                            5
Tot al yearly saving                     $364,830         Savings over years                        $1,824,150

                                       Cost of PACS - Quick Analysis
Quick Cost Est imat es f or PACS                          Savings using cost + cont ingency
Num ber of st udies over years              50000         Savings over years - just f ilm/archive    $297,330
Cost per st udy                                9.51       Savings over years - all it em s            $949,230
Tot al syst em cost - incl. Service       $475,500
Est imat e on PACS personnel
Percent age of syst em cost                    0.12
Cost of personnel over 5 years            $285,300
Tot al cost of syst em                    $760,800
Tot al cost + 15% cont ingency           $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


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