Making the Move to PACS

1. Making the Move to PACS Monte Clinton, CRA Dartmouth-Hitchcock Medical Center

2. Disclaimer • This presentation is about a PACS implementation at one facility (DHMC) with one vendor (IDX) and is being given as an example of a successful PACS implementation • Other facilities and vendors can do a similar PACS implementation using this partnering program and methodology • DHMC does not endorse IDX or any other vendor’s products and services

3. Existing 3 MR + 1 Mobile 3 CT 3 VIR + 1 PICC 8 DX 3 R/F 5 US 3 NM + PET/CT 5 Mammo New in 2004 Replace in 2004 1 CT in new ED CT/Angio 1 Angio OR compatible 6 DR-- 4 CR 1 DR/CR in ED + 1 CR trauma 1 DR/Fluoro 2 US in new building 1 NM + Fixed PET/CT 2 DR – Mammo new building Radiology Equipment 2004

4. Why Install a PACS? • Expansion to Provide New Space for: • Mammography • Nuclear Medicine • Vascular Interventional • Offices and conference space • New Outpatient Clinical Building to: • Eliminate over crowding • Add new MDs and exam rooms • Bring imaging to the patient • Minimize radiologist travel

5. Why Install a PACS? • Save money – Increase reimbursement • Reduce medico-legal risk • Eliminate Film and processing costs • Reduce Film Library staff and space • Improve billing collections • Reduce medico-legal exposure

7. Why Install a PACS? • Improve staff and imaging room productivity • Increased staff productivity • Reduction in the number of staff • Increased imaging room productivity • Eliminate imaging rooms

9. Why Install a PACS? • Improve service to your customers • Single set of film images limits collaboration • Minimize lost studies and revenue • Minimize treatment delays • Speed service to referring clinician and patient

10. DHMC’s Steps to Justify PACS • Internal justification – The major players • Large capital or operating cost impact requires multiple levels of approval – at DHMC this was: • Radiology • Information Systems

11. DHMC’s Steps to Justify PACS • Internal justification – Institutional leadership • Administrative leadership • Finance Committee • Board of Trustees – final go or no go

12. PACS: Getting Started • Outside experts – PACS consultants • Institutional experts • Radiology • Information Systems

13. PACS: Getting Started • Educate yourself about PACS • Ask your colleagues about their experiences • Attend meetings such as this one • Vendor discussions and demonstrations at trade shows - AHRA, RSNA, SCAR • Understand your own environment and needs

15. PACS: Getting Started • Request for Information (RFI) • Invite selected vendors to respond to RFI • Get a list of their customers to contact • How would their system fit into your facility • RIS and PACS compatibility

16. Interface or Integrate • The critical relationship between the RIS and the PACS • Have the RIS and the PACS vendors worked together before? • Which vendor has primary responsibility or are you expected to do problem triage?

17. PACS: Getting Started • Request for proposal (RFP) • Invite a limited number of vendors to bid • Vendor clarification meetings • RFP review and analysis • Site visits at working clinical sites • Final negotiation – Purchasing and Vendors

18. Paying for a PACS • Capital Purchase or Operating Expense • Capital purchase • Major capital expense – compete for funding • Cost to upgrade and remain technologically current • Ongoing service and maintenance cost • Application Service Provider (ASP) • Costs are an operating expense • Always kept technologically current • All inclusive - charges fluctuate with activity

19. The PACS Timeline • Develop a realistic implementation timeline with buy-in from all affected stakeholders Radiology – all levels Information Systems Institutional Leadership Referring Clinicians PACS Vendor

20. DHMC’s PACS Timeline • Phase 1 • 1-2003 Archiving started in CT, MR, US • 4-2003 Live in CT, MR and US – stop film • Phase 2 • 9-2003 Archiving started in DX • 12-2003 Live in DX – stop printing film • Phase 3 • 8-2004 Archiving started in Angio and NM • 1-2005 Angio and NM after IDXrad V10

21. Partnering with the PACS Vendor • Agreement with the vendor on the timeline and implementation phases • Appoint key staff from each stakeholder • This must be a win – win endeavor

22. Planning the Implementation • Weekly meetings of the • PACS Working Group • Radiology Director • Radiology PACS Administrator • Radiology Clinical Operations Manager • Radiology Asset Manager • IS Director • IS Liaison

23. Guiding the Implementation • PACS Implementation Team • bi-monthly meetings • Chairman of Radiology • Chief Information Officer • Vice President of Clinical Operations • The Six Working Group Members

24. Before and After Implementation • Ongoing follow-up • Weekly calls - Radiology and vendor • Updates to the clinical departments • Regular updates to the Board of Trustees • Monthly updates to the Radiology faculty • Weekly updates to the Radiology staff

25. Selecting the Hardware • Involve the end user in equipment selection • Radiologists given a choice of monitors • Referring clinicians given a choice of monitors • Specialty sections given choice of monitors • OR selected from 5 large flat panel monitors • ED selected the best monitor for their use

28. Reading Room Design • Radiologists given a choice of layout • DHMC rejected the modular systems • Radiologists preferred two image monitors • Room lighting critical • Calculate room temperature requirements • Gradual phase out of alternators

30. Dealing with Prior Studies • DHMC chose not to digitize prior studies • Prior studies are available if needed • After six months there was very little need for prior studies • Some studies are digitized so they can be used for comparison – joint replacements

31. The Archive • DHMC’s PACS Archive • In-house dual servers maintained and remotely monitored 24/7 by vendor • External archive backed up daily to vendor’s San Diego archive facility • DHMC’s failsafe back-up archive -- DVDs burned daily and stored at DHMC

32. Dartmouth Hitchcock Medical Center Imagecast™ RISv9.8/PACS Display Stations CT/Body Read Area (3) CT Rad/Onc Fiber Image Archive CT GE - 3 100MB 10/100 MB Imagecast PACS database Imaging Suite Neuro Read Area (3) MR GE- 4 MR Mobile RF Siemens 3 U/S Read Area (2) Dual DICOM Processors (~3 weeks) netCache (~6 months) Persistent Store (scalable life) DR Philips –6 CR Philips - 3 DX Read Area (5) ConnectRv4.0 IDXRad v9.8 ICU Offsite Disaster Recovery Film Digitizer 2 T-1 Enterprise Access via CIS US – 7 HDI Acuson Onsite Disaster Recovery HC5 DVD Server 10/100 MB LAN-10/100 Lebanon DHMC Campus U/S Kodak MiniPACS (priors only) Speare – Plymouth NH Kodak Drylaser Printer - 5 US – HDI 2 10/100 MB MR - Mobile CT Picker Any Image, Anywhere, Anytime 10 MB T-1 WAN/DSL/Cable Dated 05/05/03

33. Training the Radiology Technologists and Support Staff • Modality integration in advance – Imaging Suite • Super users identified - trained in each section • On-line training with vendor for super users • Make the process exciting and rewarding

34. Training of the Radiologists • Vendor provided 1 to 2 hours of one on one training 2 to 3 days before activation • Return visits after activation for more training if needed • Give them all the time and training they want • Ask radiologists and residents to offer suggestions for enhancements

36. Keep Your Staff Informed • Being upfront about what is happening and when it will impact the lives of staff will head off rumors • Publish a PACS phase in plan – DHMC 1 year • Stop hiring permanent full time Film Library \employees a year before implementation • Work with HR to find jobs for displaced staff

38. Contingency Plans • Referring clinicians demanding film • Acceptance of CD copies by other facilities • Urgent results reporting • Special requests • System failure – power failure, virus, etc.

39. Partner With Your Vendor • Clear objectives spelled out in the contract • Agree on timeline, payment and penalties • Clearly define facility - vendor responsibilities • Track progress with regular reports • Make the PACS implementation a win – win program for both your facility and the vendor

40. What DHMC Did Right • Developed and used a workflow analysis • Piloted PACS with 15 referring clinicians • Had a close relationship with the PACS vendor • Integrated modalities in advance • Integrated RIS/PACS with electronic medical record

41. A Chairman’s Perspective • “ Never in my 29 years as a chairman have I made a decision that has received such universal acceptance from both the radiologists and the referring clinicians” • Peter Spiegel, MD • Chairman – Radiology

42. A Director’s Perspective

43. Contact Information • Monte Clinton, CRA • Dartmouth-Hitchcock Medical Center • Monte.Clinton@Hitchcock.org • www.dhmc.org/dept/radiology