Introducing PACS to the late majority. A longitudinal study

Effect of Implementation of Picture Archiving and Communication System on Radiologist Reporting Time and Utilization of Radiology Services: A Case Study in Iran

We aimed to determine the effect of PACS implementation on the radiologist reporting time and utilization of radiology services in a hospital in Iran. This study was conducted in three 6-month periods (before PACS implementation, immediately after the implementation, and 1 year after implementation). Data related to reporting time of CT examinations were collected from 5074 patients with 6613 examinations and compared using the Friedman test. The utilization rate of radiology services was conducted about CT scans and radiographies. Therefore, 17,862 patients with 36,321 radiographies and 7155 patients with 10,571 CT scans were evaluated, and the ratio of the number of examinations to the number of patients and patient days was compared in three periods. The mean of reporting time on CT scan examinations in the period of immediately after PACS was changed compared to the period of before PACS from 13.05 to 24.18 days and compared to 1 year after PACS implementation, to 4.14 days (P value < 0.05). The utilization rate in CT scans, 1 year after PACS increased at least 10% to 25% compared to the immediately after PACS and before implementing PACS. The utilization rate in radiographies, 1 year after PACS, increased at least 16% to 78% compared to the immediately after PACS and before PACS implementation. In conclusion, the mean of the radiologist reporting time for CT scans is significantly decreased by PACS in the long-term. Additionally, the utilization rate of radiology services is increased in the short- and long-term after PACS implementation in most examinations of CT scan and radiography examinations.

Investigating the satisfaction level of physicians in regards to implementing medical Picture Archiving and Communication System (PACS)

Background

User satisfaction with PACS is considered as one of the important criteria for assessing success in using PACS. The objective of this study was to determine the level of user satisfaction with PACS and to compare its functional features with traditional film-based systems.

Methods

This study was conducted in 2017. Residents at three large university hospitals in Kerman filled-out a self-administered questionnaire consisting of three parts: demographic information of participants, user satisfaction with PACS, comparing features of the two digital and traditional imaging systems. The validity of this questionnaire was approved by five medical informatics, radiology, and health information management specialists and its reliability was confirmed by Cronbach’s alpha (86%). Data were analyzed using descriptive statistics and the Spearman, Mann Whitney U and Kruskal-Wallis statistical tests.

Results

The mean of the participants’ ages was 31.4 (±4.4) years and 59% of the participants were females. The mean of physicians’ satisfaction with PACS’ had no significant relationship with their age (P = 0.611), experience of using PACS (P = 0.301), specialty (P = 0.093), and percent of interpretation of images with PACS (P = 0.762). It had a significant relationship with the participants’ computer skills (P = 0.022).

Conclusions

The mean of physicians’ satisfaction with PACS was at a moderate to a high level, yet there are still problems in the successful implementation of these systems and establishing interoperability between them. PACS has not fully met all the demands of physicians and has not achieved its predetermined objectives, such as all-access from different locations.

Radiologist-initiated double reading of abdominal CT: retrospective analysis of the clinical importance of changes to radiology reports

Background

Misinterpretation of radiological examinations is an important contributing factor to diagnostic errors. Consultant radiologists in Norwegian hospitals frequently request second reads by colleagues in real time. Our objective was to estimate the frequency of clinically important changes to radiology reports produced by these prospectively obtained double readings.

Methods

We retrospectively compared the preliminary and final reports from 1071 consecutive double-read abdominal CT examinations of surgical patients at five public hospitals in Norway. Experienced gastrointestinal surgeons rated the clinical importance of changes from the preliminary to final report. The severity of the radiological findings in clinically important changes was classified as increased, unchanged or decreased.

Results

Changes were classified as clinically important in 146 of 1071 reports (14%). Changes to 3 reports (0.3%) were critical (demanding immediate action), 35 (3%) were major (implying a change in treatment) and 108 (10%) were intermediate (requiring further investigations). The severity of the radiological findings was increased in 118 (81%) of the clinically important changes. Important changes were made less frequently when abdominal radiologists were first readers, more frequently when they were second readers, and more frequently to urgent examinations.

Conclusion

A 14% rate of clinically important changes made during double reading may justify quality assurance of radiological interpretation. Using expert second readers and a targeted selection of urgent cases and radiologists reading outside their specialty may increase the yield of discrepant cases.

User Acceptance of Picture Archiving and Communication System in the Emergency Department

BACKGROUND

Picture archiving and communication system (PACS) has allowed the medical images to be transmitted, stored, retrieved, and displayed in different locations of a hospital or health system. Using PACS in the emergency department will eventually result in improved efficiency and patient care. In spite of the abundant benefits of employing PACS, there are some challenges in implementing this technology like users' resistance to accept the technology, which has a critical role in PACS success.

OBJECTIVES

In this study, we will assess and compare user acceptance of PACS in the emergency departments of three different hospitals and investigate the effect of socio-demographic factors on this acceptance.

MATERIALS AND METHODS

A variant of technology acceptance model (TAM) has been used in order to measure the acceptance level of PACS in the emergency department of three educational hospitals in Iran. A previously used questionnaire was validated and utilized to collect the study data. A stepwise multiple regression model was used to predict factors influencing acceptance score as the dependent variable.

RESULTS

Mean age of participants was 32.9 years (standard deviation [SD] = 6.08). Participants with the specialty degree got a higher acceptance score than the three other groups (Mean ± SD = 4.17 ± 0.20). Age, gender, degree of PACS usage and participant's occupation (profession) did not influence the acceptance score. In our multiple regression model, all three variables of perceived usefulness (PU), perceived ease of use (PEU) and the effect of PACS (change) had a significant effect in the prediction of acceptance. The most influencing factor was change with the beta of 0.22 (P value < 0.001).

CONCLUSION

PACS is highly accepted in all three emergency departments especially among specialists. PU, PEU and change are factors influencing PACS acceptance. Our study can be used as an evidence of PACS acceptance in emergency wards.

The Impact of a Health IT Changeover on Medical Imaging Department Work Processes and Turnaround Times: A mixed method study

OBJECTIVES

To assess the impact of introducing a new Picture Archiving and Communication System (PACS) and Radiology Information System (RIS) on: (i) Medical Imaging work processes; and (ii) turnaround times (TATs) for x-ray and CT scan orders initiated in the Emergency Department (ED).

METHODS

We employed a mixed method study design comprising: (i) semi-structured interviews with Medical Imaging Department staff; and (ii) retrospectively extracted ED data before (March/April 2010) and after (March/April 2011 and 2012) the introduction of a new PACS/RIS. TATs were calculated as: processing TAT (median time from image ordering to examination) and reporting TAT (median time from examination to final report).

RESULTS

Reporting TAT for x-rays decreased significantly after introduction of the new PACS/RIS; from a median of 76 hours to 38 hours per order (p<.0001) for patients discharged from the ED, and from 84 hours to 35 hours (p<.0001) for patients admitted to hospital. Medical Imaging staff reported that the changeover to the new PACS/RIS led to gains in efficiency, particularly regarding the accessibility of images and patient-related information. Nevertheless, assimilation of the new PACS/RIS with existing Departmental work processes was considered inadequate and in some instances unsafe. Issues highlighted related to the synchronization of work tasks (e.g., porter arrangements) and the material set up of the work place (e.g., the number and location of computers).

CONCLUSIONS

The introduction of new health IT can be a "double-edged sword" providing improved efficiency but at the same time introducing potential hazards affecting the effectiveness of the Medical Imaging Department.

Double reading rates and quality assurance practices in Norwegian hospital radiology departments: two parallel national surveys

BACKGROUND

Double reading as a quality assurance (QA) tool is employed extensively in Norwegian hospital radiology departments. The practice is resource consuming and regularly debated.

PURPOSE

To investigate the rates of double reading in Norwegian hospital radiology departments, to identify department characteristics associated with double reading rates, and to investigate associations between double reading and other quality improvement.

MATERIAL AND METHODS

We issued two parallel national surveys to management and to consultant radiologists, respectively. Management was defined as the chief medical officer and/or the head of the radiology department. The management survey covered staffing, perceived resource situation, double reading, guidelines, and quality improvement. The radiologist survey served to validate management responses concerning double reading. Management survey items concerning practices of quality improvement were organized into three indices reflecting different quality approaches, namely: appropriateness of investigations; personal performance feedback; and system performance feedback.

RESULTS

The response rates of the surveys were 100% (45/45) for management and 55% (266/483) for radiologists. Of all exams read by consultants, 33% were double read. The double reading rate was highest in university hospital departments (59%), intermediate in other teaching departments (30%), and lowest in non-teaching departments (11%) (P = 0.01). Among the quality indices, mean scores were highest on appropriateness index (68%), intermediate on the person index (56%), and lowest on system index (37%). There were no correlations between double reading rates and scores on any of the quality indices.

CONCLUSION

The rate of double reading in Norwegian hospital radiology is significantly correlated to department teaching status, but not to other practices of quality work.

The effectiveness of service delivery initiatives at improving patients' waiting times in clinical radiology departments: a systematic review

We reviewed the literature for the impact of service delivery initiatives (SDIs) on patients' waiting times within radiology departments. We searched MEDLINE, EMBASE, CINAHL, INSPEC and The Cochrane Library for relevant articles published between 1995 and February, 2013. The Cochrane EPOC risk of bias tool was used to assess the risk of bias on studies that met specified design criteria. Fifty-seven studies met the inclusion criteria. The types of SDI implemented included extended scope practice (ESP, three studies), quality management (12 studies), productivity-enhancing technologies (PETs, 29 studies), multiple interventions (11 studies), outsourcing and pay-for-performance (one study each). The uncontrolled pre- and post-intervention and the post-intervention designs were used in 54 (95%) of the studies. The reporting quality was poor: many of the studies did not test and/or report the statistical significance of their results. The studies were highly heterogeneous, therefore meta-analysis was inappropriate. The following type of SDIs showed promising results: extended scope practice; quality management methodologies including Six Sigma, Lean methodology, and continuous quality improvement; productivity-enhancing technologies including speech recognition reporting, teleradiology and computerised physician order entry systems. We have suggested improved study design and the mapping of the definitions of patient waiting times in radiology to generic timelines as a starting point for moving towards a situation where it becomes less restrictive to compare and/or pool the results of future studies in a meta-analysis.

Study on user interface of pathology picture archiving and communication system

OBJECTIVES

It is necessary to improve the pathology workflow. A workflow task analysis was performed using a pathology picture archiving and communication system (pathology PACS) in order to propose a user interface for the Pathology PACS considering user experience.

METHODS

An interface analysis of the Pathology PACS in Seoul National University Hospital and a task analysis of the pathology workflow were performed by observing recorded video. Based on obtained results, a user interface for the Pathology PACS was proposed.

RESULTS

Hierarchical task analysis of Pathology PACS was classified into 17 tasks including 1) pre-operation, 2) text, 3) images, 4) medical record viewer, 5) screen transition, 6) pathology identification number input, 7) admission date input, 8) diagnosis doctor, 9) diagnosis code, 10) diagnosis, 11) pathology identification number check box, 12) presence or absence of images, 13) search, 14) clear, 15) Excel save, 16) search results, and 17) re-search. And frequently used menu items were identified and schematized.

CONCLUSIONS

A user interface for the Pathology PACS considering user experience could be proposed as a preliminary step, and this study may contribute to the development of medical information systems based on user experience and usability.

A socio-technical assessment of the success of Picture Archiving and Communication Systems: the radiology technologist's perspective

BACKGROUND

With the increasing prevalence of Picture Archiving and Communication Systems (PACS) in healthcare institutions, there is a growing need to measure their success. However, there is a lack of published literature emphasizing the technical and social factors underlying a successful PACS.

METHODS

An updated Information Systems Success Model was utilized by radiology technologists (RTs) to evaluate the success of PACS at a large medical center in Taiwan. A survey, consisting of 109 questionnaires, was analyzed by Structural Equation Modeling.

RESULTS

Socio-technical factors (including system quality, information quality, service quality, perceived usefulness, user satisfaction, and PACS dependence) were proven to be effective measures of PACS success. Although the relationship between service quality and perceived usefulness was not significant, other proposed relationships amongst the six measurement parameters of success were all confirmed.

CONCLUSIONS

Managers have an obligation to improve the attributes of PACS. At the onset of its deployment, RTs will have formed their own subjective opinions with regards to its quality (system quality, information quality, and service quality). As these personal concepts are either refuted or reinforced based on personal experiences, RTs will become either satisfied or dissatisfied with PACS, based on their perception of its usefulness or lack of usefulness. A satisfied RT may play a pivotal role in the implementation of PACS in the future.

User acceptance of a picture archiving and communication system (PACS) in a Saudi Arabian hospital radiology department

BACKGROUND

Compared with the increasingly widespread use of picture archiving and communication systems (PACSs), knowledge concerning users' acceptance of such systems is limited. Knowledge of acceptance is needed given the large (and growing) financial investment associated with the implementation of PACSs, and because the level of user acceptance influences the degree to which the benefits of the systems for healthcare can be realized.

METHODS

A Technology Acceptance Model (TAM) was used to assess the level of acceptance of the host PACS by staff in the radiology department at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia. A questionnaire survey of 89 PACS users was employed to obtain data regarding user characteristics, perceived usefulness (PU) (6 items), perceived ease of use (PEU) (4 items), a change construct (4 items), and a behavior (acceptance) construct (9 items). Respondents graded each item in each construct using five-point likert scales.

RESULTS

Surveyed users reported high levels of PU (4.33/5), PEU (4.15/5), change (4.26/5), and acceptance (3.86/5). The three constructs of PU, PEU, and change explained 41 % of the variation in PACS user acceptance. PU was the most important predictor, explaining 38 % of the variation on its own. The most important single item in the explanatory constructs was that users found PACS to have improved the quality of their work in providing better patient care. Technologists had lower acceptance ratings than did clinicians/radiologists, but no influence on acceptance level was found due to gender, age, or length of experience using the PACS. Although not directly measured, there appeared to be no cultural influence on either the level of acceptance or its determinants.

CONCLUSIONS

User acceptance must be considered when an organization implements a PACS, in order to enhance its successful adoption. Health organizations should adopt a PACS that offers all required functions and which is likely to generate high PU on the part of its users, rather than a system that is easy to use. Training/familiarization programs should aim at establishing high levels of PU in all users, particularly technologists. Health organizations are advised to measure all the factors that influence the acceptance of a PACS by their staff, in order to optimize the productivity of the system and realize the potential benefits to the greatest extent possible.

The impact of PACS on clinician work practices in the intensive care unit: a systematic review of the literature

OBJECTIVE

To assess evidence of the impact of Picture Archiving and Communication Systems (PACS) on clinicians' work practices in the intensive care unit (ICU).

METHODS

We searched Medline, Pre-Medline, CINAHL, Embase, and the SPIE Digital Library databases for English-language publications between 1980 and September 2010 using Medical Subject Headings terms and keywords.

RESULTS

Eleven studies from the USA and UK were included. All studies measured aspects of time associated with the introduction of PACS, namely the availability of images, the time a physician took to review an image, and changes in viewing patterns. Seven studies examined the impact on clinical decision-making, with the majority measuring the time to image-based clinical action. The effect of PACS on communication modes was reported in five studies.

DISCUSSION

PACS can impact on clinician work practices in three main areas. Most of the evidence suggests an improvement in the efficiency of work practices. Quick image availability can impact on work associated with clinical decision-making, although the results were inconsistent. PACS can change communication practices, particularly between the ICU and radiology; however, the evidence base is insufficient to draw firm conclusions in this area.

CONCLUSION

The potential for PACS to impact positively on clinician work practices in the ICU and improve patient care is great. However, the evidence base is limited and does not reflect aspects of contemporary PACS technology. Performance measures developed in previous studies remain relevant, with much left to investigate to understand how PACS can support new and improved ways of delivering care in the intensive care setting.

Mapping turnaround times (TAT) to a generic timeline: a systematic review of TAT definitions in clinical domains

BACKGROUND

Assessing turnaround times can help to analyse workflows in hospital information systems. This paper presents a systematic review of literature concerning different turnaround time definitions. Our objectives were to collect relevant literature with respect to this kind of process times in hospitals and their respective domains. We then analysed the existing definitions and summarised them in an appropriate format.

METHODS

Our search strategy was based on Pubmed queries and manual reviews of the bibliographies of retrieved articles. Studies were included if precise definitions of turnaround times were available. A generic timeline was designed through a consensus process to provide an overview of these definitions.

RESULTS

More than 1000 articles were analysed and resulted in 122 papers. Of those, 162 turnaround time definitions in different clinical domains were identified. Starting and end points vary between these domains. To illustrate those turnaround time definitions, a generic timeline was constructed using preferred terms derived from the identified definitions. The consensus process resulted in the following 15 terms: admission, order, biopsy/examination, receipt of specimen in laboratory, procedure completion, interpretation, dictation, transcription, verification, report available, delivery, physician views report, treatment, discharge and discharge letter sent. Based on this analysis, several standard terms for turnaround time definitions are proposed.

CONCLUSION

Using turnaround times to benchmark clinical workflows is still difficult, because even within the same clinical domain many different definitions exist. Mapping of turnaround time definitions to a generic timeline is feasible.

Does improved access to diagnostic imaging results reduce hospital length of stay? A retrospective study

BACKGROUND

One year after the introduction of Information and Communication Technology (ICT) to support diagnostic imaging at our hospital, clinicians had faster and better access to radiology reports and images; direct access to Computed Tomography (CT) reports in the Electronic Medical Record (EMR) was particularly popular. The objective of this study was to determine whether improvements in radiology reporting and clinical access to diagnostic imaging information one year after the ICT introduction were associated with a reduction in the length of patients' hospital stays (LOS).

METHODS

Data describing hospital stays and diagnostic imaging were collected retrospectively from the EMR during periods of equal duration before and one year after the introduction of ICT. The post-ICT period was chosen because of the documented improvement in clinical access to radiology results during that period. The data set was randomly split into an exploratory part used to establish the hypotheses, and a confirmatory part. The data was used to compare the pre-ICT and post-ICT status, but also to compare differences between groups.

RESULTS

There was no general reduction in LOS one year after ICT introduction. However, there was a 25% reduction for one group - patients with CT scans. This group was heterogeneous, covering 445 different primary discharge diagnoses. Analyses of subgroups were performed to reduce the impact of this divergence.

CONCLUSION

Our results did not indicate that improved access to radiology results reduced the patients' LOS. There was, however, a significant reduction in LOS for patients undergoing CT scans. Given the clinicians' interest in CT reports and the results of the subgroup analyses, it is likely that improved access to CT reports contributed to this reduction.

HIS-based electronic documentation can significantly reduce the time from biopsy to final report for prostate tumours and supports quality management as well as clinical research

Background

Timely and accurate information is important to guide the medical treatment process. We developed, implemented and assessed an order-entry system to support documentation of prostate histologies involving urologists, pathologists and physicians in private practice.

Methods

We designed electronic forms for histological prostate biopsy reports in our hospital information system (HIS). These forms are created by urologists and sent electronically to pathologists. Pathological findings are entered into the system and sent back to the urologists. We assessed time from biopsy to final report (TBF) and compared pre-implementation phase (paper-based forms) and post-implementation phase. In addition we analysed completeness of the electronic data.

Results

We compared 87 paper-based with 86 electronic cases. Using electronic forms within the HIS decreases time span from biopsy to final report by more than one day per patient (p < 0.0001). Beyond the optimized workflow we observed a good acceptance because physicians were already familiar with the HIS. The possibility to use these routine data for quality management and research purposes is an additional important advantage of the electronic system.

Conclusion

Electronic documentation can significantly reduce the time from biopsy to final report of prostate biopsy results and generates a reliable basis for quality management and research purposes.