pacs practical experience-5570

PACS Implementation GuideProgramme PACS DOCUMENT NUMBERSub-Prog/Project National Prog Org Prog/Proj Doc SeqProg. Director K Prangley NPFIT PAC GEN PI 0001Sub Prog/Proj MgrAuthor D Jennings Version No V0.03Version Date 28/6/04 Status Final

PACS Implementation Guide

PACS Practical Experiences

PACS Practical Experiences NPFIT-PRI-GMP-0001 V0. 3 28 June 2004 Draft

Amendment History:

Version Date Amendment HistoryV0.1 22/3/04 First draft for commentV0.2 16/04/04 Updated version with information from PACSnet

and initial comments from NPfIT PACS Facilitators

V0.3 01/06/04 Updated version following comments from formal Quality Review

Reviewers:

This document must be reviewed by the following.

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This document is only valid on the day it was printed. Please contact the Document Controller for location details or printing problems.

This is a controlled document.

On receipt of a new version, please destroy all previous versions (unless a specified earlier version is in use throughout the project).

PACS Practical Experiences of 45


Related Documents.

These documents will provide additional information.

Ref no Doc Reference Number Title Version1 NPFIT-NPO-GEN-IP-0067 Glossary of Terms Consolidated.doc Latest

Glossary of Terms.

List any new terms created in this document. Mail the librarian to have these included in the master glossary above [1].Term Acronym Definition



ContentsPACS Practical Experiences.....................................................................................................11. Introduction.................................................................................................................... 6

1.1 Terms of Reference and Scope..................................................................................61.2 Audience.....................................................................................................................61.3 Acknowledgement......................................................................................................61.4 National Programme for IT.........................................................................................61.5 An Introduction to PACS.............................................................................................7

2. Road Map / Summary....................................................................................................73. Lessons Learnt...............................................................................................................8

3.1 Supplier Management.................................................................................................83.2 Executive and Clinical Commitmant...........................................................................83.3 Planning......................................................................................................................8

3.3.1 Standardisation of numbering and exam codes.................................................93.3.2 Migration of Data................................................................................................93.3.3 Reports and Outputs..........................................................................................9

Typical Queries....................................................................................................................... 105. Project Planning...........................................................................................................116. Review Current Policies, Procedures and Working Practices......................................11

6.1 Process Change and use of the Modernisation Agency...........................................117. System Testing............................................................................................................118. Training Guidelines......................................................................................................129. Technical and Interfaces..............................................................................................1310 Communication............................................................................................................1311 Staffing during Implementation.....................................................................................1312 Ongoing System Management.....................................................................................14

12.1 Maintenance of System / Database..........................................................................1512.2 Looking after the Internal Users................................................................................1512.3 Service Provision for External Users........................................................................15

13. Supporting the Paperless Environment........................................................................1614. Identifying Potential Benefits........................................................................................1615. Go-Live Period.............................................................................................................1616. Measuring Benefits / Post Implementation Review......................................................1717. Business Case Support – See Appendix F..................................................................18A Appendix A – Film Digitisers............................................................................................19

A.1 Film Digitisers..........................................................................................................19A.1.1 Camera.............................................................................................................19A.1.2 CCD (Charge-Coupled Device)........................................................................19A.1.3 Laser................................................................................................................19

A.2 Digitiser Quality Control............................................................................................19B Appendix B – Project Planning........................................................................................21

B.1 An Example Summary of the rationale behind planning...........................................21B.2 An Example of Supplier Commitment to Project Management.................................21B.3 Example Project Plan....................................................................................................22B.4 Example Multi Site Plan............................................................................................23

B.4.1 Example 1........................................................................................................23B.4.2 Example 2........................................................................................................24

B.5 An Example of a PACS Implementation Reporting Structure...................................25C Appendix C – Technical and Interfaces...........................................................................26

C.1 Networking................................................................................................................26C.2 Communication Standards.......................................................................................26

C.2.1 DICOM (Digital Imaging and Communications in Medicine).............................26C.2.2 IHE (Integrating the Healthcare Enterprise)......................................................26C.2.3 HL7................................................................................................................... 26

C.3 Interfaces.................................................................................................................. 27C.4 Digital Image.............................................................................................................27

C.4.1 Digital Image Capture.......................................................................................27C.4.2 Acquisition of Digital Data on to the PACS.......................................................28C.4.3 The Database Server and DICOM Gateway....................................................28C.4.4 Digital image display.........................................................................................29C.4.5 Digital image storage........................................................................................29

C.4.5.1 Networked Storage...............................................................................30C.4.6 Film printers......................................................................................................31



C.5 Monitors.................................................................................................................... 32C.5.1 Image Quality...................................................................................................32C.5.2 Displays............................................................................................................32

C.5.2.1 Quality Assurance of Display Devices..................................................33C.6 Web Browsers..........................................................................................................34D.1 Radiologist Office and Reporting Areas....................................................................35D.2 Radiographer Zone...................................................................................................36D.3 PACS Computer Room.............................................................................................36E.1 An example of: ‘How has the deployment of the PACS improved services'..............40F.1 Introduction...............................................................................................................42F.2 The Business Case Templates.................................................................................43

F.2.1 Strategic Case..................................................................................................43F.2.2 Economic Case................................................................................................43F.2.3 Commercial Case.............................................................................................43F.2.4 Financial Case..................................................................................................43F.2.5 Management Case...........................................................................................43

F.3 The Toolkit................................................................................................................43F.4 The Workshops.........................................................................................................43F.5 Summary.................................................................................................................. 44


PACS Implementation Guide NPFIT-PRI-GMP-PI-0001 0.216-April 2004 Draft

1. Introduction

1.1 Terms of Reference and ScopeThis document discusses and outlines tasks, considerations, resources and aspects of preparing to and implementing a Picture Archiving and Communications System (PACS) will assist when the implementation of new systems or the expansion of current systems are being considered.

It is intended to be a living document and will be updated by the NPfIT PACS Team as lessons are learnt and processes develop. The intention is that implementation information across the NHS can be collated into one document to increase knowledge utilising the experience of others.

A Picture Archiving and Communications System (PACS) typically comprises data storage devices, image display devices, database management software and links to image and/or image data acquisition devices, connected by computer networks. There will be network connections to other information systems such as the Hospital Information System (HIS), Patient Administration System (PAS) and the Radiology Information System (RIS).

1.2 AudienceThis document covers a wide range of areas and will be useful to Chief Executives, Chief Information Officers, Directorate and Clinical Managers, Clinical practitioners, IT Teams and the PACS Implementation Team.

1.3 AcknowledgementThis document has been completed based on the experiences of clinicians and IT personnel who have undertaken PACS implementations in the past, or who have specific PACS expertise, such as PACSnet. We acknowledge their help and thank them for taking the time and effort they gave in supporting us to create this document.

1.4 National Programme for ITThe National Programme for Information Technology (NPfIT) is one of the world’s largest IT programmes. To achieve this, the programme plans to ensure that the right information is in the right place and at the right time. It supports the vision of the NHS Plan by modernising information systems across the NHS in England. The programme aims to improve the convenience and quality of care for users and providers of healthcare within the National Health Service in England.

To take advantage of the possibilities offered by the National Programme, it is expected that working practices will change.

There are four key elements to the National Programme. These are:

Electronic booking of appointments (eBooking)

NHS Care Records Service (NCRS)

Electronic Transmission of Prescriptions (ETP)

An underpinning IT infrastructure with sufficient connectivity and broadband capacity to support national applications and local systems.

NCRS is the core component of the NPfIT and will completely change the way patient information is collected, stored, communicated and used. It will provide clinicians across care professions and organisational boundaries with access to integrated services that are based around the patient. PACS images may be distributed by the network, but most of the information will be about PACS images e.g. reports and the location of PACS images rather that the images themselves. Most of the interaction is with the RIS.

PACS Practical Experiences


1.5 An Introduction to PACSThe investment in PACS will support the Government’s vision for filmless diagnostic services. Advances in digital technologies, particularly in the fields of computing, imaging and in communication, have progressed to the point that it is now possible to acquire medical images in digital form, archive them on computer systems, and display them in diagnostic quality. The display monitor used to present the images can be at an adjacent or distant location to the original point of acquisition. Indeed, there can be multiple monitors at multiple locations, since once the ‘master’ image file has been archived; it is only ever a copy of the data that is transmitted for display.

The benefits of PACS are well documented and a table of benefits is included as an appendix to this document.

Several standards have proved themselves useful in implementing a PACS, notably Digital Imaging and Communications in Medicine (DICOM) and Health Level 7 (HL7). In a typical radiology department, it is likely that a large number of steps are performed in the sequence of events from the time that the patient is first registered in the department to the time that the clinical report is issued. The required sequence is likely to be a process that has evolved over many years, and it may no longer be the optimal process for a modern radiology department. Installation of a PACS gives the opportunity to re-evaluate the workflow within the radiology department. Rather than merely mimicking an existing, paper-based, system, a carefully planned PACS implementation can encourage improved workflow, i.e. the more efficient flow of information, images and patients through the department.

2. Road Map / SummaryAs all trusts will be starting the process from a different point the following ‘Road Map’ is a guideline.

Identify Need for PACS↓

Obtain Executive, Clinical and IT Commitment / Create Project Team↓

Identify “PACS Community”↓

Identify Benefits (include baseline)↓

Review current processes and define process change (Modernisation Agency involvement)↓

Approve Business Case

Create Implementation Team↓

Select Supplier/ System in conjunction with LSP including the process by which this happens↓

Review Suppliers Implementation Plan and Technical plan↓

Agree supplier/Trust Implementation Plan↓

Start site preparation (including staff aspects and technical architecture)↓

Implementation

On going maintenance / support↓

Post Implementation Review & Benefits analysis↓

Feed back to National Team



3. Lessons Learnt

3.1 Supplier ManagementImplementation is a joint task that involves a coordinated team effort. The suppliers are experienced in the implementation of the PACS solution, but the NHS has the expertise of business processes within the domain. It is in working together in one team utilising the skills available that creates successful outcomes.

Working with the suppliers is not just an implementation activity, but also an on going relationship through the provision of support over the life of the service contract.

3.2 Executive and Clinical CommitmentExecutive commitment is imperative for the success of the project, the CEO and board should be fully briefed on the progress of the project. Finance and IT should also be represented on the project board.

It is important to recognise that PACS is a clinical system that will be widely used and should be managed as a clinical project with IT support. Clinical commitment and support to the project from its conception is vital so that there is acceptance and ownership throughout the clinical setting.

PACS is not solely a Radiology tool and will be utilised by many clinicians across the PACS arena, a clinical champion within radiology and at least one from another department will help the project.

Having clinicians involved in the decision making and the project significantly helps the adoption of the system and supporting processes.

3.3 PlanningPrior to implementing PACS

A network survey must be done, the bandwidth of both backbone and branches must be assessed and any upgrading work undertaken. Advice on minimum network requirements should be obtained from the PACS supplier. They may also be helpful during the network survey process.

Ensure the Radiology Information system (RIS) can meet the requirements of a PACS installation and address this as an urgent priority. Have a clear view as to how non radiological (potentially non RIS entered studies) images will be incorporated into the system.

A unique patient identifying number is vital to a Trust and Community wide PACS system, e.g. NHS number or Hospital Registration number.

Which pieces of equipment is DICOM conformance statement? Which DICOM data elements are supported?

What is the cost of upgrades to DICOM equipment to enable interoperability?

What needs replacing? For non DICOM equipment that will not be replaced how can the images be sent to PACS? (You may need to provide space to accommodate an image gateway computer and desk and network point and power socket)

It should never be assumed that a piece of equipment supports the required DICOM communication (i.e. service classes). Therefore, always check with suppliers that the new and existing equipment should interoperate.



3.3.1 Standardisation of numbering and exam codesPACS is not a “stand alone” solution (see below) and therefore when implementing the solution you will need to discuss with other projects that may be going on throughout the Trust or SHA. In particular, review if there are coding standards or patient numbers that should be considered.

If there are multiple departments involved you may need to agree on standardised coding for examinations, a mapping exercise may be required.

It cannot be stressed highly enough how big a job this will be for most Trusts, particularly those with multiple sites and potentially multiple RIS.

The NHSIA is currently working on the standardisation of imaging examination codes. Stakeholder engagement includes the Royal College of Radiologists, the design authority of the NPfIT (workflow and messaging), NPfIT PACS Implementation Advisors and some Cluster Team representation.

The underlying coding structure that is being considered is SNOMED Clinical Terms, which will also be used for messaging with the data spine.

The understanding is that while the standardisation of local exam codes will be needed to aid work in the “PACS clinical community”, having a National code is not essential for the visions and ambitions of the NPfIT PACS program.

3.3.2 Migration of DataDecisions regarding the migration of existing digital archives, both images and radiology exam requests, must be taken locally. There are various models that have been successful, but in each case it requires clearly defined, agreed and documented processes that must be adhered to.

At the beginning of the project it is important to define any interfaces and data conversions/migration required for PACS. Data migration refers to the acquisition of data on historical events and patient demographics from existing systems to new systems. Data acquisition and transfer refers to the acquisition of “current” data to the PACS.

Previous PACS installations have taken different approaches to film migration: See section 14

No prior images digitised and no data migrated.

Scan on demand – where the PACS is introduced and from that point on film-based patient records are scanned when a patient enters ‘active’ care within a Trust.

Planned migration – where the digitisation of images is started (using the active records approach above) in advance of PACS being introduced, use a local RAID store to create an initial archive.

Target group migration – where groups of patient records (for example cancer patients, children, etc) are scanned en masse into a PACS store.

Full migration – where films are scanned in to a PACS store in large quantities.

Digitised films will need to be reconciled in PACS and RIS.

The PACS NPfIT Team would be happy to discuss the various models with you, and share the pros and cons of the approaches. Appendix A contains information on aspects of film digitisers.

3.3.3 Reports and OutputsSystem reports can be obtained from the PACS being implemented. Check what standard (both statistical and workload examination based) reports are supplied with the systems and ask to see examples.

Any new local requirement for additional system reports should be checked for validity as they are usually at an extra cost, combine reports using fields from other reports if that is effective.

Review any current reports and ensure there is not duplication, or if a given report is required, reports need to reflect the processes that are being put in place.



Typical QueriesThe suppliers should provide answers to these questions and others appropriate to local needs. If advice is sought or concerns raised these should be directed to NPfIT Implementation Advisors throughout the Implementation phase.

What support will there be from the supplier at go live and for how long?

How long will there be application support

What will be the commitment of the integration specialists

What is the long term support? From

PACS supplier – is it 24/7?

CR /DR supplier – is it 24/7?

In house Network supplier– is it 24/7?

In house local IT– is it 24/7?

PACS Systems Administrator – is it 24/7?

What are the standard system reports?

What training does the supplier provide?

Will the training be cascade

Will they train all end users

Will there be documentation

o of training manual

o of the training done

How are the reference files populated?

Which reference files are pre-populated by the supplier

Which reference files need populating by Systems Administrator

Who enters user and security settings (passwords and privileges)

Who is responsible for the data conversion or interfaces? (including mapping)

Who is responsible for Benefits Analysis?

Benefits Base line

Set date for review and report

Who will agree sign off criteria before implementation?

Who is responsible for setting sign off date for acceptance and the acceptance criteria?

How are future software developments managed?

Automatic upgrades

Local requests

Statutory requirements



How is ‘ad hoc’ reporting managed?

What tool is used

Are all data items accessible

Are there sufficient viewing workstations for imaging staff to view previous soft copy images prior to X-ray? This can be done by record checking, in individual cases it may be necessary to view the previous images.

5. Project PlanningProject planning adheres to PRINCE 2 Project Management Procedures and Processes. Project plans are shared between the customer and the supplier and are joint working documents and will reflect the tasks required for a particular project. The approach will vary whether it is a multi or single site approach, but in either case one must always plan with the wider future requirements in mind.

While there are no standard plans as such, the individual plans are often developed from a supplier’s template. Appendix B has some example project plans.

Appendix B also documents an example project reporting structure and example deliverables/key milestones, but again these will tend to locally reflect structures put in place by the Cluster and LSP Teams.

6. Review Current Policies, Procedures and Working Practices

To implement PACS correctly an understanding of current working practices is required and reviewing current policies and written procedures. These then need to be considered in light of process redesign and the changes that will need to be made to successfully utilise the new solution. Change management is a critical factor in the success of PACS projects.

New policies and procedures for the use of the system should be carefully documented with specific reference for planned and unplanned downtime for consistency of operation and data recovery.

6.1 Process Change and use of the Modernisation AgencyThe Radiology service improvement team (Associate Director, 4 National Managers and 4 National Clinical Leads) are part of the Modernisation Agency. Their role is to provide expertise and advice on service improvement to clinical teams, Trusts and SHAs.

The National Framework for Radiology Service Improvement (July 2003) was developed in partnership with the MA, DH and Professional bodies to ensure an integrated approach to Radiology service improvement. It promotes a clinically lead approach which ensures all aspects of Radiology Modernisation are aligned, including - Changes in workforce; Equipment; Education; and IT strategies which includes PACS.

To support the above framework a Radiology Service Improvement toolkit is available. This aims to provide a basis for multidisciplinary redesign, based on proven service improvement methodology and learning from a number of pilot sites.

The National teams can provide support to any clinical team to ensure that service improvement is integrated across the whole systems of care including the service redesign opportunities that can be delivered as part of the implementation of PACS.

7. System TestingDuring implementation prepare some testing scenarios for the system, take them from real life and test a combination of input events, ensure that the outputs are as expected.

e.g. Check:

That the system identifies duplicate examinations.

Patient image history is displayedPACS Practical Experiences of 45


Attempt to enter invalid data e.g. a name in a date field and evaluate the outcome.

Images acquired to the system are matched to the correct examination

Images are displayed in the appropriate orientation

Examinations are retrieved and images displayed within the required time

Worklists display the appropriate examinations

The supplier should be able to provide example test scripts, but you will need to adapt them for local use and test your working practices as well as test the system. This could be a safe test environment on your installed system.

Enquire of the supplier as to the availability of a test system environment. It may be possible to perform tests on equivalent hardware and software prior to installation on site, or to carry out the tests on a partitioned area of the system after installation. A test environment can be a duplicate database on the installed system; it need not be a separate installation.

8. Training GuidelinesDisparate groups of staff will require training to different levels. Level of access will depend on the role of the individual across the Trust. Discussion with the supplier will help formulate the training strategy.

Determine how many trainers are available and the number of available areas to train people. Training ideally should happen as close to the go live as possible; to ensure staff retain the information, and ideally a maximum of 8 trainees at a time, and 2 trainers should attend each session.

Then take each group of staff and decide the length of time their training will take.

It is usually possible to do group training for most staff members, workload permitting, this may require 1 to 1 sessions for consultant and more senior staff.

Ensure that the composition of the groups is carefully considered as the training session should be relevant for the entire group, e.g. don’t try to train nurses and radiographers at the same time as their use of the system will be very different.

Ensure that people sign up for sessions as a free for all drop in session often means that people arrive late or leave early which can disrupt the group.

Develop training guidelines for the users, ensuring that these are short and to the point, large manuals are not easily read.

Some credit card size laminated guides are useful as people can keep them in their pockets or attach them to the terminal for easy reference.

Allow for extra sessions to train people who were unable to attend their allocated session. Users should not be assigned a PACS account and password until they have completed a training session satisfactorily. Schedule training sessions as part of a staff members normal working day to ensure maximum attendance.

Have trainer and trainee evaluation forms for the sessions to ensure that there is a record of any difficulties people may have experienced or any policy decisions that need to be followed up from the session.

If a member of staff has had issues during the training ensure that they are offered additional training or extra help over the go live period. PACS training should be an integral part of junior Doctors Induction Training

Identify “keen” users during the sessions as they will provide good support to other staff members in their areas.

Allow users access to a training system once they have completed their session to practise before go-live, better to have mistakes there than in the real system.



9. Technical and InterfacesThe Output Based Specification (OBS) for the Integrated Care Records Service (now the National Care Records Service) and the relevant technical information in section 115 - Digital Imaging Including Specification for a Picture Archiving and Communications System (PACS) Solution defines technical requirements and integration standards. The OBS can be found on the Department of Health website at http://www.dh.gov.uk/assetRoot/04/0716/32/04071632.pdf

In addition the Project Initiation Document (PID) for PACS also references recommendations for networking. See OBS available on www.dh.gov.uk

There should be real time interfaces between PAS, RIS and PACS this reduces the requirements for patient demographics to be re-entered on different systems. The RIS/PACS interface should pass the examination details automatically to the PACS

Details on technical aspects can be found in Appendix C.

10 Communication Clear communication is essential to the whole Trust.

Ensure that all staff are aware of the PACS implementation, through news letters and/or ‘lunch and learn’ sessions, encourage people to ask questions.

Projects that involve change often cause concern to staff and in particular in a PACS implementation there are likely to be staff changes and some relocation of resources. Make sure that these concerns are addressed.

The following lists some observations from sites that have installed PACS:

Plan implementation meetings on “quieter” days or parts of the day to ensure fewer interruptions.

When implementing a PACS there are practical considerations to be taken into account regarding the department layout that need to be thought through as part of the project. Service re-design should incorporate these considerations.

Involve the estates department at the beginning of the planning process for a PACS installations to ensure appropriate use of accommodation and facilities e.g. to assist with planning equipment moves, air conditioning.

Health and Safety issues must be considered in department redesign and documentation to assist with this is available from the local Estates department.

When looking at these practical designs there are three main areas to focus on: Radiologist office/Reporting area; Radiographer zone; Computer Room. The Radiologists offices and the reporting areas may be quite separate and may have quite different requirements. Please see Appendix D

Consider whether the implementation approach is to be “Big Bang” or “Phased”. Each have their specific advantages. Sites should determine which approach best suits their needs

Ensure that the Trust puts in enough funds to pay for what is needed, such as networking, allowing for contingencies that become apparent once implementation is under way.

Ensure good communication with IT colleagues to explain the true implications to all radiography and other clinical staff. PACS does not just 'plug and play'.

11 Staffing during ImplementationDuring the implementation phase the amount and type of resource will vary depending upon the size, phase and scope of the project. You will require multi-skilled staff with a range of competencies.

The following table documents some suggestions for the core skills that you will be looking for along with some of the expected key roles. The supplier should be able to provide their views


http://www.dh.gov.uk/

http://www.dh.gov.uk/assetRoot/04/0716/32/04071632.pdf


on the particular skills that they see as critical to a successful implementation along with the time commitment they see as appropriate.

Personnel Key Competencies and KnowledgeProject Manager Knowledge of PCs and MS Windows

Project management skills, principles and practices PRINCE II practitioner Clinical background (helpful not mandatory) Strong communication and interpersonal skills, high level of initiative

and problem solving skills, Team player System implementation experience Acceptance by colleagues Knowledge of organisation’s business needs Ability to delegate responsibilities and tasks Ability to commit time during the implementation process with focus,

detail, drive and enthusiasm Ideally someone who will remain with the organisation throughout the

life of the projectPACS Coordinator (s) And System Administrator post live

Knowledge of PCs and MS Windows Clinical background (Preferably Radiography) Strong communication and interpersonal skills System implementation experience (useful) Departmental knowledge and organisational knowledge / enterprise

working practices Organisational skills Negotiating skills, Team player, Sense of humour Able to deliver training and disseminate knowledge to address

requirements of all users in the enterprise Decision making Authority Acceptance by colleagues Strong problem solving skills Positive attitude

PACS Technical Lead Knowledge of PCs, MS Windows and Desktop OS Knowledge of networks and communication protocols Understanding of network infrastructure and hardware Ability to teach others Troubleshooting/problem solving skills with analytical approach Database administration knowledge

These personnel will require advice and support from others around them (e.g. IT, Training, Supplier, clinical groups)

When looking at the Implementation Team, consider the cluster and SHA implementation plans. Setting up an “expert PACS Implementation Team” at SHA level may be beneficial as it is very likely that implementations through a SHA will be staggered. As the system roles out you develop a core team of expertise that works at each site, utilising local expertise, and then as the implementation matures, this core team can evolve to also provide system support, training and maintenance.

12 Ongoing System ManagementA System Administrator / Manager will be required to provide ongoing system management. The amount of time this takes will vary upon the maturity of the system and the size and scope of the installation.

The role may be split between IT services and clinical personnel, but it is important that there is a person responsible to those in the clinical arena. This person needs to be involved from the formation of the PACS Project team. They should be responsible for facilitating the provision of the following type of services:

Design of working procedures to be implemented during periods of system downtime



Training new staff and maintaining knowledge base

System maintenance

Data Integrity

QA

Main contact point and support

Trouble shooting

System Testing and training for subsequent upgrades

Specific examples of tasks undertaken by people already in this role are documented below.

12.1 Maintenance of System / Database Design of working procedures to be implemented during periods of system downtime

whether such downtime is planned or unplanned

Ensuring that the PACS and RIS databases are updated and synchronised as soon as possible after the resumption of normal service.

Maintaining integrity of database e.g. ensuring there are no unprofiled examinations.

Ensuring that correct images for the exam are contained in the relevant folder.

Checking that changes to any information on RIS are completed on PACS.

Ensuring that empty orders do not occur e.g. pelvis/spine images not all in pelvis.

Checking exams are verified to allow appearance on reporting worklist.

Creation of codes on RIS e.g. exam codes/radiographer codes/reporting codes etc.

Resending failed orders from RIS to PACS.

Checking system back-up on daily basis.

Auditing input errors RIS/PACS.

Correct any faults sent to PACS e.g. exams marked “completed” in error.

Keeping accurate and timely records with regard to all aspects of system etc.

12.2 Looking after the Internal Users Providing effective training, with follow up if required.

Provision of User ID and password to acceptable users following training.

Keeping full records of training, user Ids etc.

Ensuring that users have correct privileges for system.

Setting up Academic (manual) Folders, and providing training on the same.

Creating protocol for input of new doctors twice yearly, and dropping leaving doctors from the system.

Creation of compact discs etc for multi-disciplinary meetings/case studies etc.

Addressing user application problems.

Monitoring systems remotely to ensure correct usage/users logging out etc.

12.3 Service Provision for External Users Managing the printing of films for other hospitals (patient transfers), controlling access

rights for those carrying out the activity.

Creation of compact discs with images for other hospitals/clinics.

Setting up Web Browser access for GP surgeries/clinics/hospices.



System demonstrations.

Department tours, to include explanations of post involvement.

Liaising with other hospitals and departments re any service involving PACS.

Responsibility for ensuring continued connectivity and interoperability with cluster storage and with the NCRS

13. Supporting the Paperless EnvironmentThe significant proportion of communications both between and within departments is still paper based and it is recognised that this will continue. However, the long term aim should be the move to electronic based communications.

The reduction in paper is supported by electronic order communications and results reporting, the electronic capture of all relevant and appropriate clinical information and the overall vision of NCRS, of which PACS is a component.

Decisions about the migration of any existing analogue archive have to be made in the light of the Trust’s PACS wider role i.e. sending and receiving data from other PACS and the NCRS.

Patient demographic data also needs to be migrated with the amount of information migrated being at least commensurate with the image data migrated.

14. Identifying Potential BenefitsPACS can provide many benefits, some can be financially measured but many are aspects that improve the quality of service and patient care, and indeed some improve the work environment and the environment as a whole.

Each site will need to identify their expected benefits as a part of their business plan as the type and volume of benefits achievable will depend upon local variances such as service redesign , physical geography and services provided.

See appendix E for a table of example benefits.

Appendix E also includes an example from a site where the deployment of PACS has improved services.

15. Go-Live PeriodThe go-live date needs to be part of the implementation plan. Most clinical departments will require between 6 – 12 weeks confirmation notice. When choosing a go live date consider the timing of this in relation to workload (sometimes a go live over a weekend is preferable, but it must be ensured that support staff are available either on site or on call) or reducing workload from all areas (e.g. clinics) for a few days in advance is advisable, if appropriate. Notices for patients and communications to all other staff and GPs are essential to explain that a new system is being implemented.

The supplier should provide extra go live resources during this period and likewise the site should provide extra staff. Extra supporting documentation / crib sheets should be made available at workstations.

During this period it is important that you have a clear process for handling questions, issues and general support calls, often a dedicated go live log is used. Typically the Project Manager should be responsible for the escalation and resolution of the issues, while the System Administrators will be key in actually resolving many of them during this time. A “tier” system should be defined for the escalation of issues.

Any deviation from the go-live date should be communicated across the Trust at the earliest opportunity.



16. Measuring Benefits / Post Implementation ReviewTypical areas included in a Post Implementation Review would cover:

Executive Summary

Introduction

Need for PACS

Match with Business Strategy

Match with IM&T Strategy

Technical solution delivered

Benefits realised against targets

Benefits delivered

Unexpected benefits delivered

Costs incurred against projection

Business risks

Technical risks/considerations

Business satisfaction

Suggested changes for the future

Recommendations

A post implementation review provides the opportunity to revisit what was done, and consider any changes to processes that may be useful.



17. Business Case Support – See Appendix F



A Appendix A – Film Digitisers

A.1 Film DigitisersFilm digitisers perform the task of taking an image stored on film and converting that image information into a digital data file suitable for storage on a computer. This file can subsequently be stored, manipulated, compressed, transmitted and displayed like any image file acquired to the PACS direct from an imaging modality.

The image resolution obtained after digitising a film depends on the scanner used. The resolution used for a particular scan may also be selectable on the scanner. The ACR (American College of Radiology) recommends a resolution of 2.51 1p/mm, 10 bits deep for film digitisation for primary needs (American College of Radiology Standard for Digital Image Data Management, 1998).

Film digitisers are built using one of three different technologies.

A.1.1 Camera Light is shone through the film being digitised, and a digital camera captures the information. This is a low-cost solution, but it is also a low-quality solution, and digitisers built around this technology are probably not suitable for medical imaging work.

A.1.2 CCD (Charge-Coupled Device)Light (usually from a specially-designed fluorescent tube) is shone through the film, and is collected by a CCD array. A CCD is a sensitive electronic device that is capable of turning light into electrical signal; in turn, this signal can be turned into digital data. The quality of the image depends on the sensitivity of the CCD array, and the size and spacing of each element within the CCD array.

A.1.3 LaserA very thin beam of laser light is shone through the film; the beam is scanned across and down the film until the whole image area is covered. The light transmitted through the film is collected by a photomultiplier tube, which turns the light energy into electrical signal which is then digitised. It has the advantages over CCD of producing a sharper image, and of having a greater dynamic range, but the ultimate resolution is comparable to CCD. It is the most expensive of the three options.

Film digitisers will typically be attached to the PACS network in a similar manner to other acquisition devices, and images acquired from film digitisers onto the PACS should be managed in the same way. This will include the creation of an examination on PACS to send the image data to. One difference is that no local storage will be required, since the original film acts as its own data store. Care should be taken to ensure that when the examinations are displayed or listed on the PACS, the “examination date” is the actual date of the original examination and not the date that the examination was digitised.

A.2 Digitiser Quality ControlJust as traditional processors require QA, film digitisers require regular checks to ensure that they are performing adequately.

These checks should include:

Linearity of response of output pixel value to film optical density.

This ensures that a change in the optical density of the film from one region on the film to another produces an appropriate change in the pixel data value stored in the image data file. Pixel values of particular areas in the image data file can be determined using the tools available on most PACS workstations, and the optical density of the corresponding region of the film can be measured with a densitometer.

Consistency of response of output pixel value to film optical density.



This ensures that regions within a film - or on different films - that have the same optical density produce equal pixel data values in the image data file. Again, pixel values in the image data file can be determined using a PACS workstation, and the film’s optical density can be measured with a densitometer.

Spatial resolution.

This is a measure of the ability of the digitiser to detect small features in an image or to differentiate between two closely-spaced, but separate, features. A test film containing images of suitable test objects, e.g. line-pair test tools, can be scanned and the digital image produced can be visually inspected.

Contrast resolution.

This is a measure of the ability of the digitiser to produce a change in pixel data values for regions in the image that are of similar, but different, optical densities. The testing method is similar to that for the test for linearity of response, above.

Geometric distortion.

This is a test of the ability of the digitiser to create digital images which retain the proportions of the original image. In particular, all straight lines in the original image should remain straight when viewing an image reconstructed from the digitised image data



B Appendix B – Project PlanningSuccessful installation and implementation of a PACS system relies on good preparation and planning. Plans are constructed by identifying the products required, the activities and appropriate resources necessary to deliver them. Keep plans relevant, be aware of the audience for the prepared set of plans and aim to provide an appropriate level of detail for tasks and activities.

Time must be allowed for planning because it is a time consuming exercise. Planning for the next stage should start towards the end of the current stage.

It is easier and more accurate to plan short stages than long ones. Plans should cover all aspects of the project, giving everyone involved a common understanding of the work ahead. Consider the following initial steps

Decide what activities should be done and by whom, All activities should be thought through in advance and to a consistent level

Estimate how much effort each activity will consume

Estimate how long the activities will take and agree tolerance levels for this plan

Produce a time based schedule of activities

Calculate what the overall effort will cost, produce the budget from the cost of the effort plus any materials and equipment that must be obtained

Assess the risks contained in the plan

B.1 An Example Summary of the rationale behind planningThe key areas of the project plan have been designed to:

Highlight key milestones during implementation.

Achieve core RIS and Modality integrations early to enable a smooth ‘plug and play” core PACS installation.

Start archiving as soon as possible.

Allow for Theatre workstations to be installed over a holiday period, so as not to disrupt services.

Install local workstations last so as to allow a build up of the digital archive before softcopy reporting.

Deliver temporary CR installations during enabling works to allow for continuity of service.

Allow flexibility, as once the core system and interfaces are installed the remaining PACS roll-out phases can be easily tailored.

B.2 An Example of Supplier Commitment to Project ManagementSupplier commitment is vital to the success of the project. However, there may be more than one supplier involved in the PACS project and the commitment must be from all the suppliers.

The Company commits to working with the Trust to Project Manage the PACS implementation utilising the PRINCE 2 methodology.

The Company commits to delivering an on-site Project Manager as reasonably required, to deliver the Project within the timelines detailed in Project Plan included as an appendix to this Schedule.

The Company commits to this Project Manager attending on-site project meetings. Should the Project Manager be absent from work a suitably trained and briefed deputy will be appointed.

Full details of the Company Project Manager is given and so are details of all Company personnel involved in delivering this project.



Third parties will be managed by the Company’s Project Manager via agreements made with these companies when a purchase order is raised for their required input.

Round table meetings with these vendors will be hosted by the Company, as required, to ensure timely delivery of resources and manage the implementation process.

B.3 Example Project Plan


ID Task Name Duration Start Finish1 PACS Install 169 days? Mon 12/05/03 Thu 01/01/042 Contract signed 1 day? Thu 01/01/04 Thu 01/01/043 PACS room designated 1 day? Mon 12/05/03 Mon 12/05/034 Drawings for PACS room 20 days Tue 13/05/03 Mon 09/06/035 Proposal drawings submitted 2 wks Tue 13/05/03 Mon 26/05/036 Draft Drawings supplied 2 wks Tue 27/05/03 Mon 09/06/037 Drawings Accepted 0 days Mon 09/06/03 Mon 09/06/038 Delivery 80 days? Fri 02/01/04 Thu 22/04/049 Delivery methodology 1 day? Fri 02/01/04 Fri 02/01/04

10 Deliver PACS Site A 16 wks Fri 02/01/04 Thu 22/04/0411 Deliver PACS Site B 16 wks Fri 02/01/04 Thu 22/04/0412 Installation 21 days? Fri 23/04/04 Fri 21/05/0413 Install core components Site A 2 wks Fri 23/04/04 Thu 06/05/0414 Install core components Site B 1 wk Fri 23/04/04 Thu 29/04/0415 Integrate Dicom modalities 5 days Fri 07/05/04 Thu 13/05/0416 Integrate non Dicom modalities 5 days Fri 07/05/04 Thu 13/05/0417 Mirror Broker 5 days Fri 14/05/04 Thu 20/05/0418 Remove temp broker 1 day? Fri 21/05/04 Fri 21/05/0419 Test web functionality 1 day? Fri 14/05/04 Fri 14/05/0420 Distribute Workstations 1 day? Mon 17/05/04 Mon 17/05/0421 Test workstations 1 day? Tue 18/05/04 Tue 18/05/0422 Installation Accepted 0 days Tue 18/05/04 Tue 18/05/0423 Training Program 15 days Wed 19/05/04 Tue 08/06/0424 System Admin 5 days Wed 19/05/04 Tue 25/05/0425 Web core training 5 days Wed 26/05/04 Tue 01/06/0426 Radiologists training 5 days Wed 02/06/04 Tue 08/06/0427 Training Acceptance 0 days Tue 08/06/04 Tue 08/06/0428 GO LIVE 0 days Tue 08/06/04 Tue 08/06/0429 Go live support 5 days Tue 08/06/04 Mon 14/06/0430 System Acceptance 0 days Tue 08/06/04 Tue 08/06/04

18/05

08/0608/06

08/06

Jan Feb Mar Apr May JunQtr 1, 2004 Qtr 2, 2004 Qtr 3, 2004


B.4 Example Multi Site PlanBelow are two detailed project plans from multi site installations. The level of detail is greater, note the provision of temporary imaging solutions to facilitate continuation of service.

B.4.1 Example 1


ID Task Name Duration Start Finish1 Phase 2 install 80 days Tue 08/06/04 Mon 27/09/042 Phase 1 sign off 0 days Tue 08/06/04 Tue 08/06/04

3 Order CR 10 wks Tue 08/06/04 Mon 16/08/04

4 Order workstations 16 wks Tue 08/06/04 Mon 27/09/04

5 Drawings 20 days Tue 08/06/04 Mon 05/07/046 Proposal drawings CR 2 wks Tue 08/06/04 Mon 21/06/04

7 Proposal drawings workstations 2 wks Tue 08/06/04 Mon 21/06/04

8 Draft drawings submitted 2 wks Tue 22/06/04 Mon 05/07/04

9 Drawings Accepted 0 days Mon 05/07/04 Mon 05/07/04

10 Installation CR 18 days Tue 17/08/04 Thu 09/09/0411 Temp install CR 5 days Tue 17/08/04 Mon 23/08/04

12 refurb CR area 3 wks Tue 17/08/04 Mon 06/09/04

13 Re-site CR 3 days Tue 07/09/04 Thu 09/09/04

14 Acceptance test CR 0 days Thu 09/09/04 Thu 09/09/04

15 Installation Workstations 21 days? Tue 07/09/04 Tue 05/10/0416 Refurb radiologist offices 3 wks Tue 07/09/04 Mon 27/09/04

17 Install Workstations 1 wk Tue 28/09/04 Mon 04/10/04

18 Test workstations 1 day? Tue 05/10/04 Tue 05/10/04

19 Site 1 23 days? Fri 10/09/04 Tue 12/10/0420 delivery of CR 1 day? Fri 10/09/04 Fri 10/09/04

21 Provide temporary imaging solution 4 days Mon 13/09/04 Thu 16/09/04

22 Refurb Imaging area 5 days Fri 17/09/04 Thu 23/09/04

23 Install CR Solo +unix Dips station 2 days Fri 24/09/04 Mon 27/09/04

24 Configure cluster+training 5 days Tue 28/09/04 Mon 04/10/04

25 Acceptance of install 1 day Tue 05/10/04 Tue 05/10/04

26 Install workstation at site 2 5 days Wed 06/10/04 Tue 12/10/04

27 Test all links 0 days Tue 12/10/04 Tue 12/10/04

28 Training 47 days? Tue 24/08/04 Wed 27/10/0429 Train CR core trainers 5 days Tue 24/08/04 Mon 30/08/04

30 Core web training 5 days Tue 31/08/04 Mon 06/09/04

31 Train Radiologists 1day per Radiologist 10 days Wed 06/10/04 Tue 19/10/04

32 Training Acceptance 0 days Tue 19/10/04 Tue 19/10/04

33 GO LIVE 1 day? Wed 20/10/04 Wed 20/10/04

34 Go Live support 5 days Thu 21/10/04 Wed 27/10/04

08/06

05/07

09/09

12/10

19/10

31 07 14 21 28 05 12 19 26 02 09 16 23 30 06 13 20 27 04 11 18 25 01May '04 Jun '04 Jul '04 Aug '04 Sep '04 Oct '04 Nov '04

ID Task Name Duration Start Finish Predecessors1 PHASE 3 147 days Wed 16/06/04 Thu 06/01/052 Sign off Phase 2 0 days Fri 29/10/04 Fri 29/10/04

3 Order CR 10 wks Fri 29/10/04 Thu 06/01/05 2

4 Phase 3 PACS Accepted 0 days Wed 16/06/04 Wed 16/06/04

5 Drawings 15 days Fri 29/10/04 Thu 18/11/046 Site 2 CR 5 days Fri 29/10/04 Thu 04/11/04 2

7 Site 3 CR 5 days Fri 29/10/04 Thu 04/11/04 2



10 Site 6CR 5 days Fri 29/10/04 Thu 04/11/04 2

11 Draught copies of all Drawings 10 days Fri 05/11/04 Thu 18/11/04 6,7,8,9,10

12 All Drawings Accepted 0 days Thu 18/11/04 Thu 18/11/04 11

13 Installation 54 days? Fri 07/01/05 Wed 23/03/0514 Site 2 20 days? Fri 07/01/05 Thu 03/02/0515 Temp Install CR 2 days Fri 07/01/05 Mon 10/01/05 3,4

16 Refurb Imaging area 5 days Tue 11/01/05 Mon 17/01/05 15

17 Install CR 2 days Tue 18/01/05 Wed 19/01/05 16

18 Install Printer from Hexham 1 day? Thu 20/01/05 Thu 20/01/05 17

19 Acceptance of install 0 days Thu 20/01/05 Thu 20/01/05 18

20 Training 10 days Fri 21/01/05 Thu 03/02/05 1921 Train Core trainers 10 days Fri 21/01/05 Thu 03/02/05

22 Site 3 11 days Fri 04/02/05 Fri 18/02/0523 Provide temporary imaging solution 2 days Fri 04/02/05 Mon 07/02/05 21

24 Refurb Imaging area 5 days Tue 08/02/05 Mon 14/02/05 23

25 Install CR Solo 2 days Tue 15/02/05 Wed 16/02/05 3,24

26 Configure cluster+training 2 days Thu 17/02/05 Fri 18/02/05 25

27 Acceptance of Install 0 days Fri 18/02/05 Fri 18/02/05 26

28 Site 4 12 days Mon 21/02/05 Tue 08/03/0529 Provide temporary imaging solution 3 days Mon 21/02/05 Wed 23/02/05 27

30 Refurb Imaging area 5 days Thu 24/02/05 Wed 02/03/05 29

31 Install CR Solo 2 days Thu 03/03/05 Fri 04/03/05 30

32 Configure cluster+training refresh 2 days Mon 07/03/05 Tue 08/03/05 31

33 Acceptance of install 0 days Tue 08/03/05 Tue 08/03/05 32

34 Site 5 11 days Wed 09/03/05 Wed 23/03/0535 Provide temporary imaging solution 2 days Wed 09/03/05 Thu 10/03/05 33

36 Refurb Imaging area 5 days Fri 11/03/05 Thu 17/03/05 35

37 Install CR Solo 2 days Fri 18/03/05 Mon 21/03/05 36

38 Configure cluster+training refresh 2 days Tue 22/03/05 Wed 23/03/05 37

39 Acceptance of install 0 days Wed 23/03/05 Wed 23/03/05 38

29/10

16/06

18/11

20/01

18/02

08/03

23/03

25 01 08 15 22 29 06 13 20 27 03 10 17 24 31 07 14 21 28 07 14 21 28 04Oct '04 Nov '04 Dec '04 Jan '05 Feb '05 Mar '05 Apr '05


B.4.2 Example 2ID Task Name Duration

1 XXX HOSPITALS NHS TRUST 194.5 days2 Contract Discussions 1 day3 Sign Contract 1 day

4 Order Equipment 80 days5 IMPAX 16 wks

6 ADC 12 wks

7 PAXPORTS 6 wks

8 HARDCOPY 6 wks

9 MILESTONE 1: BROKER/CORE PACS/PAXPORTS102 days10 Sign off funct ional specification 10 days

11 Install 'Ghost Broker' 2 day s

12 Conf igurat ion and Testing with Torex 4 wks

13 Delivery of Broker Hardware 1 day

14 Migration to new Hardware 1 wk

15 Testing 1 wk

16 Acceptance tests and sign off 3 day s

17 NON-DICOM MODALITY INTEGRATION 15 days18 Deliver PAXPORTS to site 1 day

19 Install PAXPORTS to modalities 7 day s

20 Test images arriv ing at PAXPORT 3 day s

21 Test worklist arriv ing f rom Broker 3 day s

22 Acceptance and sign of f 1 day

23 DELIVER/INSTALL CORE PACS 22 days24 Deliver to site 1 day

25 Installation 3 day s

26 Install CS5000 into Theatres 3 day s

27 Broker Messaging and Testing 3 day s

28 Connection/Testing NON DICOM Images 3 day s

29 Connection/Testing DICOM Images 3 day s

21/07 25/08 29/09 03/11 08/12 12/01 16/02 22/03 26/04 31/05 05/07 09/08 13/09 18/10 22/11 27/12July October January April July October

ID Task Name Duration

30 Acceptance and Sign Of f 1 day

31 MILESTONE 2:ROLL-OUT DS3000 AND CS500026.5 days32 Deliver to site A 1 day

33 Install Basement Reporting MRI 0.5 days

34 Testing Images and Desk-Top Integrat ion 1 day

35 Acceptance Tests 1 day

36 Install Reporting CT 0.5 days



39 Install CT Scanner Report ing 0.5 days



42 Install Ground Floor Reporting 0.5 days



45 Install and Test CS5000 Workstations 2 day s

46 Deliver to site B 1 day

47 Install CT Report ing 0.5 days



50 Install Consultant Stat ion 0.5 days



53 Install and Test CS5000 Workstations 2 day s

54 Deliver to site C 1 day

55 Install Seminar Room 0.5 days



58 Install Radiology Seminar Room 0.5 days

21/07 25/08 29/09 03/11 08/12 12/01 16/02 22/03 26/04 31/05 05/07 09/08 13/09 18/10 22/11 27/12July October January April July October

ID Task Name Duration



61 Install Reporting Area 0.5 days



64 MILESTONE 3: CR IMPLEMENTATION 25 days65 Pre-Installation Work site A ITU 1 day

66 Deliver site A ITU 1 day

67 Installat ion site A ITU 1 day

68 Additonal training, testing, acceptance 2 days

69 Temp. Installation site B A&E 2 days

70 Pre-Installation site B A&E 2 days

71 Installat ion site B A&E 2 days


73 De-Install temporary install 1 day

74 Temp. Installation site C 2 days

75 Pre-Installation site C 2 days

76 Installat ion site C 2 days


78 De-Install temporary install 1 day

79 MILESTONE 4: WEB ROLL-OUT 30 days80 Roll-out of web based imaging to all clinical locations6 wks

81 MILESTONE 5: ACCEPTANCE 5 days82 Acceptance testing 5 days

83 MILESTONE 6: FINAL ACCEPTANCE 5 days84 Final acceptance rev iew 5 days

25/08 29/09 03/11 08/12 12/01 16/02 22/03 26/04 31/05 05/07 09/08 13/09 18/10 22/11 27/12 31/01July October January April July October January



B.5 An Example of a PACS Implementation Reporting StructureCommunications is an important part of the Implementation process, detailed below is an example of a reporting structure. Not all implementations would necessarily follow this structure as the teams and practice would differ between sites.


PROJECT STEERING COMMITTEESUPPLIER TEAM:Informatics Business ManagerBusiness AnalystInformatics Account ManagerProject ManagerTRUST TEAM:Trust Project ManagerGeneral Manager ImagingRadiology Service ManagerLead Radiologists

IMPLEMENTATION TEAMSUPPLIER TEAM:Project ManagerInformatics Account ManagerRegional PACS SpecialistRegional Service team leaderLead Engineer

TRUST TEAM:Project ManagerImplementation Radiographer

SENIOR MANAGEMENT TEAM

SUPPLIER TEAM: Healthcare DirectorTRUST Project Sponsor: Medical Director for Clinical Services

THIRD PARTIESRIS SuppliersPAS SuppliersHIS SuppliersModality Suppliers

PM Manages Third Party Companies:-Purchase orders-On-site commitment-Integration-Acceptance

PM feeds implementation team

Monthly Report to steering committee

Issue resolution

Monthly Report Issue Resolution

Issue Resolution

Issue Resolution

INSTALLATION TEAMSUPPLIER TEAM:EngineersApplications Specialists

TRUST TEAM:Project Manager

Report to Implementation team

Implementation Team feeds Installation Team

THIRD PARTY SENIOR MANAGEMENT

INSTALLATION TEAMSUPPLIER TEAM (incl LSP and PACS Vendor)EngineersApplications Specialists


INSTALLATION TEAMSUPPLIER TEAM:EngineersApplications Specialists


This structure reflects experience in single Trust Implementations.

It is recognised there is less experience of implementing multi-site PACS


C Appendix C – Technical and Interfaces

C.1 NetworkingThe OBS states that “The Contractor shall check that the Authority networks and connections are satisfactory to deliver the performance described in Section 4.3 (Solution Requirements) and the Contractor shall state whether any changes are required to Authority networks. The Contractor shall state the minimum network and connections required to deliver the performance described in section 4.3.”

In addition “The Contractor shall be required to warrant the performance of their system over the network, or propose enhancements if the network is not adequate.”

It should be noted that the NPfIT PACS Project Initiation Document (PID) suggests that “A robust LAN is essential. PACS must not be installed on a network less than 100Mbps Ethernet.”

The PID also recognises the dependency of N3 for the Delivery of Wide Area Network (WAN) network infrastructure work to provide required PACS bandwidth and availability (which will provide services for more than just community PACS). Image data volumes have been shared with N3 to aid their capacity planning.

So in summary the supplier will typically undertake a survey of the local Area Network and make recommendations. An example of one is available from the NPfIT if required.

C.2 Communication Standards

C.2.1 DICOM (Digital Imaging and Communications in Medicine)The DICOM standard was established to aid the distribution and viewing of digital medical image data. Conformance to the DICOM standards helps devices within a PACS to communicate. It should be noted that merely “conforming to DICOM” does not guarantee that any two devices will be able successfully to communicate; it must be ensured that the devices’ particular implementation of DICOM is complementary.

The OBS dictates that “The Service shall adhere to DICOM 3.0 and its successors to enable interoperability of multiple suppliers’ equipment in a network environment.” It documents at length the various capabilities the supplier is required to deliver.

C.2.2 IHE (Integrating the Healthcare Enterprise)Again the OBS covers this requirement, “The service provider shall provide as part of the response to this document a conformance table for all of its products in relation to the 'Integrating the Healthcare Enterprise' (IHE) standard profiles and the date that these were tested and proven. Any development paths to aspects of HIPAA compliance relevant in the NHS shall be stated.”

C.2.3 HL7IHE (Integrating the Healthcare Enterprise) is a global initiative designed to advance the data integration in healthcare. It aims to develop a framework to ease the integration of, and information flow between various medical information systems, with the ultimate goal of ensuring that all required clinical information is correct and readily available to the relevant users. Currently, interfacing systems can be difficult due to the different standards – and implementation of those standards – employed by such systems. IHE aims to define how existing standards may be used in order to facilitate communications between computer systems used in healthcare; initially, IHE will concentrate on DICOM and HL7 but mat extend to other standards if necessary.

The OBS states that “The Contractor shall ensure that the PACS service shall be fully integrated with other systems within the Authority and must confirm that the IHE, DICOM and HL7 standards are the basis for the integration with other systems.” Also where appropriate “The Contractor shall migrate communications to HL7 v3.



C.3 InterfacesWhen designing and implementing a PACS it is important to give detailed thought to storage, management and acquisition of non-image data (e.g. patient demographic data, examination details, clinic appointments, etc).

Much, if not all, of the non-image data required by a PACS is available on external systems such as Radiology Information Systems (RIS), Patient Administration System (PAS) or Hospital Information Systems (HIS). The standards described above should be used for the sharing of this data and the sort of information required includes aspects of examinations on RIS, current patient location and forthcoming appointments (HIS, PAS and RIS)

To allow for efficient communication between an external information system and a PACS, it may be necessary to use an interface engine. An interface engine is a computer system which sits between two (or more) information systems, and reformats the output from one system into a form readable by the receiving system. In a PACS implementation, this interface engine is generally referred to as a “PACS Broker”. It typically receives information on patient demographics and examination bookings from a RIS and/or a HIS, and passes this data on to the PACS, following appropriate reformatting by the broker. Data can also flow from the PACS to an external system should the external system have the ability to use data from the PACS (for example information from an imaging modality regarding the acquisition status of an examination). The PACS broker may maintain its own database of information derived from information acquired from the attached devices.

The advantages of integrating other hospital information systems with a PACS include:

A single point of entry for data means consistency, and avoids duplication of effort

Access to scheduling information aids image data storage management. Information on scheduled clinic visits or radiological examinations can be sent from the HIS or the RIS to the PACS. The PACS can then use this information on which patients will be attending the healthcare institution to ensure that all relevant images for those patients are available in on-line storage in time for their attendance.

Access to patient location information allows for filtered worklists. PACS can obtain information on patient status and location from the HIS, and use this to present useful worklists to radiologists and clinicians. For example, a list of examinations for all patients on a particular ward can be created.

C.4 Digital ImageOne of the key features of a PACS is its ability to store and transfer image data. This is a digital representation of the original image, and all image data acquired onto the PACS must be digital.

Many imaging modalities already produce data in digital form (for example, CT or MR) and these modalities may be attached directly to the PACS (although it is possible that some intermediate interfacing unit will be required). Other modalities generate image data as analogue film (for example, traditional x-ray) or video display (e.g. older ultrasound scanners) only and this analogue data must be converted to digital form before it can be sent to the PACS.

Images produced on traditional film can be converted to digital form using a film digitiser (See Appendix A2) and indeed video displays can use “frame grabbers” to be converted to digital output.

In recent years, Computed Radiography (CR) and Direct Radiography (DR) have become increasingly important for plain x-ray imaging. Both CR and DR, together with modalities such as CT and MR, produce digital data.

C.4.1 Digital Image CaptureTo capture a digital image using, for example, computed radiography (CR), there is a similar chain of events to those in capturing an image to film.

load an unexposed imaging plate into a cassette



expose the plate to x-ray radiation

produce the image by passing the plate through a CR plate reader

create and store a computer file containing the image data

Other imaging modalities will form the image by processes appropriate to that modality, but however the image is formed, the end product is a computer file containing the image data. The only exception to this is where computed radiography is used to print film, with the creation of an image data file being a temporary step towards production of the film.

C.4.2 Acquisition of Digital Data on to the PACSOnce data is in digital form, it can be transmitted to PACS storage. This storage may be centralised, with a single on-line storage facility that can accept data from anywhere in the institution and similarly distribute the data, or local storage, where image data from the local modality can be stored, for subsequent distribution as necessary. Following acquisition, image data is likely to be stored on on-line storage. The data may subsequently be saved on near-line or off-line archive storage.

It should be noted that different imaging modalities produce images requiring different amounts of data for their representation. A typical chest examination generated by CR, for example, can be of the order of 8 MB, whereas a single CT slice image may only be of the order of 0.5 MB. Note that the figure for CT is for a single slice; modern multi-slice scanners can generate many hundreds of slices and can therefore place heavy demands on the PACS network and data storage facility.

Calculation of the amount of data required for an image is straightforward: it is the size of the image in pixels multiplied by the number of bits required to store each pixel. For example, for a typical CR chest image:

Image width: 1760 pixels

Image height: 2140 pixels

Number of bits/pixel: 16 bits

Thus to store a single CR chest image requires 1760 x 2140 x 16 bits = 60262400 bits. Assuming 8 bits per byte, 1024 bytes per kB and 1024 kB per MB, this calculates to 7.2 MB per image. Lossless compression can typically reduce the storage requirements by about a factor of 2.

In order to calculate the archive storage requirements for a PACS, the data on the typical image sizes for each modality can be used. For each modality, multiply the typical image size by the average number of images per exam, and multiply this figure by the number of examinations performed in a year. This will give the annual storage requirements. This figure can be modified according to the amount of compression to be used on the data.

C.4.3 The Database Server and DICOM GatewayThe main PACS server within a healthcare enterprise holds a database of all patient examination information, which is usually a copy that the PACS server receives from the RIS.

This database includes details of patient demographics, and the examinations the patient has had since the PACS was installed (and possibly earlier examinations, if digitised). It also contains the information necessary for the PACS to be able to find the images for those examinations, and to direct copies of the images to local storage as required (depending on the architecture of the system). For systems connected to the NHS spine, there may also be the facility to request patient information and image data stored elsewhere in the NHS.

The PACS server also performs routine scheduled tasks required for system maintenance, and allows the system administrator to carry out manual tasks and system tuning as required. The regularly scheduled tasks can include daily and/or weekly backups, pre-fetching of historical images for review purposes, “flushing” of the on-line storage. Manual tasks can include management of user accounts, reconciling discrepancies within the database, and managing interfaces with external information systems.



The storing of image data uses the DICOM standard. Most medical image acquisition devices produce image data compatible with the DICOM standard. There may be occasions when imaging acquisition devices that are not DICOM-compliant will be required to send images to a PACS. It can be possible to acquire images onto the PACS by use of a “DICOM gateway.” In a similar manner to which a PACS broker allows information flow between a PACS and external information systems, a DICOM gateway can allow image data to flow from imaging devices to the PACS.

C.4.4 Digital image displayOnce the image data file has been created, the image can be displayed by transmitting this data file to a viewing workstation. Here the image data is rendered to form the image, and this image is displayed on the workstation monitor. Typically, display monitors are less bright than conventional light boxes, but they have image processing capabilities that allow for contrast resolution enhancement across the range of brightness. Display monitors and workstations are discussed in more detail later.

C.4.5 Digital image storageDigital images can be stored on a number of different types of media, including computer hard disks, tapes, optical discs, compact disc. Reasonable care should be taken that the environmental conditions are appropriate for the type of storage. Generally this means avoiding extremes of temperature and humidity, and keeping the environment clean and dust-free. Management of the images is much simpler than with film, since the PACS management application will log all stored files and their location. The problem of lost films should be much reduced, since all original image data files remain permanently in PACS storage (it is only ever a copy of stored data files that is transmitted over the network for display), and there should be no manual misfiling problems.

PACS has the ability to archive image data files and make the image data available for viewing at one or more remote viewing stations, the image data being transmitted over a computer network. The image archive may be centralised (i.e. a single, large repository for all the image data acquired from the various imaging modalities around the site) or distributed (a number of archive devices attached to the PACS network).

Medical imaging can create large amounts of image data, both in terms of the number of images generated and the size of the image files. It therefore follows that large amounts of storage are required for the image files.

An archive identifies stores and protects data, whether this data is in electronic form or in traditional paper and film form. Whatever form the archive takes, decisions have to be made regarding the amount of storage space needed – physical storage space for archiving of traditional media or computer storage space for archiving of digital data. Thought must be given both to immediate and to future needs. Thought should also go into the requirements for the back-up of image data.

On-line storage. A storage device that makes images available immediately on demand. It is generally a “RAID” (Redundant Array of Inexpensive Disks) device, consisting of a large number of hard disks. Its advantage is that data can be found and delivered very quickly. The price of RAID storage has decreased dramatically in the last few years and their storage capacity has increased. Although disks that have high access times and have a high build quality are still more expensive than the disk in a PC, it is now economically feasible when tendering for a PACS to specify an “Everything Online” (EOL) RAID. This usually allows the trust to maintain at least one to two years of examination data online.

Near-line archive. A large-capacity storage that is capable of storing more data than the on-line storage, often several years’ worth of data, which may be sufficient to store a site’s entire image archive. The near-line archive is the primary archiving device for storing the master copy of acquired image data files; it delivers copies of these image data files to the on-line storage when required. Delivering data from the near-line archive to the on-line storage takes a short but appreciable period of time, generally in the order of minutes or tens of seconds. Near-line archive devices can be built using a number of different technologies, e.g. tape or disc.



Off-line archive. Should the near-line archive become full, a third line of storage can be used. Space is freed in the near-line archive by removing archive media that become full, and replacing them with blank media. The removed media can be stored on a shelf, and replaced in the near-line archive device should the data contained upon it be required. Note that this replacement will require manual insertion by PACS support staff, and it could be several hours before the data becomes available. The removed media should be stored in a safe place, and needs to be managed properly so that the disk or tape containing the required data can easily be found.

Recent increases in the capacity of systems, together with price falls, are leading to a shift in thinking away from the above definitions of storage (which are focussed on the ease of accessibility of the data), to definitions based on the lifetime of the data within storage classes. As disk-based systems increase in capacity, it becomes feasible to store several months’ data “on-line”, with the complete archive being stored “near-line” in a tape or disk-based archive. Thus storage can be thought of as being in one of two categories: “short-term” or “long-term.”

The most common types of hardware used to provide storage solutions are those using magnetic and optical technologies. This can be further broken down into disk (e.g. RAID, DVD, Magneto Optical Disk (MOD)), and tape (e.g. Advanced Intelligent Tape (AIT), Digital Linear Tape (DLT), Linear Tape Open (LTO) Digital Audio Tape (DAT)) technologies.

The media used in archive storage are housed in a device known as a jukebox. A jukebox can contain one of many types of media (CD-ROM, tape or disks). The jukebox moves the media from its storage location, by means of a robotic mechanism or carousel, to a reading/writing area; the time for this movement of disk to read is usually in the order of 10 – 30 seconds.

C.4.5.1 Networked StorageComputer networks can be attached to two types of networked storage topologies, known as Network Attached Storage (NAS) and Storage Area Network (SAN). These storage topologies are becoming increasingly common in PACS.

Network Attached Storage (NAS)In NAS, the storage device is usually a RAID attached directly to the network, below illustrates the NAS attached to a LAN.



It is controlled by a NAS controller, which is a processor with an operating system, for example a UNIX computer. This will see all the other devices on the network allowing each to be able to access and store data on the disk array.

Storage Area Networks (SAN)The implementation of a PACS, either radiology or hospital wide has a significant impact on the hospital LAN. The size of the image files can cause a significant deterioration in the transfer of data, which has a subsequent effect on the operation or workflow of the radiology department.

The inevitable integration of PACS with the information systems of a trust (HIS & RIS) the large image data files are transferred on a dedicated network, freeing up the hospital wide LAN bandwidth for the transmission of patient related information.

The SAN allows the hospital to implement the PACS whilst retaining its legacy systems reducing the cost of implementation. The ease of implementation and the seamless scalability of a SAN makes this technology an excellent solution to the storage and backup for a PACS.

A Storage Area Network (SAN), is a network that sits behind the local area network (LAN) connecting the servers into centralised disk storage and backup libraries, a schematic is shown in fig 1 below. This allows for a scalable storage solution where each server has access to the storage pool creating an optimal and cost effective storage environment. The SAN uses a different protocol to transfer the data, this is known as Fibre Channel Protocol (FCP).

Storage Area Network (SAN) Schematic

C.4.6 Film printersIt is likely that even a “filmless” PACS will retain the ability to print to film or other hardcopy devices. The need to print film can arise under a number of conditions, including planned system down-time for maintenance or upgrades; unplanned downtime should failure of the system or a key component occur, etc.

Film printers require regular checks to ensure that they are performing adequately. These checks should include such tests as:

Linearity of film optical density to pixel value.



This ensures that a change in the pixel data value in the image data file produces an appropriate change in the optical density of the printed film.

Consistency of film optical density to pixel value.

This ensures that regions in the image that have the same pixel value have the same optical density when printed to film.

Spatial resolution.

This is a measure of the ability of the film printer to print small features in an image or to allow two closely-spaced, but separate, features in an image to be visualised separately on a film.


This is a measure of the ability of the film printer to produce a change in optical density for regions in the image that are of similar, but different, pixel values.


This is a test of the ability of the film printer to print films which retain the proportions of the reconstructed image. In particular, all straight lines in the original image should remain straight on the printed film.

Other hardcopy printing devices may be appropriate; these devices include inkjet printers, thermographic printers and laser printers. These devices also require regular checks to ensure that they are performing adequately, and these checks will be similar to those described above for film printers.

C.5 MonitorsGuidance is often asked for on recommended workstations for image display. The information below has been collated to assist people who are considering their requirements for PACS workstations.

It is hard to be prescriptive as the types and numbers required will depend upon the source of the images (e.g. CT, plain x-ray), local workflow and clinical process. Careful consideration must also be given to the ergonomics and environmental conditions of the areas in which the workstations are to be placed.

Workstations comprise a combination of base station (most often, a PC), software to allow the display and manipulation of medical images from the PACS and a display device. This guidance note concerns the display device component of workstations only.

The most important factor is that the display device should be fit for use, be available at required clinical locations and maintained in appropriate condition. It should be the Suppliers responsibility to work in conjunction with you to provide or recommend the appropriate devices in the relevant locations to meet the clinical needs of the service that is being provided. Note that specialist displays and/or workstations may also be required for remote access to images, e.g. on-call consultants reporting from home. Where there is a monitor that does not meet the required standard it is recommended that it is identified as 'Unsuitable for PACS diagnostic use' and marked in an agreed way locally. Users should be told not to use monitors so marked for diagnostic work.

C.5.1 Image Quality As stated above fitness for purpose is essential. The image presented should be suitable for its intended purpose, whether this be for diagnosis, review or treatment planning. Medical image display quality is of fundamental importance to the overall effectiveness of a diagnostic imaging practice, and it is vital that the softcopy displays do not compromise image quality.

Note that it is not only the display device that determines displayed image quality. Quality of image acquisition and storage of the image after acquisition (e.g. if compression is used) also have a major effect.

C.5.2 DisplaysThe following documents actual experiences from sites that have implemented PACS workstations and can be used as an indicative guide.



Displays purchased for diagnostic use are generally monochrome. This is because monochrome displays can be manufactured to be significantly brighter than colour displays, thus improving the contrast ratio and so the contrast resolution of the display. Typically a contrast ratio of at least 400:1 is desirable for a diagnostic display.

Colour screens may be appropriate in less demanding situations (i.e. for image review only) or when colour information is present in the original image. Note that as well as being less bright, colour displays may also demonstrate reduced spatial resolution when compared to a monochrome display.

A choice is available between traditional Cathode Ray Tube (CRT) displays and the new Liquid Crystal Displays (LCD). For most purposes the image quality of the two devices is comparable and other factors may sway the decision on which type of device to purchase – LCD flat-panel displays are lighter, take up less space and produce less heat when compared to CRT displays, but may be more expensive. At the high end of the market (5 mega pixel devices) CRT displays still have a small edge in quality compared to LCDs.

For reporting workstations: 2 or 3 mega pixel (“2k” or “3k”) 17” or 19” portrait monitors are typically used. (An example size seen is 2048 pixels x 1560 pixels). These displays are most often used in pairs, to allow for comparison of two or more images at full resolution. 5 mega pixels screens are seen for mammography.

Review / web workstations: SVGA quality, with web browser software adapted for access to images and textual reports is typical. These are usually devices of around 1 mega pixel (“1k”) display size.

It is important to have a high-quality video display card in the base workstation to drive the display screens. Standard PC display cards will not be able to provide data of sufficient quality and resolution to allow a diagnostic quality display to perform at its maximum capability. Advice should be sought from the display vendor as to the availability of appropriate display cards.

Further information on displays can be obtained from PACSnet (contact information can be found at http://www.PACSnet.org.uk) who provide a free PACS technical service to the NHS.

C.5.2.1 Quality Assurance of Display DevicesIt is essential to ensure that all workstations and screens used for diagnosis and review are performing adequately for their designated tasks.Tests that can be carried out on display monitors include:

Luminance.

Peak display brightness should be within specification the brightness should be measured at several points on the screen, and all points should be within a specified range.


A test image containing a number of steps of different brightness’ should be displayed. It should be possible to discern each step. Particular attention should be paid to the top and bottom end of the range. The SMPTE test image is a useful image to use for this test.

Focus.

A visual inspection of a test image should be made to ensure that the image is adequately sharp over the display area.


A test image which includes straight lines and circles should be displayed. Ensure that straight lines are straight to within defined limits, and similarly that circles are circular to within defined limits.

Flicker.

The display should be judged for unacceptable amounts of flicker. Significant amounts of flicker can result in user fatigue.

Dropouts.


http://www.PACSnet.org.uk/


Visually inspect the entire screen area for artefacts. CRT tubes may suffer from small areas where dark spots are apparent, due to a lack of phosphor on the screen at this area. LCD displays can have dark or light spots where individual crystals are malfunctioning

Investment of resources into performing QA checks must not be underestimated, remember that maintaining records of test results in order to evaluate any deterioration in performance over time is also important.

C.6 Web BrowsersAs part of their product lines, most PACS vendors offer the possibility of using web browsers to view images and clinical reports in addition to the use of dedicated PACS workstations. A web browser is a standard piece of software most commonly used to display pages from the World Wide Web, for example Netscape Navigator or Microsoft Internet Explorer. The use of web browsers has several advantages, both for the purchaser and for the user:

Web browsers are a simple, robust technology. They have been under development for many years, and, provided they can access the required data reliably, perform well.

They provide a low-cost, high functionality application.

Web browsers can run on relatively low specification computers, often on computers that already exist within a healthcare institution.

Many users will already be familiar with web browsers through use of the World Wide Web, and so it is possible that little additional training will be required.

Hospital I.T. support staff are likely to have familiarity with the use and installation of web browsers.

However, although it is possible that a PACS web browser will run on a standard desktop computer, as discussed above thought should be given to the display used to look at the images. The standard monitor may not be of adequate quality for the viewing of PACS images and it is important to consider the intended use of images displayed on a web browser. Another point to consider is the functionality provided by the web browser for the display and manipulation of images: although the features offered by web browsers have become increasingly sophisticated in recent years, web browsers are still unlikely to match the software available in a dedicated manipulation and viewing application.

In order for web browsers to be able to obtain the image data files required for the display of images, it is usual for a PACS that supports web browsers to include a “web server.” This is a computer that is responsible for the delivery of image data to those web browsers that request it, and may be a machine separate from the main PACS server and image data store. The server can also deliver the workstation software to the workstation and thus allow software upgrades to be maintained centrally.

There may be concern regarding the security of using web browsers. Although standard web browsers are used, of the same type as those used to access the World Wide Web, this does not mean that everyone with access to the internet can view the data. It is possible to limit access to particular computers or areas of the hospital network. In addition, it will be necessary to type in a standard username and password before images can be displayed.



D Appendix D – Practical Environment RequirementsD.1 Radiologist Office and Reporting AreasThe primary function is image viewing and one has to consider the following to comply with Health and Safety issues and ensure diagnostic accuracy.

Workstation ergonomics

Take into account the needs of the individual; consider how tasks will be performed with particular regard to Health & safety issues e.g. RSI and the need for regular breaks.

o Power and network points

Carefully plan adequate power and network points in appropriate position

o Desk – height, size etc. to take into account

PACS monitor(s) footprint Separate RIS/ multifunction PC & monitor & associated keyboard &

mouse (this is the norm for most departments) Paperwork Task lighting

o Seating

Needs to appropriate for desk height and safe working

Environment

Ambient lighting and reflection

o Diffuse lighting upwards

o Common plain wall colours to avoid reflections from pictures, patterned wallpaper etc.

o Task lighting

o Reduce shadows cast from windows, doors, corridor etc

o Avoid reflections from other monitors

o Windows should have blinds. Lighting should be controllable i.e. dimmer switches should be installed

o Radiologists training should include education on how to control lighting to the best advantage and explanations why it is important to do so

Temperature

Air conditioning needs to be considered in conjunction with the Estates Department

Noise Pollution

Acoustic screening can be effective in shared offices

If you have a grouped reporting Room

As well as the above consider the relative positions of multiple reporting workstations

Teaching and lecture areas

o These environmental principals above should be applied in conference rooms, lecture theatres and training locations

o A dedicated room such as thus will reduce noise and disturbance from visiting clinicians within the main department and reporting areas

Education

o PACS users should be instructed in the most beneficial use of the equipment. This training should cover the areas listed above, in particular, instruction on posture and adjustment of PACS equipment and the control of ambient lighting are very important.



D.2 Radiographer Zone Same considerations as discussed apply

Lack of space may be an issue reconsider your current workflow when positioning monitors

Ambient lighting is important for image QA, and for aspects of “Red Dot reporting”

D.3 PACS Computer Room Ideally this should be sited as close to Radiology to quickly assist with urgent access e.g. system restart required by the system engineer and PACS system Administrator

Air conditioning will be required. Many items of computer equipment are sensitive to temperature and may have safety cut-outs that will operate at high temperatures or may have components that will malfunction at high temperatures (e.g. disks in a RAID storage device). It is important that the temperature in the computer room is controlled and monitored.

Fire Prevention control equipment, using appropriate distinguishers

Access to equipment will be required – use proper racking

Physical Security of access and hardware and unauthorised access to data

Disaster recovery - Back up hardware needs to be stored in a separate building

PACS Administrator would be expected to have an office with sufficient space to allow for independent access to multiple systems.



E Appendix E – Table of Example Benefits

Benefits

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Who benefitsSavings in film and chemical budgets Y Trust / SHASaving in above maintenance contracts Y Trust / SHAReduction in length of stay (quicker and multiple / simultaneous viewing and remote reporting)

Y Y Patient Trust / SHA

Saving in admin time searching and filing films

Y Trust / SHA

Saving in Hospital space for film storage / chemical storage

Y Trust / SHA

Savings in porter / transport time of films Y Trust / SHA

Saving in Dark room techs Y Y Trust / SHA

Reduction in litigation Y Trust / SHA

Waste disposal savings Y Trust / SHAEnvironmental

Reduction in cost of copy films Y Trust / SHA

Stationery savings – packets and labels Y Trust / SHA

Reduced on call requirements as remote reporting can be done.

Y Trust / SHA

Reduction in radiation exposure (repeats (windowing allowed) and lost films) and (Patient and staff) and less wasted time

Y Y Patient Staff

Quicker results Y Y Patient Trust / SHA

Staff

Increased patient through put. Y Patient Trust / SHA

Reduced waiting time and LOS Y Y PatientTrust / SHA

Reduced admissions and events as films always available

Y Y Y Patient Trust / SHA

Perception of modern service with a patient centred delivery

Y Patient Staff



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Who benefitsReduction in pt journeys as images done locally and sent away for expert opinion / dx

Y Y Patient Staff

More images will be reported – reducing clinical risk


Better reporting resulting in more accurate and timely Dx (image manipulation and enhancement, availability of remote expert opinion) (Remote expert opinion saves clinical travel time) (Again 24/7 reporting remotely)


Previous views always available in any location and simultaneously (no lost films)


Remote reporting by specialists available Y Patient Trust / SHA

Referrers spend less time chasing images / visiting imaging department in prep for ward rounds etc.

Y Y Y Trust / SHAStaff

Links to EPR / NCR Y Patient

Health community wide viewing of results Y Patient Trust / SHA

Experienced clinical staff retention Y Y Patient Trust / SHA

Less time wastage (staff and pt) associated with clinic appt aborted as images not to hand


Staff

Remote learning and case studies / multi disciplinary teams – simultaneous remote viewing (not driving = cash releasing)


Staff

Better pt info on image reducing clinical errors


Smoothing of workload to deliver equity of service / release staff for more high value (remote reporting – expert opinion) PAN Community reporting

Y Y Y Trust / SHA



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Who benefitsPatient / image / consultant in same place at same time


Increases job effectiveness, (using right people in right job) performance and quality = flexible working which is part of the EU working time directive.

Y Y Staff

Process realignment Y Trust / SHAStaff

Removal of chemicals (COSHH) Y Y Trust / SHAEnvironment

More spacious environment Y Staff

Clinical governance / auditing Y Y Trust / SHAStaff

No carrying heavy / bulk film packets around (staff and patients)

Y Y Patient Staff

Staff can personally develop and further improve IT skills

Y Staff

Tangible and Value for Money Y Trust / SHA

Cancer waits and other targets more achievable

Y Y Trust / SHA

Reduction in litigation costs Y Y Y Trust / SHA

Staff retention in NHS (reduction in advertising costs)

Y Y Trust / SHA

Secure viewing by authorised users Y Y Trust / SHA



E.1 An example of: ‘How has the deployment of the PACS improved services'

With the opening of its new hospital in 2001 this Trust installed both a PACS (a computerised x-ray archive system), CR (a facility to digitise standard x-rays) and various items of x-ray equipment that produce digital images (CT Scanner, MRI, angioscope, fluoroscope). At the same time the Trust installed a wide bandwidth network and improved monitors to enable clinicians in wards and departments to view these x-rays.

A full benefits realisation appraisal has not been completed so this discussion is incomplete and partially anecdotal.

Improved reporting time by radiologists

o The radiologist now has much speedier access to images and there has been a reduction in the time between an inpatient or casualty patient being x-rayed and his report being available.

o Additionally the Trust has radiology services on more than one site. The PACS system means that the radiologist does not need to be at the remote site to report on the image again improving reporting times.

Improved radiological diagnosis

o Although the image presented to the radiologist is not as detailed as a traditional x-ray, this lack of resolution is beyond the capability of the human eye in any event

o The digital image gives the radiologist the ability to manipulate that image, to compare two or more images and to view a series of cross-sections as a single moving image. This certainly helps the radiologist who would otherwise have to hold the images in his mind and may result in more accurate diagnosis.

Reduction in radiological hazard

o Fewer images need to be taken because images can be manipulated by the radiologist, there are less exposure failures and less lost films. This will result in a lower overall radiological hazard to patients.

Availability of images to clinicians

o Images are now available where the clinician requires them and when the clinician requires them.

o In the past the clinician has had to await delivery of the x-rays to the ward and to rely on clerical procedures delivering x-rays to outpatients at the same time as the patient. In both cases if the consultant needed access to historical x-rays this resulted in further delay.

o Now the clinician has immediate access to x-rays from any workstation.

o This results in an improvement to speed of clinical diagnosis, in an earlier start to informed patient treatment and potentially in an improvement to the health of the population.

o Specifically for outpatients this will mean a reduction of repeat appointments due to missing x-rays.

Remote consultation

o When one health professional seeks advice from another, this can now be done interactively. This could be a radiologist seeking advice from a colleague. They no longer need to meet for both to view the x-ray together thus improving the speed with which a diagnostic report is issued.



GP Patient admission

o It is possible now for a GP to contact a medical clinician asking whether a patient whose x-ray he has received should be admitted and for the medical clinician to view the x-ray and respond positively, prioritising the patients' admission, whilst the patient is still in the GP's surgery. Not only is the speed of admission improved but also the GP's service to his patients.

Availability within EPR

o The digital nature of PACS will enable it to be included within the patients' EPR. This will mean that the clinician will be able to find it alongside the patients' other electronically held data again improving the delivery of healthcare.

o PACS is very popular with clinicians and improves their morale. Making their job easier because x-rays are available where and when they need them to facilitate efficiency and effectiveness.



F Appendix F – Business Case Support This section is a working draft and is based on the best available information. The detail of the Business Case Templates may change as decisions on central funding and detailed local contractual arrangements are put in place, but this does provide a way forward for addressing the local service specification, costs, benefits, and implementation planning. It will be updated to reflect process changes as they emerge.

F.1 IntroductionThe process assumes a business case is required at individual NHS organisational level. It can however be aggregated if a number of organisations want to work together. This may be where local business needs are best met by a group of Trusts working together. Alternatively an SHA may wish to proceed with all its Trusts as part of the same exercise.

Local Trusts will have to pay for elements of the implementation and the running costs over the lifetime of the contract. Each Trust either acting individually or as part of a group will need to understand and accept the financial consequences of their PACS implementation. The process ensures that Trust specific figures will be available whatever consortium approach is adopted.

The financial model envisages a mixture of capital investment and revenue. Decisions on central capital funding for local PACS implementation are yet to be made.

The process consists of 3 elements:

A set of Business Case Templates pre populated.

A toolkit which is used to drive the detailed local specification and financial model.

A workshop(s) run by the central team to facilitate the completion of the templates.

The whole package is aimed at enabling NHS organisations to speedily proceed to PACS implementation. It represents the minimum requirement consistent with good practice.

The Templates are based on the standard 5 case model as detailed in the Treasury Green Book and the Department of Health’s Capital Investment Instructions.

The process can therefore satisfy local requirements for strong governance on investment decisions. It provides the necessary business justification for Board consideration and approval to proceed.

The requirements of the detailed local PACS specification will be met through the Local Service Provider. There will be no need to undertake any separate procurement activity. Individual Clusters will provide information on how these arrangements will work in practice. This means that an Outline Business Case is not required and this process produces in a single stage the case for local approval.



F.2 The Business Case TemplatesThe aim is to provide an easy to use set of guidance for NHS Users. The written material coupled with the workshops is intended to enable the rapid development of a business case in house.

The templates cover the 5 sections of the standard model. Wherever possible they are pre populated with information which is common to all locations. They contain guidance and prompts to assist in the local customisation

F.2.1 Strategic CaseThe majority of the material will be common based on the national strategic drivers. This will have to be given a local context with an explanation of priority, e.g. service reconfiguration, new build, other related IT infrastructure issues.

F.2.2 Economic CaseThe options are appraised within the context of costs, risks and benefits to the organisation making the investment. This will focus on the National Programme arrangements for the provision of additional services (i.e. those not fully centrally funded). A common set of Critical Success Factors are provided

F.2.3 Commercial CaseThe toolkit provided enables the generation of a detailed local service specification. This is derived from the National Specification contained in section 115 of the OBS for the Integrated Care Record Service. It addresses the key contractual detail supporting the local investment. The National Programme will produce a standard approach for contracts for additional services.

F.2.4 Financial CaseThe tool kit provides a cost model. It is driven by information from the local service specification and the component costs for implementation provided by the cluster LSP.

F.2.5 Management CaseThis provides a high-level implementation plan for local customisation. Including a model of possible local project management arrangements. These are provided as a start point but will need to flex to reflect local preferences, e.g. SHA wide steering groups and other cluster specific arrangements.

F.3 The ToolkitAs described above this provides the framework within which the key data is captured and manipulated to develop the Financial Case. The data is clearly defined and will be available from sources within the Trust. Much of the data has already been collected within the context of the Modalities surveys and the work on the Financial Templates. This information is required for the Toolkit.

F.4 The WorkshopsThese support the use of the written and interactive material described above. There is a common structure, which can be modified to meet the specific requirements of individual Trust or groupings.

The process is aimed to assist the author of the business case and their attendance is critical. That individual will have a different title according to the local approach. It may be the SHA or Trust lead or both.

In addition a senior Radiology User is needed to lead on the local service specification. This may be the Radiology Services Manager but once again it is for the local project to nominate.

A finance representative from each participating Trust will be needed to assist with elements of the costed benefits and the financial template



There may be other interested parties such as the Senior Clinical Sponsor who wish to attend. The above list is the suggested minimum and the detail of the workshop package and attendees will be agreed as part of the Initial Contact.

F.4.1 Initial ContactThis can be by phone or meeting. The aim is to explain the process and agree how to proceed. The discussion will identify:

How the generic process maps onto the local user requirement

The key players and local constituencies

Specific local issues, e.g. existing PACS contracts, PFI, immediate operational requirements

Funding flows

Agree timescales and attendees for workshop/s.

Workshop 1The first workshop provides:

Overview of the whole process

Use of toolkit for local service specification

Development of the Cost Model

Identification and resolution of specific local issues

Workshop 2The second workshop provides:

Validation of the service specification

Validation of cost model

Benefit and Risk appraisal

Development of Implementation Plan

Handling specific local issues

Workshop 3The third workshop provides:

Review of all templates

Benefit realisation plan

Preparation for Approval, e.g. Board Summary

Post approval and National Programme issues.

In addition to the workshops a help line will be provided by the Central PACS team to assist users with all elements of the Business Case Templates as required. Initially Mark Freeman on 0113 280 6489

The PACS facilitators attached to each cluster are also available to provide support on implementation and associated issues.

This suggested programme can be flexed and adapted to meet the specific requirements of the Trust or group developing the PACS business case.

F.5 SummaryNHS Users wanting to arrange an Initial Contact should contact their local PACS Facilitator or use the help line number provided. The latest documentation will then be sent and an Initial contact arranged.
