PACS:
Using Picture Archiving and Communication Systems in Surgery Centers

As the parallel trends of increasingly sophisticated medical technology and the less invasive nature of surgery continue, ambulatory surgery centers (ASCs) must plan more carefully for the future. Vital to the success of any ASC is understanding which new technologies will be worthy of investment, and which ones warrant observation.¹

Some older technologies, however, are refusing to go by the wayside. They are being modified for today’s competitive outpatient marketplace. Picture archiving and communication systems (PACS) is one such technology with staying power.

The modern PACS are rapidly changing from its initial function as only an image retrieval and storage system. It is evolving into a complete surgical management solution, adding features for scheduling, registration, electronic medical records, inventory and even billing.

Current Objections

The biggest hurdle that PACS must overcome is its perception. “I think that most people, when you talk about PACS, are thinking in terms of a diagnostic format and don’t necessarily correlate that as to dictation and the organization of pictures with their dictation process,” says Arthur Casey, regional vice president of HealthSouth in Southern California.

PACS has become synonymous with filmless radiology since its debut in the late 1980s. Many imaging centers use this technology throughout the United States. For many freestanding ASCs, the question as to whether or not to acquire a PACS has been settled. The answer ranges from an unequivocal “no” to a “maybe” to “yes,” depending on the circumstances.

“Most of the facilities on an ambulatory basis are still managing and maintaining paper medical records,” Casey says.

He adds, “In an outpatient setting, you typically see the patient that one time and you’re not providing imaging types of care so that you need to have access to those medical records on a consistent basis. The need for a wireless medical record is not that prevalent and the cost of maintaining or starting an electronic medical record is pretty significant.”

The acquisition of equipment such as PACS can sometimes become increasingly difficult as capital budgets become tighter. Traditional ownership financing options in the form of direct purchasing or financing may have several limitations including fixed pricing and the need to tie up valuable capital.”²

David S. Channin, MD, CPHIMS, an associate professor of radiology at Northwestern University’s Feinberg School of Medicine counters, “If you say that you’re going to pay for this system by savings on your film budget—forget it. But, if you say you’re going to save on film budget, FTEs (full time effective employees), workflow, efficiencies and increasing your volume by 20 percent, then it makes a lot of sense.”

Channin is also a member of the Radiological Society of North America (RSNA)’s Electronic Communications Committee, which is responsible for evaluating technology for use by RSNA members.

“Do a careful return on investment calculation, taking in all the considerations of how this is going to improve your work flow,” Channin says.

For Intermountain Orthopaedics in Boise, Idaho, PACS has been a wonderful addition, says David F. Kirk, the facility’s administrator.

Intermountain is a two-room ASC with approximately 1,600 cases per year. It is owned by a group of orthopedic physicians that have an office in close proximity to the surgery center, which transmits patients’ digital images electronically using their fully integrated PACS system.

“It basically enables the surgeon to go into the operating room and pull up an image electronically,” Kirk says. “If there is an image of another patient that had a similar type of procedure performed or if the physician would like to pull up older images of the same patient, all of that is available at the physician’s fingertips.”

Kirk adds that digital X-ray services, coupled with PACS for a large stand-alone orthopedic group is “almost a no-brainer decision.” However, the purchase of a PACS for most ASCs may only be warranted if the system offers a complete management solution at a lower price point than what is currently available, he says.

And, it’s these kinds of concerns that are being addressed in the world of PACS today. Vendors say PACS will continue to become less expensive, more functional and more standardized from a hardware and software perspective.

Industry Views

The move toward PACS is inevitable, even for freestanding ASCs, say many experts. Although larger hospitals with PACS get all the press, there are more filmless environments in smaller community hospitals, imaging centers markets and ambulatory surgery centers, says Dave Mahoney, vice president of sales and marketing at eMed Technologies.

“There is quite an infusion of this technology that already exists in these facilities and will continue to grow as the demand for imaging continues to be a prime motivator to imaging centers and surgery centers that are a logical appendage to the large tertiary-care facilities,” Mahoney says.

PACS are developing into a framework upon which an ASC’s entire operations can be based.

“The main benefits of PACS is when it is combined with an outpatient management solution system in which you completely eliminate not only the film but also the paper, and drive the workflow,” says Henri Primo, division manager at Siemens Medical Solutions Health Services. “Once you have eliminated paper and film, you basically have an electronic system that will be guiding your workflow.”

With regard to workflow, vendors say the process of handling patients and their information is much more efficient. Patient information is available almost instantaneously and misplaced medical records no longer pose a problem. Referring physicians as well patients are able to access patient information via the Web, thus providing better patient care to an ASC’s primary customers.

“It’s all about customer service. Surgery centers compete with each other. And they’re always looking to attract additional referring markets,” says Brad Levin, director of strategic marketing at AMICAS. “And, the way that they do that is by providing an additional, enhanced standard of care. They can do that through a PACS vehicle to allow their referring physician to get incredibly timely information based upon their patient care that’s being given at that surgery center. It is going to enhance their market.”

Levin adds that PACS should be viewed as a life-cycle system. “It doesn’t end by signing the contract with the vendor. Once it’s installed it needs to be properly maintained, upgraded and re-enforced both internally and externally in order to be successful,” he says.

Purchasing Decisions

As with any electronic purchase, ease of use, price value, and connectivity are important factors to be considered, says Michael Kirklen, marketing manager of orthopedics at GE OEC Medical Systems, Inc. “How connected could you be with sources outside of your facility and then connectivity internally?” he asks. “Are all the computers in your facility able to connect and use the system?”

Kirklen says, “I think the ability to accept and manage all kinds of image modalities such as CTMR and fluoroscopy is important so you can have a complete patient view saved and stored.”

Another factor that should be considered is who will act as the onsite troubleshooter. “We see that the better people who are doing this actually are not IT people, but people who understand the workflow in their respective center and then move into the computer technology associated with it,” Primo says.

“With the complexity of growing cases and the amount of information that is being generated, it’s going to be impossible to compete without digital imaging in the future,” Channin says. “The government is pushing now for electronic medical records (EMR). As EMR takes off, you’re going to have your regular office EMR information integrated with larger and larger environments, governments or local hospitals, etc. You’re going to want your images tied into that or be able to be tied into that. In other words, you don’t have any choice. It’s just a question of when you’re going to jump into the water.”

References:

1. Ticer J. The OR of the future. Outpatient Care Technology. Dec./Jan. 2002-2003.
2. Reiner B and Siegel E. Understanding financing options for PACS implementation: Picture archiving and communication systems. Journal of Digital Imaging. May, 2000: 13(2), 49-54.

Voices of Experience
Here are a few recommendations from colleagues about evaluating, acquiring and implementing PACS:

“You need to look at each of the modalities you’re going to be using. You also need to look at your storage media for PACS. That is a critical piece of the PACS. Where are you going to store the data? On what medium? And, these decisions effect performance - you need to be able to retrieve images quickly, especially in the OR where minutes are very important. Lastly, how are you going to create redundancy so you have disaster recovery?”