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Modernisation AgencyNHS

PACS Benefits Realisation and Service Redesign Opportunities

National PACS Team (NPfIT) and National Radiology Service Improvement Team (MA)

National Programme forInformation Technology

NHS

National Radiology Service Improvement TeamNHS Modernisation Agency3rd FloorSt John’s HouseEast StreetLeicesterLE1 6NB

Tel: 0116 222 5100Fax: 0116 222 5101

www.modern.nhs.uk/radiology

The NHS Modernisation Agency ispart of the Department of Health

National PACS TeamNational Programme for Information Technology2nd FloorSt John’s HouseEast StreetLeicesterLE1 6NB

Tel: 0116 222 5100Fax: 0116 222 5101

www.npfit.nhs.uk

Introduction

Section 1Benefits realisation – general benefitsidentified by participating sites

Section 2Benefits and redesign opportunities

Section 3Lessons learned

Section 4The bigger picture – organisational benefits

Section 5Strategic benefits

Section 6Future vision and directions

Section 7NHS Plan delivery

Glossary of terms

Further reading and key links

Contents

PACS Benefits Realisation and Service Redesign Opportunities - 3


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The Potential of PACS (Picture Archiving and Communications Systems)

“Delivering the NHS Plan” (April 2002) set at its heart a vision of a patientcentred service offering more choice, leading to improved services for all patientsand staff, including healthcare outcomes and improved value for money. PACShas a very pivotal and extensive role to play in the delivery of the NHS plan. It lies at the heart of modernisation of the NHS IT infrastructure, and is inexorably linked to service improvement, advancing technology and a changingand developing workforce. PACS therefore has an amazing potential for themodernisation of service delivery for both patients and staff. PACS is a computer system that captures, stores, distributes and displays digitised images.Images can be relayed to any destination capable of receiving them, and can be reviewed in different destinations simultaneously. Improving the imaging ofpatients in healthcare will inevitably increase the efficiency of the healthcaresystem as a whole. This document sets out to demonstrate the impact that PACS can have across the wider healthcare community.

Roy Male Chief Executive Officer, Blackpool Victoria Hospital, (Blackpool Fylde and Wyre NHS Hospital Trust) has said:

“Putting all the technical and other benefits of going filmless aside, to my mind

the true impact of PACS is that it has demonstrated real benefit to clinicians in

their day to day work from IT systems. It changes the whole perception of IT

from the back office to the clinical arena.”

Paul Unsworth, Chief Executive Tendering PCT has said:

“This is a very helpful report which demonstrates from the pilot sites the benefits

to be delivered from PACS and breaks them down by qualitative, quantitive (non

cash releasing) and cash releasing. It is our responsibility as commissioners and

providers of health services to ensure we get maximum health gain from PACS in

each of these areas. Therefore, there should be a well constructed plan to

quantify and realise these benefits supported by strong performance

management throughout the programme to justify this sizable but welcome

investment.”

Introduction

This document is designed to assist NHS managers to take full advantage of theintroduction of PACS through sharing the experience of users to date. It is a guideto the potential and realisable benefits offered by the technology from clinical andmanagerial perspectives in a range of service areas. The objective is to deliver thebest possible outcomes for patient care.

The Evidence

Initially four sites were brought together for an exploration exercise, each site hada history of service redesign and full PACS. A day was spent exploring the benefits,lessons learned, impact on targets and the service redesign opportunities thatPACS has demonstrated. It is accepted that PACS should not be limited to acutetrusts but should be deployed throughout the healthcare community. It shouldalso be linked to training establishments, and include numerous imagingspecialities eg Radiology, Pathology, Endoscopy, Ophthalmology and Dermatologyto name just some. PACS should support the wider modernisation of healthservices.

The information in this report represents the experiences of the four sites andserves as a checklist that will demonstrate the benefits that can be achieved andwhere redesign opportunities exist for a whole range of users.

It is envisaged that more information will be needed from other sites to confirmthe messages in this document, and this will be one of the next steps. A furtherstep will be the exploration of the concept of the extension of PACS to otherspecialities that generate digital images or images capable of digitalisation in theirservices.

The sections are clearly laid out in the document and can be read in isolation if desired.



4 - PACS Benefits Realisation and Service Redesign Opportunities


Section 1Benefits realisation - generalbenefits identified byparticipating sitesThe introduction of PACS in the NHS in England opens up potentialto deliver a range of benefits to patients. Clinicians will be able toaccess images taken at stages along pathways and readily accessrelevant patient records. This will streamline care and speed updiagnosis and treatment.

PACS offers the opportunity for radiology reporting to be doneremotely, utilising telemedicine and potentially facilitating much moreflexible working of radiologists who will be able to access images ona 24-hour, seven day a week basis. It challenges traditional radiologyreporting structures and encourages organisational review andreconfiguration of imaging services across health communities formaximum efficiency.

Critically, used to its maximum potential, PACS will be pivitol in allimaging to delivering the objective set out in the NHS Plan, amaximum wait of 18 weeks from the point of referral to the start oftreatment. With the enabling of imaging services in primary care,PACS also underpins the concept of choice in imaging services.

This section provides a comprehensive list of benefits that can begained from the implementation of PACS and service redesign. Thedegree to which any benefit will be “cash releasing”, “non-cashreleasing” , “quantitative” and “qualitative” will obviouslydepend upon the position of a department prior to PACSimplementation, the realisation of benefits within a period of timewill also vary.

Benefits have been listed with their dependencies, to provide an ‘at a glance’ insight into:

• Clinical Benefits• Patient Benefits• Staff Benefits• Business Benefits









£ Cashreleasing

Quantitativenon-cashreleasing

Qualitative Dependency Who Benefits

Image and ReportAvailability and Transfer

Shorter reporting times,images immediatelyavailable, no manualhandling of analogueimages.

A&E waiting times reduced,images quickly available,opportunity for quickerreporting.

Benefits other departments(access to IT), otherdepartments able toremotely access relevantimages and reports forpatients.

No lost images, less wastedtime for staff huntingimages and reports. Imagesand reports instantaneouslyavailable to clinicians at anydestination.

Home access ‘on call’,clinicians can successfullywork from home whereappropriate, to give expertadvice at the mostappropriate time.

Communication with otherdepartments, instantinformation transferredelectronically across singleor multiple organisations.

Appropriateworkstations andreporting areas.

Appropriate staffavailable with skills toallow process to workeg. Reporting clinicalstaff.

Appropriate sittingand provision ofviewing stations.

Clinicians must be ableto use IT and theremust be sufficientviewing stationsavailable.

Suitable technology athome to ensureappropriate transfer ofpatient information,images and safety ofinformation.

Full PACS availabilityacross healthcarecommunity.

Patient, Trust,Clinicians,Primary Care

Patient, Trust

Patient, Trust,Clinicians,Clinical staff

Patient, Trust,Clinicians,Clinical staff

Clinicians,Clinical staff,Patients

Trust, Radiologydepartment

BENEFITS

Direct benefits from implementing PACS

CLINICAL

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

£ Cashreleasing




Rapid image availability forwards, clinics, other areas,images remotely availableany time any place. Multiple viewing of images,numerous specialists invarious locations can viewimages simultaneously.

Clinical outcome of IRMERimproved, good qualityimages at source no repeatimaging.

Consistency ofcomparability of images(clinical governance andaudit)

Improved knowledgemanagement, up to dateinformation and results forpatients allowing forappropriate patientmanagement decisions.

Teaching, images availablein PACS mode will beextremely versatile andtransportable for teachingpurposes, especially intraining academies. Accessto speciality opinion andteaching will be possible.

Linking of modalities, abilityto view images from variousmodalities simultaneously.


Staff are fullycompetent andconfident with thePACS system.

Appropriate archivingfacility.


Full PACS systems inplace acrossorganisations. Trainingacademies with IT ofappropriatespecifications.

Full PACS systems inplace.

Patient, Trust,Clinicians, Clinical staff

Patient, Trust

Clinician

Trust, Patient,Clinician, Clinical staff

Clinicians,Clinical staff

Clinicians, Patient,

BENEFITS


CLINICAL

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

£ Cashreleasing




No “plastics” (temporaryenvelopes), all patientsimages include previousimages, available in oneplace.

Research, long termavailability of acomprehensive set ofimages and reports forpatients will aid thosecarrying out research.

Near patient image viewingi.e. patients in clinicalcubicles, beds or patients inGP surgeries. Patientsatisfaction, high qualityintervention at consultationtimes by appropriatepeople. Images and reportsavailable at any stage of thepatient’s journey.

Reduction in hardware costs(e.g. reduction of filmcosts).

Ease of consultationbetween clinicians, clinicianscan consult in real time withthe ability to view imagessimultaneously.

Clinicians assisted, quickviewing of images andprevious imagesinstantaneously available.

No image printing –consider patients withprevious analogueimages.

Availability of imageselectronically –consider previous non-digital images.

Appropriatespecification andavailability ofworkstations etc.

Full PACS availableacross organisations.

Full PACS availableacross organisations.

Sufficient workstationsor viewing areas.

Trust, Clinicians,Clinical staff

Patient, Clinicians

Patient, Clinicians

Trust, Patient

Trust, PatientClinicians

Patient, Trust,Clinicians

BENEFITS


CLINICAL

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

£ Cashreleasing




Elimination of time wastingfor junior doctors re filmmanagement, junior doctorswill not have to chaseimages and reports they willbe available at thedestination of the juniordoctors.

Improved quality of image,reduced repeat images dueto poor quality. Imagemanipulation allowingreporting clinicians moreversatility for image viewingfor diagnosis.

Free transfer of imagesbetween institutions willprovide knowledge andlearning.

Healthcare Process

Contribution to decreasedlength of patient stay,images and reports availableat destination in a timelyfashion, can potentiallyaccelerate patient discharge.

Reduced phone calls, fewerinterruptions, fewer queriesregarding reports or images.

Reports attached to imagecomprehensive patientimaging record available.

Sufficient workstationsand IT competence forclinicians.

Staff must be fullyconversant with digitalsystems, excellentdigital acquisitionsystems.

Willingness ofclinicians to shareexpertise andknowledge.

The rest of the processmust work well egdischarge plans,consultant ward roundsor nurse-led discharge totake out medicines

Availability of sufficientviewing and workstationsacross organisations.

Sufficient viewing andworkstations availablethroughout organisation.Adequate quality PACSand RIS systems andgood quality interfaces.

Trust, DOH,Economics,Environment,Patient

Patient, TrustClinicians,Clinical staff

Patient,Clinicians,Clinical Staff

Trust, Patient,DOH

CliniciansClinical staffAdmin & clerical

Patient,Clinician, PCT,SHA, Trust

BENEFITS


CLINICAL

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y Y





Y

£ Cashreleasing



MDT – Links to othercentres, complies with thestandard that every patientwith cancer must bediscussed at MDT meetings.

CHOICE – Potentially thecross site availability ofelectronic images andreports can contribute topatients desire to exercisechoice of location fortreatment.

NEAR PATIENT IMAGEVIEWING – Patients inclinical consultation areas,beds or patients in GPsurgeries. Patientsatisfaction, high qualityintervention at consultationtimes by appropriatepeople. Images and reportsavailable at any stage of thepatient’s journey.

Appropriate IT systemsat all placesparticipating in MDTsgood timing betweenthem and a mainarchive.

Full PACS availableacross healthcarecommunity andbetween communities.

Appropriatespecification andavailability ofworkstations etc.

Patient (access tothird or specialistopinion),Clinicians

Patient

Patient,Clinicians

BENEFITS


PATIENT

Y

Y

Y

Y

Y





£ Cashreleasing



Improved WorkingLives

Reduced stress levels,happier staff, improvedprocesses that improvesworking lives, less timewasted in futile tasks.

Reduced paperwork,electronically generated andheld reports lead to lesspaper shuffling and lessstationery costs.

No chemicals , Control ofSubstances Hazardous toHealth (COSHH), reducedhazard to staff and reducedcosts. Improved workingenvironment.

Staff Development

Staff development (ITliteracy), staff need to befully conversant with the ITsystem that produces,manipulates and transfersimages, this will lead tostaff competence andconfidence.

Redesigned department and workflow, streamlinedpatient processes andimproved electronicpathways will allow staff to work very differently.

Redesign of processesand PACSimplementationsupporting theredesigned processes.

No image or reportprinting except inexceptionalcircumstances ie non PACS unit

Assume no filmprinting or very littlefilm printing in specialcircumstances only.

Timely IT training andcompetencyassessment, prioritygiven to being able tonavigate the system.

Flexible use ofresources, both humanand material.

Patient, Trust,Clinical staff,Clinicians, Admin& Clerical, Porters,Organisation as awhole (reducedgrievances)

Trust (lessstationery costs)Admin & Clerical

Trust, Clinical staff,Environment

Clinicians,Clinical staff,Admin & Clerical,(Lifelong learningfor IT)

Patient, Trust,Clinicians,Clinical staff,Porters

BENEFITS


STAFF

Y

Y

Y

Y

Y

Y

Y

Y Y

Y Y Y

£ Cashreleasing



Health Care Process

Reduced waiting times,appointments and timewithin department,streamlined process whichleads to a more efficientservice procedure atappointment stage and onday of diagnostic test.

Reduced transport costs,there will be no need forthe physical transportationof either images or paperreports these will all beavailable at any destinationelectronically.

Healthcare efficiency,diagnostic proceduresbecome much morestreamlined leading to moreeffective and efficienthospital treatment, patientflow and more effectiveprimary care.

Reduced downtime ofequipment compared tochemical “processing”, lessequipment to maintain andless equipment failure.

“Sceptics converted”, goodplanning andimplementation overcomingoriginal fears of systemsfailure.

Fully integratedradiology informationsystem with PACS.

Commitment to noprinting of images orreports.


No conventional filmprocessingundertaken.

Excellent planning andgood PACS managerin place.

Patient, Trust,Clinician,Clinical staff

Trust, PCT

Trust, Patient,SHA, PCT

Patient, Trust,Clinician,Clinical staff

Trust, Clinicians,Clinical staff

BENEFITS


BUSINESS

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

Y

£ Cashreleasing



Health Care Process

Redefined staff roles, newways of working as a resultof streamlined process, roleenrichment opportunities,better usage of staff skills.More quality time withpatient.

Outsourcing reporting,where a department cannotcope for capacity reasonswith the reporting workload images requiringreporting can potentially betransported to otherreporting centres. PACSoffers the opportunity forreorganisation of radiologyreporting to make the mostefficient use of resourcesthrough telemedicine/remote image reporting.

Financial Aspects

Financial savings, there ispotential for financialsavings in the area of moreappropriate use of staffcost, saving on chemistryand machine maintenance.However these benefitsmust be viewed againstoriginal capital out lay andcosts.

Must be able toredesign workflow ofthe department andtake opportunities towork differently.

Clinically soundreporting serviceavailable at other siteswithin UK andwithout.

Capital and revenuecosts of PACS,displaced staffappropriately andsatisfactory redeployedin a new system.

Trust, Clinicalstaff, Clinicians,DOH

Trust, Patients,Clinicians

Trust, SHA (lessprocedure costper patient),Patient

BENEFITS


BUSINESS

Y

Y

Y

Y

Y

Y





£ Cashreleasing



Financial Aspects

Reduced litigation costs,potentially because no filmsor reports will be lost andimages and reports willalways be available in atimely fashion, forappropriate patientmanagement, this couldlead to less litigation costs.

Comprehensive PatientRecord

Aids audit and ClinicalGovernance, readyavailability of images andreports and continuity ofcare.

Supports the developmentof ICRS, in line with theNPfIT programme forcomprehensive patientrecords.

Security of images, patientconfidence up held by asecurity system, all imagesheld together centrally.

Adherence to policiesaround imaging andreporting ensuringthat images andreports are always upto date and sortedcentrally.

Good RIS and PACSsystem Integrations.

Delivery of the NPfITProgramme.

Individual systemsmust be totally secure.

Trust

Patient, Trust,Clinician

DOH, SHATrust, Patient

Patient, Trust

BENEFITS


BUSINESS

Y Y

Y

Y

Y

Y Y

£ Cashreleasing



Medico-legal images

Medico-legal imagesconverted to CD ROM, nolonger have to pull filmsphysically, no packaging andno posting

Capacity Planning

Service Reconfiguration, theimage availability andtransportability of PACS willaid service reconfigurationand help address demandand capacity issues. Thereis a potential for sharingexamination and reportingcapacity.

Environmental Issues

Less background radiation(less unnecessary exposures)less chemistry and pollution.However consider energyuse especially where airconditioning units arerequired.

Film storage eliminated, lessphysical space required, Nomanual filing or pulling ofimages and reports.

Sufficient IT to view insolicitors destinations.Discussions shouldbegin early.

Flexibility in theapproach to the use ofresources, need formore flexible budgets

These benefits willonly be realised withfull PACS systems,including at satellitesites.

Redesign the way thedepartment will beworking, use of PACSto support effectiveworkflow, etc.

Trust, Patient

Patient (servicescloser to home),SHA, DOH

Patient,Environment,Trust,ClinicalStaff

Patient, TrustClinicians,Clinical staff

BENEFITS


BUSINESS

Y

Y

Y Y

Y





Y Y Y

Y Y Y

YY

Section 2

Benefits and redesignopportunities

This section identifies how particular benefits have strong linksto service redesign.

Representatives from the sites agreed that implementation ofPACS would only be truly beneficial along with the appropriateservice redesign. In some situations the service redesign mayhave taken place prior to PACS implementation or may takeplace alongside PACS implementation.

It is hoped that this section will give the reader a valuableinsight into the possibilities of different types of redesign, toestablish a robust and sustainable PACS benefits maximisation.

To achieve the NHS of the 21st Century departments need toconsider different and innovative ways of working. PACSimplementation offers an ideal opportunity to reassess workingpatterns and be at the forefront of truly effective serviceredesign.









Redefined staff roles

Improved information flow andknowledge management.

Teaching and Learning

Audit and Clinical Governance

Redesign department processes

Service reconfiguration

Environment

Reduced paperwork in radiology

Reduce radiation doses for patients

Medico-legal cost savings

Improved process time

Rapid report availability attached toimages

BENEFITS

General benefits and redesign opportunities

PACS will fundamentally alter some departmental staff roles. Instantavailability of electronic images means that valuable staff will no longer haveto chase film packets and reports meaning that their skills can be betterutilised. Clerical and administrative staff and former ‘dark room’ staff arecapable of taking enriched roles and are able to take up opportunities toundertake studies to extend their roles. The Changing Workforce Programhas evidence of such changes.

PACS will allow for improved information flow. It will also contribute to acomprehensive patient record, leading ultimately to an improved quality ofcare for the patient. Paper records will be superseded by electronicallytransferred data in a timely and dynamic fashion.

Digital projection, MDTs, Smart Board, cascade learning, lecture preparationand medical photography.

Consistent image display for clinical conferencing Dicom 14 and IntegratedHealthcare Enterprise (IHE).

The hospital’s IT and departmental IT networks may have to be redesignedalongside both physical and geographical redesign efforts.

Future planning. The potential for choice for patients improving the qualityof care; images available at any time anywhere would make this morefeasible. Image, report and opinion availability leads to more flexiblereconfiguration.

Physical layout and COSHH needs to be considered. Designing theappropriate environment around PACS leads to an improved clinicalenvironment and more staff satisfaction. The environment is improved dueto reduced Health and Safety risk.

PACS implementation means that there is no longer a need for transferral ofpaper based information. This effects the typing of reports referrals into theservice and booking of appointments.

Redesigned acquisition phase of imaging. There are less repeat images andtherefore the potential for lower patient dose.

Digital images easily located and dropped onto CD ROM. There are medicolegal cost savings, images are now presented on a CD ROM.

The improved process times involved when PACS is introduced can lead to amore streamlined service in general. Results include the potential forreduced length of stay and cross modality streamlined processes.

Redesign of RIS around PACS (and network) including interface, electronicdiary, post exam screen, clinical comments etc. The reports for images arenow available with the images, across the network involved close linking ofRIS and PACS.

REDESIGN LINKS

Speed and ease of MDTs

Remote reporting

Release of storage space

Multiple location image availabilityand rapid reporting turnaroundtimes

Comparison and availability ofprevious studies

Staff development IT literacy

Teaching, audit and research

Electronic links to other Trusts andorganisations

Communication with otherdepartments

Preparation for MDTs

Medico-legal cost savings

Outsourcing reporting

Security of images

Clinical Governance

BENEFITSPACS, with appropriate structure, applications and links across a wholehealth care community can lead to fully informed MDT meetings.

Reports for images can be generated from remote areas allowing images tobe accessed by appropriate experts wherever they are and therefore qualityreports to be sent rapidly back to the referrer.

Physically, PACS releases significant space with the removal of oldequipment and minimal space required for the storing of images.

Network upgrade and appropriate workstations. Work-list production andPACS reporting room. Increasing the number of PCs for viewing around thehospital means that images are available quickly. The production of a work-list and a PACS reporting room allows for faster reporting. There are benefitsfrom links to other centres, with image transmission externally. Centralisedreporting is possible and radiologists could report across health communities,with easier access to specialist opinion.

PACS allows an easier comparison when previous studies are availabledigitally, the early availability of such images saves a significant amount ofstaff time and frustration.

There is a need for staff development such as European Common DrivingLicense ECD ROML, for IT.

A museum archive. There is a great improvement in the availability ofimages for teaching because of the archive. Improved way of deliveringeducation and passing on knowledge, more easily accessible and quickerlinks.

Image transmission externally across healthcare community.

PACS allows for rapid transfer of images and reports in a timely package,hence providing efficient and effective communication.

Data preparation can be carried out quickly and effectively by both clericaland clinical staff.

CD ROM. Legal cases images are produced on CD ROM quickly fromarchive where available. Cost savings achieved.

CD ROM or direct image transfer. There is the potential for outsourcingreporting, if direct PACS links are not available then images can betransferred to CD ROM.

Back-up processes. There is security for images and a back up process whichbuilds in resilience. Need for excellent PACS manager.

Robust contingency planning in line with clinical governance. Futureplanning.

REDESIGN LINKS

The readers attention is drawn to the following document: PACS Practical Experiences





Section 3

Lessons learned

This document would not be complete if we did notacknowledge that along with the vast array of benefits thataccompany the implementation of PACS, there are also aspectsthat were identified by the representatives from theparticipating sites, as lessons learned.

This section is a record of these issues.

The representatives were asked what they have learned andwhat they would have done differently.





Benefits Realisation – Time Scales

Benefits realised will depend uponwhere you are now with respect toelectronic processes, equipment,staffing and space. Not all benefitswill be realised instantaneously,some cost benefits may only becomeapparent after a period of time.Some benefits attributed to differentways of working may be realisedimmediately.

Upfront Cost Implications

There are local cost implications:

• A good, electronic network systemthroughout the unit or healthcare community.

• Sufficient PC workstations and clinical viewing stations.

• A dedicated PACS manager.

New Ways Of Working

There is a need to consider theredesign of the existing department.Space will be released and there willneed to be space for specificactivities such as reporting.However, lessons from the sitessuggest that there will need to beinnovative thinking about how andwhere activities take place.

Many users have found an air-conditioned digital reporting roomto be an excellent resource forincreasing efficiency in reporting andas a learning environment for staff.

• What is the best way to work witha new digital system?

• What challenges exist for altering traditional ways of doing things?

These are challenges across theentire patient process from referralto report disseminated.

Transition Issues

This issue has become very apparentaround Multi Disciplinary Teammeetings, especially where there iscross-site involvement. Where thetechnology differs from one site toanother there are issues to considerwith respect to viewing images atMDTs, how the images will besupplied and equipment necessaryto view them.

Thought needs to be given to digitalequipment and image managementwhen equipment belongs to adepartment not linked to PACS.How will everything be linked up?For example, ultrasound examinations performed onequipment not directly linked to amain PACS department.

Supportive Technology

Voice recognition systems are seenas a potential positive innovation.Evidence suggests that there aresome excellent systems available, theconcept is well supported and itsbenefits acknowledged. PACS/RISLinks and interfaces have beenidentified as one of the maindifficulties to overcome . Redesignassociated with implementing voicerecognition will bring about:

• Changes in the role of the radiology secretary.

• Improvements in reporting times.• Real time reporting.

Role Redesign

It is important to consider early onwhat impact PACS implementationwill have upon the way in whichpeople will be working. One of themost obvious areas is that of clericaland administrative roles. It is crucialto plan for different ways of workingand it has been the experience ofsome departments that some staffcan potentially be ‘displaced’.

Additional Staff, such as a systemadministrator will be required, therole of radiology secretary may wellchange with the introduction of avoice recognition system.

• Identification of the impact on staff roles should be carried out at an early stage.

• Consider staff opportunities for redeployment.

• Continuous good quality communications is essential.

• Early involvement of the Human Resource department is important.

Work-life Balance

The potential for stress emanatingfrom an alleged 24-hour availabilitywas identified. Unless expectationsare managed, the work-life balancecan be disturbed. There is thepotential for an unlimited call on anindividuals time. There needs to bean established, accepted way ofworking, including flexible workingusing ‘at home’ technology.

This could be managed byestablishing protocols for ‘at homeworking’ Additionally it may prove tobe an advantage to support flexibleworking using at home technology.

Unsuitable New Accommodation

One site in particular recognised thatunsuitable new accommodation canhave a serious effect on the workingenvironment with PACS; there is aneed to consider all aspects ofimplementation for PACS. Forexample, appropriate airconditioning in PACS reportingareas. Risk Assessment of all areaswith major equipment installations isadvisable. There is a need forsecurity of areas with severalexpensive workstations. There is aneed to establish fireproof statusand process controls for computerserver rooms.

Protocols

Establishing protocols at an earlystage was seen as beneficial to avoidcertain pitfalls, examples include:

• Clinical colleagues acting on all electronically routed images beforethe formal report is available means that operator errors can go unquestioned.

• Where radiology is a ‘gate keeping’ service the rapid return ofreports is not to everyone’s satisfaction.

General Comments

Several general comments from aless tangible aspect were alluded to,but the sites recognised them asreal. They included work rates forradiologists and secretaries; thesecould begin to increase withoutnecessarily being recognised. Alsoincluded were:

• Loss of autonomy and control.• Lack of urgency where there is no

visible workload, means, no piles of paper and images.

• There is potential for de-skilling with a completely digitised system.There is a need to have plenty of staff information about what’s happening and issues and concerns, and to involve staff across the organisation.

Lessons Learned





Section 4

The bigger picture -organisational benefits

This section includes benefits specifically related to the widerorganisations. It includes benefits linked to inpatients andoutpatients, primary care and specifically changing workforceissues.





Inpatient benefits

Outpatient benefits

Primary care benefits

• Quicker reporting turnaround times, dependant on local circumstances – reports attached to images

• Images available instantly between departments• No lost images• Near patient image viewing e.g. bedside, theatre, clinics and GP surgeries• Home access on-call – expert advice at the most appropriate time• Public expectation, reports and images available at any point through the

patient’s journey• Elimination of wasted junior doctors time, less searching for forms and

reports• Consistency of comparability of images.

• Quicker reporting turnaround times dependant on local circumstances• No lost images• Near patient image viewing• Public expectation, reports and images available at any point through the

patients journey• Improved quality of image, image manipulation• Reduced dose to patient• Streamlined patient processes in department• Reduced waiting times for appointments, radiology and operations• Increased patient satisfaction• Ease of consultation between clinicians, simultaneous viewing of images• Choice for patients, Choice of location for treatment• Reduced transport costs between sites• Improved knowledge management – up to date information and results

for patients allowing appropriate patient management decisions.

• Reports attached to images, comprehensive patient imaging record available• Shorter reporting times and more rapid turn around times• Aids audit and clinical governance, continuity of care• Multiple viewing of images at different destinations simultaneously• Near patient image viewing in GP surgery• Security of images, images held together centrally• Home access ‘on-call’ to give expert advice at most appropriate time • Public expectation, images and reports available at any stage of patients

journey• Service reconfiguration, address demand and capacity issues• Supports the development of full ICRs in line with comprehensive

patient records• Choice for patients- potentially cross site availability of electronic images,

contributes to patients desire to exercise choice of location for treatment• Improved knowledge management – up to date information and results for

patients allowing appropriate patient management decisions.

Changing workforce

Emergency care patients

Daycase patients

• Redefined staff roles• Teaching and learning• Redefined clerical roles, the PACS system has altered the way in which

the clerical staff need to work• Clerical and darkroom staff are now helpers and assistants • Role redesign for some staff. Staff have new roles as receptionists and

helpers• Instant availability of images means valuable staff do not chase films, packets

and reports, they can be utilised more effectively elsewhere • An Imaging support worker (formally a darkroom technician) became

assistant practitioner.

• Shorter reporting times potential for more rapid turn around times• No lost images• Home access ‘on-call’ to give expert advice at most appropriate time• Communication with other departments• Rapid image availability• Clinical outcome under IRMER• Improved knowledge management - up to date information and results• No plastic wallets• Ease of consultation between clinicians, simultaneous viewing of images• Clinicians assisted quick viewing of images• Elimination of wasted junior doctors time, less searching for forms

and reports• Contribution to reduced length of stay• Reports attached to images, comprehensive patient imaging

record available• Near patient image viewing in A&E and theatres• Improved working lives of staff• Reduced paperwork• Redefined department workflows• Healthcare efficiency• Redefined staff roles.

• Shorter reporting times potential for more rapid turn around times• No lost images• Improved communication with other departments• Consistency of comparability of images• Improved knowledge management - up to date information and results• Linking modalities• Near patient image viewing eg bedside, theatre, clinics and GP surgeries• Ease of consultation between clinicians, simultaneous viewing of images• Clinicians assisted rapid availability• Elimination of wasted junior doctors time, less searching for forms

and reports• Reports attached to images, comprehensive patient imaging record available• Choice for patients - potentially cross site availability of electronic images

contributes to patients desire to exercise choice of location for treatment• Healthcare efficiency.

Organisational benefits





Section 5

Strategic benefitsPACS has the potential to be a strategic asset in the delivery and themanagement of healthcare. It has ramifications for thecomprehensive patient record with a service that will not onlysupport the day to day management of diagnostic services, but alsoallow access to information and knowledge out of hours, at alltimes at any destination.

PACS will contribute to improved service standards of delivery andoutcomes, and also contribute to improving value for money withprocesses that are more streamlined and less wasted time in thesystem.

Diagnostics are an integral part of a patient’s journey throughhealthcare, PACS will enhance the performance in this area andincrease the effectiveness of healthcare delivery, where accompaniedby rigorous service redesign.

PACS can support1:

• A balanced range of services which promote health and well-beingand tackle health inequalities.

• Ensuring safe and high quality care, with an increasing element of choice for the patient (the right care)

• Fast and convenient (at the right time)• Ending delays at all stages of the elective and emergency system

Improved patient choice could include the availability of images andreports in:

• Walk in Centres• Treatment Centres• Minor Injury Units• One-Stop Clinics• Expanded GP Practices

A community wide storage of digital images, based on practicalityand affordability will aid successful collaborative care from multi-disciplinary teams.

1Ref (PACS programme strategy 2nd September 2003.)





Section 6

Future vision and directionAll Diagnostic Specialities linked:

PACS needs to be wider than one or two specialities. Inprinciple, any diagnostic service that produces digital imagescould make excellent use of PACS technology. This wouldmean that the entire imaging record of the patient could beavailable at all times at any destination.

Access to Specialist Opinion

PACS would enable immediate access to specialist opinion notonly across the NHS but also globally. Two areas that havebeen proposed as benefiting from this approach directly wouldbe paediatric medicine and neurosciences. There are, ofcourse, many more potential beneficiaries here, but some earlythoughts have been around these two. Other beneficiarieswould include:

• Medical illustration• Dermatology• Endoscopy• Electro-physiology• Pathology• Ophthalmology

There is also the potential for PACS to play a part in ComputerAided Diagnosis (CAD) and wireless technology.

Teaching and Training

The ability to access images and reportsfor teaching and training purposes is ahuge positive aspect of PACS. There isa massive potential for learning andsharing across the whole of the NHS.With digitised information being able tobe retrieved at any accredited trainingcentre, and the advent of the newtraining academies for radiology, thispotential offers an excellent training andteaching resource.

Reporting Outsourcing

Where a department requires assistancewith reporting workload it is possiblethat reporting could be outsourced, toassist with the flow of diagnosticpatients. Obviously, quality assuranceneeds to be in place, and departmentsneed to be able to demonstrate theirown lack of capacity in this area towarrant reporting outsourcing.

Central Files

SHAs with centralised files storage, datawarehousing. Instant accessibility at alltimes.





Section 7

NHS Plan delivery

The group believed that it was important to demonstrate thatthe implementation of PACS not only benefits the NHS ingeneral ways, as in section 1, but also benefits the NHS invery specific ways in relation to the most prominent of thegovernment targets.

This section is an attempt to link some of the benefits to suchtargets.

The list of targets is extensive and we have endeavoured tocover many aspects in quite a detailed way.

The relevant target is listed clearly, at the beginning of eachsection, allowing the reader to skip from one target toanother or to read the text in its entirety.



Targets listing:

(For detailed explanation of targets please see pagenumbers)

PACS and Service Redesign can assist with the deliveryof the following targets.

Local Development Plans (LDP)

Access:

T1 Maximum wait in A+E - p37

T6 Pre-booked admission offering patient choice - p37

Cancer:

T7 Maintain cancer waiting times leading to maximum waits of 1-2 months by December 2005 - p37

T9 Extending breast screening for all women 65-70 years of age - p37-38

Coronary Heart Disease:

T12 Improve access and increase patient choice by achieving a 2-week wait for rapid access chest pain clinic - p38

T15 Improved management of patients withheart failure - p38

Emergency Hospital Admissions:

T23 Less than 1% growth each year in emergency hospital admissions - p38

IM+T Capacity:

- Access to Knowledge sources - p38-39

- Results reporting- Access to clinical records

NHS Plan and National Cancer PlanCancer Waiting Time Targets 2004, 2005, 2008

- p39- 48

Cancer Plan: - Save more lives- Patients with cancer to get

professional support- Better use of skills of existing staff- Redesigning services- Earlier detection- Faster diagnosis and treatment- Consistent high quality services- Improved quality of life through

better care- Streamlining process of care- Reduce waiting times- Education and research- New technologists- Easy access to up to date accurate

information- Co-ordination and continuity of care- Expert advice formal reviews- Increased capacity through new ways

of working- Improve working times of NHS staff- Multi disciplinary training and

effectiveness- New ways of working in partnership,

access to latest expertise and technology

- Improve quality of services and minimise errors

- Timely discharge into appropriate facilities

Choice Agenda (DOH) - p48-52

Choice for patients summer 2004, December 2005.

A+E4 hour wait - p52



Benefits linked to targetsNational Access Trgets:

Access• Efficient utilisation of PACS is critical to delivery of the

NHS Plan target for 2008, that patients begin their hospital treatment a maximum of 18 weeks from the point of referral.

• PACS facilitates the concept of choice in imaging services by enabling image services to be provided andreported on in primary care.

• Improved access to diagnostic imaging services is also critical to achievement and sustained delivery of current access targets for 2005.

A&E• Around one third of all patients attending A&E require

an imaging test, particularly x-ray.• Rapid access to diagnostic imaging and reporting is

therefore critical to sustained delivery of the four hour target.

Outpatients• Imaging services provided in primary care and linked

through PACS for reporting purposes - will enable more patients to be seen, diagnosed and treated in primary care.

• This will significantly reduce the number of outpatient appointments and therefore outpatient waits.

Inpatients• PACS enables remote reporting and therefore the

potential of many imaging tests being undertaken in primary care settings (dependent upon expansion of practitioner roles and sensible location of equipment in addition to the existing secondary care base - potential for formation of imaging service networks across health communities).

• This could reduce unnecessary hospital inpatient episodes, and current practice whereby patients are admitted to hospital in order to gain speedier access to imaging services.

Local Development Plan Targets:

Access

T1 Reduce to 4 hours maximum A&E wait, from arrivalto admission, transfer or discharge, by March 2004 forthose trusts who have completed Emergency ServicesCollaborative, and by the end of 2004 for all others:

• Reports attached to image, comprehensive patients imaging record available.

• Benefits to other departments, other departments ableto remotely access relevant images and reports for patients.

• Clinicians assisted, quick viewing of images and previous images instantly available.

• Reduced waiting times within departments, due to streamlined processes.

• A&E waiting times reduced, images quickly available, quicker reporting.

• Near patient image viewing.• Home access on-call, clinicians can successfully work

from home where appropriate, to give expert advice atthe most appropriate time.

T6 Increase the level of choice in each year, offeringroutine choice of hospital provider at point of bookingfor all patients by December 2005:

• Consistency of comparability of images.• Service reconfiguration – image availability and

transportability• Choice for patients, potentially the cross-site

availability of images and reports can contribute to thepatient’s desire to exercise choice of location for treatment.

Cancer

T7 Maintain existing Cancer working time standardsand set local waiting time targets for 2003/4 and2004/5, so that by the end of 2005 there is a maximumone month wait from the diagnosis to treatment and 2months from the urgent referral to treatment of allcancers:

• Reports attached to image comprehensive patients imaging record available.

• Improved quality of image, image manipulation, allowing reporting clinicians more versatility for image viewing for diagnosis.

• Aids audit, clinical governance, readily available imagesand reports, continuity of care.

• Rapid image availability and multiple viewing of images.

T15 Improve management of patients with heart failurein line with the NICE Clinical Guideline due in 2003, andset local targets for the consequent reduction in patientsadmitted to hospital with a diagnosis of heart failure.

• No lost images, image and reports instantly available at any destination.

• Benefits to other departments, other departments able to remotely access relevant images and reports for patients.

• Reduced waiting times for appointments and times within the department.

• Opportunity for quicker reporting in A&E – potentially less admission.

• Home access on call, clinicians can successfully work from home where appropriate, to give expert advice atthe most appropriate time.

• Elimination of wasted junior doctor time, images available for doctors at multiple locations.

• Consistency of comparability of images.• Improved knowledge management, up to date

information and results for patients allowing for appropriate patient management decisions.

Emergency Hospital Admissions

T23 Each year there will be less than 1% growth in re-admissions

• Consistency of comparability of images.• Improved knowledge management, up to date


• Rapid image availability, multiple view of images in various locations simultaneously.

• Near patient image viewing, eg A&E. theatres.• Home access on-call, clinicians can successfully work

from home where appropriate, to give expert advice atthe most appropriate time.

• A&E waiting time reduced, images quickly available, opportunity for quicker reporting.

IM+T Capacity Assumptions

Electronic records - Access to knowledge sources- Results reporting (including pathology and radiology)- Access to clinical records

• No lost images• Reports attached to images- comprehensive record• Benefits other departments, able to remotely access

relevant images and reports• A&E time reduced, images quickly available,

opportunity for quicker reporting• Teaching, image available in PACS fashion,

transportable, access to specialist opinion

• Research, long term availability of a comprehensive set of images and reports for patients, will aid those carrying out research

• Links to other centres• MDT meetings• Near patient image viewing• Security of images• Home access on-call, clinicians can successfully work

from home, give expert advice at the most appropriatetime.

• Ease of consultation between clinicians, aiding decision making

• Improved knowledge management, up to date information and results for patients, allowing appropriate management decisions.

Cancer waiting times targets 2004

Every patient diagnosed with cancer will benefit frompre-planned and pre booked care.

• Communication with other departments, instant information transferred electronically across single or multiple organisations.

• Service reconfiguration, the image availability and transportability of PACS will aid service reconfigurationand assist in addressing some demand and capacity issues.

• Sharing capacity for examinations and reporting, potentially with electronic transfer of images a balancemay be struck with respect to peaks and troughs of demand for reporting.

Cancer waiting times targets 2004 Maximum two-month wait for first outpatientappointment for patients referred urgent for suspectedcancer by a GP.


• Service reconfiguration, the image availability and transportability of PACS which will aid service reconfiguration will result to demand and capacity issues.

• Sharing capacity for examinations and reporting, potential with electrical transfer of images a balance may be struck with respect to peaks and troughs of demand for reporting.


Maximum two-month wait from urgent GP referral forsuspected cancer to first treatment for all cancers by2005.

• MDT meetings.• Healthcare efficiency, diagnosis procedure becomes

much more streamlined leading to more effective and efficient hospital treatment.

• Public expectation – patients now expect their images and reports to be available at any stage of their journey and in an appropriate time scale.

• Ease of consultation between clinicians, consult in real time, viewing images simultaneously.

• Improved knowledge management, up to date information and results, appropriate management decisions.

T9 Extending breast screening to all women aged 65 – 70:

• No lost images, images and reports instantly available to clinicians at any destination.

• Improved quality of image, image manipulation allowing clinicians more versatility for image viewing for diagnosis.

• Redesigned department and workflow, streamlined patient processes

• Reduced working times for appointments and time within departments

• Research, long-term availability of a comprehensive setof images and reports.

• MDT meetings.• Service reconfiguration, image availability and

transportability, address demand and capacity issues.• Improved knowledge management, up to date


Coronary Heart Disease.

T12 Improve access to services across the patientpathway, and increase patient choice by achieving thetwo week wait standard for Rapid Access Chest PainClinics; setting local targets to make progress towardsthe NSF goal of a 3 month maximum want forangiography; and delivering maximum waits of 3months for revascularisation by March 2005, or sooner ifpossible:

• Reduced waiting times for appointments and reduced waiting times within the department.

• Service reconfiguration, image availability and transportation, address some demand and capacity issues.

• Choice for patients.








• Radiographer led ultrasound examinations.• Improved process time for fluoroscopy.• Medico-legal images converted to CD ROM, no

longer have to pull films physically no packaging posting etc.

• Links to other centres, especially useful for such events as MDT meetings.

• Multiple viewing of images, numerous specialists in various locations can view images simultaneously.

• Rapid image availability wards, clinics, other areas, images remotely available any time any place.

Cancer waiting times targets 2005 Maximum one-month wait from urgent GP referral totreatment for children’s, testicular cancers and acuteleukaemia by 2005.



• Sharing capacity for examinations and reporting, potentially with electrical transfer of images a balance may be struck with respect to peaks and troughs of demand for reporting.


longer have to pull films physically no packaging, posting etc.




• Near patient image viewing i.e. patients in clinical cubicles or beds or patients in GP surgery.




Cancer waiting times targets 2005 Maximum one-month wait from diagnosis to firsttreatment for all cancers by 2005




• Healthcare efficiency, diagnosis procedures become much more streamline leading to more effective and efficient hospital treatment and patient flow and moreeffective primary care.





• Clinicians assisted quick viewing of images and previous images instantaneously available.



No patient with suspected cancer will wait longer thanone month from urgent GP referral to treatment





• Radiographer led ultrasound examinations.• Improved process time for fluoroscopy.• Medico-legal images converted to CD ROM, no longer

have to pull films physically no packaging posting etc. • Links to other centres, especially useful for such

events as MDT meetings. • Multiple viewing of images, numerous specialists in

various locations can view images simultaneously. • Clinicians assisted quick viewing of images and

previous images instantaneously available. • Near patient image viewing i.e. patients in clinical

cubicles or beds or patients in GP surgery.

Executive summary 2 The Cancer Plan sets out the first comprehensivenational cancer programme for England. It has fourmain aims: to save more lives…

• Shorter reporting times, images initially available no manual handling of analogy images.

• No lost images, less wasted time for staff hunting images and reports. Images and reports instantaneously available to clinician at any destination.

• Radiographer led ultrasound examinations.• Improved process times for fluoroscopy.• Medico-legal images converted to CD ROM, no longer

have to pull films physically no packaging posting etc. • Links to other centres, especially useful for such events

as MDT meetings. • Multiple viewing of images, numerous specialists in

various locations can view images simultaneously. • Clinicians assisted quick viewing of images and

previous images instantaneously available. • Near patient image viewing i.e. patients in clinical

cubicles or beds or patients in GP surgery • Communication with other departments, instant

information transferred electronically across single or multiple organisations.

• Teaching, images available in PACS mode will be extremely versatile and transportable for teaching purposes especially in training academies. Access to speciality opinion and teaching will be possible.

• Aids audit, clinical governance, ready availability of images and reports and continuity of care.


Cancer waiting times targets 2005 Maximum two-month wait from urgent GP referral tofirst treatment for breast cancer.


• Service reconfiguration, the image availability and transportability of PACS will aid service reconfigurationwill result to demand and capacity issues.


• Radiographer led ultrasound examinations.• Improved process time for fluoroscopy/mammography.• Medico-legal images converted to CD ROM, no


• Links to other centres, especially useful for such events as MDT.




Cancer waiting times targets 2005 Maximum one-month wait from diagnosis to firsttreatment for breast cancer




• Healthcare efficiency, diagnosis procedures become much more streamline leading to more effective and efficient hospital treatment, patient flow and more effective primary care.

• Radiographer led ultrasound examinations.• Improved process time for fluoroscopy/mammography.• Medico-legal images converted to CD ROM, no


• Links to other centres, especially useful for such events as MDT.





Executive summary 2 The Cancer Plan sets out the first comprehensivenational cancer programme for England. It has fourmain aims: – to ensure people with cancer get the rightprofessional support as well as the best treatments


• Radiographer led ultrasound examinations.• Improved process times for fluoroscopy procedures.• Medico-legal images converted to CD ROM, no longer

have to pull films physically no packaging posting etc. • No lost images, less wasted time for staff hunting

images and reports. Images and reports instantaneously available to clinicians at any destination.

• Links to other centres, especially useful for such eventsas MDT meetings.



• Electronic links to other Trusts and organisations.• Communication with other departments, instant


• Teaching, image available in PACS mode will be extremely versatile and transportable for teaching purposes especially in training academy. Access to speciality opinion and teaching will be possible.

• Aids audit, clinical governance, ready availability of images, reports and continuity of care.

Executive summary 28 Investment in staff and equipment the introduction ofthese new targets will be supported by investment totackle key gaps in the cancer workforce and make betteruse of the skills of existing staff, investing in extraequipment for diagnosis and treatment, and action toredesign and streamline existing services to cut outdelays.

• Redefines staff roles, new ways of working as a result of streamlined process, role enrichment opportunities, better usage of staff skills.


• Aids audit, clinical governance, ready availability of images and reports and continuity of care


• Reduced waiting times, appointments and time within department, streamlined process which lead to more efficient service procedure at appointment stage and on day of diagnostic test.


• Teaching, images available in PACS mode will be extremely versatile and transportable for teaching purposes especially in training academy. Access to speciality opinion and teaching will be possible.


• No lost images, less wasted time for staff hunting images and reports. Images and reports instantaneously available to clinicians at any destination.

• Proportion of “helper” time spent with patients, streamlined procedure and reduced none value added work allowing worker to spend quality time with patients.


The challenge of cancer 1.17 However, there are some key challenges that must bemet if the NHS is to provide world-class cancer care:….faster diagnosis and treatment….

• No lost images, less wasted time for staff hunting images and reports. Images and reports instantaneously available to clinician at any destination.


• Redesign department and workflow, streamlined patient process and improved electrical pathways will allow staff to work very different.





various locations can view images simultaneously. • Rapid image availability wards, clinics, other areas,

images remotely available any time any place.

• Near patient image viewing i.e. patients in clinical cubicles or beds, or patients in GP surgery.







The challenge of cancer 1.17 However, there are some key challenges that must bemet if the NHS is to provide world-class cancer care:….consistent high quality services….

• No lost images, less wasted time for staff hunting images and reports. Images and reports instantaneously available to clinicians at any destination

• Redesign department and workflow, streamlined patient process and improved electrical pathways will allow staff to work very differently.


• Image manipulation, allowing reporting clinical more versatile for image viewing for diagnosis.


• Teaching, image available in PACS mode will be extremely versatile and transportable for teaching purposes especially in training academies. Access to speciality opinion and teaching will be possible.

• Aids audit, clinical governance, ready availability of images, reports and continuity of care


• Staff development (IT literacy), staff need to be fully conversed with the IT system that produces, manipulates and transfers images, this will lead to staff competence and confidence.

Executive summary 31 Redesigning services, new investment alone is notenough. Services need to be streamlined, and newapproaches are needed to make best use of skills in thecancer workforce

• Redesign department and workflow, streamlined patient process and improved electrical pathways will allow staff to work very different.










• Near patient image viewing i.e. patients in clinical cubicles, beds or patients in GP surgery.




The challenge of cancer 1.17 Nevertheless, there are some key challenges that mustbe met if the NHS is to provide world-class cancer care:….earlier detection…..








• Healthcare efficiency, diagnosis procedures become much more streamline leading to more effective and efficient hospital treatment, patient flow and more effective primary care

The challenge of cancer 1.17 However, there are some key challenges that must bemet if the NHS is to provide world-class cancer care:….improved quality of life through better care...





images remotely available any time any place. • Near patient image viewing i.e. patients in clinical

cubicles or beds, or patients in GP surgery. • Teaching, images available in PACS mode will be

extremely versatile and transportable for teaching purposes especially in training academies. Access to speciality opinion and teaching will be possible.

• Reports attached to image comprehensive patient’s imaging record available.

• Catalyst for IT staff training.• Elimination of wasted junior doctors time re film

management, junior doctors will not have to chase images and reports, they will be available at the destination of the junior doctor.

• Reduction of manual handling (film packets and chemistry).

• Reduced phone calls, less interruption about queries regarding reports or images.

• Ease of consultation between clinicians, clinicians can consult in real time with the ability to view images simultaneously.

• No chemicals (COSHH), reduced hazard to staff and reduced costs.

• Financial savings, there is potential for financial savingsin the area or more appropriate use of staff cost saving on chemistry and machine maintenance however these benefits must be viewed against original capital out lay and costs.



The challenge of cancer 1.19 Reduce waiting times for cancer treatment – recognisingthe urgency of the condition….


• Reduced downtime of equipment compared to chemical “processing,” less equipment maintain and less equipment fail Reducing downtime in equipment.



• Radiographer led ultrasound examinations.• Improved process time for fluoroscopy procedures.• Medico-legal images converted to CD ROM, no longer










The challenge of cancer 1.19 To prepare for the future through education andresearch…..



• Research, long term availability of a comprehensive setof images and reports for patients will aid those carrying out research.

• Medico-legal images converted to CD ROM, no longerhave to pull films physically no packaging posting etc.






Improving screening 3.13 New technologies may assist the screening process. TheNHS Breast Screening Programme is to publish theresults of a working party group which has reviewedComputer Aided Detection in breast screening. We areclosely monitoring other new technologies such asdigital mammography, on-site processing ofmammograms and new innovative designs for screeningvans and will refer them to NICE for appraisal, ifappropriate.






• Research, long term availability of a comprehensive set of images and reports for patients will aid those carrying out research.





• Improved clinical environment. • Communication with other departments, instant

information transferred electronically across single or multiple organisations



• Reduced waiting times, appointments and time within department, streamlined process which leads to a more efficient service procedure at appointment stage and on day of diagnostic test.






The challenge of cancer 1.19 Shorten the time taken to diagnose cancer bystreamlining the process of care and investing more inequipment and staff….



• Staff retention.• Shorter reporting times, images initially available no

manual handling of analogy images.• Radiographer led ultrasound examinations.• Improved process time for fluoroscopy procedures.• Medico-legal images converted to CD ROM, no longer



various locations can view images simultaneously.






• No chemicals (COSHH) reduced hazard to staff and reduced costs.

• Improved clinical environment.• Communication with other departments, instant


Improving Treatment 6.7 A consistent theme in the “improving outcomes”guidance is that cancer services are best provided byteams of clinicians – doctors, nurses, clinical staff andother specialists – who work together effectively. Teamworking brings together staff with the necessaryknowledge, skills and experience to ensure high qualitydiagnosis, treatment and care. It also improves the co-ordination and continuity of care for patients.












Investing in Staff 8.32 Increased Capacity through new ways of working theseinitiatives to increase the number of staff in training willease the pressures on the cancer workforce and improvethe service to patients. But further action is needed totackle problems in specific areas, notably diagnostic andtherapeutic radiography.


• Radiographer led ultrasound examinations.• Improved process for fluoroscopy.• Medico-legal images converted to CD ROM, no longer






• Near patient image viewing i.e. patients in clinical cubicles or beds, or patients in GP surgery



Investing in staff 8.41 The NHS Plan sets out wide-ranging new initiatives toimprove the working lives of NHS staff which will benefitcancer staff. Improving the working lives of staffcontributes directly to enhance cancer services throughimproved recruitment and retention. Offering newopportunities for development and extended roles willopen up new career opportunities for staff that havepreviously faced restriction and dead ends.


• Improved working environment, no chemistry no wasted tasks (film hunting) more physical space(overallfuture requirement may be for less physical space leading to reduced capital costs), rooms fit for purpose(e.g. reporting) less manual handling.

• Retention of staff.• Catalyst for IT training.• Elimination of wasted junior doctors time re film

management, junior doctors will not have to chase images and reports, they will be available at the destination of the junior doctor.






• Financial savings, there is potential for financial savingsin the area or more appropriate use of staff cost saving on chemistry and machine maintenance however these benefits must be viewed against original capital out lay and on costs.

• Improve clinical environment.• Redefines staff roles, new ways of working as a result

of streamlined process, role enrichment opportunities, better usage of staff skills.

• Teaching, images available in PACS mode will be extremely versatile and transportable for teaching purposes especially in training academies. Access to speciality opinion and teaching will be possible

• Aids audit, clinical governance, ready availability of images, reports and continuity of care

•Staff development (IT literacy), staff need to be fully conversed with the IT system that produces, manipulates and transfers images, this will lead to staff competence and confidence.

• Prestige.

Investing in staff 8.51 Education and training for cancer staff will need tounderpin cancer network workforce strategies. Allcancer service providers will be required to draw up awritten training strategy for cancer clinicians, bothmedical and non-medical. Multi-disciplinary training willsupport and develop the effectiveness of the specialistmulti-disciplinary teams providing cancer care.



Improving Treatment 6.11 The care of all patients with cancer should be formallyreviewed by a specialist team. This will be done eitherthrough direct assessment or through formal discussionwith the team by the responsible clinician. This will helpensure that all patients have the benefit of the range ofexpert advice needed for high quality care. The deliveryplans to be prepared by the cancer networks should setout a timetable for the achievement of this standard.




• Improved quality of image, excellent digital acquisitionsystems, reduced repeat images due to poor quality.



• Research, long term availability of a comprehensive setof images and reports for patients will aid those carrying out research .








• Reduced waiting times, appointments and time within department, streamlined process which leads to more efficient service procedure at appointment stage and on day of diagnostic test.









• Links to other centres, especially useful for such eventsas MDT.





• Improved knowledge management, up to date information and results for patients convenience available allowing for appropriate patient management decisions.

• Staff development.• Prestige.

Investing in facilities 9.10 In implementing this expansion, we will explore thescope for public private partnerships with serviceproviders and the industry, particularly in relation topathology and imaging. Where new ways of workingoffer advantages to patients, they need to beimplemented.


• Radiographer led ultrasound examinations.• Improved process time for fluoroscopy.• No lost images, less wasted time for staff hunting







• Improved quality of image, excellent digital acquisition systems, reduced repeat images due to poor quality.









cubicles or beds, or patients in GP surgery • Communication with other departments, instant


• Public expectation, patients now expect their images and reports to be available at any stage of their journey and in an appropriate time scale.


• Choice for patients, potentially the cross-site availability of electrical images and reports can contribute to patient’s desire to exercise chose of location for treatment.

• Comprehensive patient record.

All patients who may require planned surgery will beoffered a choice of four or five hospitals or providerswhen they are referred by their GP (From Dec 2005)


• Improve process time for fluoroscopy.• Medico-legal images converted to CD ROM, no longer







• Choice for patients, potentially the cross-site availability of electrical images and reports can contribute to patient’s desire to exercise chose of location for treatment.

• Comprehensive patient records. • Patient satisfaction, high quality intervention at

appointment times by appropriate people based on images available.

MA documentRadiology National Framework for Service Improvement– support redesign in diagnostic imaging and extend therole of healthcare professionals


• Improved process time for fluoroscopy.• Medico-legal images converted to CD ROM, no longer








• Teaching, images available in PACS mode will be extremely versatile and transportable for teaching purposes especially in training academies. Access to speciality opinion and teaching will be possible



• Retention of staff.• Staff development (IT literacy), staff need to be fully

conversed with the IT system that produces, manipulates and transfers images, this will lead to staff competence and confidence.

Investing in facilities 9.12 These new partnerships will extend over a number ofNHS organisations rather than being restricted to asingle NHS Trust. Public private partnerships offer newways to organise services in a way which improvesservices for patients and provides them with access tothe latest expertise and technology where and whenthey are required.


• Radiographer led ultrasound examinations.• Improve process time for fluoroscopy.• No lost images, less wasted time for staff hunting










Non ReferencedThe supportive and palliative care guidance recommendsthat patients and carers are offered high qualityinformation materials, tailored to their individual needs,at appropriate points in the care pathway

• Patient satisfaction, high quality intervention at appointment times by appropriate people based on images available.

Choice Agenda (DOH)

All patients waiting over six months for surgery will beoffered a choice of moving to another hospital orprovider (Summer 2004)






NHS Cancer Plan (DOH)Preface 5 – The NHS will work continuously to improvequality services and to minimise errors. The NHS willensure that services are driven by a cycle of continuousquality improvement. Quality will not just be restricted tothe clinical aspects of care, but include quality of life andthe entire patient experience. Healthcare organisationsand professions will establish ways to identifyprocedures that should be modified or abandoned andnew practices that will lead to improved patient care. Allthose providing care will work to make ever safer, andsupport a culture where we can learn from andeffectively reduce mistakes. The NHS will continuouslyimprove its efficiency productivity and performance.



• Improved process time for fluoroscopy.• Medico-legal images converted to CD ROM, no longer


images and reports. Images and reports instantaneously available to clinician at any destination.





• Research, long term availability of a comprehensive setof images and reports for patients will aid those carrying out research Improved.


• Catalyst for IT skills.• Elimination of wasted junior doctors time re film

management, junior doctors will not have to chase images and reports they will be available at the destination of the junior doctor.





• Financial savings, there is potential for financial savingsin the area or more appropriate use of staff cost saving on chemistry and machine maintenance





• Comprehensive patient records.• Proportion of “helper” time spent with patients,

streamlined procedure and reduced none value added work allowing worker to spend quality time with patients.

Investing in facilities 4.4 Respondents saw the use of intermediate care as centralto this more joined up approach. It should concentrateon maintaining and restoring independence, and onrehabilitation. It would act as a bridge betweencommunity and hospital care. Both staff and patientswould experience new ways of working which wouldblur the boundary between primary and secondary care.Specific elements of the new service would include...timely discharge into appropriate settings…



as MDT meetings.• Multiple viewing of images, numerous specialists in



cubicles or beds, or patients in GP surgery • Shorter reporting times, images initially available no

manual handling of analogy images. • Contribution to decreased length of patient stay,

images and reports availability at destination in a timely fashion can potential accelerate patient discharge.





Investing in facilities 4.22NHS staff will also benefit from the investment in newinformation technology. Staff will get easy access to up-to-date and accurate information on patients’ medicalhistories. NHS staff will be able to order tests, referpatients and make booking of appointments for patientsusing new IT. The National Electronic Library for Healthwill provide electronic access to state-of-the-artinformation on latest treatments and best practice. Thisinvestment will allow for greater efficiency and also foreasier access to the information necessary to monitorlocal performance and practices against nationalstandards and performance indicators.

• Supports the development of ICRS, in line with the NPfIT programme for comprehensive patient record.


• Environmental, less background radiology (less unnecessary exposure) less chemistry and pollution. However consider energy use especially where air condition units are required.

• Hospital efficiency.

Investing in NHS staff 5.5 These are very challenging targets but we must meetthem – and, if possible, exceed them – if the NHS is tomake the service gains for patients they need. We willachieve them by... improving the working lives of staff.

• Reduced stress levels, happier staff, improved process that improves working lives less time wasted in futile tasks.

• Reduced phone calls, less interruption about queries regarding reports or images

• Redefines staff roles, new ways of working as a result of streamlined process, role enrichment opportunities, better usage of staff skills

• Staff retention• Improved working environment, no chemistry no

wasted tasks (film hunting) more physical space (overall future requirement may be for less physical space leading to reduced capital costs), rooms fit for purpose (e.g. reporting) less manual handling.

• Catalyst for IT skills• Elimination of time wasted for junior doctors.• Reduced manual handling risks• Ease of consultation between radiologists and other

clinicians• Improved teaching and research facilities

however these benefits must be viewed against original capital out lay and on costs.

• Improved clinical environment.• Aids audit, clinical governance, ready availability of

images, reports and continuity of care. • Reduced litigation costs, potentially because no films

or reports will be lost and images and reports will always be available in a timely fashion for appropriate patient management, this could lead to less litigation costs.


Investing in facilities 4.4 Respondents saw the use of intermediate care as centralto this more joined up approach. It should concentrateon maintaining and restoring independence, and onrehabilitation. It would act as a bridge betweencommunity and hospital care. Both staff and patientswould experience new ways of working which wouldblur the boundary between primary and secondary care.Specific elements of the new service would include...fast access to diagnostics and pathology leading toeffective interventions….






• Reduced waiting times, appointments and time within department, streamlined process which leads to more efficient service procedure at appointment stage and on day of diagnostic test.






images remotely available any time any place.





• Production of portables images CD ROM• Medico-legal cost savings• Rapid reporting turnaround times• Recruitment and retention• Staff development• Teaching and learning• Electronic links to other Trusts and organisations

Investing in NHS staff 5.16 The Improving Working Lives standard means that everymember of staff in the NHS is entitled to belong to anorganisation that can prove that it is investing in theirtraining and development, tackling discrimination andharassment, improving diversity, applying a zerotolerance on violence against staff, reducing workplaceaccidents, reducing sick absences, providing betteroccupational health and counselling services, conductingannual attitude surveys – asking relevant questions andacting on the key messages. Standards and targets havealready been established to support these goals. It isnow down to NHS employees to deliver them. As aresult of the NHS Plan we give their efforts a furtherimpetus.

• Improved environment (COSHH)• Reduced manual handling• Reduced telephone calls• Reduced stress levels• Catalyst for IT skills• Redefine staff roles• Teaching and learning• Clinical governance• Training facilities (Academies and local)• Knowledge management• Recruitment

Changed systems for the NHS 6.11 Support to design care around patients ... planning thepathway or route that a patient takes from start to finishto see how it could be easier and swifter – every step,from the moment a patient arrives at the GP up to andincluding when they are discharged. Unnecessary stagesfor care are removed, more test and treatment are doneon a one-stop and day-case basis.

• Radiographer led ultrasound examinations• Improved process time for fluoroscopy• Production of portable images CD ROM• Speed and ease of MDT meeting• Simultaneous multi-user access to images and reports• 24 hour availability of images• Electronic link to other Trusts and organisations• Rapid reporting turnaround times• Redefine staff roles• Improved information flow

• Rapid report availability attached to images• Image manipulation• Catalyst for IT skills• Elimination of time wasted by junior doctors• Reduced manual handling risks• Reduced telephone calls• Ease of consultation between radiologists and other

clinicians• Improved environment (COSHH)• Medico-legal cost savings• Improved clinical environment

A & E 4-hour wait

• No lost images• Rapid report availability attached to images• Redefine staff roles• Reduced waiting times in department• Reduced downtime of equipment• Radiographer led ultrasound examinations• Increased helper time with patient• Elimination of time wasted for junior doctors• Remote reporting• Image manipulation• Electronic links to other Trusts and organisations• Consistency and comparability• 24 hour availability• Improved information flow• Meeting public expectation• Audit and clinical governance• Redesigned departmental processes• Choice for patients• Shared capacity• Reduced radiation dose for patients• Reduced length of stay• Comprehensive patient record• Politically appropriate

• Service reconfiguration• Redesign departmental processes• No lost images• Hospital efficiency

Cutting waiting for treatment 12.10By 2004, no one should be waiting more than fourhours in accident and emergency from arrival toadmission, transfer or discharge. Average waiting timesaccident and emergency will fall as a result to 75minutes. By then we will have ended inappropriatetrolley waits for assessment and admission. Of course,some patients such as those emergencies arriving byambulance will clinically need to be assessed on a trolley,but after that if they need a hospital bed they should beadmitted to one without undue delay.

• A & E waiting time reduced• Radiographer led ultrasound examinations• Improved process time for fluoroscopy• Production of portable images CD ROM• Speed and ease of MDT meeting• Simultaneous multi-user access to images and reports• 24 hour availability of images• Electronic link to other Trusts and organisations• Rapid reporting turnaround times• Redefine staff roles• Improved information flow• Redesign departmental processes• Service reconfiguration• No lost images

Aim A3.1 To transform the health and social care system so that itproduces faster, fairer services that deliver better healthand tackles health inequalities.

• Redefine staff roles• Improved information flow• Redesign departmental processes• Service reconfiguration• Hospital efficiency• Rapid reporting turnaround times• Radiographer led ultrasound examinations• Improved process time for fluoroscopy• Production of portable images CD ROM• No lost images• Speed and ease of MDT meetings• Simultaneous multi-user to access and reports• 24 hour availability of images• Electronic links to other Trusts and organisations• Improved teaching and research facilities





PACS - Picture Archiving and Communications Systems

RIS - Radiology Information System

IRMER - Ionising Radiation (Medical Exposure)Regulations

COSHH - Control of Substances Hazardous to Health

NPfIT - National Programme for Information Technology

ICRS - Integrated Care Record System

CD-Rom - Compact Disc Read Only Memory

CR - Computerised Radiology

DR - Digital Radiology

MDT - Multidisciplinary Team

IHE - Institute of Health Education

PC - Personal Computer

SHA - Strategic Health Authority

IT - Information Technology

Glossary of terms

PACS Practical Experiencewww.npfit.nhs.uk/programmes/pacs

Radiology: A National Framework for ServiceImprovement. NHS Modernisation Agency (June 2003)

NHS Modernisation Agency radiology websitewww.modern.nhs.uk/radiology

Secondary care booking: towards a fully booked NHSwww.modern.nhs.uk/access

National Programme for Information Technology (NPfIT) website www.npfit.nhs.uk

National Programme for Information Technology (NPfIT) electronic booking websitewww.chooseandbook.nhs.uk

Further reading andkey links



AcknowledgementsOur thanks go to the following people for their contribution to this report.

Dr. Laurence Sutton Consultant Radiologist, Calderdale Royal Hospital, Diane Rooney Service Lead, Calderdale Royal HospitalMark Rodgers Radiology Service Manager, Calderdale Royal HospitalGlynis Wivell Acting Service Manager, Norwich & NorfolkHelen ClarkePACS Systems Administrator, Norwich & NorfolkWill Smith Radiology Services Manager, TelfordRichard Williams PACS Manager, TelfordJulie YoungSuperintendent Radiographer, TelfordDouglas MantonDirectorate Manager, Derriford HospitalDr. Graham Hoadley Consultant Radiologist, Blackpool, Fylde & Wyre. National Clinical Lead for Radiology Service ImprovementStewart WhitleyRadiology Services Manager, Blackpool, Fylde & WyreDavid Dewitt,General Manager X-ray Services, Blackpool, Fylde & WyreDr Stephen DaviesConsultant Radiologist, Royal Glamorgan HospitalPaul UnsworthChief Executive Tending PCTBeverly Peacock Director of Finance, Bolton NHS Hospital TrustKeith SmithBranch Head - DH Diagnostic Services BranchKate Prangley Director of National PACS teamLesley Wright Associate Director - Diagnostics, NHS Modernisation Agency Sue Beckman National Manager for Radiology, NHS Modernisation Agency David JenningsNPfIT PACS Team

Report Composition by Sue Beckman, Hannah Bywater and Shirley Steeples

pacs realisation and service redesign opportunities€¦ · 19.10.2004 · pacs benefits...

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