In her presentation “PACS installations in a networked environment – combining multiple hospitals” Strickland provided interesting insights into basic clinical and IT requirements that have to be considered prior to implementation.
“The first questions you have to ask yourself before installing a PACS are: Why do I want to combine the sites of the hospital? and: What are my workflow goals? To define the purpose of your network, you must define the work pattern. This is the key step,” Strickland emphasised. She distinguishes between two basis models: Either you want a single unit “virtual hospital” which is seamless, fully integrated and location-independent, or you opt for what she called “degrees of hub and spoke”, an approach which offers different scenarios but which is thus more complex and more difficult to define.
A single unit “virtual hospital” is characterized by shared worklists irrespective of the acquisition site, equal access to imaging studies and reports, one set of statistics and cross-site multidisciplinary team meetings, e.g. by teleconferencing. “In short the only difference to a common single unit hospital is the physical separation,” Strickland said.
“In consequence you need to have exactly the same IT and the same ID numbering system in the whole environment, meaning the same PACS, the same RIS, speech recognition, EPR, electronic requesting, electronic feedback of results – everything. There is no other option! Anything less will lead to a significant clinical risk caused by lost and unnecessary repeat studies which in turn will lead to serious medical staff frustration.
Standardized IT solutions in the different sites of a hospital network are easy to implement if there is no existing PACS. Otherwise you have defend the change, for example by underlining improved efficiency and patient care, e.g. less radiation exposure since repeat exams are avoided and thus reduced clinical risk. “In a situation where you roll out the best PACS to the other sites, it is commendable to speak to staff members about an ‘upgrade’ that will result in less work for everyone,” Strickland advises.
Institutions that work together in a hub and spoke scenario are for example specialist referral centres with large district general hospitals, large hospitals with smaller remote hospitals, or main hospitals with independent outsourcing centres. “It is the clinician’s role to define the clinical scenario because he knows the realistic clinical needs best but he cannot be the one to decide what IT solution, e.g. data transmission protocols or data storage method and management, would fit those needs best.” Which IT solutions are available? First of all, the use of portable media, although this should been seen as last resort. “Portable media such as CDs are fraught with problems. The Integrating the Healthcare Enterprise (IHE) defined two integration profiles for CDs which you should in any way insist to be implemented: PDI (portable data for imaging) and IRWF (import reconciliation workflow).”
The second option, Strickland explained, is point-to-point transmission as a direct agreement between institutions. “Make sure that in such a scenario report and images are delivered together – often they are not!” Thirdly, there are commercial proprietary solutions: “This is only efficient if all hospitals buy in. And you have to consider that you might become dependent on the chosen vendor which could limit your hospital when future changes are required,” Strickland said. Another option is cross-platform document sharing for imaging with IHE defined XDSi. The problem here is that XDSi still lacks universal supplier buy-in and that there are still gaps in IHE XDSi specifications for example with regard to data security mechanisms, document categorisation or the definition of ‘affinity domain’ (a data sharing community).
„Many of these issues are currently inadequately addressed resulting in radiologists and other clinicians in Europe and North America working in environments equivalent to "digital islands" isolated by their own IT which functions well in a stand-alone mode, but which integrates poorly, if at all, in a networked setting’, Strickland resumed at the end of her speech.
Dr. Nicola H. Strickland is Consultant Radiologist at Hammersmith Hospital, a major teaching hospital in West London, UK, and part of the Imperial College Healthcare NHS Trust. Strickland is Committee Member of the UK PACS & Teleradiology Group and chairs the working group Subcommittee on Management in Radiology (MIR) of the European Society of Radiology (ESR).
In almost 12 years of filmless PACS and imaging IT experience, at Hammersmith Hospital she has encountered nearly every problem that can arise during implementation and use of a hospital-wide PACS. The clinical imaging centre at Hammersmith – the largest new clinical research imaging centre in Europe – opened in June 2007.”