Inna Brikman

A methodology for the economic assessment of picture archiving and communication systems

Most economic studies of picture archiving and communication systems (PACS) to date, including our own, have focused on the perspectives of the radiology department and its direct costs. However, many researchers have suggested additional cost savings that may accrue to the medical center as a whole through increased operational capacity, fewer lost images, rapid simultaneous access to images, and other decreases in resource utilization. We describe here an economic analysis framework we have developed to estimate these potential additional savings. Our framework is comprised of two parallel measurement methods. The first method estimates the cost of care actually delivered through online capture of charge entries from the hospital’s billing computer and from the clinical practices’ billing database. Multiple regression analyses will be used to model cost of care, length of stay, and other estimates of resource utilization. The second method is the observational measurement of actual resource utilization, such as technologist time, frequency and duration of film searches, and equipment utilization rates. The costs associated with changes in resource use will be estimated using wage rates and other standard economic methods. Our working hypothesis is that after controlling for the underlying clinical and demographic differences among patients, patients imaged using a PACS will have shorter lengths of stay, shorter exam performance times, and decreased costs of care. We expect the results of our analysis to explain and resolve some of the conflicting views of the cost-effectiveness of PACS.

An Automated Results Notification System for PACS

The purpose of this study was to determine if the interval between an examination being ordered by an Emergency Department physician and his or her review of the report and images could be shortened by notifying the physician that the results were available. This hypothesis was based on work done previously in the Medical Intensive Care Unit that showed that physicians would wait to review results for a time considerably longer than the time required for the radiologist to review the images and provide a preliminary report. The software developments operate properly and show that even simple integration of multiple information systems (PACS, RIS, speech recognition) can provide useful features. Early results indicate that the Emergency Department (ED) physicians prefer the notification system over the previous (travel to check on images and reports) methods. The hypothesized time reductions did occur, although it is not clear that the notification system accounted for all of them. A system for automated notification of radiology results availability has been shown to be possible and practical. To do this automated interaction of 3 systems with a low-level or no electronic integration was required. Although not fully successful for this study, early physician response has been positive, and requests to expand this service hospitalwide now are common.

Assessing the impact of PACS on patient care in a medical intensive care unit

In this paper we have present data from pilot studies to estimate the impact on patient care of an intensive care unit display station. The data were collected during two separate one-month periods in 1992. We compared these two different periods in terms of the relative speeds with which images were first viewed by MICU physicians. First, we found that images for routine chest radiographs (CXRs) are viewed by a greater number of physicians and slightly sooner with the PACS display station operating in the MICU than when it is not. Thus, for routine exams, PACS provide the potential for shortening of time intervals between exam completions and image-based clinical actions. A second finding is that the use of the display station for viewing non-routine CXRs is strongly influenced by the speed with which films are digitized. Hence, if film digitization is not rapid, the presence of a MICU display station is unlikely to contribute to a shortening of time intervals between exam completions and image-based clinical actions. This finding supports the use of computed radiography for CXRs in an intensive care unit.

Prospective comparison of the usage of conventional film and PACS based computed radiography for portable chest x-ray imaging in a medical intensive care unit

The purpose of this study was to compare the efficiency of image delivery, the effectiveness of image information transfer, and the timeliness of clinical actions in a medical intensive care unit (MICU) using either conventional screen-film imaging (SF-HC), computed radiography (CR-HC) or a CR based PACS. When the CR based PACS was in use, images could be viewed in the MICU on digital workstation (CR-WS) or in the radiology department as laser printed hard copy (CR-HC). Data were collected by daily interviews with the house-staff, by monitoring computer log-ons and other time stamped activities, and by observing film viewing times in the radiology department with surveillance cameras. The time at which image information was made available to the MICU physicians was decreased during the CR-PACS period as compared with either the SF-HC periods or the CR-HC periods but the image information was not accessed more quickly by the clinical staff. However, the time required to perform image related clinical actions for pulmonary and pleural problems was decreased when images were viewed on the workstation.

Replacing film with PACS: work shifting and lack of automation

The purpose of this paper is to examine the effects of PACS installation on the tasks related to the performance and interpretation of diagnostic radiological examinations.

PACS workstation usage and patient outcome surrogates

Investigate the availability and use of radiographic reports both with and without a PACS workstation and investigate physicians opinions on using a workstation. The availability and use of radiographic reports and related patient care were evaluate in a randomized prospective study. Data from a 20 week period of collection, when images were displayed on multiviewers was compared to a 16 week period of data collection, when images were available on an image workstation in the clinical area. Patient care was evaluated by comparing clinical actions. A survey was distributed to the clinical staff to clinical area. Patient care was evaluated by comparing clinical actions. A survey was distributed to the clinical staff to determine their opinion of the image workstation. During periods without the workstation the clinical staff obtained reports o n 90 percent of the exams. During the PACS periods reports were obtained on 51 percent of exams. Sixty four percent of the surveyed clinicians reported a low to moderate level of confidence in interpreting images on the workstation. The percentage of image based clinical actions taken without radiology input increased from 12 percent during periods without the workstation to 74 percent during PACS. A PACS workstation in the clinical area decreases consultation if not supported with timely radiographic reports and may not benefit patient care.

Evaluation of PACS in a medical intensive care unit: the effect of computed radiography

Preliminary data is presented from a prospective study of a Picture Archiving and Communication System (PACS) in a Medical Intensive Care Unit (MICU). These data compare the efficiency of image information communication and utilization when the MICU operates in a conventional manner using standard x-ray film as an image acquisition, storage and display medium and a digital manner when images are acquired by Computed Radiography (CR), transmitted and displayed digitally. The CR images were made available for viewing more quickly than conventional film images due to the increased automation provided by the management system of the PACS. Despite the improvement of the availability of images, the time required for the MICU physicians to utilize the image information did not change.

Automated results notification system for PACS

The purpose of this study was to determine if the interval between an examination being ordered by an Emergency Department physician and his or her review of the report and images could be shortened by notifying the physician that the results were available. Though some time shortening was shown, it was not clearly attributable to the notification process.

Image workstation in a medical intensive care unit changes viewing patterns and timing of image-based clinical actions in routine portable chest radiographs

In order to determine the effect of an image workstation, viewing patterns and related clinical actions were evaluated in a randomized prospective study. During 16 weeks of Computed Radiography data collection, an image workstation was conveniently available to the Medical Intensive Care Unit clinicians. The workstation was not available for clinical use during 16 weeks of Analog Film data collection. Viewing patterns were evaluated by comparing viewing times. Patient care was evaluated by comparing the time of performing image based clinical actions. The percentage of routine exams viewed before AM Radiology Conference increased from 0% during the Analog Periods to 27% during the CR PACS Periods. Clinicians selected images taken during the first few days of the patients admission for viewing before conference. Images taken later in admission were viewed during or after conference. On days when radiology conference was not held, images were viewed significantly earlier when the workstation was available. Clinical actions based on images viewed on the workstation were performed significantly earlier. When an image workstation was available routine images were viewed sooner and image based actions occurred earlier.

Incremental cost of PACS in a medical intensive care unit

Our purpose is to determine the incremental costs (or savings) due to the introduction of picture archiving and communication systems (PACS) and computed radiology (CR) in a medical intensive care unit (MICU). Our economic analysis consists of three measurement methods. The first method is an assessment of the direct costs to the radiology department, implemented in a spreadsheet model. The second method consists of a series of brief observational studies to measure potential changes in personnel costs that might not be reflected in administrative claims. The third method (results not reported here) is a multivariate modeling technique which estimates the independent effect of PACS/CR on the cost of care (estimated from administrative claims data), while controlling for clinical case- mix variables. Our direct cost model shows no cost savings to the radiology department after the introduction of PACS in the medical intensive care unit. Savings in film supplies and film library personnel are offset by increases in capital equipment costs and PACS operation personnel. The results of observational studies to date demonstrate significant savings in clinician film-search time, but no significant change in technologist time or lost films. Our model suggests that direct radiology costs will increase after the limited introduction of PACS/CR in the MICU. Our observational studies show a small but significant effect on clinician film search time by the introduction of PACS/CR in the MICU, but no significant effect on other variables. The projected costs of a hospital-wide PACS are currently under study.