Tips for selecting a new PACS or RIS

Just a few thing that I feel are often overlooked or not understood when sites buy a new PACS or RIS system. This isn’t a complete list and I am sure and some of you may disagree with some of my points. That is OK. If this list helps one site make an informed decision in product selection then it has done it’s job.

I will not make any references to any particular vendor here. These are general rules. I don’t think any one PACS or RIS Vendor is the best answer for anyone since everyone has different needs and requirements. I do believe that following and taking note of some of the things I have listed will help sites make better decisions.

That being said let us proceed:

1. Realize that it is the salesperson’s job to sell you a system. It’s how they feed their families.
   
2. Take information he/she gives you as just information on HIS/HER system. No one system has all of your answers despite what you may be told.
   
3. Beware of the “Their system isn’t good because blah blah blah” sales tactic. Don’t let the salesperson evaluate some else’s product for you. This is often done to hide or draw attention away from inadequacies in their own system.
   
4. A lot salesmen I have come across will tell you what they think you want to hear to get a sale. ( see point 1)
   
5. Beware of phrases like “ we are looking to implement that in the next version or a future version” This translates into “ we don’t have that feature right now and possibly never will” . Any feature that you get this response on know that if you go with this vendor you may or may not get this feature so decide if that feature is critical to your installation, since you might never actually see it.
6. Make sure you know how any PACS or RIS is going to fit into YOUR workflow. Decide ahead of time if you are willing to change your workflow to fit the product. I have seen numerous cases where sites are not using products to the full potential because they want to hold on to doing things “the way we have always done them”.( see next point)
   
7. PACS/RIS implementation is ALWAYS a change in workflow, make no mistake about that. If done with proper consideration it will be a change for the better.
   
8. Always get references on the product. Ask for an install base and contact other sites already using the product. Don’t just talk to the people that the Vendor gives you. Any Vendor with a worthwhile product will give you a list of all their sites and even help you contact someone there.
   
9. If you are buying a PACS system make sure your Radiologists get some hands on time with it before purchase. Talk to other Radiologists using the products and have your Radiologists talk to them as well.
   
10. Have your support personnel/support structure in place BEFORE you decide and buy. More than once I have encountered someone who hasn’t even seen the system they are going to be supporting nor do they know what to expect as far as what will be expected of them in terms of user support. This is a sure recipe for failure.
    
11. Include your IT/PACS support people in the selection process. I personally feel that the final decision should not be made until these folks have seen the system. Some vendors will lead you believe that daily maintenance is minimal or even that a local support person isn’t needed. DON’T YOU BELIEVE IT !!! Let your own support people look at it and decide how hard it will be to implement/support. Things like is there software to install to use the viewer. Will the software requirement for the product interfere with anything else we have ( this is know as a tip-toe through the Java version ring of hell in some circles)
    
12. Make sure that whoever is supporting the system has knowledge of the clinical side of things. Pure IT people look at the system differently than pure Radiology folks. Not all IT people understand the Radiology workflow or the clinical urgency of a down system.
    
13. If you are going to use a RIS for billing make sure someone with intimate knowledge from your billing Dept is included in the decision. The same goes for transcription services.
14. Ask about interfaces between your other systems ( PACS,RIS,EMR,ect..) and the system you are buying . Make sure they have had successful integration with the specific products you are using. Talk to the sites where those integrations were done. Ask THE SITES about any special problems they encountered. Never take for granted that your new system will talk successfully with your current systems.
15. The biggest point that is missed…… ASK QUESTIONS ABOUT EVERYTHING YOU DON’T KNOW OR UNDERSTAND and ASK FOR EXAMPLES. There is never any shame in asking. The question you ask today could be the ulcer you avoid in 6 months.
    
    For some other tips on PACS selection See also http://doctordalai.blogspot.com/2007/03/dalais-laws-of-pacs.html
    
    Hope this helps someone.
    

The decline of Tech Positioning skills

I had a long discussion the other day with a Radiologist who was commenting on the decline of positioning skills demonstrated by a large number of today’s technologists. Now this is something I had noticed myself with increasing frequency in the last 5-6 years and have commented on often to Radiologists and Tech Supervisors . I thought maybe I was just being overly critical because I was always a stickler for film quality. The X-ray school I went to had a hard fast rule regarding film quality that went like this, if at any time when you are looking at an x-ray that you have taken and the thought crosses you mind “ should I repeat this film” then the answer was ALWAYS yes. I always tried to follow that line of thinking for the 16 years I took radiographs. I am sure I drove my staff nuts when I was a tech supervisor. I just always felt that the better the radiograph was the better chance that the Radiologist had of identifying any pathology that was there. Pretty obvious right? Well I thought so but recently I have noticed that positioning skills have been declining or Technologists just don’t seem to care much anymore.

I have pondered as to why this seems to be happening and have come up with a few theories that I will list below in no particular order as I think they all have a part in the decline of the skills:

1) 4 year x-ray schools that focus more on the degree than the clinical aspect of the training are partially to blame in my opinion. They just don’t seem to get the necessary clinic time to train technologist the “art” of taking x-rays on “real world” patients. Granted they can give the book names for all the positions but the ability to properly position a patient who can’t move like the ones seen in the books seems to throw some techs completely off. Taking high quality radiographs is an art that in my opinion can only be properly learned by doing. I don’t care what your test scores are or how you did on your registry, until you have been in a trauma bay and have had to produce quality radiographs on a patient that you can’t move, all the reading in the world will not help you. It always seemed to me that tech who attended 2 year hospital based programs adapted much faster to tech life in the real world.

2) PACS has both helped and added to the decline of radiograph quality. It has certainly given techs much more latitude in selecting Kv and mAs as small variations do not have as much effect on the outcome of the radiograph as it did in the film world. Now that is not to say that techs don’t still have to select the proper settings but small miscalculations will no longer instantly mean you have to repeat a film. That is the good part.. The bad part of that is that I have seen techs that don’t pay much attention to the technical factors they are setting because of that fact. I am reminded of a case quite a few years ago when a tech actually asked me what the Kv and mAs should be for a lateral cervical spine because the PACS was down and she had to go back to regular film. Needless to say I was shocked and appalled and didn’t answer her in the most polite fashion. Unfortunately this lackadaisical attitude seems to have spilled over into positioning as well. Add to this that most PACS systems don’t provide for good comprehensive film/image QA. It is too easy for a slack tech to simply make an bad image disappear once it has been repeated. The PACS/CR vendors really need to come up with a solution that not only tracks the number of repeat images but lets the QA tech see the actual images so that they can talk to the tech on how to correct the problem when they identify a pattern.

3) The third contributing factor are the Radiologists. While over the years I have heard many of them complain about image quality, quite a few of them seem reluctant to reject the image and force the techs to repeat them. While making the tech repeat the image is a hassle NOT making them repeat the image contributes to the attitude that as long as the Radiologist doesn’t make me repeat it that means must be an ok image. This past week I saw no fewer than 4 chest x-ray images that had the lateral border of one lung or the other clipped off. All 4 images were read by the Radiologist.

For years Technologists have been fighting for respect within the medical community. The ARRT has responded with requiring more education during training and CE credits bi-annually after graduation. While I think this has some merit I think a much better approach would be to increase the amount of real clinic time. A tech who can consistently produce high quality radiography in any situation will gain the respect of the doctors, nurses and fellow techs much faster and easier than one who can recite facts out of a book.

I guess it all comes down to good old fashion pride in the job you do. If you’re just punching a clock to get a paycheck go find a different career where people’s lives don’t depend on the quality of your work. If nothing else I have said sinks in remember, you are not doing the patients any good passing poorly positioned films and may actually be hurting them.

Self Referal from a different angle

Ok there has been a lot of talk and news lately about evils of self referral. While I am in agreement with all the arguments against self referral I think there is another issue that is being skipped over. If the government isn’t going to stop self referral, which quite honestly I don’t think they can, will, or have a real desire to, then they need to at least regulate the quality of the equipment used in these offices. Not only are the Doctors using this equipment ordering more tests than they ever did before they had their own machines, which some studies suggest is an increase of 2 to 6 times the number of studies ordered, but the patients are unaware that some of the scans that they are getting are inferior to a scan that may be obtained at a local hospital due to the age of the equipment being used. In addition to that with a lot of the old CT scanners the radiation doses that the patients are getting are a good deal higher when compared to the new technology employed by the current generation of CT scanners. Think about it, would you rather have a study done on a scanner that is from 1992 with technology from that time or a study done using technology from the last 5 or so years? I know which one I would send my family members to.

The other part of this issue which I have a SERIOUS problem is that the reimbursements are the same and sometimes higher for these scans performed on inferior equipment than the reimbursements given for scans done in hospitals on scanners using the newer and better technology. This is eventually going to make hospitals think twice before updating to newer and better technology for the scanners they use. It may even prevent some hospitals from being able to afford to upgrade to the latest technology. Now I am not a huge fan of upgrading for the sake of upgrading but if there is a new technology that is going to detect and therefore help prevent, by way of earlier detection, diseases or anomalies I would like to think that the hospital I go to has that technology.

Now do I think the self referrers are alone in causing this problem? Nope!! As much as I am ashamed to say it, I think the Radiologists are also to blame here. Without a Radiologist to interpret the study a lot of these self referrers would not be able to have these machines. A good number of Radiologists take the approach that “If I don’t read it someone else will”. The problem with that philosophy is that if all Radiologists take that stance then there is ALWAYS someone willing to read the studies and the problem becomes a self perpetuating cycle. Radiologists in hospitals complain that there are too many Doctors doing scans in their offices and not referring patients to hospitals but in the same breath they are interpreting exams for these same doctors. I also think the Radiologists have a responsibility to help regulate the quality of the equipment that is being used in the offices of those self referrers. They should be refusing to read sub-standard exams resulting from sub-standard equipment. I mean geez have you ever seen a Lumbar Spine MRI done on a 250+ lb. patient that has been performed on a 1992 era .3 field MRI scanner? Is that quality patient care? In a word NO !!

In conclusion I think this is a practice that never should have been allowed in the first place but has gotten too big to stop completely now. As I said earlier if they aren’t going to stop it or won’t stop it then they need to regulate it so that patients who don’t understand that they aren’t getting the best possible medical care are protected.

Where have all the polite people gone

Ok time for my first rant

What has happened to common social courtesies in the world today? Have our lives become so hurried that we can’t say excuse me or thank you anymore? Or is it simply a case of perceived self importance that has led us to disregard even the simplest forms of politeness? Is it too much to expect a thank you when holding a door for a stranger or an excuse me when bumped into? I find myself as I get older becoming more and more annoyed at people to fail to show even the smallest signs of social graces. Even a common sense behavior like letting people who are on the elevator exit before trying to enter the elevator yourself seem to be lost. I am sure some will say that I am just being petty and over sensitive to these things but I think that is also a by-product of our times. Too many people sit idle and just let things go on thinking that “oh well I guess that is just the way it is”. Now I am no charm school valedictorian, people who know me will attest to that, but I rarely forget to say thank you or hold a door. Simple things like letting the person behind you at the grocery store who only has 2 items go in front of you and your full shopping cart, letting someone into a stream of traffic or stopping so someone can cross the street go a long way toward making this a better place to live for all of us.
Do I think that doing these things makes me a better person than the next guy? No of course not . Do I think that mere politeness will cure this country of it’s ills? Not a chance. But it may make someone else’s day a little more pleasant and even though that has no effect on me at all I think that alone is worth the little bit of effort it takes me to be polite. Who knows maybe someone will let you ahead of them in the grocery store checkout line one day. Remember to say thank you if it happens.

First entry

Let me start by saying thanks for stopping by. This blog will be a way for me to vent and share my opinions with the world. They wont always be popular opinions but at least they will be honest opinions.