Dr Nicola H Strickland Consultant Radiologist Imperial College Healthcare NHS Trust

1. Delivering the Paperless and Filmless NHS:Getting the most out of RIS and PACSThe Hammersmith experience: the original UK filmless hospital! Dr Nicola H Strickland Consultant Radiologist Imperial College Healthcare NHS Trust

2. The remit: • The first UK filmless hospital: what have we learnt? • Critical success factors and how we would do things differently • How we have developed an entire fully filmless Trust: enabling all radiology images to be available to radiologists and clinicians at all times: the impact on patient care • A virtual hospital independent of film: our experience • Next generation PACS: looking to the future • Lessons for new and existing PACS implementers

3. The topics • overview • history • what we did wrong • what we did right • our current problems • our new tender • moving on: RIS/PACS added value

4. Hammersmith Hospital HistorybeforeImperial College Healthcare NHS Trust 1988: RIS 1996: PACS • Hammersmith Hospital • 17 years ago: • one of very first totally filmless hospitals in the world • with US military and VA Baltimore hospitals • large UK government grant • hardware cost • software development cost • “pioneers” significant clinical risk

5. History: what it was like then...... PACS and I were in our infancy...........................

6. History: HH PACS in 1996 What it was like then: • no DICOM • ACR-Nema v2 • MIUs = modality interface units • proprietary networks • “taxi protocol” • closed system • Macintosh workstations • no web browser technology • PACS workstations everywhere • no thin clients • no email….!

7. History: immediate clinical benefit • no film • transport: no delays, staff handling • storage space released • image access: anywhere, anytime, any place • multiple simultaneous viewers • image availability • immediate • all comparative studies (historical, multimodality) • softcopy tools • image manipulation • a new way of viewing: stack cine mode • etc. etc…..

8. Linking hospitals 1. A single unit “virtual hospital” • seamless • fully integrated • location independent 2. Degrees of hub and spoke • one dominant hospital 3. 2 equal linked, but disparate units • common EPR (now!) SMH HH/CX

9. St Mary’s Hospital Hammersmith Hospital Charing Cross Hospital October 2007: ICHT different RIS, different PACS same RIS, no PACS History of ICHT 1988: RIS 1996: PACS samePACS: 2003 • At local level • only exactly the same imaging IT enables you to work as a true virtual hospital • must have same patient id system • anything less leads to: • significant clinical risk • missed imaging studies • unnecessary repeat studies • serious medical staff frustration

10. What it means to be a “virtual hospital” Clinical requirements: • common worklists • irrespective of acquisition site • equal access to imaging studies (+ reports) • rights of access • speed of access + display • one set of statistics • cross-site multidisciplinary team meetings • teleconferencing equality • the only difference = physical separation

11. What we did wrong • training • too early • too much: clinicians requirements simple! • hardly anyone came • concentrate on post go-live • digitizing • solved by overlap period ~3/12 • recall • sealed x-ray packets!

12. What we did wrong • some 4 monitor workstations • use software properly: stack mode

13. What we did wrong • the “unmouse”! • theatre solutions: debate (cost) • no screen saver! • long log-out time • not appreciating the lost film issue • immediate availability of images want reports! • more studies to report • nothing lost (15-20%) • sequential x-rays (ITU) • serious reporting backlogs

14. What we did right • PACS is a clinical tool • not a radiological gimmick • multidisciplinary PACS board • respected older clinicians, not geeks! • buy in • orthopaedic surgeons biggest supporters at CX • specified clinical requirements only • e.g. first image to screen in 2 seconds • did not prescribe IT solution • meticulous workflow analysis • fast dedicated network • speed the priority

15. What we did right • the contract • tough penalty clauses • invoked them for breech • rigorous CCNs • historical document through vendor changes • worked directly with PACS engineers • a partnership • designed our own software: clinically relevant • DDPs; worklists and folders • a completely novel concept Strickland NH, Allison DJ. Default display arrangement of images on PACS monitors. Brit J. Radiol 1995; 68: 252-260 • win-win

16. What we did right • single reporting room • expensive kit: max use • dimmer lighting • heating/air con • double reporting! • learning experience • camaraderie! • accessibility/visibility

17. What we did right • speech rec • early adopters • fully integrated with RIS and PACS • single sign-on • compulsory use • “benign dictatorship!”

18. Our current problems • not having the same IT across the Trust • a show-stopper • no virtual hospital with SMH • dangerous • the LSP at St Mary’s • must deal directly with PACS and RIS vendors • arguments with BT over terminating contract • obstacles ++ to data migration • EPR and electronic requesting/results feedback • multiple outstanding problems • SSO – single sign on

19. Our current problems • IT personnel in Imaging = (just resolved!) • essential • specific problems • speed of resolution • no image library • a universal need (kleptomaniacs!) • nationwide ideally • IG issues • image addition and viewing from PACS workstation • complex software requirements • e.g. quiz mode

20. Our new tender • writing the spec • workflow based • use recent ones • demos • set specify tasks • publicity • site visits • few! • similar to your practice • speak to radiologists alone • assessing the company personnel • trust • credibility • a partnership

21. Moving on: PACS added value • same regional RIS-PACS-EPR • clinical referral pattern based • not geographical! • networked NHS reporting “in-sourcing” • XDSi: cross platform document sharing for imaging • described by IHE • allows intersite connectivity • specify in new PACS contracts • storage • VNAs:vendor neutral archives (?!) • the cloud • not new! = ‘data warehouse,’‘off site storage’ • data ownership, control, recovery..... • data migration  contract

22. Moving on: PACS added value • cardiology on the same PACS • modern cardiac imaging requirements • other imaging easily accessible • EPR, PACS etc. • integrated post-processing • same workstation, SSO • one click MPRs • thin client • home working • as if at work • MDTMs – multidisciplinary team meetings • hand held devices • ubiquitous personal desktop

23. Moving on: RIS-PACS added value • value added software: design needed • digital library and self learning • revalidation • MDTMs – multidisciplinary team meetings • outcomes record • standard reporting proforma • double reporting/dispassionate audit • scoring • digital dashboard: efficiency • statistics, audit trails, real time graphs etc. • turn around times • room use • personal patient dose log

24. “Becoming Paperless….” • RIS and PACS only a part of the EPR • electronic requesting • including direct from GP practices • access to the whole paperless EPR • blood tests • surgical operations • drug chart and medications • ward notes, clinic notes • outcomes of MDTMs – multidisciplinary team meetings • All electronic systems seamlessly integated • statistics, audit trails, real time graphs etc.

25. Conclusion • a personalized view of RIS-PACS • past • present • future • issues for us all to address • improve our working lives • benefit patient care

26. “Pax vobiscum”