1. PACS A difficult implementation Richard Miles MRCP FRCR Derriford Hospital Plymouth

2. Introduction • Scope of the implementation • Resources • What went well • What went badly • Complications • Recovery Commercial and In Confidence

3. Scope of implementation Derriford Hospital Commercial and In Confidence

4. Scope of implementation Commercial and In Confidence

5. Pre LSP PACS Situation • Limited PACS -Agfa • CT, Ultrasound, Some Plain X-Ray • Inadequate Viewing Facilities • Obsolete Radiology Information System Commercial and In Confidence

6. Health Community connectivity Data store & RIS Commercial and In Confidence

7. Commercial and In Confidence

8. Derriford & community hospitals 300,000 examinations per year Radiologists 25 SPR 47 Radiographers 80 Examinations & staff Commercial and In Confidence

9. Community Hospitals X 6 Modalities with direct connection Modalities using plates Plates CR reader X 10 RIS terminal (PC) Reporting workstations X 41 Other Workstations Web PACS (PC) Radiology Academy Workstations Remote data store N3 connection PACS RIS Local data store 2 x printers Commercial and In Confidence

10. Modalities • Include: 16 CR plate readers 3 CT scanners 2 MRI scanners 25 ultrasound scanners 4 gamma cameras 4 angio suites 10 fluoro rooms In all over 130 modalities and workstations-costs excessive for some modalities Commercial and In Confidence

11. Key milestones Trust Board approval Academy Go Live Optimisation visit RIS migration & Project Completion CRIS Update Hospital Go Live Sept 06 Jul 05 Sept 05 Nov 05 Jan 06 Mar 06 May 06 Jul 06 Nov 06 Commercial and In Confidence

12. Training • Ris- 300 main users- ended up as 800 • Web Pacs- 2000 e-learning/presentations • Pacs – 50+ Commercial and In Confidence

13. Challenges • Large implementation • Data migration • Critical clinical implications • Change management challenge • Challenges related to the contract Commercial and In Confidence

14. Internal Audit Management structure ISIG PlymPfiT Trust Board PARB Project Board Project team meetings Clinical User Group Commercial and In Confidence

15. Project work structure Commercial and In Confidence

16. Core resources Commercial and In Confidence

17. What went well • Project roll out to schedule despite tight time scale • Project delivered within budget • Phased roll out maintaining imaging capacity • Dedicated implementation team • Support from, networks, estates, and hospital IT • Equipment scoping close to requirements • WebPACS is well liked and trouble free Commercial and In Confidence

18. What also went well • Migration of data from old RAD/Agfa system But at a cost • 12 weeks of the project technical lead’s time • Significant planning resource • Forced big bang deployment of CRIS and PACS Commercial and In Confidence

19. What went badly • CRIS referrer list seriously deficient • CRIS Rollout labour and time intensive • Resource mapping was made more complex by our system design Commercial and In Confidence

20. Training and technical support • Suppliers unprepared for a hospital of this size and complexity • Inadequate system training from supplier • No integrated training on the whole system prior to implementation led to many problems particularly related to workflows and generation of unspecified and split examinations • Training given was much too long before go live date • Inadequate system support from supplier after implementation- little activity until we really shouted • No provision for support in contract • Fujitsu Help desk extremely time consuming and frustrating Commercial and In Confidence

21. CRIS a beta release? • Slow speed of system due to CRIS • Log in times averaged 10mins Audited 7th Sept with community log in times of 45mins • Reporting Initially much slower than old Agfa PACS system, reporting efficiency reduced by approximately 30%. Commercial and In Confidence

22. CRIS login times Commercial and In Confidence

23. Internal difficulties Size of Radiology IT team much too small • Overwhelmed by technical problems and requests for training/support following implementation • CRIS roll out much more time consuming than expected • Lack of understanding of size and complexity of PACS project • Level of support from clinicians outside radiology variable during the difficult early days following roll out, expectations perhaps unrealistic • Needed more contribution from users inside and outside radiology • Workflows inadequately thought through • Due in part to lack of integrated training • Should have done more work on this ‘in house’ before go live Commercial and In Confidence

24. More issues • Lack of sharing of problems and solutions with other hospitals • Problems with connecting peripheral sites to Derriford • Image sharing with other hospitals Commercial and In Confidence

25. Complications • Real clinical risk • Serious impact on reporting throughput • Split studies in CT and ultrasound • Workstations incorrectly setup not automatically displaying doppler ultrasound images Commercial and In Confidence

26. Ultrasound and CT Audit • 50 sonographer ultrasounds all 2nd reported by Radiologist reviewed • 35 had split studies • 4 had radiologist reports that were incomplete • 3 no clinical impact 1 possible clinical impact Commercial and In Confidence

27. CT Audit • 50 unspecified CT examinations reviewed • All 50 had split examinations • 49 reports were regarded as complete, with radiologists clearly having sought out the additional images • 1 study which had pelvic images in a separate file was deficient Commercial and In Confidence

28. Recovery • Weekly Clinical Governance meeting with CE and Medical Director • Galvanised assistance from suppliers • Resolution of numerous technical issues • Fujitsu operational analysis July 30th • Reallocated internal resources • Increased reporting capacity • Strengthen the Radiology IT team Commercial and In Confidence

29. GP Film reporting status Commercial and In Confidence

30. LSP optimisation visit 18th-21st Sept • GE/Kodak/HSS representatives • Workplace training throughout the directorate • Kodak assessment of dose and process issues • Resolution of many outstanding system integration problems Commercial and In Confidence

31. Unresolved issues • Image sharing- unresourced • WebPACS sharing • Truro/Torbay/Exeter/Barnstaple/Bristol • Non NHS image sharing? Commercial and In Confidence

32. Any questions?