PACS System Selection Methodology

Rex Osborn2004

Project MethodologyWe support a full spectrum of project activities.

Plan Plan Architect Architect Integrate Integrate Optimize Optimize

• Requirements: Technical, Functional, Integration, & Process

• Clinical Scenarios

• Technology Selection and System Design

• Vendor Contracting

• Readiness Assessment

• Strategic Benefits

• Total Value Calculation / Financial Planning

• Executive Education

• Budget Approval

• Implementation Planning

• Implementation and Integration

• Process Improvement Baseline

• Administration

• Maintenance

• Reinvestment

• Process Improvement Measurement

OptimizeOptimizeRedesignRedesign

Planning

Image volumes: Priorities based on image volumes and users who need access

to them

Operational readiness: Experience with and willingness to use digital images

Support staff readiness: Dedicated resources in the imaging departments and in Information Services

Clinical systems readiness: Common patient and study indexing schemes and interfaces between the clinical information systems and the enterprise imaging system

Equipment readiness: Standard configurations and adequate space for all components

Network readiness: Adequate bandwidth, redundancy, security and performance

PlanPlan ArchitectArchitect IntegrateIntegrate OperateOperate

Step 1. Assessment and Financial Planning Step 1. Assessment and Financial Planning

Link to Strategic DirectionProject Objectives

Strategic DirectionClinical Quality

Enable

Growth

Service Excellence

Physician

Partnership

Community Service

Employer

Of

Choice

Improve Patient Care and Satisfaction

Efficiently Read Multi-Image and Serial Studies

Increase Involvement in the Care Delivery Process

Eliminate Unread Studies

Reduce Lost and Misplaced Films

Improve Report Turnaround Time

Provide Concurrent Access to Diverse Image Information

Easily Find Any Image, Anywhere Throughout the Healthcare System

Improve Physician Satisfaction

Integrated with EHR

Reduce Operational Costs

PlanPlan

Many organization’s Vision is to provide their clinicians an integrated, “content-rich” point of care environment that transcends departments on a common workstation enabling timely access to a patient’s comprehensive clinical information for optimum diagnoses and treatment. Imaging is a significant portion of the required clinical information.

Integrate with Overall IT Plan

PlanPlan

System Readiness PlanningFocus Area Planning Steps

Executive Leadership Committed to a structured approach: e.g. enterprise-wide planning, multi-year investment, policy that no departments can opt out.

Physician Acceptance

Physician project champions working with site coordinators who help educate the physician community on the benefits of PACS.

Enterprise Connectivity

Network enhancements are budgeted to provide an enhanced, reliable network and storage.

Clinical Integration Integration plans and system acceptance testing procedures.

Data Confidentiality Systems planning for user log-ins and passwords integrated with the EHR.

Technology Obsolescence

Contractually bind the vendor to upgrade PACS hardware and software - purchase workstation, network and storage separately from existing vendors

System Implementation

Have a dedicated project management and train PACS administrator's.

PlanPlan

Identify Success & Risk FactorsFactor Risk Level Steps

Executive Leadership Sustained commitment to a structured and disciplined approach against plan: program management, funding, purchasing, operating procedures. No departments opt out.

Physician Acceptance Identify a physician project champions and site coordinators who will help educate the physician community on the benefits.

Enterprise Connectivity Incremental network enhancements are budgeted to provide an enhanced, reliable network and storage.

Clinical Integration Have a solid contract with the vendor for system acceptance; bind system acceptance to final payment.

Data Confidentiality Enterprise systems support user log-ins and passwords and may be integrated with the EMR.

Technology Obsolescence

Contractually bind the vendor to upgrade hardware and software to keep the system current. Purchase workstation, network and storage separately for your existing vendors.

System Implementation

Have dedicated project management to deliver a successful implementation.

Medium

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Medium

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PlanPlan

Implementation Phase and Activities

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PACS PlanningPACS Internal Marketing and Approval ProcessVendor SelectionContract NegotiationsImplementation Planning

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Network Improvements and UpgradesBuild/Implement HIS/RIS InterfacesImplement Back-Office EquipmentBegin Acquiring/Archiving Images from all Modalities

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PACS trainingImplement Diagnostic Workstations in all Reading AreasPACS TrainingImplement Clinical Review Stations in ED & Critical Care AreasPACS trainingImplement Enterprise-wide Web Image Access on hospital campus

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Implement Enterprise-wide Web Image Access to remaining remote sites and physician offices/homesPACS trainingExpand PACS services to ORs

Hospital USA PACS Implementation Roadmap2003 2004 2005

Phase 1 - Implement PACS Infrastructure and Digital Modalities

2002 2003 2004

Phase 2 - Implement PACS Review Stations

2002 2003 2004

Phase 3 - Expand Web Image Access

2002 2003 2004

Establish High-Level Implementation Plan

PlanPlan

Calculate Financial Impact

PlanPlan

Outflows Capital

DI/PACS System Core / Back-office User Equipment

Computed/Digital Radiography Modality Upgrades Infrastructure Upgrades System Integration Renovations Vendor Services Re-investment

Operational Support Staff DI/PACS system maintenance CR/DR maintenance Network equipment maintenance Incremental network cost

Inflows Capital

Potential increase revenue Reduction in missed billings Increase in utilization

Operational Labor Film Film processing Supplies Storage space Courier / Transportation

Sample-PACS Financial Model

PlanPlan

Radiology PACS Summary Costs

PACS Component Baptist LR Baptist NLR ArkadelphiaHeber

Springs MRI OP LR MT1 OP OP NLR TOTAL

PACS Workstations 858,000$ 177,000$ 90,000$ 90,000$ 130,000$ 65,000$ 130,000$ 1,540,000$ PACS Core/Back Office 1,590,000 539,000 189,000 189,000 135,000 27,000 27,000 2,696,000 Computed Radiography 1,080,000 540,000 428,000 428,000 - - - 2,476,000 Radiology Information System 1,456,000 1,456,000 DICOM Upgrades 40,000 80,000 60,000 100,000 - - - 280,000 Network Upgrades 488,000 116,000 33,000 33,000 28,000 15,000 29,000 742,000 Data Center Renovations 50,000 50,000 Radiology Renovations 200,000 200,000 Third Party Services 429,000 107,000 536,000

TOTAL CAPITAL (10% disc) 6,191,000$ 1,559,000$ 800,000$ 840,000$ 293,000$ 107,000$ 186,000$ 9,976,000$

Potential Add'l PACS Disc (15%) (529,200) (188,400) (106,050) (106,050) (39,750) (13,800) (23,550) (1,006,800) TOTAL CAPITAL (Discounted) 5,661,800$ 1,370,600$ 693,950$ 733,950$ 253,250$ 93,200$ 162,450$ 8,969,200$

PACS Reinvestment (15% every 3 yrs, thru 2013 ) 1,101,600$ 322,200$ 125,550$ 125,550$ 119,250$ 41,400$ 70,650$ 1,906,200$ TOTAL CAPITAL INVESTMENT THROUGH 2013 10,875,400$

Possible Operating Expense Reductions & Avoidance (cumulative thru 2013) (21,768,269)$ Incremental Operating Expenses (cumulative thru 2013) 11,071,339$

(10,696,930)$

Baptist Health FacilityHealth System USA

Hospital A Hospital B Hospital C Hospital D OPC 1 OPC 2 OPC 3

Radiology PACS Summary Costs

PACS Component Baptist LR Baptist NLR ArkadelphiaHeber

Springs MRI OP LR MT1 OP OP NLR TOTAL

PACS Workstations 858,000$ 177,000$ 90,000$ 90,000$ 130,000$ 65,000$ 130,000$ 1,540,000$ PACS Core/Back Office 1,590,000 539,000 189,000 189,000 135,000 27,000 27,000 2,696,000 Computed Radiography 1,080,000 540,000 428,000 428,000 - - - 2,476,000 Radiology Information System 1,456,000 1,456,000 DICOM Upgrades 40,000 80,000 60,000 100,000 - - - 280,000 Network Upgrades 488,000 116,000 33,000 33,000 28,000 15,000 29,000 742,000 Data Center Renovations 50,000 50,000 Radiology Renovations 200,000 200,000 Third Party Services 429,000 107,000 536,000

TOTAL CAPITAL (10% disc) 6,191,000$ 1,559,000$ 800,000$ 840,000$ 293,000$ 107,000$ 186,000$ 9,976,000$

Potential Add'l PACS Disc (15%) (529,200) (188,400) (106,050) (106,050) (39,750) (13,800) (23,550) (1,006,800) TOTAL CAPITAL (Discounted) 5,661,800$ 1,370,600$ 693,950$ 733,950$ 253,250$ 93,200$ 162,450$ 8,969,200$

PACS Reinvestment (15% every 3 yrs, thru 2013 ) 1,101,600$ 322,200$ 125,550$ 125,550$ 119,250$ 41,400$ 70,650$ 1,906,200$ TOTAL CAPITAL INVESTMENT THROUGH 2013 10,875,400$

Possible Operating Expense Reductions & Avoidance (cumulative thru 2013) (21,768,269)$ Incremental Operating Expenses (cumulative thru 2013) 11,071,339$

(10,696,930)$

Baptist Health FacilityHealth System USA

Hospital A Hospital B Hospital C Hospital D OPC 1 OPC 2 OPC 3

Health System USA

Hospital A Hospital B Hospital C Hospital D OPC 1 OPC 2 OPC 3

Step 2. Architect: Vendor SelectionStep 2. Architect: Vendor Selection

Architect the Solution

Technical, Functional, & Process Requirements:

Priorities based on diagnostic, clinical, and technical needs of the organization

Clinical Scenarios: Developed to demonstrate DI capabilities and evaluate vendors ability to deliver functionality and workflow improvements

System Design: Based on Vision & Guiding Principles, Requirements, Standards, Technology,

Vendor Selection: Selection approach aligned with organizations goals & objectives

Contract Negotiation: Standard configurations and adequate space for all components

PlanPlan ArchitectArchitect IntegrateIntegrate OperateOperate

Determine PrioritiesArchitectArchitect

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Angiography CT C-Arm Computed Radiography Diagnostic (X-ray) Digital Radiography Fluoro MRI Mammo Nuclear Medicine PET Tomo Ultrasound Cardiac Catheterization Echo/Doppler EEG EKG Fetal Heart Monitoring Holter TEE

Image Viewers

OtherClinical Specialties

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Selection - Sample Goals & Objectives

To mitigate your risk during the vendor selection and contract negotiation process

To ensure the selected solution meets requirements

Provide investment protection to ensure investments in the solution are properly timed and aligned with an overall strategic vision

Guarantee Integration to Enable Digital Workflow

To arrive at a well-designed solution with preferred digital imaging vendors

To develop a comprehensive contract that will set a strong foundation for both a successful implementation and long-term relationship between Bassett and the vendor

To shorten the time-to-contract with the vendor

ArchitectArchitect

Approach: Leverage the IHE* Standards

Allows for focus on workflow solutions, not connectivity issues Lowers integration costs – implementation durations Minimizes custom interfaces – clearly defined interface owners Vendors representing 90% of the digital imaging market

participate - RIS, CVIS, PACS, Modality, Web, Reporting, 3D Workstations, Voice Recognition Systems

You get integrated information systems vs. information islands

MPI

ADT

RIS

PACS

Modality

Display

HIS*Integrated Healthcare Enterprise

ArchitectArchitect

Example: Selection Criteria

References RFP Response Clinical Visit Visit Evaluation

Functionality

Technology

Criteria Weight Definition

Cost

Experience

Integration Vision

Source

RFP Response Clinical Site Visit

Evaluation

References RFP Response Clinical Site Visit Evaluation

RFP Response Vendor - Cost Benefit

Models (RFP)

RFP Response Demonstration

Functionality Coverage Detailed Scenario Ratings Overall Scenario Ratings Application Maturity

Alignment with Vision Shared integration approach Vendor track record, IHE, CCOW

Customer Service Implementation Depth, Methods R&D Expenditures Annual Contracts

Preliminary Cost Models Implementation /Benefit Timing Cost of Ownership

Technology Assessment, Ownership Cost of Ownership Technology Risk Assessment Number/ Complexity of Integration

25%

15%

15%

15%

30%

ArchitectArchitect

Example: Workflow Enablement

Guarantee Requirements

Proof of Concept Approach Vendor X Vendor Y Comments

Image Acquisition PerformanceTime First Image is acquired to first image read (lossless display) demonstration/site visits Need to conduct measurements

Review Workstation UsabilityDesktop Defaults configurable by user demonstration/site visits Need usability feedback

Defaults include, applications accessibility, User defined hanging protocols

demonstration/site visits Need usability feedback

Global Worklist and image Availability demonstration/site visits Images and past reports were easier to access on Vendor X

Key Filmless Workflow Cath Lab demonstration/site visits Referring demonstration/site visits

Vendor X 3D package does not allow for integration with 3rd party SW

ER/Trauma demonstration/site visits

Need templating software from 3rd party vendor Measurement tools better on Vendor Y

Cross Domain Complex Study site visits

Does not identify if images are on film only

Fault ToleranceNo single point of failure design review

Vendor X is a SW only approach Vendor Y provides true disaster recovery

Continuous operation in degraded mode design review

Site Integration ExpectationsRapid Deployment Capable site screen Multiple Imaging Sites site visits

RIS/CVIS IntegrationIntegration w/ADT,ORM,ORU demonstration/site visits Patient Care Inquiry demonstration/site visits

Modality Integration & SupportDICOM C-STORE, SC, MWL, PPS site visits

Vendor X will not be ready until future release

Integration Experience with modality vendors site visits Expedient Process to resolve integration issues process review Need process review

Proof of Concept Scorecard

ArchitectArchitect

What’s in a Contract and Why Examples of Final Contract Exhibits, System Configuration, and Bill

of Materials: Terms and Conditions Bill of Materials License Software Module Schedule System Requirements Compliance Matrix from RFP Specifications and Acceptance Testing Protocols Payment Schedule Service Agreements Project Milestones Escrow Agreement User Documentation Original RFI/P/Q Response and Subsequently Issued Requirements &

Specifications Works in Progress Agreements

Ensure common understanding and agreement to cost, performance, capacity, and scalability

Minimize client risk associated with vendor terms and conditions, solution offerings, costs, and future product direction.

ArchitectArchitect

Technology Selection Process

ProjectInitiation

ProjectInitiation

Organize Selection

Teams

Organize Selection

Teams

Prepare and Distribute

RFP

Prepare and Distribute

RFP

RequirementsSession

RequirementsSession

Develop Requirements

Workflow Analysis

Develop Requirements

Workflow Analysis

Assess Against Current Vendors; Identify Benefits

Assess Against Current Vendors; Identify Benefits

PrepareScripted

Scenarios

PrepareScripted

Scenarios

Analyze VendorResponses

Analyze VendorResponsesVendor

Responses

VendorResponses

Conduct VendorDemos

Conduct VendorDemos

ConductReference

Calls

ConductReference

Calls

RecommendVendor(s)Of Choice

RecommendVendor(s)Of Choice

ExecutivePresentation and Approval

ExecutivePresentation and ApprovalFinal Approval

Final Approval

Down Select to 2 Vendors

Down Select to 2 Vendors

ArchitectArchitect

For enterprise systems to be successful, standards are

critical Guarantee information flow which allows the organization to

focus on workflow solutions, not connectivity issues

Less integration complexity and lower costs shorten

implementation durations

Minimize custom interfaces and clearly define which vendor

owns each integration boundary

Using Standards in Selection

*Integrated Healthcare Enterprise

ArchitectArchitect

Prenuptials for Partnerships Terms and Conditions Referencing Exhibits:

Service Levels Bill of Materials Schedule of Software Acceptance Testing Procedures System Requirements and Performance Specifications Project plan and Statements of Work Links to Payment Service and Maintenance Agreements with Uptime Guarantees Training Materials, Schedules and Documentation The Original RFP Response Product Roadmaps

Goals Ensure agreement - costs, project scope, system performance,

capacity, and scalability Understand and mitigate risk associated new product offerings

and future product direction

ArchitectArchitect

Integrate

PlanPlan ArchitectArchitect IntegrateIntegrate OperateOperate

Pre-Implementation Planning:

Detailed Program Plan built to align all resources and steps necessary for successful implementation

Process Improvement: Further define specific DI transformation objectives, establish baselines metrics

Implementation Management: Establish DI Program Manager, team, tools and processes

Organization Training: Develop and conduct training based on system functionality and transformation objectives and processes

Implementation & Integration: Implement and integrate according to Program Plan

Step 3: Integration & ImplementationStep 3: Integration & Implementation

Improvement Example

Patient arrives

Films are printed

Trauma team ispaged

Exam is performed

Tech hangs theimages on ER

rotator

Wet readperformed by ER

clinician

Radiologistoverreads or readsthe stat images (if

necessary)

ER enters order inTDS with a stat

note

ER Workflow

Receptionistarrives patient

Patient informationfrom TDS is

printed out andgiven to radiology

TDS printsrequisition with

patient information

Technologistcompletes order

on Maxifile

Trauma No

Yes Exam is performedRadiologist reads

examClinical decision

rendered

Paperwork printedand given to tech Tech allocated to

patient

Tech gets patientX-ray cassette

taken to ERprocessor

File room stripsthe rotator - every

2 hours

Films filed in thefile room

Priors requested Contact file roomER process

continues withoutfilms

Film on site

Yes

No

SimultaneousProcess

Dispatch tech toread film

Patient checked outof ER - noted on

ER board

Tech takes patient back to ER - patient checked

back in on board

(Before 5 pmONLY)

Tech brings filmback to radiology to

be read

(Before 5 pm ONLY)Radiologist reads film

Note - Highlighted areas can be eliminated with PACS

"After organizing work flow to take maximum advantage of the capabilities inherent to PACS, we saw the number of steps involved in scheduling, producing, reading, reporting and billing a single chest radiographic study decrease from 59 to nine""Clinicians are now able to quickly retrieve diagnostic images-in full fidelity with imaging reports at workstations we've deployed throughout the medical center," says Siegel. "Because we're saving them time, clinicians are able to focus more attention on patient care, delivering care that's of higher quality than ever before." – VA Hospital Baltimore

IntegrateIntegrate

Driving AccountabilityIntegrate

Integrate

Resource Optimization

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Transform Implement Operate (Six Months)

Facilities

Administration

Consultant

Modality Vendor 2

Modality Vendor 1

PACS Vendor

IT Department

Rad/Card Departments

Rad/Card Groups

IntegrateIntegrate

Project Timeline

Implement, Operate, Optimize

Board Approval for

PACS

PACS Training Kickoff

Softcopy ReadingPACS

Subnetwork“Live”

Interface Design

Modality Integration

ArchiveInstalled

Database Preparation GO LIVE

Acceptance Test Complete

RFI Released

Negotiations

PACS RFP Released

CR Workshop

Contract/Re-quote Released

PACSVendor

Selected

Site Visits and Reference Checks

DI Architecture,Selection

Contract Complete

Workflow Redesign

Network Preparation

Facilities Preparation

ImplementationTeam Resource

Checkpoint

Pre-Implementation

Planning

“GO”

Web Distribution

IntegrateIntegrate

PACS Planning

FCG Engaged Network

Assessment

StaffInterviews

Modality/DICOM

Assessment

Current EnvironmentAssessment

12 - 16 Months

DI Transformation – Operate

Operations: Daily diagnostic and clinical operations

Maintenance & Administration:

System performance, capacity, availability, vendor support, system administration

Process Improvement: Measure performance improvements against baseline and DI Transformation objectives; further refine processes to gain additional benefit from DI Transformation

Reinvestment: Plan for and reinvest in DI systems and architecture as appropriate

PlanPlan ArchitectArchitect IntegrateIntegrate OperateOperate

Step 4. Operate: Transform & OperateStep 4. Operate: Transform & Operate