3. Obtaining a Digital Image for PACS AHRA Electronic Imaging Conference April 23, 2005 Tampa, FL Monte Clinton, CRA Dartmouth-Hitchcock Medical Center

4. Disclaimer This presentation is about a conversion from film to CR and DR at one facility. It is being given as an example of a successful digital conversion. DHMC does not endorse any vendor’s products or services

5. The Goal is PACS Picture Archive and Communications System PACS Requires a Digital Image CT, MR, NM and Ultrasound – Digital Now Routine Radiography Must be Digital Install all at Once or Phased in Over Time The Mixed Environment – Film and Digital

6. Electronic Communication A Common Language DICOM HL7 An Electronic Network Ethernet 100 Mb 10 Mb 1 Gb

7. Radiology’s DR/CR Partners Information Systems Purchasing Equipment Vendors Radiology Staff Referring Clinicians Administration

8. Information Systems Partner with Information Systems Dept. Your implementation schedule must fit with their availability Do they have the technical expertise Do it yourself You must build the expertise and infrastructure Ongoing support is costly and labor intensive A good relationship with IS is essential

9. Purchasing Department Institutional Requirement Good Business Practice Price Comparison Payment Options Protect Your Investment

10. DR-CR Equipment Vendors Take Advantage of Vendor Experience Benefit from Vendor Competition Compare Products and Services Must be a Good Long Term Relationship This Must be a Win – Win Endeavor

11. DR-CR and the Radiology Staff Radiology Admin. Staff - Implementation Technologists – Critically important buy-in Support Staff – Minimal involvement Radiologists – Minimal involvement

12. Referring Clinicians Minimal involvement in DR/CR decisions Loss of film a concern for – Ortho -OR Let them participate in PACS decisions Let them champion the need for PACS

13. Administration Requires a good business plan Demonstrate the impact on finances Compatibility with the Strategic Plan Huge investment in time and money Stress positive impact on customers

14. Benefits of DR/CR DR-CR is the Road to PACS Increase technologist productivity Increase imaging room capacity Utilize existing space better Decrease patient waiting time

15. Why DHMC Went Digital Electronic Image Distribution Accommodate hospital’s expansion Facilitate Radiology’s expansion Improve reimbursement Reduce medico-legal risk Reduce MD and Patient travel time

16. Digital Equipment: Benefits for the Patient and Clinician Improved Radiology service PACS images are always available Eliminate technique-related repeats Minimize waiting and treatment delays Faster service with quicker examinations

17. The Options When Going from Film to Digital The three choices: CR – Computed Radiography $$ $$ DR – Digital Radiography $$$$ $$$$$$ Digitize Film $ Cost Payback

18. Going Digital with CR Advantages Inexpensive way to get to digital Currently required for cross-table and portable studies Disadvantages Slow as film – minimal productivity gains Requires technologists to handle cassettes

19. Going Digital with DR Advantages: Productivity increase for techs – less hard labor Technologist does not leave room during exam Productivity increases for imaging rooms Enables smooth PACS integration Disadvantages: The equipment is more expensive then film or CR Requires CR for cross-table and portable studies

20. DR Options Dual detector Single table or wall detector Dual purpose single detector Portable DR detector

21. Dual Detector

22. Dual Detector DR

23. Trolley Used with Upright DR

24. Cross Table Using Upright DR

25. Single Multi Purpose Detector

26. Single Multi Purpose Detector Cross Table Projection

27. Portable DR Detector

28. Going Digital by Digitizing Film Digitize Film Advantages Least costly way to get into digital imaging Disadvantages Slower then film, CR or DR No productivity gains for tech or room All the costs of film plus added labor/cost

30. DR/CR – Getting Started Assess your needs Volume analysis and a 3 year projection Talk to your colleagues Attend conference such as this one Form an evaluation team Administrator Clinical Operations Manage Asset Manager Technologist

31. Request for Information (RFI) The RFI – first step in technology assessment RFI only to companies you can work with Purchasing can help with the RFI Template available DHMC.org website Evaluate the RFI and select 2 to 4 vendors

32. Site Visits to See DR/CR Equipment Visit the vendors you can work with Select sites comparable to your own Spend some time alone with host Look for functionality, technologist acceptance, downtime, were goals achieved, vendor responsiveness

33. Request for Proposal (RFP) Spell out exactly what is required The amount of equipment What it will be expected to do How will it be expected to perform When you want the equipment Installation and applications details

34. RFP (Continued) Spell out exactly what is required Networking requirements for PACS Post warranty service agreement Value added products and services Require vendor to reply in your format

35. Vendor’s RFP Response Must be in the exact format of the RFP to facilitate comparison between vendors Options and post-warranty service The vendor’s RFP response will be a legally binding document of what they will do Let Purchasing negotiate price and terms Purchase order is based on the RFP

36. RFP Evaluation Evaluate on a point system Image Quality Reliability and Service Price Features Upgradeability Company Stability Value Added

37. Weighted Selection Criteria Participant's Weights by % AVE CRITERIAP1P2P3P4Wt. #1 Reliability & Service20%40%20% 25% #2Image Quality25%10%20%25%20% #3Price20% #4Features15%10% 15%12.5 #5Upgradeability10% #6Company-stability5%10% 5%7.5% #7Value Added5%0%10%5% 100%

38. Weighted Selection Criteria COMPANY 1 AVE CRITERIAP1P2P3P4ScoreWt. #1 Reliability & Service87867.2525% #2Image Quality7867720% #3Price10 20% #4Features5676612.5 #5Upgradeability7768710% #6Company-stability9108 9.257.5% #7Value Added43343.55% 50100%

39. Weighted Selection Criteria COMPANY 2 AVE CRITERIAP1P2P3P4ScoreWt. #1 Reliability & Service87867.2525% #2Image Quality7867720% #3Price5645520% #4Features5676612.5 #5Upgradeability7768710% #6Company-stability9108 9.257.5% #7Value Added43343.55% 45100%

40. Weighted Selection Criteria COMPARITIVE SCORE AVE CRITERIAC1 C2 Wt. #1 Reliability & Service417.251.825% #2Image Quality3.671.420% #3Price1025120% #4Features5,66.7512.5 #5Upgradeability5,57.7510% #6Company-stability6.49.25.77.5% #7Value Added3.153.5.185% 365.25456.53100%

41. Awarding the Contract Careful review of the equipment, options, service and guarantees Purchasing Department completes the negotiation The purchase order is awarded Plan for installation

42. Preparing the Installation Room size and layout is determined Electrical, shielding and HVAC Construction plan is developed Contractor selected Time lines established

43. Partnering with the Vendor Agreement with the vendor on the timeline and implementation phases Appoint key staff from each stakeholder This must be a win – win endeavor

44. Radiology Equipment 2003/4 DHMC Case Study Existing 3MR + 1 Mobile 3CT 3VIR + 1 PICC 8DX 3R/F 5US 3NM + PET/CT 5Mammo New in 2003 Replace in 2004 1 CT in new ED 1CT/Angio 1 Angio OR compatible 6 DR-- 4 CR 1 DR/CR in ED + 1 CR trauma 1 DR/Fluoro 2 US in new building 1 NM + Fixed PET/CT 2 DR – Mammo new building

45. Digital Imaging: Benefits for the Technologist Advantages Eliminate handling of cassettes Increased imaging equipment options Faster study times - less waiting Eliminate technique-related repeats Disadvantages It’s a change in the way of doing work

47. Digital Imaging: Benefits for the Radiology Director Save money – Increase reimbursement Increase Productivity - Reduce Risk Eliminate film and processing costs Reduce Film Library staff - space Improve productivity Improve billing collections Reduce medico-legal exposure

48. Productivity Benefits of DR Source: Philips Medical System

49. DHMC Productivity Gains TUCK Review of 46,000 Studies 36% Productivity Gain Technologist Capacity Reduced Waiting Time <12 Minutes Significantly Better Turn Around Time Fewer Imaging Rooms

51. Keep The Staff Informed Involve technologists Have a tech rep. on selection team Keep everyone informed of progress Train key technologists Get ideas for improvement Change is hard for many people

53. Contingency Plans Referring clinicians demanding film Acceptance of CDs by other facilities Urgent results reporting Special requests System failure – power failure - virus

55. What DHMC Did Right Kept an open mind Goal Oriented – PACS & Productivity Diverse Selection Team Director, Operations Mgr, Asset Mgr, RT DR all at once -- Summer 2003 Partnered with vendor

57. Thank you Monte Clinton, CRA Dartmouth-Hitchcock Medical Center Monte.Clinton@Hitchcock.org www.dhmc.org/dept/radiology Questions?