The Canadian government unveiled a plan in 2001 to create an interoperable electronic health record (EHR) for half of the country’s population by 2009. The plan is aimed at increasing healthcare efficiency, hereby helping to address Canada’s critical human resource shortages and potentially saving billions of dollars annually. As part of this effort, many hospitals have been transitioning from film-based diagnostic imaging to picture archiving and communications systems, or PACS.
The Health Care Corporation of St. John’s is the largest healthcare organization in the Canadian province of Newfoundland and Labrador, and one of the province’s largest employers. With 7,000 employees, 500 physicians and six facilities, the organization provides primary and secondary health care services to the capital city region with a local population of about 200,000, and tertiary service to the entire province, with a population of approximately 520,000.
The use of PACS allows radiologists to digitally capture, compare, manipulate and print a wide variety of medical images including X-rays, computed tomography (CT) and magnetic resonance imaging (MRI). The technology offers clear advantages for both patients and providers, including greater productivity, faster results and fewer errors. Successful implementation, however, can be challenging.
Some challenges involve the technical aspects of interfacing and sharing electronic data with other information systems already in place. Other issues relate to the human side of change – setting appropriate expectations, altering workflow, responding to resistance, and addressing interactions between people, process and technology. With the right amount of planning, guidance, innovation and patience, the Health Care Corporation of St. John’s was able to overcome such challenges and make a rapid transition. In fact, one site, St. John’s General Hospital in Newfoundland, was able to actually able to go “filmless” within a day.
St. John’s performs more than 250,000 diagnostic imaging procedures annually. With the majority of communities in the province of Newfoundland and Labrador being rural and remote, it was clear that the adoption of technologies such as PACS would dramatically improve the ability of St. John’s to address the challenges in caring for isolated populations.
The ambitious effort to implement PACS across five sites – two acute care facilities, one maternal facility, one pediatric facility and one long-term care facility – began last year. The corporation developed and obtained approval for a detailed business plan that outlined a projected return on investment. This was a huge undertaking and in order to carry it off some effort had to be made in the area of change management.
So, besides investing in the right technology, St. John’s hired a consultant to help with the implementation of the new process. The St. John’s project team consisted of representatives from diagnostic imaging and information technologies, as well as multiple stakeholders throughout the organization.
“Initially, the team thought that in order to minimize disruption they would need to operate simultaneously in both a film and PACS setting for at least a month,” the corporation’s consultant noted. “Instead, sufficient up-front planning allowed for a complete switch to be made over the course of a single day immediately following go-live in the diagnostic imaging department.”
Team members worked closely with the consultant at two of the five sites, then were able to leverage the techniques and lessons they learned to finish the implementation on their own across the remaining facilities.
St. John’s General Hospital set the “go-live” date at Sept. 14, 2004. At 8 a.m. that day, ultrasound went live, as filming stopped and the hospital implemented paper scanning of requests. At 9:30 a.m., MRI went live and filming stopped. At 11 a.m., computed radiography (CR) went live and by 1 p.m., the team received calls from the orthopedics clinic and emergency to stop sending hard copy images. On Sept. 15, 2004, CT went live and filming stopped. In the span of 24 hours, the hospital had managed a digital transformation in imaging.
Several factors enabled St. John’s to avoid some of the pitfalls that other healthcare organizations typically encounter when undertaking a similar initiative. Based on its experiences, St. John’s project team offers the following best practices for a successful implementation:
1. Plan for the shift in technology: Before any decisions are made, investigate equipment compatibility. Evaluate the level of access or number of viewing stations that will be required. Also, consider the type of access (i.e., workstation versus web-based access).
2. Develop solid communication strategies: A solid communication plan is important in managing expectations, building physician champions, and mobilizing commitment. St. John’s enlisted participation from nurse educators and the hospital’s communications department, and tailored special presentations for senior management. To get the message out, a variety of other tactics were useful, including email, memos, flyers, table tents, an open house, feedback stations and the creation of an in-house communication committee.
3. Establish roles and responsibilities: To make sure the project team is able to handle both the complexities and uncertainties associated with a PACS implementation, it is important to select the right people with the necessary skills. The project manager should be task-oriented, energetic, self-motivated and well organized. This role also requires excellent communication and interpersonal skills. The system administrator certainly needs solid computer skills, and should be highly regarded by co-workers. Master trainers need excellent communication and computer skills, and should enjoy working with people. Patience is one key requirement common to all roles – team members must be prepared for possible delays and the upheaval associated with major change initiatives.
4. Work with physicians: Early on, identify and engage physicians who are willing to champion the project. Convey the benefits (for both patient and provider) to them in clear terms. Know who the “resistors” might be, and develop strategies for dealing with them or converting them from skeptics to supporters. Anticipate issues that may affect medical staff and offer meaningful assistance when problems arise.
5. Engage stakeholders: Plan to visit key areas within the organization to talk with the end-users. Understand the workflow and image access needs for each area that will be affected by the transition. Define the scope of the project and clearly articulate end-user responsibilities. Address any service issues that may not be included in the framework of the project. Be sure to set and manage expectations to minimize disappointment or rebellion.
6. Encourage and expand ownership: One of the most important things to keep in mind is that bringing PACS into the organization is not solely a diagnostic imaging project. The initiative will have an impact on the entire organization. Make sure adequate support is enlisted from the administration, information management and technology, and facilities maintenance. The team also should ensure that other programs and services assume a certain level of ownership.
7. Manage the impact on staff: Since a change of this magnitude obviously carries ramifications for staff, it is important to carefully consider issues related to human resources. Anticipate and manage the impact on film library staff. A reduction in staffing levels may be necessary as duties associated with a film-based environment are no longer required. Communicate openly and address concerns. Develop a strategy to assist displaced staff by offering to retrain or re-deploy employees to other parts of the organization that would benefit from their skills and experience.
8. Plan for downtime and service delays: Expect and plan for delays that may affect services. Reduce appointments for the scheduled go-live date, and manage the public’s expectations as the institution adjusts to a new working environment. Within the organization, notify end-users as to the date when film will no longer be used. Schedule training sessions for radiologists and other physicians. Make sure timelines accommodate the fact that knowledge levels will vary and there will be a learning curve for all staff as they become familiar with the new technology and processes.
From the perspective of the St. John’s project team, it is never too early to start managing the change. Image access to end-users should be a top priority. This needs to happen in tandem with, or prior to, the go-live date. In addition, select a vendor willing to recognize and accommodate the institution’s unique needs. The support St. John’s received allowed the corporation to become filmless and paperless in a much shorter time span.
Implementation began about a year ago and now (September 2005), the Health Care Corporation of St. John’s is completely filmless at all sites, with the exception of mammography. Twenty-five radiologists are using PACS on a daily basis, and they are satisfied with the changes.
Since switching to PACS, St. John’s has noticed a positive impact on patients, and a definite improvement in exam reporting times. In addition, the technology allows doctors to do a certain amount of surgical planning while an emergency patient is en route, saving critical time when every minute counts.
Although a cost savings in film and related materials had been anticipated, reduced costs also were experienced in diagnostic imaging associated with staffing. With the changes the team put in place, a significant reduction in the number of film library staff was possible. And, with advanced human resource planning, many of the staff from the film library were deployed to other key areas in the hospital.
Building on the successes achieved so far, the Health Care Corporation of St. John’s is currently in the process of connecting systems to enable PACS linkages across the entire province, thereby furthering the goal to create an interoperable electronic health record.