Memorandum submitted by Mrs Barbara Greggains
Mrs Barbara Greggains MBE BA(Hons) MMRS Lay
Member of Council: The Royal College of Radiologists: 2002-05
Past Chair: RCR Clinical Radiology Patients' Liaison Group 1999-2002.
SUMMARY OF
PAPER
For all those who have fought for implementation
of a national PACS roll-out as part of the NHS IT programme, it
has been gratifying to see the benefits they foresaw for patients
now becoming reality. This is a case of IT bringing such major
benefits to patients that their whole experience of radiology
is being transformed by the Picture Archiving and Communications
System. Major efficiencies are being experienced in the NHS where
PACS is up and running. As PACS rolls out, there is progress towards
an IT-enabled radiology service fit for the 21st century.
BACKGROUND TO
PACS ROLL-OUT
The patient representatives in the Royal College
of Radiologists (RCR) have been vociferous over the last eight
years in calling for PACS (Picture Archiving and Communications
System) to be rolled out across the NHS. They were convinced of
the benefits and efficiencies of having imaging put straight onto
computer. Indeed, they enlisted the support of the e-Envoy's office
in the Cabinet Office and got a business case written for PACS.
They warmly welcomed the funding for the NHS roll-out which means
PACS should soon be in every Trust in England and they are pleased
that the other UK countries are moving forward too.
The benefits for patients are remarkable. All
this is happening at the same time as the NHS Care Record Scheme
is being developed and Radiology Information systems are increasingly
in place, and these developments taken together are revolutionising
radiology processes and outcomes for patients.
THE BENEFITS
OF COMPUTER
STORAGE AND
MULTIPLE COPIES
OF IMAGES
It is of huge benefit to patients that PACS
puts patient images straight onto computer. Sick patients are
not left alone while the success of the imaging is checked nor
do they have to return to the department if the consultant is
dissatisfied with the imaging. With PACS, the storage and quality
checking of the image is immediate.
The electronic storage and transfer of imaging
frees patients from the problems associated with single copies
of images. Under single image systems, the single copies get dispersed
around hospital sites in spite of the best efforts of radiology
departments. The lost images create serious problems for patients
and hospital staff. Images are not to hand when needed and consultations
are hindered, with the result that diagnosis is delayed and future
treatment cannot be planned. Surgery gets cancelled for the same
reasons. With PACS, patients can hope not to suffer the confusion,
delays, waste and health risks that this has involved. Even if
there is some computer down time (and there are ways of keeping
this to a minimum) the basic imaging is not lost.
REDUCTION IN
REPEAT IMAGING
AND GREATER
SAFETY FOR
PATIENTS
Very importantly, patients need not be subjected
to unnecessary radiation as a result of repeat imaging when images
are lost. It is unforgivable and against IR(ME)R regulations to
impose this on a patient, yet lost "one copy" imaging
means that sometimes there is no alternative.
Patients can also expect that, as records build
up, their recent imaging history will be available to all those
caring for them so that again there is a reduction in unnecessary
imaging. This could mean, for example, an anaesthetist will know
if a chest X-ray has been carried out recently during investigations
and will not re-order another prior to surgery. Consultants, hospital
staff and in time, even GPs, will also have access to imaging
records and not inadvertently request repeat imaging. Knowledge
of any adverse reactions to contrast materials can also be registered
on the system, an important safety feature.
BETTER USE
OF RADIOLOGISTS'
TIME, SKILLS
AND GENERAL
NHS RESOURCES
There has in recent years been a severe shortfall
in capacity in radiology, both of workforce and equipment and
a major benefit of PACS is greater efficiency in working methods.
A clinical (or diagnostic) radiologist member of the RCR, with
long years of training and experience should be doing the highly
skilled work of interpreting images, not being delayed while images
are located.
Equally, the other RCR Members and Fellows,
the clinical oncologists, should be able to put their long years
of training into devising radiotherapy regimes on the basis of
readily available images. Cancer patients are benefiting from
more focussed and powerful radiotherapy because modern radiotherapy
planning increasingly uses sophisticated imaging and image fusion
to pinpoint tumours. PACS technology lends itself perfectly to
this.
Other doctors outside the radiology department,
who also need sight of patients' images, will not need to waste
their own time or that of their patients chasing up mislaid imaging
if they are able to access PACS. The radiographers who work alongside
radiologists and other members of staff should also not be wasting
their valuable time in image location.
Finally, it is extremely wasteful for NHS resources
to be used in developing traditional film, storing the films (sometimes
off-site) and the physical transfer of single images by hand,
taxi etc.
SPEEDIER AND
MORE EFFICIENT
DIAGNOSIS SYSTEMS
PACS offers the potential for speedier diagnosis
for the patient. Modern technology allows images to be available
round hospital sites or across sites immediately they are taken.
Multi-disciplinary discussions can take place at once, even if
participants are in different places. Many Accident and Emergency
patients, in particular, are having reason to be grateful as their
imaging is flashed to the relevant site in a hospital for an urgent
discussion and decision on the next best move.
The greater efficiency of PACS speeds up reporting.
The Hammersmith Hospital, the first filmless hospital in the UK
where PACS has been pioneered, offers the stellar performance
of same-day dictation of reports within the radiology department.
This dream is currently becoming achievable in other hospitals.
Patients have every right to ask why they should suffer days and
even weeks of agonising delay for a diagnosis, especially in relation
to a life-threatening disease.
Gradually, all the PACS installations will link
up and, if a patient needs treatment, say on holiday in Yorkshire,
existing images from the home hospital miles away should be available
on-line. GPs should eventually be able to order imaging from their
surgeries. In the meantime, if a patient requires a hard copy
of some imaging to take to another site, this can be offered very
cheaply with PACS at a fraction of the normal cost.
POTENTIAL TO
IMPROVE DIAGNOSIS
STANDARDS
As PACS installations join up across the NHS,
the patient can begin to expect an even higher level of service
from the profession. Currently, if patients have a cancer history
and an apparent secondary symptom appears, they may well undergo
a series of different forms of imaging to check all over the body,
probably taken over a number of different centres which specialise
in CT, MRI , nuclear medicine etc. Without PACS, radiologists
at each centre report in isolation. It is now possible to combine
different forms of imaging so that better quality information
is available and one radiologist can bring together the information
from a series of images.
The diagnostic radiologist working with PACS
will eventually also have easy access to previous imaging to track
changes. This reduces the chance of missed problems. It is of
especial benefit for the breast screening programme where tracking
change is of key importance.
Manipulation of images is also advancing. Images
can be combined to produce, for example, a neck or foot which
can be viewed from all angles and rotated and manipulated as necessary.
It will be possible to zoom in on aspects of images and flip them
over. Furthermore, the integration of PACS with other hospital
IT systems means radiologists can access other information such
as pathology reports. Thus patients can begin to look for a more
informed and rounded diagnosis from radiologists who increasingly
are the front-line diagnosticians, since their colleagues in other
specialties rely more and more on their increasing skills and
advanced equipment.
Second opinions are more easily obtained with
PACS. It offers the potential for difficult interpretation to
be passed swiftly to experts in that field—a specialist
radiologist in a major teaching hospital might provide an immediate
second opinion for a patient anywhere in the UK. Emerging satellite
technology is also beginning to offer the potential in time for
high-grade image transfer to be the made to the specialist radiologist's
home, if necessary, again speeding the diagnostic process. In
some parts of the world, images taken during the day are interpreted
overnight in other countries where radiologists are awake.
This international transfer of imaging hugely
expands the expert diagnosis field, and the issue of ensuring
parity of standards is being successfully addressed. The potential
is there one day for patients with obscure or difficult health
problems to have the benefit of diagnosis from the world's finest
experts in that field.
Furthermore, any number of people can simultaneously
look at the same image but be situated in different places. This
makes it easy for a team of people to discuss an image and its
implications.
NEW TEACHING
METHODS FOR
RADIOLOGISTS
The innovative radiology Academies which have
been set up in three English teaching hospitals will benefit hugely
from PACS, The development of a centralised electronic database
of training material will mean these trainees can receive a wider
exposure to imaging during their training than was hitherto possible.
Their trainers can also cope with more trainees at a time, even
though these trainees will still spend important time in the hospitals.
The reason for this is that video links can be used together with
PACS, so trainees can track cases using PACS, study real-life
reports, observe multi-disciplinary meetings while they look at
the relevant imaging and watch patient consultations.
Radiologists trained in this way should be skilled
in the habit of drawing on multiple sources for their diagnosis,
of using modern methods for combining and manipulating images
even from different forms of imaging and of taking a full view
before drawing conclusions. Refresher courses for qualified radiologists
will also in time be easier using the database.
THE BRIGHTER
FUTURE FOR
RADIOLOGY PATIENTS
For all those who have fought for implementation
of a national PACS programme, it has been gratifying to see the
benefits they foresaw for patients now becoming reality. This
is a case of IT bringing such major benefits to patients that
their whole experience of radiology is being transformed. As PACS
rolls out, there is progress towards an IT-enabled radiology service
fit for the 21st century.
Business cases were being drawn up initially
which showed PACS implementation to be cost neutral over a few
years, but, now PACS is rolling out, the anecdotal evidence of
greater efficiencies suggests that it is likely that the benefits
of operating an efficient service will offer even better financial
outcomes than anticipated. Fewer members of staff are walking
about searching for, or carrying, single copies of imaging or
putting imaging in taxis to go to other sites. Fewer operations
are being cancelled because of lost imaging. Fewer consultations
are being wasted for the same reason. It is possible for A and
E patients to undergo instant imaging and for their cases to be
discussed immediately by doctors in different sites so that expensive
precautionary referrals to trauma units can often safely be avoided..
Cases can be discussed by people in different sites without the
need to gather in one place. All this not only saves money, it
frees up resource.
The national 18-week wait target can only be
achieved with PACS.
In summary, PACS implementation is one of the
shining stars of the NHS IT programme.
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