Say Aloha to Your PACS: The Selection Process

When Hawaii Health Systems Corp (HHSC), Honolulu, began shopping for a PACS solution for three of its five island regions, newly hired CIO Money Atwal had a few unique issues to take into consideration. Though multisite PACS configurations are increasingly commonplace, most don’t have to cross water in order to work. Atwal needed a solution that could not only connect facilities on the east and west sides of the main island, but could also be shared by HHSC’s Maui location—around 100 miles of Pacific Ocean away.

“First and foremost, we were looking for distributed architecture. We wanted to allow each of the regions to hold some short-term storage, backing up for the long term at a centralized location, but if a region wanted to keep something locally for more than five years, we still needed that flexibility.” —Money Atwal, CIO

In addition, the remoteness of HHSC’s locations required exceptional customer service from a vendor with the reach and clout to be able to serve a client properly outside the continental United States. Atwal was hired by HHSC just in time to spearhead the PACS-selection process. He had been through a similar process in his previous position, but while the first facility was bigger, the challenges were less daunting. “It was more difficult at HHSC because of the other regions’ involvement,” he notes. “The other regions have different workflows and personalities to be worked through.” Of course, Atwal was interested in much more than simply finding the right multisite architecture for HHSC’s needs. He was also looking for robust storage, thin-client Web access, CR and mammography integration, and the right image-manipulation tools to keep his radiologists happy. With such diverse system requirements to meet and so many parties from across the health care continuum invested in the outcome, it was crucial that Atwal appoint the right people to the selection team. Grassroots-up Decision Making Atwal’s prior experience with systems selection taught him one thing: decisions cannot be made without the participation of the clinicians who will actually be using the application daily. “We wanted to pick people who would live the software every day,” he says. “It wouldn’t be a true evaluation if it was an executive-level decision. We wanted grassroots-up decision making.” Picking the right team is easier said than done, however, when multiple, geographically disparate locations are involved. Atwal brought in the same players from each region: the director of radiology, a local IT representative, and one or two radiologists. “Each of the regions was well represented on the selection team,” he says. In the end, it was the radiologists who had the most to contribute—and rightly so, Atwal says. “The radiologists wanted to be able to stay within the same module while dictating and doing the final report,” he notes. “They needed sophisticated image-manipulation tools. They also pointed out the importance of managing technologist workflow. We needed to be able to see when the patient came in and when the tech started an order to track our productivity better. Scheduling was also very important, as well as the ease of what the technologist would have to do in terms of documenting exams and studies.” Getting clinicians involved is a strategy that lasts well beyond smoothing out the decision-making process, Atwal notes. There are also benefits throughout implementation and training. “The more grassroots representatives involved, the better buy in and change management go as well,” he says. Because HHSC had never had a RIS or PACS, some of the team members weren’t sure what questions to ask. Atwal’s solution was to have the group collaborate in developing a single line of inquiry for vendors. “After we sent out our request for proposal (RFP), we read and studied the proposals together,” Atwal says. “From there, we were able to come up with a list of group questions.” Window Shopping To begin with, Atwal wanted to be sure to meet HHSC’s unique needs, which include a robust distributed architecture and premium customer service. “How supportive is the vendor on the island?” he says. “What’s the response time? Is there support available in terms of technicians or spare parts? These questions were extremely important. We wanted to see which vendors were already live on the island, how their PACS were being used, and how their current customers felt about their responsiveness.” Atwal and his selection team commenced a series of local site visits designed to help them assess the various vendors’ performance. “We looked at how much maintenance was required and how much time it took,” he says. “More than anything else, we asked the vendor sites about operational processes and training. We were looking for a system that was intuitive and easy to maintain.” Because vendors tend to demonstrate their software on canned processes designed to show off their systems’ strong points, Atwal hired a project manager to develop demo scripts based on the selection team’s feedback. “We had our staff come up with scenarios that we really do see on a regular basis,” he says, “so during the demos, we were able to see very easily how easy or difficult the systems were to use. It was quite evident how many screens were involved in a given scenario, and how many times the user had to go back and forth.” Throughout the evaluation process, the team rated each vendor across five key criteria: general assessment, registration and scheduling, imaging services, image archival and communication, and system management. Quantifying the most important aspects of the systems helped keep the selection process on the right track, which was especially important for a health system selecting its first PACS. “Sometimes, people look at the bells and whistles too much,” Atwal notes. “What’s important is getting the base product in place and building the foundation. The bells and whistles don’t come in until after the core implementation is complete.” Weighing Options When the time came to weigh the different vendors against one another, Atwal made sure that each region’s contribution to the discussion was considered equally—though the decision-making process was rendered considerably easier by the fact that a clear frontrunner had already emerged. “It came down to our legacy hospital information system (HIS) vendor versus another vendor who seemed to be head and shoulders above everyone else,” he says. “Our HIS is a very old system, and if we ever choose to upgrade it, it might help to have a PACS from the same vendor. That was a consideration, but no one is very happy with the HIS, so in the end, we decided not to make it a factor in our decision making.” Each region had its own needs, but Atwal was surprised at the degree of cooperation and harmony among the three groups. “Through the site visits and the RFP process, a trust had been developed among the three regions,” he says. “Reconciling their different priorities wasn’t as hard as I thought it would be. I tried to give them some additional insights based on my prior experience.” At the outset of the selection process, it wasn’t clear whether a single vendor would be able to meet the needs of all three regions or individual solutions would have to be pursued. Much to Atwal’s relief, by the end of 2007, it was clear that a single vendor would be capable of uniting the three regions while addressing each of their individual processing and storage requirements. “The decision to go with a single vendor really helped,” he says. “In any selection process, the key to a successful implementation is having your clinicians involved with the process and happy with the decision.” In March 2008, Atwal and the team passed along their recommendation to HHSC: a Synapse RIS/PACS from FUJIFILM Medical Systems USA Inc, Stamford, Conn. “We’d heard a lot from other sites on the island about FUJIFILM’s customer service and responsiveness, as well as its seamless upgrades,” Atwal says. “Its CR-to-PACS integration was spoken of highly, and our radiologists were impressed with its image-processing tools. We felt that it had the functionality we were looking for.” Implementation and Beyond As Atwal and the team prepare to begin the implementation process, he emphasizes that his job has been made infinitely easier by the consensus reached by stakeholders from each of the three regions. Meanwhile, HHSC’s corporate leaders are ready to experience the operational efficiencies and reduced costs that will accompany the long-awaited transition to a digital imaging environment. "This is really going to help with the bottom line," Atwal says. "Savings on film is a huge factor in terms of return on investment. That’s part of why everyone involved was able to get behind this implementation: It’s a no-brainer." As for HHSC's other two regions, Kauai and Oahu, Atwal anticipates that they will be more interested in going digital when they see how using a RIS/PACS simplifies operations for the other three regions. "We do have plans to bring Kauai and Oahu online in the future," he says. "When we began this process, they weren't interested, but once they see the benefits, I think that will change."