Bethesda Healthcare System made a strategic decision to invest in PACS technology when its executive management team conceded that traditional X-ray film management would never achieve the information access expectations of its physicians, patients and medical staff. In 2001, Bethesda Healthcare System was typical of many U.S. hospitals: a not-for- profit community hospital with 362 licensed beds, with an annual volume of 165,000 diagnostic procedures interpreted by a team of 10 radiologists.
In 2001, the imaging department had problems managing films—problems associated with retrieval, storage space for fil- ing, and delivery of films where they were needed in a timely manner. Efforts to improve film file room functionality had been made without much impact on performance. Staff was added. Procedures were changed. Complaints continued.
CEO Robert Hill decided to personally investigate. The experience of working a one day, 8-hour shift was enough to con- vince Bethesda's technology oriented chairman that hospital-wide conversion to digital image management was neces- sary.
The imaging department needed more than a PACS. It also needed a major upgrade of its existing radiology information system. The timing happened to coincide with a search by Siemens Medical Solutions for a partner to launch its new SIENET Integrated Radiology Suite, a fully integrated brokerless RIS/PACS solution. Bethesda agreed to become a major beta site for Siemen's new NOVIUS RIS.
The new RIS was installed in October 2001. The go-live date for the PACS was May 2002. From the outset, the perform- ance of the integrated system more than exceeded expectations. The impact on providing better service to ER patients was profound. ER physicians had immediate, unprecedented access to images. With the new system, turnaround times from exam order to completion of procedure dropped from of an average of 54 minutes to an average of 42 minutes for all modalities, with an average of 32 minutes turnaround time for diagnostic radiology. For emergency patients, every minute counts. The increase in imaging department efficiency positively impacted patient treatment. Patient care decisions were expedited. Emergency department efficiency overall improved. While not as dramatic, workflow efficiencies generated by the integrated RIS/PACS impacted every single hospital department within months of implementation.
The Financial Case for PACS. Hospitals without PACS know that they must make this expensive investment sometime in this decade. PACS has become an infrastructure issue, a component of a hospital information system and electronic patient record strategy. Hands-on film management is becoming obsolete.
Yet is there a positive financial case for a PACS, in this case, an integrated RIS/PACS? For Bethesda Healthcare System, the answer is yes. Bethesda did receive financial incentives to be a luminary site for Siemens.(Theimagingdepartmenthostssitevisitbyprospectivecustomersseveraltimesamonth.) Yetthecostofthesystemoverafiveyearperiodforcapitalandoperationalexpenseswasstillsub- stantial at $6,298,000. Based on realistic estimates, direct and indirect cost reductions would be $7,080,768. This would yield a positive net present value of $132,083, with an actual averaged cost savings of $156,553 per annum. Either way—an affordable decision for the hospital.
But were these estimates realistic? Only time would tell. Bethesda assumed that it would reduce film production in Year 1 by approximately 50%, and that the equivalent of up to 4 FTEs could be eliminated from the file room staff during the course of the year. Within one week of the PACS implementation, films were being printed only for surgeons and the OR within the hospital. Films also were printed for referring physicians who specifically requested them, rather than the CD that the department routinely provided.
Inthefirst12monthsofPACSoperation,filmsavingsof$396,514wasachieved,3.5%greaterthananticipated. Thisestimatewasrightontarget.Otherestimateswerewayofftrackinamostpositive way. Savings from elimination of forms and labels for film and patient jackets was underestimated by 49%, or $32,807. Similarly, the FTE reduction in film library staff was also significantly underestimated. It was possible to entirely eliminate file room staff for the night shift and during weekends, as well as reduce the number of individuals during the 1st and 2nd shifts. This represented a reduction of 7.2 FTEs. Instead of $97,587, a cost savings of $189,658 was achieved, or 94% more than had been forecast!
For repeat exams, a $9,000 cost savings was estimated. This represents the cost of procedures performed in FY 2001 that had to be retaken due to misplaced films.
Space reduction expenses, as well as repairs and maintenance contracts for film processors that could be eliminated had not been included in the original estimate. The savings of $56,250 for space reduc- tion is a combination of not having to transfer 12 months of films to Bethesda's off site commercial storage warehouse and actual space reduction within the hospital's file room. Three film processors were retired, reducing annual maintenance contracts and chemistry costs by $97,522.
Transcription cost savings was underestimated by 146%. The new RIS incorporates site-customizable report templates. When the RIS was first launched, these originated as a library of normal reports for the most common exams, but have expanded dramatically. When a radiologist is preparing a report, he/she can select a report template with a single mouseclick, fill in some fields, and electronically sign. Once electronically signed, the system autofaxes the report wherever it is needed. The impact on report turnaround time has been significant; the domino effect savings to other hospital departments has not been calculated, but may in fact be even greater than the total of $136,852 in 2002. Bethesda changed its transcription services company in 2003, obtaining a more favorable contract, so the cost sav- ings of the report template feature in 2003-2004 is less.
The $91,000 savings for Web image retrieval represents on-call time savings for the radiologists themselves. It represents the minutes wasted by an on-call radiologist waiting for images to arrive at his home using the pre-PACS teleradiology system versus use of the Web server to access PACS. One may argue that this is not a hospital savings, but it translates into more rapid diagnosis for acute care emergency patients.
Year one cost savings for the imaging department was originally estimated at $702,403. It actually totaled $1,075,916. The cost savings projection for year two ending April 30, 2004 is $1,036,599.