LMIC (Low and Middle Income Countries) as it provides a good start to gain experience with managing digital medical images with a relatively low entry cost. In this paper we’ll discuss the PACS features that can be offered by open source providers, implementations strategies, and lessons learned.
Why would someone want to use an open source PACS?
· Open source PACS allows an organization to find out what they need as they are changing from using hardcopy films to a digital environment with which they have often no experience and/or exposure. As many open source PACS systems have a free and commercial version, it is easy to migrate at a later date to the paid version, which provides the upgrades and support as the organization feels comfortable with the vendor.
· This is not only applicable to LMIC regions, but an open source PACS can be used to address a missing feature in your current system. For example, they can be used as a DICOM router.
· The open source PACS can function as a free back-up in case the commercial production PACS goes down as part of an unscheduled or scheduled downtime.
· It can be used as a “test-PACS” for troubleshooting, diagnostics and training.
But the main reason is still the cost advantage. If a LMIC hospital has to choose between a purchasing a used CT or MRI for let’s say $350k US, which could have a major impact on patient care as it might be the only one in a large region serving a big population, and investing in a PACS system, the choice is clear: they will first get the modality and then use maybe another $50k or so to buy the hardware servers, PC’s and monitors and string cable to get a network in place and install an open source PACS. One should also be aware that the argument of not having any vendor support for an open source PACS is grossly over-rated. I have seen some good dealers and support but also some very poor service engineers, so even if you would use a commercial PACS, the chance that you get any decent support is often slim in the LMIC region.
1. Expand the current open source BB-PACS, e.g. upgrade the storage capacity, replace the server, have a more robust back-up solution and add a commercial workstation workflow manager, a Modality Worklist Provider and reporting system. This assumes there is a mechanism to enter orders, i.e. through a RIS or EMR.
2. Keep the BB-PACS and turn it into a Vendor Neutral Archive (VNA) and purchase a commercial T-PACS which serves as a front end to the radiologist. The new PACS might store images for 3-6 months and the “old” PACS will function as the permanent archive.
3. Replace the BB-PACS with a commercial T-PACS or even a FF-PACS assuming the funds are available and you are looking for a cost effective solution.
Note that the advantage of option 1 and 2 is that you don’t need to migrate the images from the old to the new PACS, which can be a lengthy and potential costly endeavor.
· Be prepared to assign an in-house IT and/or clinical person who is computer literate to support the PACS. This person will be responsible for day-to-day support, back-ups, managing scheduled and unscheduled downtimes, adding additional modalities and interfaces with a RIS, EMR or reporting system as they are being introduced. This staff member will also be responsible for troubleshooting any issues that might occur. They will also be the go-to person for questions about its usage and he or she will train incoming users. These so-called PACS administrators are a well-established profession in the developed world, but it will be a challenge initially to justify a designated position for these people to the department and hospital administration in the LMIC region as it is a new position.
· How will these PACS administrators get their knowledge? There are fortunately many on-line resources, including on-line training, and organizations such as RAD-aid, which has been conducting PACS bootcamp training session in LMIC regions to educate these professionals.
· PACS is a mission critical resource that has impact on the infrastructure (power, network, HVAC, etc.). In most cases the existing network is not secure and reliable enough and/or does not have sufficient bandwidth, which requires a dedicated network with its own switches and routers.
· It is preferred to use locally sourced hardware for the IT components to allow for a service contract and access to parts. The only problem you might have is to get medical grade monitors in some regions as they are not as popular yet.
· Pay attention to the reading environment for diagnostics, I had to instruct people to switch off their lightboxes that were used to look at old films and even paint some outside windows to reduce the ambient light. Use medical grade monitors for diagnostic reading.
· Use good IT practices that includes implementing cyber security measures, reliable back-up and OS patch management.
· Create a set of Policies and Procedures for the PACS that include access control, who can import and export data on CD’s and how that is done, unscheduled and scheduled down-time procedures, and everything else needed to manage a relatively complex healthcare imaging and IT system.