Study: PACS deployment increases consultative role for radiologists
The introduction of PACS may carry the same clinical significance in terms of the way radiologists work as the deployment of technological innovations such as CT, MRI, and ultrasound. A team from the department for clinical science, intervention and technology at the Karolinska Institutet in Huddinge, Sweden, and the Skane County Council in Lund, Sweden, recently studied the impact of PACS on medical work and found that it is not an isolated artifact, but rather that it has created new activities and responsibilities for its adopters.

“In this study, PACS function in a hospital-wide electronic network connecting different image production modules, archives, printers, diagnosis and reporting workstations, and workstations in other units within the hospital ” wrote the authors of a longitudinal review conducted between 1999 and 2005 and published in the December issue of the Journal of Digital Imaging.

A series of 46 interviews with radiologists were conducted over six years at four medical institutions where PACS had been introduced. A series of questions covered three areas: technology in use; practice related to technology in use; and professional skills and learning processes, according to the authors. The interviews were transcribed, analyzed, and coded using grounded theory as an organizing principle. The researchers, using an open coding methodology, agreed on three main categories for the data: professional role; diagnostic practice; and technology in use.

The research team found that over the period of their study, PACS changed the role of the radiologist in the clinical spectrum of care from professional experts in the reading x-ray films to a consultant to clinical decision-makers.

“In 1999, when clinicians met with the radiologist in clinical meetings, the radiologist was the professional expert with experience in reading x-ray films,” the authors wrote. “However, over time, as the clinicians obtained access to images, their ability to read images improved. In this process of change, the radiologist received more questions from the clinicians as their interest in and ability to view digital images and reports increased.”

When the interviews were first conducted in 1999, radiologists worried that they would become less skilled in diagnostic reading of images because they felt that their role was becoming more technology oriented, the researchers reported.

“However, the technology improved access to images for distributed radiology, and it became possible to access a greater number of comparable cases as well as any previous examinations of a specific patient,” the authors wrote. “For example, the technology allowed clinicians to keep in more frequent contact with radiologists, and to derive second opinions in a dialog whenever needed.”

The researchers observed that with PACS, by giving clinicians access to the basic interpretative skills of radiology through technology, has changed the scope of the radiologist’s profession. They found that the introduction of PACS has led radiologists to move from a role of individual professional expertise to becoming more of an actor in a clinical network

The study also found that getting used to digital images with PACS technology took approximately four years for many of the radiologists.

“As physical objects, x-ray films have different properties from digital images; in 1999 radiologists could hold x-ray films, feel them, and know they were looking at the whole image,” the authors wrote. “This allowed them to be relatively confident in the opinions they expressed because no extra information could be obtained from the image.”

Digital images, according to the researchers, allow a wide scope of functionalities for subsequent manipulation in a dynamic pattern of interactivity. They found that this required radiologists to develop a new mental framework for the change in workflow as a result of PACS introduction.

However, as radiologists became more comfortable with the capabilities provided by the new technology, it was found that none of the radiologists interviewed wanted to return to the old work practice of using x-ray films.

“Using digital images, it is possible to increase the illustration of details, e.g., one could illustrate the acoustic nerve for the neurosurgeon in its full length,” the authors wrote. “In this way the radiologist has become, for instance, a new and important advisor in discussions with the neurosurgeons.”

Although the introduction of PACS has led to clinicians outside radiology gaining greater access to diagnostic images, and allowed some of them to develop basic interpretative skills of these images, the researchers believe that this will not diminish the role of radiologists in the continuum of care.

“It is likely that there will be a development of increasing expertise in subspecialty areas, leading to better quality of care, for instance, in developing from a general neuroradiologist to a neuroradiologist specializing in the acoustic nerve,” the authors wrote. “We predict that increase specialization is the future for radiology.”