The findings are presented under the following headings: adoption and evolution of PACS, locations and roles, tasks and features, workflow, performance issues, training, and touchless interaction and sterility.
Adoption and Evolution of PACS
HPs report that the introduction of PACS had a dramatic impact on the clinicians’ working day, bringing a newfound convenience to the clinical workflow. However, despite the fundamental nature of PACS in the clinical workflow, multiple HPs commented that they had observed no appreciable improvements over time. If anything, it is noted that PACS has become less usable over time for the typical user.
SREG4: “What stands out the most is that in 12 years, there’s been very little change.”
Though there are multiple providers of PACS solutions, HPs reported finding little difference between the various offerings.
Consultant Rheumatologist (CR1): “They all appear the same to me, to be honest.”
Impact on work practices
Participants are positive about the beneficial impact of PACS on their work practices. PC. 1: “I could easily see an X-ray and give my expertise based on an X-ray. That could only be done through PACS. It’s convenient. It allows you to outsource the expertise.”
Analytic functionality integrated with PACS is also mentioned, and these capabilities are likely to increase in the future . PC 1: “I use engines of artificial intelligence to actually get a better diagnosis ...you can make it more precise, faster, cheaper, more efficient, etc.”
Locations and Roles
HPs report three primary locations where they would use PACS: dedicated hospital workstations specific to the user (e.g., a radiologist’s office), at a shared hospital workstation/desktop (e.g., in the nurses’ office, on the ward, or in the clinic), and in the operating theatre.
Users report that gaining access to computers to use PACS can be a challenge on shared hardware as there is not enough hardware for the number of users. One user states that they use PACS (SHO 8) “Wherever I can get a computer.” In terms of computing power, many HPs report a lack of dedicated PACS hardware. Often, they access PACS software on general-purpose desktops that are frequently described as slow and not powerful enough for their needs.
Tasks and Features
HPs report basic navigation and management tasks as being common, such as searching for and opening scans; deleting images if they are not wanted was also referred to, though much less frequently. Deletion of unwanted or flawed imaging is reported as being performed in the radiology department, generally at the time the scan is being performed.
There is a strong emphasis on efficiency; HPs refer to a ‘red dot system’, where images in a sequence are marked with a red dot by the radiologist to identify images of significance, allowing faster identification of key images when reviewing the report. Use of dynamic features to play a sequence of images is also reported.
The lack of online access to scans performed in some hospitals is a clear source of frustration for certain HPs; when a scan is needed in that scenario the imaging and reporting need to be burned to disc, sent to the relevant hospital, and then uploaded into the local PACS. As patients often have differing identifying numbers between hospitals, difficulties are encountered when trying to determine if a patient has had previous scans.
One radiographer notes that sometimes image uploading can go wrong, with images ending up in incorrect locations. Radiographer 5: “Sometimes there’s multiple names or slight changes. Like, we’ll say, into the wrong folders”.
Despite the high level of functionality that PACS offers, it is reported that “for the most part [it’s] basic functions, basic functions”(PC 1). Many HPs report using very limited subsets of PACS features. HPs from the radiology department report using a wider range of PACS features.
Across the interview process it became clear that various feature sets are shared by HPs in the same role. Further, it is clear that the feature set someone would use can change if they change role, e.g., one HP reported previously using inverting a lot in a different role, but now not using the feature at all.
Measurement is one feature where HPs either report having no use for the feature, or having significant use for it. Not all measurement occurs on PACS itself, with some being performed directly on the scanner before the imaging is added to PACS. The need to perform a measurement can be situational, depending on the information a scan contains.
Use of the PACS suite in multidisciplinary team meetings
Several HPs referred to multidisciplinary meetings (MDTs), and reported that a more extensive range of tools is employed during those meetings. It is during the multidisciplinary meetings that various specialties come together to plan treatment for a patient . Medical imaging is a key tool in the MDT that allows the clinicians to leverage their expertise, resulting in more informed diagnosis.
SHO 1: “So obviously PACS is a pivotal part of that meeting. It’s loaded up on a big screen and everybody is looking at it, things are being measured, we’re looking for lymph nodes, things like that. But it’s the radiologist that’s operating, we’re all just viewing.”
PACS as a tool to enhance imaging during post-processing
HPs report that they need to adjust the contrast of scans when the scan exposure is less than ideal, with a number of reasons being cited.
HPs note that human error, differences between the image displayed on the scanner versus the image that is saved to PACS, or even the patient’s physical size can impact on the exposure of a scan being not quite right. In these scenarios, adjusting the contrast allows the HP to better interpret the scan. Some HPs note that they perform this contrast adjustment directly on the scanner before sending the image to PACS.
Zooming is relatively commonly reported as being useful, especially for investigating subtle features such as certain fractures. Usage of inverting (flipping black to white, and white to black) is heavily task related, e.g., chest X-rays are frequently inverted, while other forms of imaging are not. Inverting is described as very helpful for appropriate uses.
Labelling and Annotating
Labelling and annotating are not commonly reported as being used. One HP notes that annotating can be used to record information that would otherwise be lost, such as the state of the patient during the scan, e.g., if the patient was in a state of expiration (breathed out). Such annotations allow HPs to understand and make allowances for potential shortcomings in the imaging.
Radiation Safety Officer: “might not be evident on the x-ray. You just write the patient was expiration.”
One HP reports that sometimes the emergency department would order scans but then not collect the scan. Every scan must be viewed by the person who ordered the scan, and must be recorded as having been viewed. If a scan is not viewed by the ordering clinician, additional workload is created for other members of staff in resolving this issue. This can arise due to issues with the structure of the organization or in errors entering the ordering clinician. SHO 9: “Sometimes the primary consultant is incorrect. So, scans that are ordered get attributed to the wrong department.”
Of note is the reported simplicity of the average clinician’s PACS workflow. Though PACS supports a wide range of functions, the vast majority of interactions will only use a small portion of those functions. This large feature set is reported as having led to difficulties using PACS, with HPs reporting a desire for simplification of the user interface.
SREG4: “We’re just trying to log in, find the patient, look at a report, look at an image. Having two dozen different options in not really useful for most of us.”
PACS is Often used in Busy Environments
HPs report that they frequently use PACS in busy environments with high levels of noise and human traffic. Further, it is reported that multiple people would be performing the same role on a given day, sharing the PACS between multiple HPs (with each HP having their own login). HPs note that rather than there being a lack of space, there is an abundance of people.
PACS as a Part of the Operating Theatre Workflow
In the context of the operating theatre, it is noted that there is a circulating scrub nurse who can be directed to use PACS. However, it is also noted that this is very inefficient and inconvenient as often the user being instructed may not be familiar with PACS and may not fully grasp the intent of the surgeon.
SHO 1: “It’s such a pain to try and direct a circulating scrub nurse on how to get to the exact point, scroll to the exact slice that you want.”
The Impact of Clinical Governance and Data Protection on HPs’ use of PACS
It is reported that there is a workflow/clinical governance balance that must be maintained. In order to protect patient information, PACS systems log the user out after a period of inactivity. Some HPs report this period as being as short as 5 minutes. All PACS logout automatically, including PACS in the operating theatre. HPs report that in the operating theatre the mouse needs to be ‘jiggled’ periodically by an unscrubbed staff member to keep the system awake. If the system goes to sleep it will log out, and then the correct login details will need to be entered and the system logged back in. In the context of the operating theater, it is noted that this involves an additional staff member knowing the clinicians log in details. After logging back in, the correct image needs to be navigated to and displayed correctly. HPs describe this as being a significant frustration.
SHO 8: “That’s really frustrating because we’ll have the imaging up, everything logged in and on the image that we want, and then as soon as the computer goes to sleep it logs out.”
Some HPs report that the PACS they have access to do not allow multiple simultaneous windows. Similarly, it is reported that switching patients, and between RIS and PACS for the same patient would completely close one application in order to open the other. This is deemed to be very frustrating for the HPs. The lack of system integration can have a significant impact on user efficiency as, in order to move between different functionalities, they must sacrifice their existing progress through the interface.
CS 1: “...you have their information up in the RIS and you’re like ‘oh God, did they have a scan?’, you have to go to click on the imaging part, and it closes that down completely. It doesn’t even minimise the window, it actually just closes it.”
PACS in the WHO Surgical Safety Checklist
In the context of the operating theatre, there is a specific WHO checklist that aims to decrease errors and adverse events . It defines the workflow for multiple stages of a surgery, including ensuring that essential imaging is displayed, and thus PACS plays an important role in the checklist.
Performance Issues and Their Impact on User Attitudes
While not universal, many HPs report various performance issues when using PACS. The number one complaint is speed, with many HPs reporting that PACS would run very slowly, with an adverse impact on their workflow, both from the delay, and from creating a reluctance to look at imaging.
SREG4: “Everyone should be looking at the images ...but we are discouraged from doing that because the system is so incredibly slow.”
Perceived Shortcomings in Training in PACS
A significant majority of HPs report having never received any formal training in PACS, with most learning by observing their colleagues. Many HPs report a lack of understanding of PACS, saying that there are features of the software that they do not know how to use and therefore simply ignore.
Intern 3: “Pretty much all of my PACS knowledge is self-taught, or like is taught by someone else on the go. I feel like I could function more quickly and efficiently if I had had more formal training.”
One HP reports that though PACS training is available, most people do not take advantage of the training. It should be noted that many HPs are unaware of any available training.
SREG 2: “I think people don’t possibly take those opportunities up because they’re like ‘oh, I’ve used that before’ ...So I think that perhaps it’s not that there isn’t access to opportunity in training in PACS but more so that people don’t avail of them properly.”
When asked whether they feel that training would be beneficial, most HPs respond in the affirmative, though a small minority say they do not think that training would be beneficial, or would only be beneficial for more junior staff. Some HPs suggest that a basic level of training should be provided when first being introduced to a hospital’s PACS, with further, more advanced, training being provided some time after (between a month and a year). Some HPs suggest that short refresher courses would also be beneficial.
SHO3: “...you don’t really understand what you’re going to be doing, and then it would probably be good to train you in your first week and then maybe after a month to touch base with people again.”
It is reported that the scope of PACS software can make it difficult to learn in a single training session. HPs expressed a strong appetite for ongoing microlearning.
CR2: “But you know you bombarded at the beginning, it can do this this this and you’re only going to retain a very small amount of it. To be honest what you’re trying to do is the very basics, how do I call up the image and how do I report. But there are lots of other things you can do that most of us never use because you know you might be told on the first day but that’s no good. You really need to kind of to be retrained on it.”
It is suggested that PACS training could be incorporated as a component of other forms of training.
SHO3: “maybe as part of the surgical training or the medical training.”
Due to the fundamental nature of PACS, it is also suggested that PACS should be sufficiently intuitive as to not require face-to-face training. Instead, the majority of functions should be intuitive to use, with more advanced features available in additional views.
SREG4: “It shouldn’t really be required. So, a PACS system is so fundamental that training should either be able to be almost non-existent, then it’s so straightforward as you’re logging in for the first time, that your training is like a tutorial when you open up a new app on your phone.”
The Impact of Poor User Interface Design on User Understanding of the Software
Many HPs express a feeling that they lacked a proper understanding of PACS, opining that with a greater understanding they would be more efficient in using PACS, and would be able to leverage a greater number of tools to achieve more. This lack of understanding is attributed to a combination of an unfriendly user interface and a lack of training. HPs confirm that they would be more likely to use PACS if they feel more familiar with it.
HPs report that PACS is unclear and unintuitive to use, suffering from complex UI and poor UX. Even basic and essential features such as comparing images are described as being difficult to use, with this difficulty being attributed to a lack of understanding of the software. HPs report adopting manual solutions that lack the efficiency of built-in tools to get around their difficulties in using PACS.
Touchless Interaction and Sterility
The Perceived Lack of Importance of Sterility Among PACS Users
A significant majority of HPs report that sterility is not important to them when using PACS. Most HPs state that this is because they would have an opportunity to wash their hands between using PACS and interacting with a patient. Those users with a dedicated workstations (such as radiologists) report that they are not concerned with cross-contamination. CR 2: “No, because essentially it’s my own grime...I don’t tend to use anyone else’s so I’m not worried about that at all.” A few HPs report that as they have no patient interactions, sterility is not a concern, though COVID-19 was cited as being a motivation for an increased awareness of the potential need for sterility.
SREG 6: “In the light of COVID it would be more important, particularly in a hospital that has seen a lot of COVID, and the terminals are almost never wiped down.”
HPs who use PACS in the operating theatre report that sterility is important to them in that context especially.
User Attitudes to the Potential of Touchless Interaction with PACS
Most HPs react positively to the idea of touchless interaction with PACS being available. In particular, HPs are easily able to visualize using voice-controlled shortcuts to speed up their workflow. HPs note that many tasks in PACS take a large number of clicks to achieve, with each click potentially taking a long time, and minimizing clicks is seen as an important requirement.
HPs also express positivity toward the idea of using a touchless system during aseptic procedures, or at times when the HPs hands might be busy. It is clear that, while touchless interaction might not be ideal for all environments in a hospital, there are a number of situations where the idea of access to touchless interaction of PACS is very appealing for HPs.
SHO 2: “I suppose if the technology was there it would be fine. You’d just need to make sure the theatres would just have to be set up properly so that there’s actually room for someone to move and make gestures, cause often theatres can be so tightly packed surrounding the computer that it would be hard to maintain sterility and perform gestures.”
Social context is also seen as affecting the acceptability of voice and gesture-based interfaces. PC 1: “In the operating room we also work with head gestures like nodding and things like that. It was just, you look almost stupid. So people would make fun of you.”
PACS and Touchless Interaction in the Operating Theatre
HPs report that PACS use in the operating theater is not a given, but rather is situation dependent. HPs note that when PACS is used in theatre it is very important. The operation is planned around a few key image(s), which are displayed from the start until the end of the operation. HPs in our sample reported that any interaction with PACS during a procedure is generally unplanned, with all imaging having been reviewed in advance of the operation.
SREG 1: “Typically you’d have a screen up in theatre and you’d have one key image up that you’re interested in. ...Then you can plan around it, just to refer back to just so you can know if your screws are in the correct orientation or something like that.”
HPs react favourably to the idea of touchless interaction with PACS in the operating theater. Currently, to directly interact with PACS the clinician needs to unscrub, interact with PACS, and then rescrub, which can be a time-consuming process. Alternatively, the clinician can direct another member of staff to interact with PACS on their behalf. SHO 3: “It would be really nice to be able to control the images yourself while you’re scrubbed in theatre wearing your gloves and your mask and not having to ask a nurse, a scrub nurse, ’scroll up, scroll down, go back, go this’.”
HPs report that they would be happy to adopt a robust touchless system, especially in a scrubbed environment, noting that voice dictation has already been successfully adopted in their hospitals.
The Preference of HPs for Voice Control
Many HPs express an interest in being able to use voice control to interact with PACS. Many people can visualize themselves leveraging voice commands to accelerate their workflow. Voice dictation is already commonplace in hospitals, so the use of voice as an interaction method is already commonplace. Gesture interaction by contrast is harder for people to visualize themselves using. Gesture-based interactions are not currently used in hospitals, resulting in a greater learning curve for gesture as compared to voice control.
SHO 11: “I don’t think there would be a downside...for me if you pull up simple commands, for example when comparing chest x-rays, if you have a command like ‘show me the [unclear] x-ray of the chest’, I mean that would be so useful rather than trying to trawl through all the investigations and find the last one.”
HPs report that they would be happy with some specific training for voice control if it improves performance. CS 1: “If you are trained to use specific words, or if you have to put it in chart number this and then it recognises that you’re searching for a patient.”
Based on feedback from HPs, there exists a desire for effective shortcuts within PACS. Many HPs express a desire to issue commands such as ‘display all images for patient X’. Aside from the convenience of being a verbal command, the greatest benefit of this instruction is that it reduces the complexity of performing the task, combining several actions into one.
Several HPs raised a potential issue regarding noise levels and the feasibility of voice control in the operating theatre. There can be many people talking at once, and in some scenarios music playing too. They assert that a voice control system would need to be very robust to background noise to be of use in a real-world environment. SHO 8: “It’s very noisy. And there’s always beeps and machines going, and a lot of people talking. So it would need to account for that....If we need to use it while we’re scrubbed, it tends to be, you know, an unplanned use.”
One other potential issue for voice control is data protection and privacy. While this issue is only raised by PC 1, with regulations such as GDPR protecting data privacy within the EU, any touchless technology needs to designed in such a way as to properly protect patient information.
PC 1: “Sometimes, for example, voice interface there can be a little privacy issues where you need to be aware of your surroundings. You may not want to give information that you could otherwise just type.”
Adoption of PACS Technologies
Overall, HPs express a positive attitude to adopting a touchless PACS. One HP asserts that new technologies in the hospital are often adopted from the bottom up, with junior doctors trying the technology first and word of the technology trickling up through the ranks until either the technology is adopted or fails to gain traction.
Intern 2: “You’ll have people starting to use it in the hospital and buy in from a couple of people, then that gets around...Generally it’ll be more junior doctors and if they find that it’s more efficient that’ll catch on ...If you had a negative experience the first time you might be less inclined to try it again, but if you had feedback from other people that it was very easy to use that would change your practice.”
A negative attitude is expressed by some HPs towards the adoption of touchless PACS, reporting that if there is not a clear benefit to their day to day work, then they would be unlikely to adopt the technology.
Some HPs note that they would like to have the option of both touchless interaction and conventional interaction methods, at least initially. It is noted that for seated interaction with PACS, touchless interactions such as gestures would be unlikely to be used due to the convenience of the mouse and keyboard. However, combining voice control and mouse and keyboard is suggested as being a beneficial combination as regards workflow efficiency.
The Central role of Radiology Reports in the Clinical Workflow
HPs in Ireland report the implementation of a nationwide system, National Integrated Medical Imaging System (NIMIS) that exists alongside PACS; NIMIS has come to replace a number of the functions of previous PACS setups, most notably the reporting element.
Although the content of the imaging is considered important, HPs note that often the report is of greater importance than the imaging, with some saying that they would only open the scans if they need to check something in the report. As the report is considered the authoritative interpretation of the scan, more junior HPs in particular report a preference for relying on the report rather than trying to interpret the scan themselves.
HPs report that all scans are officially interpreted by radiologists, with results being available to view generally by the next day. Many HPs report that, in the interest of speed, for more simple scans, such as chest X-rays, they would often make an initial assessment of the scan before the radiologist report is available. HPs note that often time is of the essence, and there is an emphasis placed on getting through as many patients as possible.
Integration of PACS with Other Systems
While there has been progress toward greater levels of integration between PACS and other EHR systems, HPs report that there are still significant shortcomings in this area. HPs note that this reduces their ability to carry skills between hospitals, often having to learn how to use unfamiliar software to perform familiar tasks.
SREG4: “Once you’re in the PACS, even you’re using an EHR, they tend not to be well integrated ...Even in private hospitals, which have relatively well integrated electronic records, the PACS tends not to work with it.”
HPs note that they tend to move between solutions based on the strengths of each system, e.g., between PACS and NIMIS.