Controlled Document Word Template€¦ · Web view2003/07/03 · V3.0 29/03/06 Revised following review with PACS technical team and further input from Diagnostics Branch V3.1 31/03/06

Vision for future developmentProgramme NPfIT DOCUMENT NUMBERSub-Prog/Project PACS National

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Group Prog. DirectorNat Impl Director

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KM NPFIT PACS PMGPACS Prog. Director

MJ

Author KM/DJ/ED Version No 3.2NPO/PSO Contact Status Final Draft

Picture Archiving and Communications System (PACS)

Vision for future development of PACS and RIS

National Clinical Reference Panel

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Version Date Amendment HistoryV 1.2 26/09/05 First draft for comment by PACS TeamV 1.3 14/10/05 Draft revisions KM/EDV 1.4 - 5 24 & 25/10/05 Draft revisions by KM/DJV 1.6 - 8 15, 18 &

25/11/05Draft revisions and additions by KM

V 1.9 28/11/05 Additions by DJV 2.0 30/12/05 Major redraft by KM, taking account of stakeholder

commentsV 2.1 09/01/06 Further content addedV2.2 10/01/06 Section 2.2 revisedV2.3 12/01/06 Content addedV2.4 16/01/06 Initial QA comments included. Content added. Issued as

first draft for DH reviewV2.5 20/01/06 Revisions by KM on behalf ED

Technology assessment moved to Appendix BV2.6 28/03/06 Revisions by KM following feedback from stakeholders

including Physiological Measurement GroupV3.0 29/03/06 Revised following review with PACS technical team and

further input from Diagnostics Branch V3.1 31/03/06 Minor revisions following review by ED and NCRP 30/3/06V3.2 Final Draft 25/04/06 Final additions of CRP list and K&M diagram

ApprovalsThis document to be approved by:

Name Signature Title Date of Issue VersionErika Denton National Clinical

Lead for Imaging; Joint Chair PACS NCRP

Michael Thick Joint Chair PACS NCRP

Kathy Mason National Implementation Director

Max Jones PACS Programme Director

This is a controlled document.

To be reviewed by:The PACS National Clinical Reference PanelPACS Connecting for Health Technical Team

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Table of Contents1. INTRODUCTION............................................................................................................................4

1.1 PURPOSE OF THIS DOCUMENT.................................................................................................41.2 BACKGROUND.........................................................................................................................41.3 SUMMARY OF REVIEW APPROACH..........................................................................................4

2. OVERVIEW OF DEVELOPMENT STRATEGY FOR DIAGNOSTIC IMAGING.............6

2.1 POLICY DRIVERS.....................................................................................................................62.1.1. System reform....................................................................................................................62.1.2. Patient Led NHS...............................................................................................................62.1.3. Patient choice....................................................................................................................72.1.4. Workforce reform and service redesign...........................................................................72.1.5. Organisational change, commissioning a patient-led NHS............................................82.1.6. Integrated Service Improvement Programme (ISIP)......................................................82.1.7. Financial reform, Payment by Results.............................................................................8

2.2 VISION FOR DIAGNOSTIC IMAGING SERVICES.........................................................................82.2.1. Information Vision for Diagnostic Services..................................................................12

3. MEETING THE VISION............................................................................................................13

3.1 VISION ENABLERS.................................................................................................................133.1.1. Imaging workforce modernisation.................................................................................143.1.2. Independent sector capacity............................................................................................143.1.3. Technology solutions......................................................................................................143.1.3.1. PACS solutions...........................................................................................................143.1.3.2. Clinical Information Systems....................................................................................153.1.3.3. Medical Devices (Modalities).....................................................................................163.1.4. Service Transformation..................................................................................................16

4. CONCLUSIONS...........................................................................................................................18

4.1 PROLIFERATION OF MEDICAL DEVICES..................................................................................194.2 IMAGE VOLUMES...................................................................................................................204.3 IMAGE TRAFFIC.....................................................................................................................224.4 INFORMATION GOVERNANCE ISSUES....................................................................................224.5 STANDARD NATIONAL CODING AND REPORTING REQUIREMENTS.......................................224.6 SERVICE TRANSFORMATION IMPACTS...................................................................................234.7 INTEGRATION WITH OTHER NPFIT APPLICATIONS................................................................234.8 INDEPENDENT SECTOR INTERDEPENDENCIES........................................................................244.9 NON-NHS CFH PACS SOLUTIONS.......................................................................................244.10 NON RADIOLOGICAL IMAGING INFORMATION SYSTEMS........................................................254.11 BROADENING PACS ACCESS................................................................................................25

APPENDIX A: NATIONAL PACS CLINICAL REFERENCE PANEL MEMBERSHIP............26

APPENDIX B: INITIAL ASSESSMENT OF TECHNOLOGY SOLUTIONS BY SERVICE .........

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PACS Programme: NCRP Vision for future development

1. Introduction1.1Purpose of this DocumentThis document aims to set out the vision and next steps in the ongoing development

of PACS to support the wider strategy for diagnostic imaging across the NHS.

1.2BackgroundAs part of the process that underpinned the decision to proceed with the procurement

of PACS systems as part of the implementation of the National Programme for IT

(NPfIT), a PACS Programme Strategy was developed in December 2003. This was

later reflected in the Programme Initiation Document, finalised in January 20051. The

PACS Programme, in the light of emerging policy and strategy for the development of

diagnostic imaging services in the NHS and the progress with implementation to

date, has identified the need to review these original strategic plans for the

procurement and ongoing development of PACS for the NHS.

1.3Summary of Review ApproachTo commence this review, a facilitated workshop was held with members of the

PACS National Clinical Reference Panel (NCRP) on 31 August 2005. A list of

members of the NCRP is included at Appendix A. This identified the key clinical and

service issues that PACS needs to support in the future.

This document forms the second element of the review; taking the development

strategy for diagnostic imaging and assessing any potential gaps in the current

provision and plans for PACS (and where relevant other national enabling initiatives).

The third element, planned to occur following release of this document, is further

analysis by technical and commercial members of the NHS Connecting for Health

(NHS CfH) PACS central team to provide an action plan for which issues will be

resolved through the NHS CfH contracts and to identify any issues which are beyond

the scope of NHS CfH to resolve.

Following this, an assessment will be made by the PACS NCRP and the National

Diagnostic Imaging Board to recommend any further work to enable delivery of the

diagnostic imaging strategy for the NHS. The three other DH Diagnostics Steering 1 Picture Archive and Communications System (PACS) Programme Initiation Document, version 2.0 Final, 07/01/05, Connecting for Health Programme Office, doc number: NPFIT/PAC/PMG/GOV/0001.

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Groups, Endoscopy; Pathology and Physiological Measurement, will also be

consulted, along with the 18 weeks programme.

The timeline for this Strategy Review process is:

1) NCRP Strategy Review Launch Workshop – August 2005

2) Review and discussion with key stakeholders – Sept 05 – March 06

(Including the National Imaging Forum in April 2006)

3) Vision Document approved by NCRP – April 2006

4) NHS CfH PACS Development Roadmap – April – June 2006

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2. Overview of Development Strategy for Diagnostic Imaging

Diagnostic imaging is an essential part of the care pathway for a large proportion of

patient care.

It is provided in diverse locations and has to be ‘on-demand’, since further care is

often very dependent on the findings of the diagnostics undertaken. The demand for

diagnostic images, in terms of volume and image diversity, is increasing year on year

and is expected to continue as such.

Many stakeholders rely on diagnostic images, often needing information remote from

the image source and over different time periods.

Technology advances in image acquisition, storage and analysis have changed the

way in which this service operates and is used over the last two decades. The

technology advance is expected to continue over the next decade, thereby further

improving efficiency, value and quality.

2.1Policy Drivers

There are a number of policy drivers directly relevant to diagnostic imaging and

others where diagnostic imaging plays an important role in their wider achievement.

Relevant policy drivers are summarised here:

2.1.1. System reform System reform represents a group of interconnected policies that aim to support the

transformation of the NHS to a system that is truly patient-led. They will give patients

more choice, more personalised care and real control to improve their own health.

Most recently the Primary Care White Paper: Our Health, Our Care, Our Say.2

2.1.2. Patient Led NHSIn March 2005 the Department of Health’s ‘Creating a Patient-led NHS – Delivering

the NHS Improvement Plan’3, set out the next steps in delivery of the NHS

Improvement Plan focusing on the system reform required to put patients at the

centre of care delivery.

2 http://www.dh.gov.uk/ourhealthourcareoursay/3 Creating a Patient-led NHS – Delivering the NHS Improvement Plan; DoH, 17 March 2005.

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Service models will be developed to give patients more choice, control and improved

access. Integrated patient pathways will follow the patient’s journey; ensuring

services are designed and delivered around the patient. Diagnostic imaging is a key

component in a very high proportion of such patient pathways and work is in hand to

develop much more flexible and accessible services across the country. There is

also an increasing move towards use of diagnostics in screening services and early

diagnosis in priority pathways such as cancer and CHD, contributing to better health

promotion, protection and improvement.

Diagnostics is identified as one of the five key targets set for the NHS to enable

delivery of the overall system reform. The other four key target areas are:

18 week waiting targets4

Health improvement

Long term conditions

Unscheduled care

Clearly, improved diagnostic services will also impact on the other target areas

2.1.3. Patient choice Patient choice is at the core of the governments’ current policy, this is reflected in the

current targets that are being implemented to give patients a choice. Of particular

relevance to this review is the ‘choice of scan’ target.5

2.1.4. Workforce reform and service redesignEffective implementation of Agenda for Change6, the new consultants’ contract7 and

realising the benefits in terms of a workforce appropriately skilled and available to

deliver the health service of the future is a key factor in achieving these changes.

The appropriate and effective use of extended roles is another aspect of workforce

reform that has been identified as one of the Modernisation Agency’s Ten High

Impact Changes8.

4 http://www.18weeks.nhs.uk/public/default.aspx5 http//www.18weeks.nhs.uk/documents/Choice_of_scan.pdf6http://www.dh.gov.uk/PolicyAndGuidance/HumanResourcesAndTraining/ModernisingPay/fs/en7 as above8 http://www.wise.nhs.uk/cmsWISE/HIC/HIC+Intro.htm

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2.1.5. Organisational change, commissioning a patient-led NHSThe planned organisational changes for Strategic Health Authorities, Primary Care

Trusts and the inclusion of private healthcare providers in the ongoing provision of

NHS services to patients must not constrain patient choice or access to services. It

is also essential that future service transformation in the NHS is coordinated across

providers to provide seamless and cost effective services.

2.1.6. Integrated Service Improvement Programme (ISIP)The Integrated Service Improvement Programme (ISIP)9 is a national initiative

enabling health economy-wide service transformation with consistent, transparent

and comparable measures across the whole of the NHS. For diagnostic imaging

services spread over a large number of organisations, this planning regime will be

essential to focus scare resources and make best use of capital investment.

2.1.7. Financial reform, Payment by ResultsIn future, all services, including diagnostic imaging will need to be able to be

identified and accurately costed in line with standard national tariffs in order to

support the new financial regime, where services will be invoiced to commissioners

on the basis of activity.

This approach is being supported by the development of standard national coding for

all diagnostic imaging interventions and activities to enable compilation of invoices

based on activity.

2.2Vision for Diagnostic Imaging Services

The delivery of diagnostic imaging services across the NHS is a wide ranging and

complex challenge. The vision is described below, grouped within a number of

change areas.

Access

It is planned that, patients will not wait longer than six weeks for any imaging

and in many cases this will be available on demand in order to deliver this

target of maximum waiting times for treatment overall of 18 weeks, from GP

9 See ISIP website: http://www.isip.nhs.uk/

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referral to hospital treatment. This is a psa target to achievable by December

200810.

To achieve this target will require redesign of the referral pathways and

protocols, including increased and earlier use of diagnostics imaging. It is

also likely to include direct access to imaging services from primary care.

Availability

Different delivery models, where services are provided in different

environments such as one stop diagnostic and treatment centres and walk in

centres, tailored to local health community needs.

Further development of specialist clinical networks, such as those currently in

place for cancer, CHD and emergency care.

More centralised diagnostic imaging reporting services, able to provide

services to a wide health community 24 hours a day 7 days a week. Such

models will maximise the benefits from capital equipment and enable greater

flexibility of the imaging workforce.

There will be plurality and contestability of the provision of imaging services,

which will be delivered through a combination of NHS and independent sector

provision.

Choice

Patients will be offered a choice of time and place for their diagnostic imaging.

Scope of diagnostic services

The following have been identified by the PACS National Clinical Reference

Panel for inclusion within the vision scope:

o Diagnostic Imaging

Angiography inc cardiology

Breast screening

CT

Dental imaging

10 ‘Commissioning an 18 week patient pathway, Proposed Principles and definitions: Discussion document’, DH October 2005.

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DEXA

Fluoroscopy

MRI

Nuclear medicine

PET

Plain film radiography

Radiotherapy

Symptomatic mammography

Thermography

Ultrasound

o Pathology

Cytology

Haematology

Histology

Microbiology

Pathology

Virology

o Endoscopy (including gastro and intestinal)

o Physiological measurement

Dermatology

ECG waveforms

Echo cardiography

Electrophysiological measurement

Endoscopy (other, eg. Laproscopy)

Medical photography

Ophthalmology

Clinical Standards

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All services commissioned by the NHS will be delivered to the same

comprehensive framework of national standards that encompasses all

providers, both public and independent sector.

Professional training will be carried out in line with DH policy and

recommendations made by the Royal Colleges and other appropriate bodies.

Diagnostic imaging services will be delivered in line with best practice as

advised by the Royal Colleges and other appropriate bodies. This will include

policy on National retention of appropriate images.

Technology and information

PACS solutions are central to the delivery of the vision for diagnostic imaging,

supporting the development and improvement of clinical practice. Current

and future generations of medical devices and associated peripherals that are

required to capture and translate diagnostic images and associated data will

also form the basis of delivery of this vision.

This will include:

o A transition towards Direct Digital Radiology

o Increased use of imaging as an interventional treatment, eg. Stroke

and other image guided therapies,

o Non-invasive autopsy

o Use of enhanced modalities such as:

Multislice Computerised Tomography (CT)

Positron Electron Tomography (PET) scanning

Diagnostic images and reports will be available as clinically required,

accessible as part of a national care record for every patient. This will be

securely accessible to relevant clinicians and other healthcare professional

requiring it to support delivery of healthcare, 24 hours a day, 7 days a week.

Information on wider care issues, pathways and protocols, relating to diagnostic

imaging will be made available through the National Knowledge Service, providing

robust evidence-based information for clinicians.

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PACS will also need to be developed in the context of the implementation of the

Map of Medicine.

The development of PACS will be in the context of the commitment to meet the

Care Record Guarantee in respect of security and confidentiality of patient

information.

2.2.1. Information Vision for Diagnostic ServicesFor the purposes of this document, we have focused on the information aspect of the

overall service vision. The ‘information vision’ for diagnostic imaging for the NHS is

“to have relevant diagnostic images and associated data

available and useable in a timely manner at the point of care for all

clinicians, irrespective of the location and timing of the care being

provided. This would apply to any aspect of care delivery

requiring images and associated data and would integrate

relevant diagnostic images and data seamlessly with wider

pertinent clinical information.

Further, to have relevant diagnostic images and associated data

securely available and useable for all clinicians as appropriate and

relevant to support service improvements in care delivery, service

planning, research or education.”

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3. Meeting the vision

3.1Vision enablers

To achieve the service vision set out above will require comprehensive development

of a range of enabling elements, which are being driven and overseen by the

Diagnostics Branch of the Department of Health. Diagnostics has been grouped into

four main areas, each with a national steering group led by a national clinical lead:

Endoscopy

Imaging

Pathology

Physiological Measurement

The PACS Programme is already working closely with the National Imaging Board

and the National Clinical Lead for Imaging, formally linking governance arrangements

to ensure effective links and communication.

Links with the other three areas are being established.

Within these arrangements, the key areas for development to enable development

towards the future vision in all four areas include:

Workforce modernisation

Independent Sector capacity

Technology solutions (PACS, related information systems and medical

devices)

Service Transformation

This set of changes will, collectively, support diagnostics services as a seamless

component part of the patient’s pathway from GP referral to delivery of secondary

care, all within the 18 week timeframe.

This document focuses on the technology solutions area. Other areas are

summarised briefly below but are not within the scope of this analysis.

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3.1.1. Imaging workforce modernisationThe Diagnostics Branch of the Department of Health are leading the work, in

partnership with the Workforce Review Team11, to identify and plan for the workforce

requirements of the future to support the delivery of diagnostic services in line with a

patient-led NHS. This incorporates issues such as recruitment/ retention, skill mix,

education and learning.

These changes in workforce are further supported by the establishment of three

National Radiology Academies, which, in addition to addressing shortages in the

radiologist workforce, will train these professionals in line with the new ways of

working including maximising the benefits of PACS and CRS (Care Records Service)

technology as it is deployed across the country.

3.1.2. Independent sector capacity To achieve the goals set by the NHS Plan and subsequent policy and plans, there

was the requirement to increase capacity in key areas, including diagnostic imaging.

This has resulted in the procurement of a first phase of independent sector diagnostic

imaging services for MRI and CT. A second phase encompassing most imaging

modalities is currently being procured.

This procurement from the independent sector has also contributed to the objective

of increasing contestability between providers in the NHS.

3.1.3. Technology solutions

3.1.3.1. PACS solutionsA vision for the implementation and subsequent development of PACS solutions

within the National Programme for IT (NPfIT) was set out in the Programme Initiation

Document (PID)12. This document made it clear that deployment of PACS

technology across the whole of the NHS is seen as a key enabler to the delivery of

diagnostic imaging services in line with the vision and strategic policy context

outlined above.

An overriding objective is to ensure that the right images and related clinical

information is available in the right place at the right time to support patient care.

11 www.healthcareworkforce.org.uk12

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http://www.healthcareworkforce.org.uk/


This will require complete integration of data and functionality across all areas of

healthcare, including primary, community and secondary care.

PACS can already be deployed to achieve filmless radiology departments. The

scope of the current PACS programme has an initial objective to deliver 100% digital

and filmless radiology services in acute Trusts across England by March 2007. To

support progress beyond this the current programme has contracts structured such

that local health communities (LHCs) are able to evolve further, from a single Trust’s

radiology service becoming filmless to the ultimate community-wide PACS

encompassing a number of other diagnostic services that use images of various

kinds, e.g. digital images of microscopic images such as those used in pathology and

services being delivered across a number of provider organisations acting in

collaboration. PACS is intended as the storage and retrieval tool for providing the

complete suite of medical images as part of the Clinical patient record.

PACS solutions have always required the availability of powerful and resilient data

communications networks. At a community level, PACS will require an acceptable

level of both local and wide area networking through N3.

3.1.3.2. Clinical Information SystemsPACS is an excellent storage, retrieval and viewing technology but it relies on other

information systems to process image data and handle image transactions.

Within the present NHS CfH solution, the focus has been on ensuring RIS solutions

and, ultimately, CRS functionality operate seamlessly with the PACS solutions

provided to the NHS. While provision in the contracts has been made for extending

the range of information systems that potentially could connect to PACS solutions,

this is not currently planned for deployment to a specific timeframe. It remains

unclear whether the incorporation of further separate information systems or awaiting

the deployment of CRS functionality to link to PACS solutions is the best route

forward in the short to medium term.

Of equal importance is the relationship of NHS CfH PACS solutions to wider

functionality and information, including:

Choose and Book

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Existing PACS solutions supplied outside of the current programme (including

independent sector provision)

GP systems

Order Communications and Results Reporting

Decision support and the use of protocols

3.1.3.3. Medical Devices (Modalities)The pace of technology change in medical devices relevant to the diagnostic imaging

service is significant. Each year, technology increases the service’s potential to

acquire more images and in ever greater detail.

This growth in digital medical devices will transform the diagnostic imaging service

for the NHS; one impact of this will be the requirement for NHS CfH technology

solutions to cope with increasing volumes of data to be stored.

In relation to PACS solutions, there are two essential elements to be achieved for all

medical devices and modalities; to ensure images are produced to a DICOM

standard and to provide storage and retrieval infrastructure able to handle anticipated

image volumes.

3.1.4. Service TransformationThere are many aspects to service transformation in relation to imaging services.

Services within NHS organisations will benefit from the new investment in

technology, the modernised workforce and the inclusion of the Independent sector in

this service area but only holistic and community-wide service improvement will fully

deliver the government’s transformation agenda and maintain continuous

improvement of services.

The DH has an initiative in place, the Integrated Service Improvement Programme

(ISIP), which is providing a methodology to enable and coordinate local health

economies, including all relevant service partners, to plan service change

collaboratively to optimise efficiency, value and quality.

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One of the leading SHAs in using PACS technology to underpin integrated service

transformation across the local community has identified the following transformation

pathway13.

13 Kent & Medway Strategic Health Authority

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Federation Network Mutual Network Managed Network

Advice and guidance group Some central management of services

All radiology services centrally managed

Sharing best practice Centralised film archives

Central training and educationPooled reportingReporting Centres

Teaching files

During PACS implementation

On completion of implementation

With a matured PACS


4. Conclusions

The next stage of this Strategy refresh process is for the NHS CfH PACS team to

prepare a development roadmap taking account of the vision set out in this report. In

addition, an initial analysis has been prepared of some of the key services using

imaging, Appendix B, and the extent to which current PACS and RIS functionality

supports clinical practice. This analysis uses a red/amber/green rating to indicate the

current state of play. For red items, it is concluded that substantial work needs to be

delivered to improve the current PACS applications to meet the vision. For amber

items, the requirement is to consider these further and determine if they are green or

red.

Overall, a number of emergent general themes requiring resolution are already

evident:

Proliferation of medical devices

Image volumes - retention policy and volume modelling

Image traffic and system performance

Information governance issues

Standard national coding and reporting requirements

Service transformation impacts

Integration with other NPfIT applications in line with clinical and business

priorities

Independent sector interdependencies

Non-NHS CfH NHS PACS solutions

Non radiological imaging information systems

Broadening PACS Access to other clinical services

In taking this agenda forward the following are key stakeholders that will need to be

involved and in some cases, take a lead:

NHS CfH PACS Team, National & Cluster levels

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NHS CfH Other key programmes

NHS CfH Service Implementation Directorate

NHS CfH Information Standards Board

DH Diagnostics Branch

National Imaging Board

Other Diagnostic Steering Groups

Royal Colleges

PPI Representatives

DH ISTC Directorate

ISIP Initiative

DH Medical Devices Directorate

PASA

Monitor

4.1Proliferation of medical devices

It is clear that there are continuing advances taking place in medical imaging devices.

These increase service access to/usage of digital images and/or increase the volume

of digital images acquired.

In planning the original PACS solution, a national stock-take was attempted to

ascertain the extent to which relevant medical devices were already deployed. This

exercise demonstrated that there was insufficient clarity over what was already out

there and deployments are happening all the time.

Further work is required to obtain data on what relevant devices are currently

deployed and an update mechanism put in place to monitor new devices. These

devices often represent a major capital investment by the NHS and need to be fully

utilised. Funding sources are variable, including local charitable donations and

National Lottery funds, so it is not always traceable through normal NHS funding

sources.

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Data recorded needs to take account of what impact any given device might have on

the PACS solution. For example, a new device that is not to a DICOM agreed

standard will require some level of interface device to connect it to the LSP PACS

solution, which may be at additional cost. These costs need to be factored into the

purchase of the device itself.

Recommendation 1: That a review is completed using already established data flows if possible, to estimate the current and future size of increased image volumes arising from this source.

Recommendation 2: That guidance is developed and issued to Trusts procuring devices to highlight the need to ensure data standards are met and that increases in image volumes is factored into business cases for such devices.

4.2Image volumes

Image volumes are certain to rise over time due to the advances in acquisition

technology and in the innovative use of this technology by clinicians as well as by the

national roll out of PACS solutions to the NHS. This is a desired state; the

investment made in PACS solutions and supporting technologies needs to be fully

utilised by the NHS. However, the consequences of this growth are based on

estimates derived from historical data.

The planning assumptions made for image storage in the original contract for LSP

PACS solutions took a baseline position from DH statistical returns (based primarily

on radiological image data) and extrapolated this based on extending PACS across

all of England, retaining every image that was created and a 12% per annum

compound growth rate in image creation. These assumptions did not take into

account i) image data from non-radiological sources and ii) adopting a policy of

selective image retention.

Given the bulk of images acquired at present (in storage capacity terms) are

Radiological images and growth was factored for 10 years (the life of the contract)

there is plenty of capacity for the short and medium term at least. Another

assumption made at the time of contract was that storage technology would continue

to reduce in price and improve in efficiency. This is still valid; however the LSPs are

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still costing additional storage at high rates by taking onto account peripheral

resources (servers, manpower, networks, back ups, etc). This means that the initial

strategy of simply buying more storage as we need it may not now be the best

approach.

We do know the prices to be charged for additional storage but there are two other

areas where further analysis is required to inform decision making; volume modelling

and image retention.

Volume modelling – It is not clear at this time what impact all the different service

users will have on image storage capacity needs over time. Each clinical specialty

(or in some cases sub-speciality) has different variables in the areas of image

volumes, image size and breadth of need for service access. The first two areas

directly relate to storage issues, while all three have a potential impact on image

traffic and therefore solution and infrastructure performance. Further work is required

to model each of the proposed service users of PACS solutions and consider what

storage issues could be involved over the contract term.

Image retention – The architecture for LSP PAS solutions currently allows for every

image to be retained online, but this is at a considerable cost. However, work in

Scotland has demonstrated that it is not necessary for every image to be retained

and that PACS solutions have the capability (through rules engines) to keep or

remove images based on user rules. To keep every image acquired in case it might

be needed and deploy infrastructure to store, move and access all these images may

be cost prohibitive and creates a storage legacy cost that lasts far beyond the LSP

contract term. Further work is required to assess the legal and clinical reasons for

retaining images and the timescale involved for their retention. This has two sub

strands to explore; what image data is not required at all to be stored on PACS

solutions, for example a whole cardiology video or a the full set of slices from a CT

body scan as opposed to selecting the images of interest and ignoring the rest, and

what image data is stored on PACS solutions and for how long.

Recommendation 3: That work is undertaken to clarify and prepare guidance on image retention policies, in conjunction with the Royal Colleges

Recommendation 4: That estimates are updates and commercial options reviewed for most cost efficient methods of storage

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Recommendation 5: That Business Case guidance for PACS is updated to reflect the findings of 3 and 4 above, to support business cases for current and future implementations and upgrades.

4.3Image traffic

LSP PACS solutions are presently architected to handle PACS traffic based on the

historical data about image volumes NHS CfH supplied. While the contracts oblige

the LSPs to deploy scalable solutions, there will be physical limits on how much

image traffic can be coped with by LSP PACS solutions.

The volume modelling work and the image retention analysis are both necessary to

fully understand this issue. Following results from these two areas, further work is

required to assess the implications on N3 and PACS technical architectures to

ensure service performance is maintained.

Recommendation 6: That the capacity of N3, both within Trusts and between Trusts and the Cluster Stores and the Spine are reviewed in the light of updated information on image volumes and traffic in the future and recommendations prepared for the most cost efficient and effective procurement of any additional capacity identified.

4.4Information Governance Issues

As one of the vanguard applications to be implemented within the NPfIT, the PACS

deployments are having to deal with information governance issues ahead of the

strategic planned solutions, such as smart card access control and legitimate

relationships, that have been developed to ensure appropriate access taking account

of patient confidentiality. This has resulted in the requirement for acceptable

pragmatic tactical solutions in the interim.

Recommendation 7: That the NHS CfH Information Standards Board reviews these interim solutions and that worthwhile lessons learned are shared across the PACS and other Programmes and effectively communicated to the service.

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4.5Standard National Coding and Reporting Requirements

The implementation of a national system clearly requires coherent and consistent

coding for the effective sharing of images and related information for activity and

financial reporting. Work is well underway on this aspect of the programme.

Recommendation 8: That the PACS Programme continues to coordinate and support effective and integrated development of coding and reporting requirements.

4.6Service transformation impacts

The delivery of modernised diagnostic imaging services requires a holistic approach

bringing changes in workforce, process, technology and organisation together.

Current deployment plans for NHS CfH PACS solutions mostly consider architectures

where each acute hospital is a ‘hub’ (containing the main PACS components) with

other smaller service outlets stretching from each hub, for example a health centre or

community hospital.

However, initiatives like the DH-sponsored Integrated Service Improvement

Programme are highlighting the need for diagnostic imaging services to be

transformed at a local health economy level. Such change may result in a disparity

between what PACS solutions, supporting technology infrastructure and medical

imaging devices are planned for individual hospitals and what is the optimal

arrangement for the health economy.

Further work is required to analyse the plans emerging from ISIP, the local

aspirations of NHS organisations and the current PACS deployment plans to ensure

that changes are factored in to LSP deployment arrangements over the next two

years.

Recommendation 9: That the PACS team collaborate with the ISIP team and RSU to map the service improvements that are planned that will require additional PACS services beyond the core deployments and ensure that the commercial framework can accommodate them in the most cost effective and efficient way

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4.7Integration with other NPfIT applications

Clearly this will already be a factor within the NPfIT planning process, however as the

different aspects of overall programme are subject to inevitable replanning and

reprioritising the PACS Programme will need to ensure that the clinical and business

priorities of diagnostic imaging services and their development programmes are

appropriately taken account of.

Recommendation 10: That the PACS Programme continues to coordinate and support effective and integrated development of integration requirements and priorities.

4.8Independent sector interdependencies

The independent sector is increasingly being used to support diagnostic imaging

service provision to the NHS. This means that even more digital images are being

created as part of care delivery.

The NHS CfH contracts will deliver PACS solutions to support those NHS

organisations taking the solution but private sector providers are not covered by

these contracts. It is possible that private sector providers have made their own

arrangements for the acquisition, storage and access to digital images created

through their own business units.

Further work is required to understand i) what arrangements private sector providers

have made for digital images, ii) how these are shared with the NHS and iii) how the

NHS will share its images with the independent sector.

Recommendation 11: That the PACS Team collaborate with the IS Procurement Team to review the requirements for enabling images captured by independent providers to be transferred into the cluster stores

4.9Non-NHS CfH PACS solutions

There are a number of PACS solutions (35+) currently operating the NHS that are not

part of the NHS CfH contracts. These are either i) legacy PACS solutions that were

in place prior to NHS CfH contracts being agreed or ii) PACS solutions procured by

NHS Foundation Trusts in the last three years from suppliers outside of NHS CfH

contracts. All these solutions are expected to link in with the Cluster data stores.

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However, no plans have been finalised to ensure local service provision is

maintained for all NHS organisations over the duration of the current contract term for

the LSP PACS solution. Any NHS organisations operating outside the LSP contracts

for PACS would incur additional costs to be brought into the programme.

Further work is required to identify which PACS solutions remain outside the national

contract and, on a case by case basis, what implications there are for guaranteeing

service provision over the next 8 years.

Recommendation 12: That the PACS team review legacy implementations and identify recommendations for future developments and implementations to bring them into line with the NPfIT in a cost effective and efficient way.

4.10 Non radiological imaging information systems

The NHS CfH PACS solution is technically able to interact with a wide range of

clinical information systems but to date the effort on deployment has been with RIS

solutions only. Further work is already underway to ensure necessary interfacing

with NHS CRS solutions as they come on line.

But there are a large number of diagnostic imaging service users that currently rely

on clinical information systems other than RIS to support them.

Further work is required to determine i) what functionality and systems are required

for each service user to work with PACS solutions, ii) whether the NHS CRS solution

will incorporate this functionality (making legacy systems obsolete), iii) whether it is

better to integrate existing systems or await NHS CRS deployment for wider PACS

deployment to diagnostic image users and iv) how a mixture of different information

systems/ functionality will have to operate collectively with a common PACS solution.

Recommendation 13: To review the scale and scope of PACS solutions required for images outside of radiological imaging in collaboration with the DH Diagnostics Branch and the Royal Colleges.

4.11 Broadening PACS Access

The NHS Connecting for Health PACS solution is founded on an architecture that

makes the ‘traditional’ teleradiology function largely obsolete (other than perhaps

where the service is required in a consultant’s own home). Essentially, the PACS

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solution can be wherever it is needed. But NHS CfH PACS solutions are demanding

on equipment and infrastructure, especially networking, and therefore extending the

full functionality of the solution to everywhere may not be cost effective.

There needs to be a further debate on the optimal access required for different users

(particularly service users outside of the Radiology department) that incorporates

wider service access, including traditional teleradiology where this is still required. It

is likely that PACS vendors will remain keen to extend their solution where they are

able to charge more additional services; however we should describe the nature and

complexity of the remote solution so that implementation is consistent and fit for

purpose.

Recommendation 14: As part of the review of scope and scale in 10, above. To included the requirement for remote access to images by clinicians.

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APPENDIX A: NATIONAL PACS CLINICAL REFERENCE PANEL MEMBERSHIP

Role Name Title Email AddressJoint Chair Erika Denton Consultant Radiologist, Norfolk and Norwich University

Hospital NHS Trust.National Clinical Lead for Diagnostic Imaging, Department of Health

[email protected]

Joint Chair Michael Thick Heart and Lung Transplant Surgeon and National Medical Director for Choose & Book and PACS

[email protected]

Secretary Margaret Budd PACS Implementation Coordinator NHS Connecting for Health

[email protected]

Department of Health PACS Lead

Kathy Mason DH National Implementation Director - PACS [email protected]

Royal College of Radiologists

Nicola Strickland

Consultant Radiologist, Hammersmith, representing the Royal College of Radiologists as Chair of the IT Sub-Committee

[email protected]

RCR Representative Rhidian Bramley

Consultant Radiologist, Chair of the Royal College of Radiologists PACS and Teleradiology Special Interest Group

[email protected]

National PACS Team David Jennings PACS Implementation Manager, Department of Health (Radiographer)

[email protected]

National PACS Team Gavin Mander PACS Technical Manager NHS Connecting for Health [email protected] PACS Team Jerry Norman PACS Technical Team Lead NHS Connecting for Health [email protected] PACS Team Moira Crotty NHS CFH NE Cluster PACS Implementation Advisor

(Radiographer)[email protected]

Cluster PACS Team Judi Humphreys

NHS CFH NWWM Cluster PACS Implementation Advisor (Radiographer)

[email protected]

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mailto:[email protected]








mailto:[email protected]@dh.gsi.gov.uk





Cluster PACS Team Pam Kemp NHS CFH Southern Cluster PACS Implementation Advisor (Radiographer)

[email protected]

Cluster PACS Team Mona Pal-Singh NHS CFH Southern Cluster PACS Implementation Advisor (Radiographer)

[email protected]

Primary and Secondary care healthcare professionals and managers

Maxine Bullock Norfolk & Norwich University Hospital NHS Trust (Radiographer and PACS Manager)

[email protected]


Tony Corkett Kent and Medway PACS Programme Director (Also representative for College and Society of Radiographers)

[email protected]


Sarah Cush National Breast Screening Service (Radiographer) [email protected]


Jonathan Davies

Specialist Registrar in Dental Radiology, Dept. of Dental Radiology, Guy’s Hospital

[email protected]


Phil Dunmall Radiographer and ex PACS Implementation Advisor [email protected]


Keith Foord Consultant Radiologist, East Sussex Hospitals NHS Trust. [email protected]


Keith Goldsworthy

Radiology Services Manager (South Devon Healthcare NHS Trust)

[email protected]


David Grant Consultant Radiologist and Clinical Director of Diagnostics and Therapies at the Whittington Hospital NHS Trust

[email protected]

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Charles Hutchinson

Consultant Radiologist, Salford Royal Hospitals NHS Trust [email protected]


Robin Kantor Consultant Radiologist, Hillingdon Hospital NHS Trust [email protected]


Kim Krarup Consultant Radiologist, University Hospitals of Leicester [email protected]


Roddy McColl Head of DepartmentOxford Medical Illustration John Radcliffe Hospital - Representing Medical Photography

[email protected]


Nigel Morris Royal Free Hampstead NHS Trust - Radiology General Manager. Radiographer and ex PACS Implementation Advisor

[email protected]


Jackie Nicklin Senior Radiology Manager (Poole Hospitals NHS Trust) [email protected]


William Saywell Consultant Radiologist, Caldicott Guardian, NPfIT Clinical Lead, East Somerset NHS Trust

[email protected]


Richard Seymour

Consultant Radiologist, South Devon and National Clinical Lead for Radiology Service Improvement

[email protected]

AHP Clinical Champion, CfH Clinical Leads Group

Jan Laidlow National Clinical Lead for AHPs for NHS CfH (Radiographer)

[email protected]

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Nationally appointed Clusters PACS Programme Clinical Advisors

Tony Newman-Sanders

Consultant Radiologist, Mayday Healthcare NHS Trust , London Cluster representative and National Clinical Advisor

[email protected]


Kishore Reddy Consultant Radiologist, Medway NHS Trust. Southern Cluster representative and National Clinical Advisor.

[email protected]


John Somers Consultant Radiologist, Nottingham City Hospital. East of England & East Midlands Cluster representative and National Clinical Advisor.

[email protected]


Laurence Sutton

Consultant Radiologist, Huddersfield and Calderdale. North East Cluster representative and National Clinical Advisor

[email protected]

Radiology Service Improvement Team

Graham Hoadley

Consultant Radiologist, Blackpool and National Clinical Lead for Radiology Service Improvement

[email protected]

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Documents

Controlled Document Word Template€¦ · Web view2003/07/03 · V3.0 29/03/06 Revised following review with PACS technical team and further input from Diagnostics Branch V3.1 31/03/06