Overcoming Challenges for Successful PACS Installation in Low-Resource Regions: Our Experience in Nigeria

Abstract

In this paper, we walk you through our challenges, successes, and experience while participating in a Global Health Outreach Project at the University College Hospital (UCH) Ibadan, Nigeria. The scope of the project was to install a Picture Archive and Communication System (PACS) to establish a centralized viewing network at UCH’s Radiology Department, for each of their digital modalities. Installing a PACS requires robust servers, the ability to retrieve and archive studies, ensuring workstations can view studies, and the configuration of imaging modalities to send studies. We anticipated that we might experience hurdles for each of these requirements, due to limited resources and without the availability to make a site visit prior to the start of the project. While we ultimately experienced delays and troubleshooting was required at each turn of the install, with the help of dedicated volunteers both on and off-site and the UCH staff, our shared goal was accomplished.

Introduction

The SIIM (Society of Imaging Informatics in Medicine) Global Outreach Committee, in partnership with RAD-AID International, created the Global Ambassador Program, whose mission is to advance Imaging Informatics throughout the low-middle income countries (formerly referred to as “the developing world”). Two of the 2019 RAD-AID SIIM Global Ambassadors were provided grants to work alongside two other RAD-AID volunteers to help implement the RAD-AID Friendship Cloud PACS (Picture Archiving and Communications System), at the University College Hospital (UCH) in Ibadan, Nigeria. Two additional RAD-AID volunteers remotely assisted the project from the USA during the installation.

The RAD-AID Friendship PACS is designed to provide imaging services to underserved and resource-poor regions, enabling them to improve their position in providing key health medical solutions. We discuss the successful installation of PACS, and the challenges we overcame while participating in this Global Health Outreach Project, during our 2 weeks on-site.

Background

Having opened in 1956, UCH was the first medical school in Nigeria and has trained most physicians in Nigeria; however, they do not yet have all the technical resources that would automate many of their manual processes. PACS is a vital piece in clinical imaging, with advantages that include providing a more efficient workflow when managing studies, ensuring studies are easily accessible, reducing errors from manual data entry, and providing the ability to manipulate images for a proper diagnosis; to name a few.

The RAD-AID Friendship PACS is a synthesis of a conventional web-based locally deployed PACS (see Acknowledgements section for list of institutional contributors) in combination with a second cloud-based PACS instance with a mirror copy of the imaging data, sometimes referred to as a “hybrid PACS.” Hybrid PACS offers the additional benefits of data backup, easy and secure access to imaging studies from outside of the health systems network, electronic image sharing for the continuation of patient care, and consultation with other physicians. It allows end-users to safely and securely access data from anywhere and will help further ensure that everyone who accesses the data is seeing the same results, reducing the risk of missing pertinent patient information [1]. The PACS installation was the result of a broader collaboration between RAD-AID and UCH that was initiated over a year prior with the completion of the RAD-AID Radiology- Readiness Survey (Fig. 1)

Fig. 1.

Timeline showing major events in the UCH/RAD-AID collaboration resulting in the RAD-AID Friendship PACS installation

UCH Radiology

Workflow and Modalities

UCH’s Radiology Department is 75% digital and 25% analog. Their modalities include five diagnostic x-ray devices, three of which were not functioning during the installation. Of the x-ray devices, two are digital radiography (DR), and three are computed radiography (CR). They have one 0.35 Tesla MRI, almost solely used for neuroradiology examinations, and much less commonly the occasional musculoskeletal exam. They have three computed tomography (CT) scanners, 64, 16, and 8 slices. Only the 16 slice scanner was functional during the time of our visit. They have six ultrasound (US) machines and one mammography unit, which have been down for 5 years, restricting breast exams to only ultrasound. Of these devices, the MRI, the 64 slice CT, and one of the DR x-ray devices were connected to their previous server when the team arrived.

The workflow consists of administrative and technical staff receiving handwritten orders and appointments scheduled in a physical book due to limited computers and inadequate networking. UCH lacks a hospital-wide email system, so team members use a combination of network telephones, personal phones and personal e-mail accounts to communicate amongst each other.

UCH does not have a dictation system, so reports are either typed in a Microsoft Word document and copied, or handwritten and then manually transcribed and entered by a typist into a reporting system that was developed in-house. The reporting system is not integrated with PACS, so reports are accessed separately from the studies available in the viewer. Many of the interpretations saved to the reporting system are lost due to lack of adequate storage, causing a further gap in patients’ records, which are subsequently missing a prior report for comparison. The new PACS has a built-in reporting and recording feature, which makes the dictation process more efficient, and provides a secure way to save reports and help ensure they are properly matched to the correct patient [2, 3] (Fig. 2)

Fig. 2.

Schematic demonstrating UCH Radiology workflow prior to RAD-AID Friendship Cloud PACS Installation

There was one licensed departmental computer that could burn CDs or DVDs, which referring physicians often had issues uploading. Therefore, film was not only required to view studies performed on the analog x-rays, but it was the primary means of viewing and storing all images. The printed film consists of x-rays or key images from cross-sectional studies. Patients bring the films to referring physicians, whether they are located across the corridor in another section of the hospital, or at an outside institution. Patients are also responsible for returning their films to the radiology department for storage; if the film is not returned, the patient may not have a study available for comparison in the future. The new PACS allows for the sharing of images electronically and burning studies to disk from any computer on the departmental network [4].

Barriers and Challenges

Geographic and Time Barriers

Due to travel constraints, onsite support from the PACS vendor was not available during the installation. However, communication with the PACS vendor was continuous via WhatsApp, a smartphone communication application designed for messaging, allowing the team to reach the US team in real-time. In addition to not having onsite support from the PACS vendor, there is a 7-h time difference between West African Standard Time (WAT) and Mountain Time (MST), which at times delayed critical phone-based input needed for the installation. To resolve this, a purposeful list of questions and issues was created at the end of each day, so feedback and solutions were available each morning from the communicating PACS vendor and RAD-AID teams.

Technical Challenges

Successful implementation of a PACS requires the installation of server(s), the configuration of imaging modalities to send studies, and testing to ensure workstations can view studies. Prior to the commencement of the project, RAD-AID performed its “PACS-Readiness” assessment, which is designed as a due-diligence survey data-collection step for planning out a PACS installation based on first knowing about the available infrastructure. The RAD-AID “PACS-Readiness” assessment includes detailed inquiries about the facility’s power supply, internet, network, how they acquire and store studies and the make, model, and software revision of their imaging modalities. Further inquiry and recommendations are made based on information entered into the survey by the host institution.

The implementation team learned shortly after arrival that the UCH Information Technology (IT) department had concerns about aging network devices and an unfavorable network design and felt that they could not guarantee adequate performance. Reboots were often required several times a day during peak clinical hours due to aging switches, wireless access points, and routers that were installed over 10 years ago. The standard network design between a 64 slice CT and the image server generally should not exceed four switches; there were five installed at UCH’s 64 slice CT, slowing down the rate of transfer. The network connections also needed to be re-terminated due to the corrosion of RJ45 connectors. While a significant amount of time was spent troubleshooting internal networking issues while we were on-site, fortunately, we were able to perform the install.

As part of the donated PACS installation, a new server was provided, which was hand-carried from the USA. While attempting to connect to the server, we encountered issues accessing the internet Domain Name System (DNS) service required to translate the domain name to the server IP (Internet Protocol) address. A DNS service was updated and configured on the local router to resolve this issue. Next, the server local IP addresses were bypassed on the router to allow remote connection, and the objective of installing the server the first day on-site was accomplished.

Configuring the imaging modalities for DICOM (Digital Imaging and Communications in Medicine) expanded the length of the project. Many issues revolved around understanding the user interfaces in the various imaging devices and the basic connection to the network. The networking issues were overcome by overhauling network switches, and by purchasing wireless access points and routers. Network switches were upgraded from 100 to 1000Mbps on major paths where the modalities are located to increase throughput and transfer speed. Where vendors had segmented their network from the hospital’s network, a router was integrated to allow routing to the hospital network. Replacement of fiber optics cable and a CAT 6 UTP were necessary to improve image transfer performance [5]. The 64 slice CT, US, the MRI, and DR modalities were all in the same segment of the radiology network and were placed on fiber optics backbone due to the distance to the image server. The other modalities (A&E x-ray, 16 slice CT, and OPD Digital x-ray) could run on CAT6 backbone.

The CT’s, x-ray, and MRI modalities required administrative rights to configure them to send to PACS. Prior to the start of the project, UCH coordinated with vendors to be on-site, but there were delays configuring the modalities, as it took time to understand the configuration user interface, even with the vendor’s assistance. There were several failed image transfers while setting up the required DICOM configuration parameters on the imaging devices, i.e., AE (Application Entity) Title, IP address, Device name, and Port. It was later discovered that the same configuration parameters had to be input in other parts of the system settings before a proper handshake with the server could be established.

The 8 and 64 slice CT’s had some antivirus functions which had to be disabled, and a new firewall rule was created to allow a DICOM handshake with PACS. On these same modalities, there were configuration and routing issues. After troubleshooting routing parameters, it was discovered that both suites were not on the same virtual local area network (VLAN). They both needed unique routing paths to be configured to allow data exchange. It was also discovered some routing protocols were missing in the routing path for the 8 slice CT.

We looked into setting up DICOM modality worklist (DMWL) to circumvent the manual entry of patient and study demographics into each imaging modality; however, we discovered the ultrasound machines were not licensed to do so. Time did not permit further review of setting up DMWL on other modalities, given the networking issues and delays due to power outages.

Upon arrival, the team learned that the hard drives in the system the site had been using for image storage were damaged, and approximately 22,000 studies were potentially lost. The newly installed system is a hybrid PACS, with images stored both locally to an on-site web server, and to a cloud-based web server with both systems are running essentially the same software, each providing the ability to view and archive images. This should significantly decrease the possibility of losing studies in the future [6].

To cap off these technical challenges, on-site power outages, typical in some low-middle income countries, occurred up to five times a day due to a poor inverter.

Operational Challenges

Obtaining a thorough assessment and understanding of UCH’s priorities and their desired outcome was necessary for the success of the project. This was achieved by continuously engaging in open discussions with UCH about their workflow, and then outlining the necessary steps to tailor a PACS to meet their needs. This is accomplished via RAD-AID’s Radiology-Readiness and PACS-Readiness Assessments.

Ordinarily, a site visit by a RAD-AID Informatics/IT specialist is recommended to validate departmental workflow, the imaging modalities, networking, staff expertise, etc. prior to the installation. For this PACS installation, in light of resource-constraints and calendar timeline considerations for this deployment, this step was addressed instead via remote-based communications in conjunction with active engagement with the site on other initiatives. The team, therefore, had to rely solely on the PACS-Readiness checklist completed by the UCH IT team prior to installation.

The UCH team was excited about the PACS installation, but it was still necessary to develop buy-in across the department for skeptical team members worried that implementing a new system that would change their workflow. The head of the radiology department and UCH’s CEO, along with other key stakeholders, were instrumental in identifying champions who understood the project and helped educate the team on the benefits of PACS to the health system as a whole. We explained in detail that an accession number was a unique number used to identify a study, and how setting up a DICOM modality worklist (DMWL) could circumvent the manual entry of patient and study demographics, significantly reducing data entry errors, which helped propel the project forward.

To help lay down a solid foundation and keep the momentum post-go-live, education on Informatics and PACS were provided; and interested residents were encouraged to participate in the National Imaging Informatics Curriculum and Course (NIIC). Six total UCH radiology residents completed the course. During the project go-live, the department formed an informatics committee, and they now hold weekly in-house meetings and have a monthly international conference call with RAD-AID volunteers. This endeavor was specifically created in order to augment the sustainability of this project, as a potential barrier could be a lack of longitudinal engagement without adequate personnel onsite to propel the project forward. By holding monthly phone calls with IT personnel, specific issues could be addressed to promote the sustainability of the project.

The project time-line included scheduled end-user training sessions during the entire second week, thus ensuring IT, administration, radiologists, and technologists were comfortable with the new workflow in their various roles, prior to the team’s departure. The technical issues in week one spilled over into week two, cutting the previously allotted training time in half. The onsite volunteer team was also reduced from four to two people in the second week. To make the most of our allotted time, training began with selected super-users in each role so they could potentially help train their teammates. In the end, the team found the system to be fairly intuitive, and we were able to train them quickly, leaving time to review advanced settings with the super-users.

Recommendations for Future Implementations

Ideally, the modality vendors on-site will have the information needed to configure the modalities they support, but the project team should keep in mind they may be unfamiliar with networking and DICOM configuration. Securing documentation prior to the onsite deployment for each imaging device detailing configuration settings for network connection and DICOM communication would be extremely helpful but the authors recognize that this documentation may not be freely available.

A request was made for all modalities to be integrated with PACS to be connected to the hospital network before our arrival, but testing was not done to ensure proper network routing to the server. Arranging for the vendor of all password-protected modalities to perform IP ping testing to an address on the same subnet as the server could anticipate any routing issues, but the authors recognize that an additional on-site visit from the vendor may be cost prohibitive for the site.

Discussion

The primary goals while onsite were to develop a thorough understanding of the radiology department’s layout and workflow, installation of the on-site server to the network, to configure the modalities to communicate with the server, and to train the end-users.

Prior to the installation, the UCH Radiology Department only had access to a free version of PACS software for viewing studies. That system was also not centralized and thus did not allow the team to efficiently share, store, or retrieve studies. UCH’s new Friendship PACS provides them with the ability to burn disks from any PC, share images electronically, view studies outside of the network, and dictate reports in one system. Currently, their newly installed PACS is localized within their radiology department, but the goal is to make the platform enterprise-wide, for broad institutional participation. This step forward would not only increase the quality and efficiency of the clinical operations at UCH but also advance the patients’ use of their own health information since the images would be accessible to providers across departments and hospital-affiliated sites.

The hybrid PACS installed at UCH also provides the institutions with teaching possibilities with its ability to view and share studies remotely. RAD-AID has volunteer tele-teachers able to log into the system and view cases with the UCH staff and trainees in order to support UCH’s clinical education. RAD-AID Friendship PACS is not intended as a teleradiology platform for performing reads remotely because such an arrangement may displace local personnel from reading UCH’s radiology exams. Instead, such a platform can provide tele-teaching and tele-consulting for remotely based radiologists to help local staff grow in skills and perform their own radiologic interpretations for UCH patients with RAD-AID’s educational and consultative support.

Conclusion

The installation of PACS at UCH in Nigeria made Africa the third continent to receive the RAD-AID Friendship PACS. We encountered hurdles and technical difficulties throughout the project, which made the stakes even higher, given we had only 2 weeks onsite. While we were successful with the physical server installation, the configuration of the modalities, and training of end-users, we concluded that UCH would greatly benefit from additional IT resources, additional PCs, a voice dictation system, and an electronic medical record (EMR) system. Securing these resources would not only eliminate manual processes and bottlenecks in the workflow but also greatly reduce data entry errors associated with manual entry and help sustain the RAD-AID Friendship PACS [7–10] (Fig. 3) in the long run. We view this project as the first step of many in a longitudinal partnership between UCH and RAD-AID to sustain and advance radiology and health IT, in which we hope to further engage these other technologies as future steps in our ongoing effort to improve medical imaging and health care for underserved populations. We also learn from the lessons and experiences in the UCH installation in order to improve the present and future installations at other sites throughout the world as we scale up this important program for medical imaging informatics and radiology services.

Fig. 3.

Schematic demonstrating UCH Radiology workflow after RAD-AID Friendship Cloud PACS Installation