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November 17, 2010

When Worlds Collide

Many hospitals and imaging centres are installing picture archiving and communication systems (PACS). But what sort of skills are needed by the people who maintain them? Should they be an expert in IT or do they need a weather eye for clinical needs? Dr Paul Nagy of the University of Maryland School of Medicine tells Nic Paton where the balance between the two disciplines lies.

By Dr Paul Nagy

It’s a truism that no matter how sophisticated your IT and technology solutions are, they are only as good as the people using them, and, in the case of imaging facilities, the people interpreting them.

In the past few years radiology departments have witnessed a revolution in the effectiveness of PACS and radiology information systems (RIS), with digital imaging and archiving leading to huge advances in the diagnosis, interpretation and delivery of images.

Two new roles have emerged in tandem: the imaging informatics professional and the PACS administrator, both of whom play a key behind-the-scenes role within imaging services and radiology departments. The planning, implementation and maintenance of PACS or other radiology systems is now a central part of an effective radiology department.

Yet, as the technology has evolved, there is also a growing debate about what sort of skills the modern PACS administrator needs to have. Is it better to have someone whose strength lies in their IT background – who can, in effect, keep the wheels turning seamlessly? Or is someone who is coming at things more from the clinical perspective going to be more use?

“This debate has been going on for about six years, and it is very much a live issue,” says Dr Paul Nagy, director of the imaging informatics research laboratory at the University of Maryland School of Medicine. “There have been a number of roundtable events about it.”

Answering the debate

“This debate has been going on for about six years, and it is very much a live issue.”

This is clearly seen in the online FAQs of the American Board of Imaging Informatics (ABII), the first of which is “RT vs IT: Which role is best suited to be a PACS/imaging informatics professional?” Its answer, less than helpfully, is “both”, arguing that imaging informatics professionals need to be conversant with IT and radiotherapy concepts to be successful.

It was partly to start trying to answer this debate that the ABII developed a new certification examination in imaging informatics (see box) four years ago. Some 540 people have now taken the exam, which, Nagy stresses, addresses this tension head-on.

“What the ABII exam requires is that you can show you have been exposed
to a clinical environment for at least two years,” he explains.

“What is telling about it is that you are not going to pass it unless you can show you are aware of some of the clinical aspects. For example, you need to have knowledge of anatomical positions and have at least some awareness of the clinical space, perhaps the ergonomics of the room or how to make the best use of 3D imaging in the conditions that you have.

“It is not just about the technology. You can be excellent at supporting the system, but if you do not understand it is being used within the clinical setting you may not appreciate what is required, how to get the best image or how to add value.

“You also need to have an understanding of clinical workflow. PACS is very powerful, but if it is not well integrated into workflow or the clinical space, then it can potentially contribute to medical errors being made. For example, if we are unaware of anatomical positions or have not configured the RIS properly, it can lead to unnecessary delays in response or diagnosis.”

Maturing technology

A little over a decade ago there was not much debate over this issue, partly because the technology was still in its infancy. One of the factors behind the debate, Nagy says, is the recognition that the technology behind radiology is maturing and becoming standardised.

“There is a greater need for people to be able to speak the language of clinicians.”

“In the late 1990s supporting a PACS pretty much required engineering expertise; it was an engineering exercise on the part of each vendor,” he says. “So the challenge for the PACS administrator was more around data support.

“Now that the technology has matured, PACS vendors tend to use standard commercial software and there is much less of a requirement for that sort of engineering expertise. There is a much more standardised user interface, so things have begun to move towards creating a balance. On the one hand the PACS administrator role is still a typical IT support role, but on the other it is now more likely to have to be closely embedded on the clinical side.”

This means that there is a greater need for people to be able to speak the language of clinicians, to understand them, their requirements and expectations and how they work. Considering its reputation for being at the technological cutting edge, medicine remains one of the few professions where it is still possible to train and progress without much of a knowledge of or familiarity with computers and IT systems, unlike in the corporate
or commercial environment.

IT professionals tend to work in a fairly planned, singular and rational way; in comparison, the clinical world often works in a more disruptive, reactive and collaborative fashion. To an IT person, Nagy argues, having a system that takes 30 seconds to boot up after logging on may not be that much of an issue. But for a clinician dealing with a heavy caseload of patients and who has to log on around 100 times a day as a result, such a delay can deeply frustrating.

“People with technological expertise are required, yes, but so are people with vision.”

“As an administrator you need to have an awareness of these sorts of cultural issues,” he says. “You may find yourself speaking to a radiologist first, but then a podiatrist or surgeon. They all want their needs to be prioritised, so you need to be able to work around and empathise with that. Probably the most important skill is learning how to be embedded in that world, within that clinical care team.

“People with technological expertise are required, yes, but so are people with vision, who can manage systems and make processes better and develop services for the end users. It may be that we end up with some teams with one technological person and one clinical person. In many cases the volume of work these days can easily justify having more than one person and a multi-disciplinary set-up.”

He suggests that this could lead to an array of new administrator titles.

“The most successful people are going to be those who can bridge the gap between these cultures, and who can collaborate across them,” he says.

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