Most of the institutions who install PACS systems are not quite paperless (yet). Paper slips are needed to convey certain information about the requested procedure, such as admitting diagnosis, main complaint, for a radiologist, and allergy and weight for the technologist. There is also a need for a copy for the transporters so in-patients can be retrieved from the floor. Furthermore, there could be old reports brought in that need to be scanned in and other relevant clinical information that a radiologist migth want to see. Then there are also the technologist comments and measurements as well as the various release forms. As you can see, there is plenty of paper work still going around, the complete extend of which should be evaluated during a workflow analysis.
How do we deal with these information pieces? The ultimate goal is to have everything electronic, i.e. have a electronic document management system as part of the HIS or EMR. However, as the far majority of healthcare institutions are not quite there yet, we need to find intermediate, temporary solutions. Some of the RIS systems have an integrated document management feature which we can use. This requires a seamless integration of the PACS and RIS, and/or a RIS driven worklist that makes this available at the desktop. After the document management system being available in the EMR, this is probably the 2nd best solution. However, if we don’t have either solution, we might look for integrating documents and papers in the PACS.
Documents in the PACS can take several forms. One can use a simple paper scanner and get a 3rd party software package that digitizes the document into a so-called secondary capture object. Important is to have the same patient demographics and study information which requires the worklist to be available for this purpose. Unfortunately, these objects are somewhat large and the resulting bitmap images are not quite high quality. Another solution is to use an encapsulated pdf DICOM format, which is more compact and has a better quality. The support of this object migth be lacking with some of the PACS vendors. For measurements, e.g. from an Ultrasound, one is strongly encouraged to use DICOM Structured Reports. Again, there might be some support issues there.
Whatever solution is selected for incorporating paper, keep in mind the long term solution so that whatever you pick is consistent with that. Also, perform an in-depth analysis of all the pieces of information and why they are used. I have seen departments that kept on printing multiple copies of a requisition of which most of the data is never used by anyone. On the other hand, some departments who tried to go paperless found that they still need to print copies so that people can use the accession number that is bar-coded to do reporting. As with implementing digital imaging, digital documentation is challenging but the gain could be considerable.