Abstract
When new information and communication technologies are implemented there are organizational effects. Picture Archiving and Communication Systems (PACS) have been implemented not only within radiology but also within the orthopaedic context. We studied the impact of PACS on the work practice and professional role of orthopaedic surgeons in relation to radiologists. Qualitative interviews were performed with 15 surgeons at two hospitals. The interviews were transcribed, analysed and then coded using grounded theory. Three main categories were defined: professional role, diagnostic practice and technology used. There was a shift in orthopaedics from a single to a mixed profession, and from a relatively static practice in interpreting images to a more flexible practice, where every orthopaedic surgeon could view and access images from anywhere at any time, including three-dimensional imaging. It was easier for surgeons to see and interpret the images, and their diagnostic skills became accessible to everyone. The use of PACS also improved the dialogue with patients, according to the respondents. This was necessary in order to explain the treatment options for the patient or the details of the disease. PACS therefore acts as an information and communications technology and users required new knowledge and skills.
Introduction
Orthopaedic departments are changing due to the implementation of digital imaging and PACS (Picture Archiving and Communication Systems). In distributed image production, using PACS, work images can be accessed at different times and places, and by different organizations. To the best of our knowledge, there have been no previous studies on the effects of PACS on orthopaedic surgeons and their relationships to radiologists. The aim of the present study was to analyse the influence of PACS on orthopaedic practice.
Methods
Interviews were conducted with staff from the orthopaedic department at Solna and Huddinge, two hospitals in the Karolinska University Hospital group. The prerequisites were that individuals needed to:
Have working experience in both the analogue and digital environment; Be an orthopaedic specialist.
The interviews were carried out between October 2008 and March 2009. The interviews were semi-structured and open-ended, so that follow-up questions were permitted. The interviews covered questions such as: (1) What trends could be identified regarding changes in practice? (2) Why had these changes occurred? (3) What were the indicators of change? (4) Describe the transition from analogue to digital work (5) Describe how you work today (6) Are there systems that you use? (7) If so, which do you use? (8) How do you know what to do in work? (9) What do you do when unexpected and unwanted situations occur?
The material was analysed and coded using grounded theory. Grounded theory methods have recently become more widely recognized in the field of health care. 1–4 The principle was to analyse and describe emerging categories and core categories from the interviews.
In grounded theory, the analysis is named coding, i.e. coding represents the operations by which data are broken down, conceptualized and put together in new ways. 5 The coding of data occurs in three steps. The first step consists of forming categories. The next step involves the identification of characteristics relating to each category. In the final step, key categories are identified on the basis that they hold large amounts of material.
Results
A total of 15 orthopaedic specialists agreed to participate in the project (see Table 1). All participants were men. The process of categorization resulted in three key categories: professional role, orthopaedic practice and technology used. The consequences of PACS for orthopaedic surgeons are summarised in Table 2.
Characteristics of the surgeons who were interviewed
The consequences of PACS for orthopaedic surgeons
Before digitization
Professional role. The professional relationship between radiologists and orthopaedic surgeons has been quite clear. The role of the radiologist is to read the images while the role of the orthopaedic surgeon is to apply that information, e.g. in surgical or non-surgical treatment. In practice this means that they have single disciplinary roles. At the clinical meetings the radiologists contribute expert knowledge needed by the orthopaedic surgeons for the diagnostic work-up. In the orthopaedic surgeons’ specialist education there is no theoretical training in image interpretation. Thus, the communication with the radiologist is a form of education for the orthopaedic specialist. Orthopaedic surgeons interpret images in a slightly different way compared to radiologists. They need more information about the patient in order to make their clinical diagnostic work-up. Orthopaedic surgeons view the X-ray film as an important tool in their work. When access to these films is limited, the orthopaedic surgeons’ possibilities for combining information related to films and clinical patient data are restricted. In the orthopaedic surgeon’s meeting with the patient in the outpatient clinic, the surgeon had to rely on the diagnostic report and try to convey this to the patient in a form that the patient could understand. This limitation was due to lack of access to the images.
Work practice. Working in the analogue environment, the orthopaedic surgeon was supported in the planning and preparation work by other categories of staff working in the department. The radiologist identified and analysed the images to be demonstrated at the forthcoming clinical meeting. If an orthopaedic surgeon wanted a specific patient case to be demonstrated at the clinical meeting, he/she needed to inform the radiologist in advance of the conference. If possible, the radiologist informed a secretary that additional films, relating to a specific patient request, were to be retrieved from the radiological archive and mounted on the light boxes in the clinical meeting room. Performing the work required the handling and management of several actions. Conferences are an important communication forum in orthopaedic practice. If the surgeon wanted to discuss a specific patient, the surgeon sent a request to the radiology department to have the relevant patient examinations demonstrated at a forthcoming clinical meeting. The fixed properties of the film made practice more static.
Technology used. Before digitization, orthopaedic surgeons used simple tools to support their work. These consisted of films, paper documents and templates, which had a fixed format. Template properties are tangible, exact in measures and ‘light in weight’. These properties have implications for the ease with which they can be physically placed and scaled in order to develop the most suitable prosthesis for the patient. They have exact measures. Working with simple films had its drawbacks. For example, they could be misplaced. The process of purchasing and implementing PACS was carried out by radiologists and the radiology department. The involvement of orthopaedic surgeons was limited.
After digitization
Professional role. There are different professional roles for the orthopaedic surgeon and the radiologist. Where does the radiologist's work stop? And where does the orthopaedic work start? This boundary differs among individual surgeons, individual radiologists and their personal relations as well as from patient to patient. In practice, it leads to the development of spontaneous groups of multidisciplinary teams that change over time. The advent of PACS has created new possibilities for orthopaedic surgeons and radiologists to work more closely together in heterogeneous teams. The trend is a more multidisciplinary way of working where radiologists need to become more knowledgeable about clinical work and orthopaedic surgeons need greater knowledge about the systematic interpretation of images. The orthopaedic profession has gone through a process of specialization during the last decade. Knowledge within different areas has grown and made it impossible for individuals to be experts on everything. This has forced orthopaedic surgeons to become more specialized, and may also force the radiologists to specialize.
Work practice. In the digitized environment, images are accessible to orthopaedic surgeons from any location where there is a connection to the hospital network, opening up a more flexible practice. The new digitized images and communication systems open up new ways of communicating and team-working between orthopaedic surgeon colleagues. Digitized images and communication systems create the possibility of holding clinical meetings in any location where there is a PACS workstation and projector.
Technology used. The PACS that was implemented was slow, and retrieving images of a patient from the digital archive took 10–15 min. The expectation was that one would simply be able to press the ‘enter’ button. The orthopaedic surgeon had to log into and use many different systems at work. The systems are not integrated. After digitization, the digital environment made work more complex, in the sense that there were more technologies, interconnections and activities included in the work.
Discussion
The use of grounded theory in the present study influenced it in different ways. One was the empirical creation of categories and trends. The categories (professional role, orthopaedic practice and technology used) were specified from the material analysed at the beginning of the analysis. There is some risk of the categories being general and not always being based on the material analysed. There is also a risk that there may be a large number of categories which can be created and that these can lose their context. This was not seen as a problem in the present study since the analysis was performed by two researchers, first individually and then together. In addition, the aim was to increase the level of abstraction for the categories created. In the end, the result was based on numerous implemented levels of analyses.
Qualitative studies which involve insight and understanding mean that the researcher is participating and present. Naturally the researcher's understanding will then be of importance. In the study, one of the researchers had a background as a radiographer and was well-informed about the context in which the study took place. Medical activities are complex and a number of different participants are involved. Without this previous understanding of the context, it would have been more difficult to derive meaning from this part of the study. Another criticism can also be raised against the background of the qualitative methodology. It is the researcher who decides when the analysis is complete, and this may result in categories that are too basic in level. This was counteracted in the present study by specifying that the analysis was complete only after a number of levels of analyses had been carried out.
It seems likely that our qualitative analysis is transferable to other similar orthopaedic settings. However, the present study was firmly grounded in the Karolinska University Hospital and we can only speculate about other ways of working elsewhere and differences in the relative contributions of different types of work practice and roles.
Professional role – before and after digitization
In any change process, a number of factors influence the change. Technology is just one of these factors. However, information technology has the potential to support new professional roles and new ways of cooperating and working. The complexity of technology is vast, as the same technology may spread and develop a variety of uses by different groups in the medical health-care chain. The different groups may develop different procedures and conventions around the use of a technology. In practice, this means that the technology is perceived and cultivated over time in a multifaceted way by different groups. This implies that we need to look closely and thoroughly at the technology in use in order to understand its development and meaning in work in various communities.
The present study illustrates that the joint use of technology in practice has resulted in a more multidisciplinary focus, where the boundaries between the professional roles are not as strict any more. Both professions are approaching each other's fields as a result of the professional roles becoming intermingled. Professional roles change over time as the technology in use changes over time. The properties of the technologies enable the professions to work together more closely or force them to work further apart from each other. The technology also enables the orthopaedic surgeons to become more specialized. Knowledge in the orthopaedic field has grown during the last decade and it is not possible to be an expert in everything. This has forced orthopaedic surgeons to become more specialized. In order for radiologists to work closely with orthopaedic surgeons, they also need to become specialized so that they can ‘match’ the orthopaedic surgeon when working together in a team.
The use of PACS has also improved the dialogue with patients, according to the respondents. This is needed in order to explain the treatment options for the patient or the details of the disease.
Work practice – before and after digitization
One must be aware that not all individuals interpret images, collaborate and question with the same ease. Differences arise because people are different and choose to do things in different ways. However, in order to promote mutual support and to optimize results, work can be done with cooperation 6,7 and in teams. To have a tool that supports this is important so that teamwork can be initiated when appropriate. Not only do people working in teams complement each other's skills, but a new collective ability is usually developed within the team. To develop teams is time consuming, especially if one is to gain maximum benefit from the system and resources within it. 8,9
In practice, teams that are aligned with the medical care and the patient are created, e.g. neurology teams, specialized care teams. There are advantages to multidisciplinary teams, because the competence surrounding the patient increases. When the medical panorama is complex, more units are involved in the care chain, e.g. cardiology, thoracic surgeons, nuclear medicine, urologists and radiologists. To optimize the delivery of care for the patient, a dialogue is needed between many kinds of staff. In multifaceted illnesses, the various organic problems are linked, and decisions need to be discussed and synchronized. The availability of radiology images is essential during these joint discussions. 10,11 The present study indicates a shift in orthopaedics from a single to a mixed profession, and from a more static practice in the interpretation of images to a more flexible practice, where every orthopaedic specialist could view and access images whenever required, including three-dimensional pictures.
In working with PACS, as the present study illustrates, orthopaedic surgeons initiate and complete most administrative activities as well as the challenging surgical ones. Work is not handed over to secretaries as a standard procedure. Orthopaedic surgeons now have an increased responsibility to keep the entire trajectory of diagnostic work moving. They are now their own assistants and secretaries, for example. It is not just that they have to do what other ‘communities of practice’ had to do before, but the introduction of PACS also generates new activities, such as more retrieval and reading of images, creation of meeting lists and manipulation of image data.
The relation of dependencies between communities of practice and different specialties was very clear in the old network where ‘a doctor was a doctor and a nurse was a nurse’ and ‘an orthopaedic surgeon was an orthopaedic surgeon and a radiologist was a radiologist’. 12 This has become less clear in the PACS hospital, where orthopaedic surgeons retrieve images and plans and store the results of surgery in the electronic patient records themselves. Technology requires social processes and conventions in order to be used and taken into practice. 13 This means that the more digital we become, the more social we become.
Technology used – before and after digitization
With PACS, images are immediately accessible to all clinicians at the hospital, even before the radiologist has finalized the radiology report. Diagnostic skills become accessible to all clinicians at the hospital. The shared image and text information may be discussed by telephone and simultaneously demonstrated at a multidisciplinary meeting. This shows that the orthopaedic surgeon has become less dependent on radiologists, secretaries, clerical staff and assistants at work. However, the transition from simple to complex technology and practice increases the demand for competence in the orthopaedic surgeons.
PACS leads to new expectations of work. As a result, the interpretation and report are expected to be delivered in real-time. However, the volume of images and information in each image has increased enormously. 14,15 This means that the interpretation of images may take more time if the practice of reading images is to be kept constant. When images and three-dimensional reconstructions were available through the new implemented computer systems, the orthopaedic surgeons were confronted with more options and decisions in work. This made much of their work more complex.
The present study shows that, as the technology in use takes on new properties, it triggers the development of new processes of working. The planned change involving clinical conferences at the orthopaedic department and not at the radiology department is an example. This can also create new possibilities, such as orthopaedic surgeons ordering image production in-house, but ordering diagnostic work from external providers. When images become digital, they can also be managed in new ways. For instance, MRI examinations are produced in Sweden and interpreted in Barcelona, and emergency departments in Uppsala and Danderyd send some images to Sydney in Australia for interpretation. 16,17
There is also a trend for other specialties to take over diagnostic work previously performed by radiologists. 18 This change in practice would not have been possible without PACS and teleradiology. Another trend is for new specialization among radiologists. For example, radiologists may become experts in fields such as molecular imaging or percutaneous gene therapy. Dalla Palma concluded that in the future radiologists must increase their clinical knowledge and revisit their communication with the patient, i.e. they must ‘reinvent themselves’. 19 Other studies show that the implementation of PACS cannot be seen as a technology project, 6 but rather as a project for change that can transform the radiological organization. 20
Footnotes
Acknowledgements
We thank the orthopaedic surgeons at Karolinska Sjukhuset Huddinge and Solna. We are also grateful to Jessica Ekberg, Linda Wennberg, Bo Jacobsson and the Radiological Informatics team, CLINTEC, Karolinska Institute.