View source for Journal:Users’ perspectives on a picture archiving and communication system (PACS): An in-depth study in a teaching hospital in Kuwait

{{Infobox journal article
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|caption      = 
|title_full   = Users’ perspectives on a picture archiving and communication system (PACS): An in-depth study in a teaching hospital in Kuwait
|journal      = ''JMIR Medical Informatics''
|authors      = Buabbas, Ali Jassem; Al-Shamali, Dawood Ameer; Sharma, Prem; Haidar, Salwa; Al-Shawaf, Hamza
|affiliations = Kuwait University, Mubarak AlKabeer Hospital
|contact      = Email: ali.buabbas [at] hsc.edu.kw; Phone: 965 25319504
|editors      = Eysenbach, G.
|pub_year     = 2016
|vol_iss      = '''4''' (2)
|pages        = e21
|doi          = [http://doi.org/10.2196/medinform.5703 10.2196/medinform.5703]
|issn         = 2291-9694
|license      = [http://creativecommons.org/licenses/by/2.0/ Creative Commons Attribution 2.0]
|website      = [http://medinform.jmir.org/2016/2/e21/ http://medinform.jmir.org/2016/2/e21/]
|download     = [http://medinform.jmir.org/2016/2/e21/pdf http://medinform.jmir.org/2016/2/e21/pdf] (PDF)
}}
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==Abstract==
'''Background''': The [[picture archiving and communication system]] (PACS) is a well-known [[imaging informatics]] application in health care organizations, specifically designed for the radiology department. Health care providers have exhibited willingness toward evaluating PACS in hospitals to ascertain the critical success and failure of the technology, considering that evaluation is a basic requirement.

'''Objective''': This study aimed to evaluate the success of a PACS in a regional teaching hospital of Kuwait, from users’ perspectives, using information systems success criteria.

'''Methods''': An in-depth study was conducted by using quantitative and qualitative methods. This mixed-method study was based on: (1) questionnaires, distributed to all radiologists and technologists and (2) interviews, conducted with PACS administrators.

'''Results''': In all, 60 questionnaires were received from the respondents. These included 39 radiologists (75% response rate) and 21 technologists (62% response rate), with the results showing almost three-quarters (74%, 44 of 59) of the respondents rating PACS positively and as user-friendly. This study’s findings revealed that the demographic data, including computer experience, was an insignificant factor, having no influence on the users’ responses. The findings were further substantiated by the administrators’ interview responses, which supported the benefits of PACS, indicating the need for developing a unified policy aimed at streamlining and improving the departmental workflow.

'''Conclusions''': The PACS had a positive and productive impact on the radiologists’ and technologists’ work performance. They were endeavoring to resolve current problems while keeping abreast of advances in PACS technology, including teleradiology and the mobile image viewer, which is steadily increasing in usage in the Kuwaiti health system.

'''Keywords''': PACS evaluation, user perspective, IS success, imaging informatics, radiology 

==Introduction==
The picture archiving and communication system (PACS) is a well-known imaging informatics application in health care organizations, specifically designed for the radiology department. A PACS could be defined as “an electronic information system (IS) used to acquire, store, transmit, and display medical images.”<ref name="TzengASocio13">{{cite journal |title=A socio-technical assessment of the success of Picture Archiving and Communication Systems: The radiology technologist's perspective |journal=BMC Medical Informatics and Decision Making |author=Tzeng, W.S.; Kuo, K.M.; Lin, H.W.; Chen, T.Y. |volume=13 |pages=109 |year=2013 |doi=10.1186/1472-6947-13-109 |pmid=24053458 |pmc=PMC3849362}}</ref> Using a PACS in a hospital has innumerable benefits at various levels.<ref name="VestImage15">{{cite journal |title=Image Sharing Technologies and Reduction of Imaging Utilization: A Systematic Review and Meta-analysis |journal=Journal of the American College of Radiology |author=Vest, J.R.; Jung, H.Y.; Ostrovsky, A. et al. |volume=12 |issue=12 Pt B |pages=1371-1379.e3 |year=2015 |doi=10.1016/j.jacr.2015.09.014 |pmid=26614882 |pmc=PMC4730956}}</ref> At the management level, this technology has direct implications for cost reduction, rendering the film production process redundant. At the departmental level, the technology enhances productivity, as all tasks are performed digitally and swiftly. And at the clinical level, image interpretation and diagnosis become more precise and accurate.<ref name="DuyckMonitoring10">{{cite journal |title=Monitoring the PACS implementation process in a large university hospital: Discrepancies between radiologists and physicians |journal=Journal of Digital Imaging |author=Duyck, P.; Pynoo, B.; Devolder, P. et al. |volume=23 |issue=1 |pages=73–80 |year=2010 |doi=10.1007/s10278-008-9163-7 |pmid=18956231 |pmc=PMC3043749}}</ref> For these reasons, health care organizations are increasingly adopting the PACS in their clinical radiology departments, despite the high costs, to benefit from the full advantages of using the technology. PACSs are currently being applied in many medical imaging projects around the world, such as in the United States, the United Kingdom, and Asia. However, the available literature reveals gaps with regard to the systems’ effectiveness and efficiency concerning their intended use.

The existing literature abounds with studies evaluating the PACS.<ref name="HainsTheImpact12">{{cite journal |title=The impact of PACS on clinician work practices in the intensive care unit: a systematic review of the literature |journal=JAMIA |author=Hains, I.M.; Georgiou, A.; Westbrook, J.I. |volume=19 |issue=4 |pages=506–13 |year=2012 |doi=10.1136/amiajnl-2011-000422 |pmid=22323392 |pmc=PMC3384105}}</ref> However, these evaluations invariably had different focuses and objectives; for instance, there are studies on the PACS before and after the system’s implementation<ref name="BryanTheBenefits99">{{cite journal |title=The benefits of hospital-wide picture archiving and communication systems: A survey of clinical users of radiology services |journal=The British Journal of Radiology |author=Bryan, S.; Weatherburn, G.C.; Watkins, J.R.; Buxton, M.J. |volume=72 |issue=857 |pages=469-78 |year=1999 |doi=10.1259/bjr.72.857.10505012 |pmid=10505012}}</ref>, users’ satisfaction<ref name="TanPicture10">{{cite journal |title=Picture archiving and communication systems: A multicentre survey of users experience and satisfaction |journal=European Journal of Radiology |author=Tan, S.L.; Lewis, R.A. |volume=75 |issue=3 |pages=406–10 |year=2010 |doi=10.1016/j.ejrad.2009.05.008 |pmid=19523778}}</ref>, PACS acceptance<ref name="AldosariUser12">{{cite journal |title=User acceptance of a picture archiving and communication system (PACS) in a Saudi Arabian hospital radiology department |journal=BMC Medical Informatics and Decision Making |author=Aldosari, B. |volume=12 |pages=44 |year=2012 |doi=10.1186/1472-6947-12-44 |pmid=22640490 |pmc=PMC3423046}}</ref>, cost-effectiveness<ref name="BryanEval99">{{cite journal |title=Evaluation of a hospital picture archiving and communication system |journal=Journal of Health Services Research and Policy |author=Bryan, S.; Weatherburn, G.; Buxton, M. et al. |volume=4 |issue=4 |pages=204-9 |year=1999 |doi=10.1177/135581969900400405 |pmid=10623035}}</ref><ref name="MoodleyAComp15">{{cite journal |title=A comparative cost analysis of picture archiving and communications systems (PACS) versus conventional radiology in the private sector |journal=South African Journal of Radiology |author=Moodley, I.; Moodley, S. |volume=19 |issue=1 |pages=634-641 |year=2015 |doi=10.4102/sajr.v19i1.634}}</ref>, and the system’s efficiency concerning its use and in saving time.<ref name="MackinnonPicture08">{{cite journal |title=Picture archiving and communication systems lead to sustained improvements in reporting times and productivity: Results of a 5-year audit |journal=Clinical Radiology |author=Mackinnon, A.D.; Billington, R.A.; Adam, E.J. et al. |volume=63 |issue=7 |pages=796-804 |year=2008 |doi=10.1016/j.crad.2007.12.015 |pmid=18555038}}</ref> The most widely used form of the PACS evaluation concerns its impact on users.<ref name="HainsTheImpact12" /><ref name="VanDeWeteringABalanced06">{{cite journal |title=A balanced evaluation perspective: Picture archiving and communication system impacts on hospital workflow |journal=Journal of Digital Imaging |author=van de Wetering, R.; Batenburg, R.; Versendaal, J. et al. |volume=19 |issue=Suppl 1 |pages=10 |year=2006 |doi=10.1007/s10278-006-0628-2 |pmid=16763932 |pmc=PMC3045172}}</ref><ref name="CreswickInnovation11">{{cite journal |title=Innovation in intensive care nursing work practices with PACS |journal=Studies in Health Technology and Informatics |author=Creswick, N.; Hains, I.M.; Westbrook, J.I. |volume=169 |pages=402–6 |year=2011 |doi=10.3233/978-1-60750-806-9-402 |pmid=21893781}}</ref>

In PACS research and practice, once the system has been adopted and implemented, it becomes imperative to evaluate the technology’s effectiveness within an organization.<ref name="VanDeWeteringTowards14">{{cite journal |title=Towards a theory of PACS deployment: An integrative PACS maturity framework |journal=Journal of Digital Imaging |author=van de Wetering, R.; Batenburg, R. |volume=27 |issue=3 |pages=337–50 |year=2014 |doi=10.1007/s10278-013-9671-y |pmid=24448919 |pmc=PMC4026462}}</ref> For all practical purposes, evaluation could be defined as “the process of describing the implementation of an information resource and judging its merits and worth.”<ref name="FriedmanEvaluation06">{{cite book |title=Evaluation Methods in Biomedical Informatics |author=Friedman, C.P.; Wyatt, J. |publisher=Springer-Verlag New York |pages=386 |year=2006 |isbn=9780387258898 |doi=10.1007/0-387-30677-3}}</ref> IS deployment may invariably lead to unintended consequences, affecting the chances of the technology’s success.<ref name="FriedmanEvaluation06" /> Several researchers have, therefore, recommended evaluation studies specially focused on PACSs to assess their impact in clinical practice [4,15].<ref name="HainsTheImpact12" /><ref name="MansooriPicture12">{{cite journal |title=Picture Archiving and Communication System (PACS) implementation, integration & benefits in an integrated health system |journal=Academic Radiology |author=Mansoori, B.; Erhard, K.K.; Sunshine, J.L. |volume=19 |issue=2 |pages=229–35 |year=2012 |doi=10.1016/j.acra.2011.11.009 |pmid=22212425}}</ref>

It is of paramount significance to investigate the success of the PACS, exploring the factors responsible for the success or failure to determine its worth clinically, based on the direct users of this system.

The conceptual basis of this study is focused on this: the impact of a PACS in a regional hospital in Kuwait based on specific criteria. This study is the first of its kind in Kuwait, there being a scarcity of literature in this field.

===Research questions===
The research questions were specifically as follows: (1) What impact does the PACS have on the clinical practice of radiologists and technologists in the radiology department of Mubarak Al-Kabeer Hospital? (2) Has the use of the PACS proven successful in improving the radiology department’s work performance?

This study aimed at evaluating the success of the PACS in clinical practice, in a bid to determine the technology’s merits for radiologists and technologists, including its drawbacks.

==Methods==
===Research settings===
The universe of this study was Mubarak Al-Kabeer Teaching Hospital, which is one of the five regional hospitals in the State of Kuwait. Table 1 presents the site’s profile. 

{| 
 | STYLE="vertical-align:top;"|
{| class="wikitable" border="1" cellpadding="5" cellspacing="0" width="100%"
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;" colspan="2"|'''Table 1.''' Mubarak Al-Kabeer teaching hospital’s profile
 |-
  ! style="padding-left:10px; padding-right:10px;"|Categories
  ! style="padding-left:10px; padding-right:10px;"|Number
 |- 
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Hospital beds
  | style="background-color:white; padding-left:10px; padding-right:10px;"|734
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Hospitalized patients
  | style="background-color:white; padding-left:10px; padding-right:10px;"|21,124
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Physicians
  | style="background-color:white; padding-left:10px; padding-right:10px;"|559
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Radiologists
  | style="background-color:white; padding-left:10px; padding-right:10px;"|52
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Radiology technologists
  | style="background-color:white; padding-left:10px; padding-right:10px;"|34
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|PACS administrators
  | style="background-color:white; padding-left:10px; padding-right:10px;"|5
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Average number of images examined monthly
  | style="background-color:white; padding-left:10px; padding-right:10px;"|32,787
 |-
|}
|}

This general hospital is a university-teaching hospital in Kuwait and was chosen because it is always at the forefront of development and advanced medicine. Therefore, to ensure the full advantage of the health information system (HIS), the PACS’s success needed to be verified. The PACS was first introduced in the radiology department of Mubarak Al-Kabeer Hospital in 2004, marking the transition of clinical services from a film-based system to an electronic-based system. The PACS used is an off-the-shelf, Oracle-based HIS (GE Centrisity RIS i 4.2 plus, GE PACS IW 3.7.3.9 SP 3). The PACS currently has 35 workstations, with a server capacity of 64 terabytes. Radiologists use the PACS to view images through the [[radiology information system]] (RIS), which they use to report their cases. The reports generated by the RIS are then sent to the PACS, through which final reports can be sent to the HIS. The treating physician needs to submit an access request to see patients’ images on the PACS. In June 2013, the PACS software was upgraded, and currently the system is fully integrated technically with the RIS and the HIS, providing the users with a secure system.

===Study design===
An in-depth study was conducted by using quantitative and qualitative methods. This mixed-method study was based on: (1) survey questionnaires, which were distributed to gather information from radiologists and technologists in the radiology department of Mubarak Al-Kabeer Hospital and (2) semi structured interviews, which were conducted to gather empirical information from the PACS administrators. Ethical approval for the study was obtained from the research department of the Ministry of Health, Kuwait.

To gather the responses of radiologists and technologists concerning the use of the PACS in their clinical practice, a validated questionnaire from a previous study was used.<ref name="ParéToward05">{{cite journal |title=Toward a multidimensional assessment of picture archiving and communication system success |journal=International Journal of Technology Assessment in Health Care |author=Paré, G.; Lepanto, L.; Aubry, D.; Sicotte, C. |volume=21 |issue=4 |pages=471–9 |year=2005 |doi=10.1017/S0266462305050658 |pmid=16262970}}</ref> The questionnaire was translated from French into English through an official translation office in Kuwait. The English version of the questionnaire was pretested with five radiologists and three technologists to ensure the suitability and usability of the questions. Accordingly, a number of amendments were made to the questionnaire. These included excluding questions that were found to be irrelevant to the technologists’ use of the PACS, which comprised items that focused on retrieving, displaying, comparing, and manipulating images, including confidence level. In addition, a seven-point Likert scale was changed to five points to make it easier and more familiar for the respondents.

In this study, evaluating the PACS’s success was based on an integrated multidimensional model, which was constructed from the model primarily developed by DeLone and McLean<ref name="DeLoneInformation92">{{cite journal |title=Information Systems Success: The Quest for the Dependent Variable |journal=Information Systems Research |author=DeLone, W.H.; McLean, E.R. |volume=3 |issue=1 |pages=60–95 |year=1992 |doi=10.1287/isre.3.1.60}}</ref><ref name="DeLoneTheDeLone03">{{cite journal |title=The DeLone and McLean Model of Information Systems Success: A Ten-Year Update |journal=Journal of Management Information Systems |author=DeLone, W.H.; McLean, E.R. |volume=19 |issue=4 |pages=9–30 |year=2003 |doi=10.1080/07421222.2003.11045748}}</ref>, later developed with two constructs added to the model, namely system continuance intention and confirmation of expectations.<ref name="ParéToward05" /> (See Figure 1.)


[[File:Fig1 Buabbas JMIRMedInfo2016 4-2.png|854px]]
{{clear}}
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{| border="0" cellpadding="5" cellspacing="0" width="854px"
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  | style="background-color:white; padding-left:10px; padding-right:10px;"| <blockquote>'''Fig. 1''' An integrated model of picture archiving and communication system (PACS) success</blockquote>
 |- 
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The questionnaire comprised seven sections (Textbox 1) for assessing the users’ perspectives on eight interrelated dimensions of the PACS success model. These included: (1) perceived system quality; (2) perceived information quality; (3) perceived service quality; (4) system usage; (5) user satisfaction; (6) perceived net benefits; (7) system continuance intention; and (8) confirmed expectations. The questionnaire was distributed to all radiologists and radiology technologists who had used the PACS in their clinical practice for the last two years.

{| 
 | STYLE="vertical-align:top;"|
{| class="wikitable" border="1" cellpadding="5" cellspacing="0" width="100%"
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;" colspan="1"|'''Textbox 1.''' Sections of the questionnaire
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Section 1: Quality of PACS<br />
Ease of access and use<br />&nbsp;<br />* Diversity of functionalities offered by the PACS<br />* Reliability of the hardware and software<br />* PACS integration and compatibility with the RIS and the HIS<br />* Security of the PACS
|}
|}

The data gathered through the questionnaire were complemented by conducting semi-structured interviews with PACS administrators to gain an understanding of the prevailing clinical environment, which entails them communicating with radiologists, doctors, and technologists, including providing information technology services and support.<ref name="JoshiPACS14">{{cite journal |title=PACS administrators' and radiologists' perspective on the importance of features for PACS selection |journal=Journal of Digital Imaging |author=Joshi, V.; Narra, V.R.; Joshi, K. |volume=27 |issue=4 |pages=486-95 |year=2014 |doi=10.1007/s10278-014-9682-3 |pmid=24744278 |pmc=PMC4090402}}</ref> Their experience further enriched the information gathered and the study’s purpose.

The focus of the interviews was primarily similar to that of the questionnaire: to gain a deeper insight into the response patterns of the respondents. The interviews were conducted with the radiology technologists, who are responsible for administering the PACS and overseeing the RIS operations in the radiology department.

===Statistical analysis===
Data management, analysis, and graphical presentation were carried out using the software Statistical Package for the Social Sciences (SPSS), version 22.0. The questionnaire was evaluated for internal consistency and reliability, and Cronbach alpha values were estimated for major perspectives by combining the Likert scale items for specific aspects, including quality, information, images, technical support and usage, user satisfaction, and overall opinion on the PACS. The descriptive statistics analysis generated frequencies and percentages for all the five-point Likert scale items (1 as lowest or strongly disagree and 5 as highest or strongly agree) in the questionnaire. The Likert scale data were also analyzed to find average values for overall responses and to compare the mean (±standard deviation, SD) between radiologists and technologists using ''t'' tests or nonparametric Mann-Whitney tests. The quantitative or continuous variables, age, duration of use (h), and minutes saved every day were first ascertained for normal distribution, applying the Kolmogorov-Smirnov test and were presented as mean ± SD and range for normally distributed variables and as median, range and interquartile (IQ) for skewed data. The chi-square or Fisher exact test was applied to find any association or significant difference between categorical variables. The Spearman correlation coefficient (rho) was used to find any correlations among the number of hours worked, the use of the PACS, and the minutes saved in daily practice. The two-tailed probability value ''P''<.05 was considered statistically significant.

==Results==
===Questionnaires===
====Respondent demographics====
The study’s overall response rate was 70%: 75% of the radiologists and 62% of the technologists of the radiology department. The study had 60 respondents: 39 radiologists (mean age = 36±7.5 SD) and 21 technologists (mean age = 28±10 SD). The respondents’ ages varied between 20 and 60 years, with the majority (85%; 51 of 60) aged younger than 40 years. The respondents’ average self-rated level of familiarity with computers was 4.8 ± 1.34 (mean ± SD) on a scale of 1-7, and 41% (24 of 59) of the respondents had earlier experience with PACSs before working at this radiology department.

====Evaluation of Different Perspectives on the PACS====
The overall responses on different perspectives were analyzed, and composite reliability and coefficients (Cronbach alpha) were computed and presented in Table 2, along with mean and range for each perspective. The Cronbach alpha values ranged between .73 and .96, except for one as shown in in Table 2. System quality, images produced, and services all had high (>.9) Cronbach alpha values.

The overall perspectives of users have been presented on the following aspects:

'''System quality'''

Almost three-quarters (75%; 44 of 59) of the respondents rated the PACS positively and as user-friendly, with a mean of 3.28 (Table 2). Comparatively fewer (64%; 38 of 59) respondents mentioned some drawbacks of the system, such as it being temporarily out-of-service or not working, having numerous bugs, causing wait times at the workstations, and exhibiting reduced screen quality which slowed down PACS use. The majority (81%; 48 of 59) agreed that the PACS had improved the quality of services at the radiology department (mean=4.01). However, some suggestions were provided by respondents (mean=3.57) with regard to the system’s improvement, including the provision of more options and investment in upgrading the visualization equipment (PC monitors).

{| 
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{| class="wikitable" border="1" cellpadding="5" cellspacing="0" width="100%"
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;" colspan="6"|'''Table 2.''' PACS users and their responses<br />&nbsp;<br /><sup>a</sup>Cronbach Alpha: Measure of Internal Consistency Reliability<br /><sup>b</sup>Mean values are based on a five-point Likert scale, with 1 being the lowest and 5 being the highest.
 |-
  ! style="padding-left:10px; padding-right:10px;" colspan="2"|User perspectives of the PACS
  ! style="padding-left:10px; padding-right:10px;"|Number of items
  ! style="padding-left:10px; padding-right:10px;"|Alpha<sup>a</sup>
  ! style="padding-left:10px; padding-right:10px;"|Mean<sup>b</sup>
  ! style="padding-left:10px; padding-right:10px;"|Range
 |- 
  | style="background-color:white; padding-left:10px; padding-right:10px;"|'''Quality'''
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Encouraging features
  | style="background-color:white; padding-left:10px; padding-right:10px;"|15
  | style="background-color:white; padding-left:10px; padding-right:10px;"|.906
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.284
  | style="background-color:white; padding-left:10px; padding-right:10px;"|1.567-4.033
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Non-encouraging features
  | style="background-color:white; padding-left:10px; padding-right:10px;"|5
  | style="background-color:white; padding-left:10px; padding-right:10px;"|.767
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.000
  | style="background-color:white; padding-left:10px; padding-right:10px;"|2.50-3.400
 |-
 |- 
  | style="background-color:white; padding-left:10px; padding-right:10px;"|'''Information'''
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Produce better information
  | style="background-color:white; padding-left:10px; padding-right:10px;"|4
  | style="background-color:white; padding-left:10px; padding-right:10px;"|.888
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.754
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.650-4.000
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|'''Images'''
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Quality of images produced
  | style="background-color:white; padding-left:10px; padding-right:10px;"|4
  | style="background-color:white; padding-left:10px; padding-right:10px;"|.910
  | style="background-color:white; padding-left:10px; padding-right:10px;"|4.272
  | style="background-color:white; padding-left:10px; padding-right:10px;"|4.183-4.333
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Compared to traditional films
  | style="background-color:white; padding-left:10px; padding-right:10px;"|4
  | style="background-color:white; padding-left:10px; padding-right:10px;"|.855
  | style="background-color:white; padding-left:10px; padding-right:10px;"|4.333
  | style="background-color:white; padding-left:10px; padding-right:10px;"|4.100-4.483
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Confidence in image quality
  | style="background-color:white; padding-left:10px; padding-right:10px;"|2
  | style="background-color:white; padding-left:10px; padding-right:10px;"|.875
  | style="background-color:white; padding-left:10px; padding-right:10px;"|4.205
  | style="background-color:white; padding-left:10px; padding-right:10px;"|4.154-4.256
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Data adequacy—access to patient data
  | style="background-color:white; padding-left:10px; padding-right:10px;"|2
  | style="background-color:white; padding-left:10px; padding-right:10px;"|.808
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.558
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.500-3.617
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|'''Technical support'''
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Reliable, prompt services
  | style="background-color:white; padding-left:10px; padding-right:10px;"|7
  | style="background-color:white; padding-left:10px; padding-right:10px;"|.961
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.598
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.483-3.683
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|'''Use of the PACS and satisfaction'''
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Frequency of PACS use
  | style="background-color:white; padding-left:10px; padding-right:10px;"|5
  | style="background-color:white; padding-left:10px; padding-right:10px;"|.638
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.573
  | style="background-color:white; padding-left:10px; padding-right:10px;"|2.583-4.000
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|User satisfaction
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3
  | style="background-color:white; padding-left:10px; padding-right:10px;"|.887
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.650
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.533-3.717
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|'''Future use of the PACS'''
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Expectations, and continuance of use
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3
  | style="background-color:white; padding-left:10px; padding-right:10px;"|.734
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.394
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.233-3.483
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|'''Overall opinion and impact of the PACS'''
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Improved quality and services (benefits)
  | style="background-color:white; padding-left:10px; padding-right:10px;"|21
  | style="background-color:white; padding-left:10px; padding-right:10px;"|.919
  | style="background-color:white; padding-left:10px; padding-right:10px;"|4.008
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.169-4.390
 |-
|}
|}

'''Information quality'''

In all, 90% (53 of 59) agreed that the PACS produced better and higher-quality information (mean=3.75) that was accurate, updated, relevant, and timely. The system also provided complete patient information, including adequate access to patients’ historical data (mean=3.56).

'''Image quality'''

The PACS users were extremely satisfied with regard to the quality of the images produced, ease of understanding, and relevance (mean=4.27). They found that the PACS produced much better images compared to traditional film (mean=4.33).

'''Technical support and services'''

The PACS users were quite satisfied with technical support (mean=3.60) and the reliability, promptness, and dependability of services.

'''Use of PACS and satisfaction'''

In all, 50% (30 of 60) of the respondents mentioned using the PACS for more than 30 hours per week (Figure 2), although a significant difference was found regarding the duration of PACS use (hours/week) between radiologists and technologists (P<.001). A high level of user satisfaction was shown with regard to their experience in using the PACS (mean=3.65). The usage of various tools, including changing display format, retrieving, and “split screening” to compare images, was found to be quite satisfactory (mean=3.57), especially among radiologists.


[[File:Fig2 Buabbas JMIRMedInfo2016 4-2.png|854px]]
{{clear}}
{| 
 | STYLE="vertical-align:top;"|
{| border="0" cellpadding="5" cellspacing="0" width="854px"
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"| <blockquote>'''Fig. 2''' Respondents’ picture archiving and communication system (PACS) use per week</blockquote>
 |- 
|}
|}

'''Future use and expectations on PACS'''

In all, 83.9% (mean=3.39) of PACS users mentioned their expectations better than what they expected originally and showed intention to continue using PACS.

'''Overall opinions and impact of PACS'''

Based on 21 different statements, 93% (56 of 60) of the PACS users showed consensus on various aspects of the system’s benefits and effectiveness (mean=4.01), and the mean was significantly higher for technologists as compared with radiologists (4.22 vs 3.89). Furthermore, the results showed that 80% (48 of 60) of the PACS users reported saving more than 30 minutes of their practice time each day, whereas 38% (23 of 60) mentioned saving more than an hour each day.

====Radiologists versus technologists====
Table 3 summarizes the comparison between radiologists’ and technologists’ responses with regard to their perspectives concerning the PACS. The mean values were significantly higher for the technologists as compared with the radiologists, especially concerning quality, information, patient data, technical support, and overall opinion on impact of the PACS (P<.05). Both professionals showed the highest level of satisfaction (mean >4) with regard to image produced, and their overall opinions on PACS demonstrated improved quality and services (radiologist 3.9 and technologists 4.2).

{| 
 | STYLE="vertical-align:top;"|
{| class="wikitable" border="1" cellpadding="5" cellspacing="0" width="100%"
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;" colspan="7"|'''Table 3.''' Radiologists’ and technologists’ responses<br />&nbsp;<br /><sup>a</sup>Mean values are based on a five-point Likert scale, with 1 being the lowest and 5 being the highest.<br /><sup>b</sup>Technologists were not asked this question, as the decision on image quality lies on radiologists.
 |-
  ! style="padding-left:10px; padding-right:10px;" colspan="2" rowspan="2"|User perspectives of the PACS
  ! style="padding-left:10px; padding-right:10px;" colspan="2"|Radiologists (n=39)
  ! style="padding-left:10px; padding-right:10px;" colspan="2"|Technologists (n=21)
  ! style="padding-left:10px; padding-right:10px;" rowspan="2"|''P'' value
 |- 
  ! style="padding-left:10px; padding-right:10px;"|Mean<sup>a</sup>
  ! style="padding-left:10px; padding-right:10px;"|SD
  ! style="padding-left:10px; padding-right:10px;"|Mean<sup>a</sup>
  ! style="padding-left:10px; padding-right:10px;"|SD
 |- 
  | style="background-color:white; padding-left:10px; padding-right:10px;"|'''Quality'''
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Encouraging features
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.109
  | style="background-color:white; padding-left:10px; padding-right:10px;"|0.559
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.733
  | style="background-color:white; padding-left:10px; padding-right:10px;"|0.528
  | style="background-color:white; padding-left:10px; padding-right:10px;"|.006
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Non-encouraging features
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.070
  | style="background-color:white; padding-left:10px; padding-right:10px;"|0.693
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.333
  | style="background-color:white; padding-left:10px; padding-right:10px;"|0.563
  | style="background-color:white; padding-left:10px; padding-right:10px;"|.244
 |- 
  | style="background-color:white; padding-left:10px; padding-right:10px;"|'''Information'''
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Produce better information
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.539
  | style="background-color:white; padding-left:10px; padding-right:10px;"|0.830
  | style="background-color:white; padding-left:10px; padding-right:10px;"|4.155
  | style="background-color:white; padding-left:10px; padding-right:10px;"|0.886
  | style="background-color:white; padding-left:10px; padding-right:10px;"|.007
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|'''Images'''
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Quality of images produced
  | style="background-color:white; padding-left:10px; padding-right:10px;"|4.188
  | style="background-color:white; padding-left:10px; padding-right:10px;"|0.692
  | style="background-color:white; padding-left:10px; padding-right:10px;"|4.429
  | style="background-color:white; padding-left:10px; padding-right:10px;"|0.598	
  | style="background-color:white; padding-left:10px; padding-right:10px;"|.186
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Compared to traditional films
  | style="background-color:white; padding-left:10px; padding-right:10px;"|4.436
  | style="background-color:white; padding-left:10px; padding-right:10px;"|0.622
  | style="background-color:white; padding-left:10px; padding-right:10px;"|4.143
  | style="background-color:white; padding-left:10px; padding-right:10px;"|0.705
  | style="background-color:white; padding-left:10px; padding-right:10px;"|.083
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Confidence in image quality<sup>b</sup>
  | style="background-color:white; padding-left:10px; padding-right:10px;"|4.205
  | style="background-color:white; padding-left:10px; padding-right:10px;"|0.704
  | style="background-color:white; padding-left:10px; padding-right:10px;"|---
  | style="background-color:white; padding-left:10px; padding-right:10px;"|---
  | style="background-color:white; padding-left:10px; padding-right:10px;"|---
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Data adequacy—access to patient data
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.295
  | style="background-color:white; padding-left:10px; padding-right:10px;"|1.074
  | style="background-color:white; padding-left:10px; padding-right:10px;"|4.048
  | style="background-color:white; padding-left:10px; padding-right:10px;"|0.879
  | style="background-color:white; padding-left:10px; padding-right:10px;"|.005
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|'''Technical support'''
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Reliable, prompt services
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.396
  | style="background-color:white; padding-left:10px; padding-right:10px;"|1.080
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.973
  | style="background-color:white; padding-left:10px; padding-right:10px;"|0.600
  | style="background-color:white; padding-left:10px; padding-right:10px;"|.029
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|'''Use of the PACS and satisfaction'''
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Frequency of PACS use
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.585
  | style="background-color:white; padding-left:10px; padding-right:10px;"|0.760
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.552
  | style="background-color:white; padding-left:10px; padding-right:10px;"|0.819
  | style="background-color:white; padding-left:10px; padding-right:10px;"|.963
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|User satisfaction
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.556
  | style="background-color:white; padding-left:10px; padding-right:10px;"|0.863
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.825
  | style="background-color:white; padding-left:10px; padding-right:10px;"|0.611
  | style="background-color:white; padding-left:10px; padding-right:10px;"|.144
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|'''Future use of the PACS'''
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Expectations, and continuance of use
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.282
  | style="background-color:white; padding-left:10px; padding-right:10px;"|0.867
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.603
  | style="background-color:white; padding-left:10px; padding-right:10px;"|0.629
  | style="background-color:white; padding-left:10px; padding-right:10px;"|.140
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|'''Overall opinion and impact of the PACS'''
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"|
  | style="background-color:white; padding-left:10px; padding-right:10px;"|Improved quality and services (benefits)
  | style="background-color:white; padding-left:10px; padding-right:10px;"|3.892
  | style="background-color:white; padding-left:10px; padding-right:10px;"|0.623
  | style="background-color:white; padding-left:10px; padding-right:10px;"|4.218
  | style="background-color:white; padding-left:10px; padding-right:10px;"|0.427
  | style="background-color:white; padding-left:10px; padding-right:10px;"|.050
 |-
|}
|}

In total, 49% (19 of 39) of the radiologists mentioned saving more than 60 minutes every day, as compared to 19% (4 of 21) of the technologists (P=.048) (Figure 3).


[[File:Fig3 Buabbas JMIRMedInfo2016 4-2.png|837px]]
{{clear}}
{| 
 | STYLE="vertical-align:top;"|
{| border="0" cellpadding="5" cellspacing="0" width="837px"
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"| <blockquote>'''Fig. 3''' Respondents’ minutes saved per day</blockquote>
 |- 
|}
|}

During use of the PACS, both professional groups reported significant savings in the working time for different modalities, though with much variation (the Kolmogorov–Smirnov tests showed a skewed distribution); the median and interquartile have been presented in Figure 4 as a box-plot. The maximum number of minutes saved was 52 minutes (median time) by radiologists in magnetic resonance imaging and 50 minutes by technologists in radiography.


[[File:Fig4 Buabbas JMIRMedInfo2016 4-2.png|874px]]
{{clear}}
{| 
 | STYLE="vertical-align:top;"|
{| border="0" cellpadding="5" cellspacing="0" width="874px"
 |-
  | style="background-color:white; padding-left:10px; padding-right:10px;"| <blockquote>'''Fig. 4''' Average minutes (median with interquartile range) saved per day by picture archiving and communication system (PACS) users in different modalities</blockquote>
 |- 
|}
|}

A significant positive correlation was observed between the number of hours using the PACS and the minutes saved in daily practice since the introduction of the PACS (r=0.27, P=.037).

The level of prior familiarity with computers was found to be similar between the radiologists (4.84±1.34 SD) and the technologists (4.71±1.35 SD) and did not make any significant difference either in the average duration (hours/week) of working with the PACS or the time saved (minutes/day) during practice.

The results of the open-ended questions showed that 24% (9 of 38) of the radiologists and 33% (7 of 21) of the technologists stated that storing, retrieving, and comparing images were the most positive elements associated with the use of the PACS. By contrast, 33% (13 of 39) of the radiologists and 43% (9 of 21) of the technologists stated that frequent glitches were the most negative element associated with the PACS.

Overall, the study’s findings revealed that both the radiologists and the technologists perceived the adoption of the PACS positively. The mean scores were mostly above 3 or 4 on a scale of 1-5. The mean scores for image quality and information produced were 4.3 and 3.8, respectively. The users seemed quite satisfied with the services and technical support, with a mean score of 3.6 and showed satisfaction in working with the PACS (mean=3.65). The PACS users clearly mentioned improved services and quality since the system came into practice, with a mean score of 4.

====Interviews====
The opinions of the PACS administrators were obtained by using the interview method, for which a series of semi-structured questions on specific themes (Textbox 1) provided the basis for soliciting information.

At the time of the interviews, Mubarak Al-Kabeer Hospital had five PACS administrators. For scheduling the interviews, requisite permission was taken from the head of the radiology department, and interview sessions were arranged with the staff during their respective work breaks, over a five-day period. Each interview session lasted approximately 50 minutes. The interviews were transcribed, and the responses were coded and analyzed using thematic analysis.

The interview results showed that all the interviewees had a BSc degree in radiological sciences, with their ages ranging between 25 and 35 years, and each having work experience of 2-5 years in PACS administration. Of the interviewees, only three had undertaken an introductory training program abroad on PACS use and management.

====Perceived system quality====
The interview responses confirmed that the PACS provided easy access to authorized users, each with a user identification (ID) number and password, thereby providing a secured workspace depending on the user’s position. For instance, a radiology technologist’s access is limited to only viewing the reporting screen, with no authorization to change or manipulate it, thus preserving the data, with no hacking or security problems ever encountered or reported.

The interviewees unanimously agreed that the PACS was user friendly and hassle free in its functionality. In one of the interviewee’s words, “We haven’t experienced any complaints from radiologists regarding the clarity of the PACS’s features, or any difficulties in moving between its functions,” further adding that training in the PACS should be a prerequisite before its use.

The participants also endorsed the reliability and consistency of the existing hardware, including computer systems, networks, and printers, with the software used. The interviews further revealed that the PACS was fully integrated and compatible with the RIS and the HIS, although the workflow did not follow the planned process, as Figure 5 demonstrates. According to one interviewee, “The real mistakes are not coming from the PACS but from humans, so they’re human errors.” The interview responses also highlighted that the problems associated with PACS integration and compatibility with the RIS and the HIS were the result of disorganized workflow, as shown in Figure 5.


[[File:Fig5 Buabbas JMIRMedInfo2016 4-2.png|886px]]
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{| border="0" cellpadding="5" cellspacing="0" width="886px"
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  | style="background-color:white; padding-left:10px; padding-right:10px;"| <blockquote>'''Fig. 5''' Workstations where electronic registrations of patients failed through the health information system (HIS) and radiology information system (RIS)</blockquote>
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Figure 5 (above) illustrates the workstations where electronic registration of patients through the HIS and the RIS failed due to receptionist errors such as: (1) no data entry into HIS, manual registration in the RIS; (2) failure of communication between the HIS and the RIS, manual registration in the RIS; (3) and incorrect registration at reception, manual registration in the RIS (Figure 6).


[[File:Fig6 Buabbas JMIRMedInfo2016 4-2.png|882px]]
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{| border="0" cellpadding="5" cellspacing="0" width="882px"
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  | style="background-color:white; padding-left:10px; padding-right:10px;"| <blockquote>'''Fig. 6''' Manual registration of patients through the health information system (HIS) and radiology information system (RIS)</blockquote>
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The manual registration at these three workstations resulted in: (1) a lack of direct access to patients’ imaging results through the HIS; (2) the creation of multiple PACS numbers for the same patient, making it difficult to retrieve previous reports for comparison, as well as the loss of patient data; and (3) delayed patient case management due to a failure in the rapid delivery of results.

====Perceived information quality====
The interviewees agreed that the PACS provided a standard format for the acquisition of accurate and complete information, together with images, concerning the patients’ medical cases, including their name, age, gender, national identification number, medical record number, and medical history. The lapses that occurred in the recorded information were attributed to the registration staff of the diagnostic radiology department because of their noncompliance to instructions, which resulted in incomplete data records of patients at the time of registration.

====Perceived image quality====
The interview responses indicated that one of the main roles of PACS administrators was to ensure that the images were transferred and displayed with clarity to facilitate studying and reporting. The participants further confirmed that “We experience hangs in the images in PACS, but at an acceptable rate” and no complaints were mentioned concerning image manipulation and management.

====Perceived technical support services====
As the interviewees mentioned, the main IT support is delivered through the company that sold the PACS. This usually happens when the PACS administrators face a technical problem that can only be solved through the main IT support at the company. Thus, the PACS administrators asked to have some power to authorize them to solve the technical issues within the radiology department. One of the interviewees stated: “…even when we want to connect a new printer to the PACS, we have to call the main IT support to perform this function for us.” However, all of the interviewees complimented the IT support services at the company for their prompt responses to any technical issues.

====Impact of PACS on clinical practice====
PACS has an impact on the clinical practice of radiologists and technologists, as shown in the interviews' results.

====Perceived net benefits of the PACS====
From the interviews, it was easy to see that the PACS has increased users’ productivity in comparison to the traditional filming system by minimizing their effort and time. In addition, the retaking of images is not required, as the PACS facilitates image storage and retrieval faster and over a longer period. “We are happy with the PACS’s benefits,” reported one interviewee, although the system has slowed in speed due to the huge number of cases, with the intervening procedures passing through several modalities, such as computed tomography and magnetic resonance imaging. There is also the possibility of missed images, especially concerning unknown IDs, although these could be traced using the patient’s civil ID, the patient’s PACS ID, or the excision ID of images.

====User satisfaction with the PACS====
All the interviewees were apparently satisfied with the PACS; however, the technology-associated problems need to be addressed to optimize the system’s versatility and performance.

====Opinions on the PACS====
Overall, from the interviews, the responses revealed that as long as the image is electronically collected, stored, and communicated to another system successfully, the productively of work will be increased, diagnosis will be precisely performed, the patient will be treated accurately and quickly, and health services will be improved.

====Expectations of the current PACS and future trends====
The interviewees expressed satisfaction in using the PACS system but also highlighted the need for resolving the current problems, as well as to keep abreast of the latest advances in PACS operations, to meet the growing demands of the Kuwaiti health system. The emerging requirements for potential trends in the future concern the areas of: (1) teleradiology services (for radiologists to use the PACS anywhere and anytime); (2) a mobile image viewer for faster accessibility to images; (3) speech recognition functions; (4) computer-assisted diagnosis (CAD); (5) advanced training; and (6) recruiting health informatics graduates to support the PACS administrators.

==Discussion==
In general, the study’s findings revealed that the PACS has had a productive impact on the staff’s clinical practice. Despite some of the technical limitations of the infrastructure, most of the respondents rated the system positively and as user-friendly. The findings showed that the technologists were more satisfied than the radiologists were with using the PACS. Interestingly, there was a significant relationship between the perceived benefits of the PACS and the willingness of users to continue using it. It was also noteworthy that the problems associated with the PACS’s integration with the RIS were the result of disorganized workflow.

The results of the study revealed that the users’ demographic data, including computer experience, had no influence on their response patterns, being insignificant determinants of their predilection or preference for the PACS in enhancing their work efficiency. These findings were consistent with the study’s results on PACS acceptance<ref name="AldosariUser12" />, but contradicted with the results of earlier studies that reported the significant influence of age and gender on users’ choices concerning information technology, such as computer use patterns<ref name="WardTheAttitudes08">{{cite journal |title=The attitudes of health care staff to information technology: A comprehensive review of the research literature |journal=Health Information and Libraries Journal |author=Ward, R.; Stevens, C.; Brentnall, P.; Briddon, J. |volume=25 |issue=2 |pages=81-97 |year=2008 |doi=10.1111/j.1471-1842.2008.00777.x |pmid=18494643}}</ref><ref name="AdelekeICT15">{{cite journal |title=ICT knowledge, Utilization and Perception among Healthcare Providers at National Hospital Abuja, Nigeria |journal=American Journal of Health Research |author=Adeleke, I.; Adejoke, A.; Achinbee, M. et al. |volume=3 |issue=1-1 |pages=47-53 |year=2015 |doi=10.11648/j.ajhr.s.2015030101.173}}</ref>, particularly to adopting PACS.<ref name="DuyckMonitoring10" /><ref name="BryanEval99" />

===Perceptions of PACS quality, information, images, and services===
The study further revealed that both the radiologists and the technologists were satisfied with the quality of information and images produced and had positive views regarding the use of this technology. The PACS offered the users with the requisite information on a medical case and facilitated the accomplishment of several functions with efficiency and ease in producing high-quality images with precision and clarity. This positive relationship found between users' satisfaction and quality of information and images produced by PACS was consistent with the findings of previous studies.<ref name="TzengASocio13" /><ref name="SicotteVirtual10">{{cite journal |title=Virtual organization of hospital medical imaging: A user satisfaction survey |journal=Journal of Digital Imaging |author=Sicotte, C.; Paré, G.; Bini, K.K. et al. |volume=23 |issue=6 |pages=689-700 |year=2010 |doi=10.1007/s10278-009-9220-x |pmid=19588196 |pmc=PMC3046687}}</ref> The results of the interviews further complemented these findings, with no mention of lost images posing a major problem, due to successful image retrieval by PACS administrators.

The study found that the technologists were more satisfied than the radiologists concerning their current PACS use, attributing their satisfaction to two reasons, which had been confirmed in previous studies<ref name="VestImage15" /><ref name="TanPicture10" /><ref name="FolioQuantitative15">{{cite journal |title=Quantitative Radiology Reporting in Oncology: Survey of Oncologists and Radiologists |journal=American Journal of Roentgenology |author=Folio, L.R.; Nelson, C.J.; Benjamin, M. et al. |volume=205 |issue=3 |pages=W233-43 |year=2015 |doi=10.2214/AJR.14.14054 |pmid=26295661}}</ref>: the technologists achieved their core objectives of using the PACS, including image access, storage, and retrieval; and (2) the radiologists looked beyond these features for additional facilities and functions, such as the PACS being packaged with CAD, teleradiology, or speech recognition functions. As the radiologists had been using the PACS far longer than the technologists had, their understanding and familiarity with the PACS appeared to be relatively higher.

Concerning the quality of the services offered to support PACS technically, the findings showed that both users were satisfied with the technical support provided with regard to the promptness, reliability, and dependability of the services. However, the results of the interviews revealed that the radiologists and the technologists encountered organizational and infrastructure deficiencies. On the technical level, there was frequent breakdown of the system during rush hours; and on organizational level, there was negligence of some receptionists in recording patients’ information from the RIS to the HIS. Interestingly, the respondents still showed satisfaction in confirming the benefits of the PACS over conventional radiology despite some deficiencies, as reportedly addressed in previous studies.<ref name="DuyckMonitoring10" /><ref name="SicotteVirtual10" />

===Perceptions of the PACS’s impact, including net benefits and user satisfaction===
Regarding the PACS’s net benefits, the findings demonstrated that both the radiologists and the technologists had used the PACS to enhance their work productivity with ease due to the swift storage, retrieval, and transfer of images along with reports. These findings were consistent with those reported in previous evaluative studies on the impact of PACS<ref name="TanPicture10" /><ref name="SevensterImproved15">{{cite journal |title=Improved efficiency in clinical workflow of reporting measured oncology lesions via PACS-integrated lesion tracking tool |journal=American Journal of Roentgenology |author=Sevenster, M.; Travis, A.R.; Ganesh, R.K. et al. |volume=204 |issue=3 |pages=576-83 |year=2015 |doi=10.2214/AJR.14.12915 |pmid=25714288}}</ref>, confirming that work productivity in regard to the given effort, time, and accuracy of reporting has obviously been improved. Furthermore, the PACS’s benefits were found to have direct implications for user satisfaction, affecting their continued use of the PACS in the future.<ref name="ParéToward05" /> These previous studies concluded that the more the users agreed with a PACS’s effectiveness in their work, the more they were satisfied and willing to continue using it. The findings of the interviews further confirmed that both types of users benefited from the PACS’s advantages, expressing their readiness toward the technology’s continuous use while looking ahead for additional functions, without deficiencies, which coincided with other studies.<ref name="HsiaoCritical16">{{cite journal |title=Critical factors influencing physicians' intention to use computerized clinical practice guidelines: An integrative model of activity theory and the technology acceptance model |journal=BMC Medical Informatics and Decision Making |author=Hsiao, J.L.; Chen, R.F. |volume=16 |pages=3 |year=2016 |doi=10.1186/s12911-016-0241-3 |pmid=26772169 |pmc=PMC4715302}}</ref><ref name="LiuExploring15">{{cite journal |title=Exploring critical factors influencing physicians' acceptance of mobile electronic medical records based on the dual-factor model: A validation in Taiwan |journal=BMC Medical Informatics and Decision Making |author=Liu, C.F.; Cheng, T.J. |volume=15 |pages=4 |year=2015 |doi=10.1186/s12911-014-0125-3 |pmid=25889506 |pmc=PMC4333263}}</ref><ref name="FloydStudy15">{{cite journal |title=Study of Radiologic Technologists' Perceptions of Picture Archiving and Communication System (PACS) Competence and Educational Issues in Western Australia |journal=Journal of Digital Imaging |author=Floyd, D.M.; Trepp, E.R.; Ipaki, M.; Ng, C.K. |volume=28 |issue=3 |pages=315–22 |year=2015 |doi=10.1007/s10278-014-9765-1 |pmid=25561072 |pmc=PMC4441692}}</ref>

==References==
{{Reflist|colwidth=30em}}

==Abbreviations==
'''CAD''': computer-assisted diagnosis

'''HIS''': health information system

'''ID''': identification

'''IS''': information system

'''PACS''': picture archiving and communication System

'''RIS''': radiology information system

==Notes==
This presentation is faithful to the original, with only a few minor changes to presentation. In several cases the PubMed ID was missing and was added to make the reference more useful. 

Per the distribution agreement, the following copyright information is also being added: 

©Ali Jassem Buabbas, Dawood Ameer Al-Shamali, Prem Sharma, Salwa Haidar, Hamza Al-Shawaf. Originally published in JMIR Medical Informatics (http://medinform.jmir.org), 15.06.2016.

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