The wind of change : individuals change when technology change

Abstract

The production of digital images has been well-known within radiology for many years through its use of modalities such as computer tomography, ultrasound and magnetic resonance tomography. During the latter part of the 1980´s a new technology, Picture Archiving and Communication System (PACS) was introduced making it possible to manage X-ray pictures in their original, digital form. The changeover from an analogous to a digital environment was not just a change for the radiology departments; it was a change which concerned the entire hospital. Osteaux, et al. (1997) feels that digitalization is the largest change within radiology since X-ray technology was introduced. However, in order for PACS to be a successful project, both cultural and organizational changes are required.

The purpose of the study is to analyze and describe how the professional role of radiologists and radiographers, work practices and use of the technology are influenced by the introduction and use of PACS within the Region of Skåne. The study is longitudinal and based on 119 interviews with radiologists and radiographers in Lund, the hospitals in Landskrona, Ystad and Simrishamn and the healthcare centres at Eslöv and Hörby. The study was performed from 1999 to 2006. During this time, PACS was implemented at all the units, however at different periods in time. The purpose was to study the entire digitalization process at all the units. Data collection and analyses were inspired by Grounded Theory, especially those techniques such as open interviews, coding and categorization to allow a reduction of data and a creation of terms to symbolize the occupational role, work practice and use of new technology during different points in time of the study. In addition to digitalization the study focused on trying to understand what the radiologists themselves felt about the change. This description included three different areas: the professional occupational role, the diagnostic work and the technology used.

With the new technology images were always available to all those having the PACS system. In practice, this meant that there were more discussions with clinicians and that radiologists changed from doing more individual work to becoming actors in a networkconsisting of different specialties. The radiologist also felt an increase in demands for sub-specialization in this process.

With regards to the diagnostic work, this was described by the radiologists in 1999 as work which partly required extensive medical skills but in addition, to its advantage, could include a special ability in interpreting images which can almost be described as a "form of art". During the period of changeover when PACS was implemented, the radiologist felt that the technology itself became more centralized at the cost of the diagnostics. In time the focus was transferred back to the diagnostics while the radiologists saw the advantages of e.g. the availability of having access to image material.

The radiologist felt secure in using the analogous technology. Analogous films were tangible. Digital PACS images could be manipulated. The radiologist felt uncertain as to when the manipulation of images was "optimal". This uncertainty was reduced with time. Along with the focus on digitalization, the study tried to find how the radiographers felt about digitalization and the use of PACS. This description included three different areas: the occupational role, the image-producing practices and the technology used.

When the study began in 1999 and PACS was implemented, the radiographers were very positively inclined towards the change. They saw possibilities of filling the occupational role with new activities, such as quality review of images for diagnosis and being personally able to complete examinations. The needs for exposure skills decreased. In reality this meant an increased risk because the patients were exposed to unnecessarily high doses of radiation. It was discovered that "sluice" area with the developing machine as its centre had disappeared. No one had previously thought of its being a central meeting place for communications and radiologists. With time, the exposure parameters became once again more central to the professional role of the radiographers, however this time with a focus on patient safety.

To begin with, the radiographers saw great possibilities in the introduction of new work routines using PACS, since the images were available to everyone who had the PACS system. The opinion at the larger clinics was that the work method with PACS was adapted to the old analogous routines. It was discovered that the discussions within the work groups for the implementation had focused on the technology. It was realized that discussion on changes in work methods and organization should have been started much earlier.

It took many years before a new work method was successfully found through new and more open network configurations. As a contrast, the smaller departments had implemented work routines when PACS was implemented and its use was started. In the digital context and the new technology the natural breaks at the sluice disappeared, creating an experience of an increase in stress. Another concern which also arose during the years was that the technology became more and more imaginary making it hard to understand errors when they occurred.