Most people, at some point in their lives, have had an x-ray. It’s a common practice. In fact, today at Yale-New Haven Hospital alone, every year more than 70 radiologists perform more than one million x-ray, ultrasound, CT and MRI imaging studies to diagnose and monitor the treatment of various health conditions for more than 500,000 people. Typically, once an image is taken, it is digitized and can be immediately shared electronically with the patient’s general practitioner and other medical specialists, enabling them to make a quick diagnosis and provide care in a timely manner.
In many countries, however, operating an effective medical imaging program is much more challenging. Many imaging programs worldwide still use hard-copy film, which is expensive, frequently in short supply, and not as easily and quickly shared as digitized images.
To help remedy this, Dr. Frank Minja, assistant professor of radiology and biomedical imaging at Yale School of Medicine, traveled to Tanzania, Africa in 2014 to implement a Picture Archiving and Communication System (PACS), a medical imaging technology that provides economical storage and convenient access to medical images including x-rays, ultrasounds, CTs, and MRIs.
Minja is no stranger to Tanzania. He was born and raised in the former Tanzanian capitol of Dar es Salaam, and traveled to the United States for college and medical school at Harvard University. Minja came to Yale School of Medicine in 2004 for a fellowship in diagnostic radiology residency and neuroradiology; he joined the Yale faculty in the Department of Radiology and Biomedical Imaging in 2009.
Even before completing his Neuroradiology Fellowship, Minja had already begun collaborating with radiology colleagues at the Muhimbili University of Health and Allied Sciences (MUHAS) in Dar es Salaam, who were establishing the first Diagnostic Radiology residency training program in Tanzania.
In 2014, Yale granted Minja a public service leave of absence to travel with his family to Tanzania to help implement a PACS at the Muhimbili Orthopaedic Institute (MOI), a specialty hospital on the Muhimbili National Hospital (MNH) campus. MUHAS, MOI and MNH are three autonomous institutions that share the same campus in Dar es Salaam.
Minja knew that setting up a modern radiology department in Tanzania would be a very complex and demanding undertaking, which was why he requested a year-long leave of absence. “For such a project to be successful, one has to physically embed themselves within the institutions to fully understand and respond to the challenging environment,” said Minja. “It was the first time I had spent more than two weeks in Tanzania, since leaving for college more than 20 years ago, which was both an emotional and yet energizing home-coming experience for me.”
The first step of the project was to conduct a rigorous needs assessment and analysis. Once the analysis was complete, Minja gave numerous presentations to MOI administrators to showcase the merits of PACS and the feasibility of installing it at MOI within a limited budget.
“Initially we had proposed a commercial PACS at a total cost of $60,000 over three years; that would enable the institution to recoup its entire investment at the end of the first year from just hard-copy film savings alone,” said Minja. “Even so, this upfront capital expense was still prohibitive, but after numerous discussions the MOI administration agreed to a ‘pilot’ installation of an open-source PACS to demonstrate that the idea was feasible within the budget, network and reliable electricity constraints at MOI.”
Next IT technology hardware, including servers computers and several clinical workstations, were installed to provide an effective network for capturing and sharing of medical images. In addition, an open source PACS software was installed across the entire network, enabling images to be viewed on computer monitors to avoid the high costs of hard copy film, and significantly improve access to x-ray images among healthcare practitioners.
According to Minja, initially the main hold up during the installation phase was actually the lack of a server computer.
“We initially started the pilot phase of the PACS installation using an old desktop computer which was configured with a server operating system in order to run the proof-of-concept phase for initial demonstrations,” said Minja. “I was then able to convince a colleague who loaned us a ‘real’ server as well as installation expertise from his software company.” This colleague (Mr. Gilbert Herman) was a former classmate of Minja from secondary school. He had no medical background, but quickly understood the potential of PACS, believed in the potential, and wanted to help. Working with him, Minja was able to quickly obtain the necessary equipment to efficiently get the PACS up and running.
Later additional hardware and software was added to the network to increase server memory, server storage capacity, and the number of clinical workstations. While most of the additional hardware was donated from the United States, it was gratifying that the MOI administration purchased several clinical workstations to help expand the availability of PACS at the clinical points of care, said Minja.
The final phase of PACS started with the addition of a backup server to ensure storage redundancy and disaster recovery preparedness. The MOI IT team oversees the ongoing maintenance and expansion of the PACS network which now includes more than 20 separate clinical workstations.
Since implementation of the PACS at MOI in 2014, an analysis of its effectiveness concluded the project is a resounding success, said Minja, noting that the financial benefits enjoyed by the MOI administration are significant and ever-increasing. “Simply eliminating the use of hard-copy films, an expense that used to run them $250 or more each day, enabled more than $60,000 in savings the first year alone,” he said. “As of today, just three years after implementation, total savings have surpassed $200,000 and are expected to increase as more imaging modalities are installed at MOI.”
Minja said that these savings illustrate the importance of presenting a business case to institution administrators when introducing new ideas and concepts.
“Initially, we had focused more on the potential for PACS in improving direct patient care through easier access to x-ray images for diagnosis and follow-up, which is certainly important,” said Minja. “However, also positioning PACS as powerful way to save money was critical to its successful implementation.”
Another important lesson learned during the PACS implementation, said the Yale physician, was the need for an on-site and in-person demonstration of its proof-of concept.
“The PACS implementation idea was not fully embraced until we could demonstrate in-person, on-site at MOI, how the PACS software could perform with multiple different users with different computer abilities, all within the internet network and electrical outage constraints,” said Minja. “In fact, when we demonstrated the working PACS to a different medical center in Tanzania, we were able to reduce the planning phase to less than two months, instead of the two years we took trying to convince the MOI administration using just concept notes and PowerPoint slides. Indeed, seeing is believing.”
Now that PACS has been successfully implemented, Minja notes, there is a urgent need to expand and leverage the system to enable improved and faster training of radiologists in Tanzania, where there is dire shortage. Currently, according to Minja, Tanzania has less than 70 radiologists to serve a burgeoning population of nearly 60 million people. By contrast, in member countries of the Organisation for Economic Co-operation and Development (OECD), there is an average of 100 radiologists for every one million people — although, to date, many countries worldwide fall far short of that average. Tanzania, which only began training radiologists in the early 2000s, needs 6,000 radiologists to meet the OECD average — 100-fold increase over the next 20 years.
“We’re facing a grave shortage, which will only worsen as the population grows and ages, requiring more imaging services,” said Minja. “Since radiology facilities are still in relative short supply across Tanzania, now is the ideal time to ramp up radiologist training to meet both the current demand and the anticipated expansion of radiology facilities in the country. Wider adoption of PACS will enable easier sharing of medical images and radiology expertise across radiology facilities in the country.”
At the current training pace in Tanzania, 1,000 radiologists will be trained by the year 2040, said Minja, by which time the population of Tanzania is projected to nearly double, resulting in a continued shortage of radiologists — a fact that does not discourage the Yale physician.
“The first 500 to 1,000 radiologists we help to train will form the critical mass, which will then train the next 1,000 radiologists in Tanzania and the East Africa region,” said Minja. “We desperately need to get to the point where we have enough well-trained radiologists who cannot only engage in medical imaging work, but can also contribute to training other radiologists and medical specialists.
“Reaching that point will be a game changer, because it will then free up Tanzanian radiologists to embark on research projects that contribute to the body of knowledge regarding imaging findings to better diagnose and treat local endemic diseases.”
To learn more about Minja’s work in Tanzania and Yale Radiology Global Outreach efforts, visit the Yale Radiology & Biomedical Imaging website here.
