Over the past few decades, there have been some major changes in radiology practice and in medical imaging technology worldwide leading up to the changeover of medical imaging machines to a digital format replacing the commonly used X-ray film [1]. These revolutionary changes include the introduction and broad use of Picture Archiving and Communication Systems (PACS), a sub-division of healthcare information systems (also called medical information systems or clinical information systems), which has modified workflows in hospitals and increased clinical efficiency between healthcare practitioners and patients [2]. A simple PACS workflow is shown in Figure 1.

PACS forms an integral part of medical imaging informatics, which concerns itself with the development and adaptation of techniques from medicine, engineering, computer science and other fields to create and manage medical data and knowledge and improve clinical care [3]. During the last few years, PACS technology has been adopted by many radiology departments within South Africa, particularly in the private sector [4]. The South African Department of Health recognized the potential benefit of PACS and consequently endorsed its implementation in the South African public health sector to benefit the wider population [5]. The public helath sector is massive compared to the private sector and treats almost 90% of the population. Table 1 lists the number of public and private clinics and hospitals there are in South Africa and the number of beds per provance.

After all this time, even with several deployment efforts for PACS combined with the support of the Department of Health, the systems were not operating successfully and only a small number of PACS were fully operational [6]. The success of PACS implementation is based on the vendor's ability to meet a list of requirements such as desirable features, system uptime, ease of use and professional training programs defined by the stakeholders such as radiologists, PACS administrators, radiographers and others [7]. A PACS vendor represents the company that sells, installs and implements the healthcare information systems.

The current situation in South Africa is one such where medical equipment vendors (PACS vendors) become exclusively responsible for the appropriate implementation of the equipment and its accompanying software; their expertise and skills are heavily relied upon by the Department of Health and its users. PACS implementation projects are typically handled by vendors until the project is handed over, and even after the handover, external expertise is available until the system is classified as a success [8]. With almost 60%–70% of all software implementation projects failing in healthcare, it is agreed that healthcare information technology is difficult to implement, and the manner of implementation is best left to the actual vendor [89]. Supporting the PACS vendor is deemed crucial at the primary implementation stages to achieve a successful project [8]. This can be achieved by persuading vendors to be held more responsible for their involvement in the PACS project [10].

A number of PACS related studies conducted internationally have included participants such as radiologists, technologists and referring doctors, but few have gathered data based on vendor and expert reviews from a developing country [21112]. Most investigations have considered a single, or at best, a small number of factors that contribute to a fragmented view of PACS success. PACS implementation from an institutional perspective is also generally reported [13] rather than at the vendor level. To summarize, past empirical and evaluative studies have provided limited discussion on the conceptual frameworks for holistic or comprehensive understanding of PACS success or systematic and practical descriptions of challenges endured in a developing country. The outcome would enable healthcare management and users and vendors to anticipate possible challenges during implementation that would later mitigate their downside effects.

Thus, the aim of this study was to identify and describe PACS challenges endured by PACS vendors during implementations in South African public healthcare institutions. This was achieved by engaging in a methodological approach that was qualitative in nature and collected data through semi-structured interviews from 10 PACS experts/participants.

This study used an interpretive qualitative research approach. It enabled an information rich narration of a population of PACS vendor employees with the aim to capture data of their live experiences and to report on their meanings and understandings in context [14]. Ethics permission was sought and granted, by the University of KwaZulu-Natal (UKZN) Humanities and Social Sciences Research Ethics Committee as this study (No. HSS/1582/016M) was completed in partial fulfilment for a Masters of Medical Science in medical informatics. Permission to perform the study was also obtained from the UKZN Registrar's Office and was conducted with the participants' consent.

The study population consisted of PACS experts currently employed by a PACS vendor with a minimum of 2 years implementation experience within a South African public healthcare institution. Convenience sampling was used, and participant selection was based on both the judgement of the researcher and the availability of participants. Ten participants were selected for this study, and the cohort consisted of PACS managers, application specialists and technicians.

The data were collected by a qualitative approach utilizing semi structured interviews. Participant interviews were audio recorded, numbered and transcribed for detailed thematic analysis. The analysis aimed to capture and narrate the subjective experiences and understandings of the participants. Reading and re-reading of the transcribed information steered the author into classifying key themes which were subsequently used to establish connections and associations with the aims of this study. After identifying the themes, the authors re-interviewed the participants asking about their opinions on the emerging themes.

A summary of the challenges that vendors face is shown in Table 1. A general lack of space to position the PACS workstations and its accompanying peripheral devices was intensified with the absence of proper furniture limiting the potential for their use. Triegaardt [6] concurred by noting that the resistance from users during a PACS implementation in the Eastern Cape, South Africa was generally due to minor system changes such as uncomfortable ergonomic positioning of equipment. The current situation leaves the PACS vendor responsible for the positioning of these workstations and the removal of the older equipment which is said to be a laborious task. Moreover respondents noted that old X-ray darkrooms are often converted to unsafe server rooms with the possibility of damage to the equipment. In South Africa, there is a lack of physical infrastructure like rooms, offices and general space [15]. This has been identified as a problem by the vendors as well.

The most important elements of a sufficient infrastructure needed for PACS deployment are power and networking as noted by the respondents. Similarly, the failure of Limpopo's health system in 1999 had comparable examples of infrastructure problems that included difficulties identifying the appropriate computer rooms with air conditioning, reliable power and installed local networks which was delayed by a concurrent plan to upgrade hospitals [16]. South Africa has a general problem with power and electricity that affects all sectors, including business and healthcare [17]. This clearly also poses a challenge to PACS implementation as the entire system depends on stable power.

The lack of financial support was the most significant barrier to successfully implementing information technology in healthcare from both the clients' and vendors' perspective [18]. Moreover, funds are available, but vendor contracts limit system adjustability, and governmental systems limit the options that hospitals can purchase [6]. Other barriers include the additional costs of space modifications, budgets for future upgrades, maintenance of the system and replacement for theft of equipment. Respondents noted that theft is a concerning factor in the South African healthcare sector.

A general lack of IT knowledge was noted as a challenge that impaired the implementation of PACS systems because PACS software training is reliant on a basic understanding of IT. This has been also reported in the healthcare domain. In a recent study that determined the perceptions of healthcare workers in Africa on IT, only 40% had seen a computer in their lifetime, and only a meager 29% had received basic computer literacy training [19]. This is a major challenge to vendors during PACS implementation. If the users are not even computer literate, there will be major issues with using the PACS systems.

A general resistance to change was reported with PACS users lacking IT experience said to be the most reluctant. In addition, there is a lack of leadership and change management which creates challenges during implementation and training phases of the project. Lorenzi and Riley [20] advocated that organizational resistance always occurs during the implementation of new healthcare information systems. Along similar lines, the PACS workflow was reiterated by the respondents suggesting that operators do not follow the guidelines set out at the planning stages. In addition, it was noted that the workflow related issues are the responsibility of the vendor, and proper workflow training along with process improvements can only be visualized once the entire implementation is successfully accomplished.

Respondents noted that healthcare institutions do not project their storage needs accurately, and hospitals often have their storage space depleted meaning they will not be able to archive any more patients. Moreover, customers are unaware of the system's life expectancy, and they do not plan for SLAs after the initial warranties expire. System maturity was stressed as a challenge. Because South Africa has been implementing PACS for over 10 years, there are many systems operating without possible service contracts in place translating into higher costs and system instability. PACS vendors endure many software and hardware encounters, some of which are expected such as software bugs that can easily be eliminated with system upgrades. It was generally advocated by the respondents that all these matters are of no concern when the customer has an active SLA but can become costly when there is no service contract in place. PACS vendors endure some of their own challenges that have a token impact on PACS implementations. Lack of specialist training, lack of man power on large projects and timely professional support from international manufacturers are the most salient points because these can lead to implementation delays and dissatisfied customers contributing to the resistance mentioned earlier.

The study respondents were tasked to name the greatest challenge anticipated during the implementation, and it was the healthcare user (operator) of the PACS that was mentioned for varying reasons. A lack of training was noted with either the current PACS, basic IT or an interconnected system that transmits data to the PACS. It is well-known that users have unfounded expectations of the system, and this has proven to be challenging for the PACS vendors. Furthermore, respondents noted that users are reluctant to attend PACS meetings aimed at solving some of these challenges. As a final point, users were observed not helping each other with PACS related queries during implementation which if achieved can reduce the constant training liability of the PACS vendor.

Understanding and evaluating PACS implementation challenges are paramount in developing countries where many unforeseen encounters can take center stage by triggering a system to fail. The results of this paper indicate that space, insufficient infrastructure, image storage capacity, system maturity and vendor related concerns are the more pertinent challenges noted by the study respondents among others. PACS vendors anticipate these challenges when facing a public healthcare institution, and it is recommended that the hospital management and potential PACS stakeholders be made aware of these challenges to mitigate their effects and to aid in a successful implementation.