An-Najah National University 

Faculty of Graduate Studies 

 
THE PERCEPTION OF RADIOGRAPHERS IN 

RADIOLOGY DEPARTMENT TOWARDS THE 

IMPLEMENTATION OF PICTURE ARCHIVING AND 

COMMUNICATION (PACS) IN PALESTINIAN 

HOSPITALS 

 

 

By 

Nada “Joul Jamal” Saleem Shalabi 

 

 

 

Supervisor 

Dr. Rayah Sawalha  

 

 

This Thesis is Submitted in Partial Fulfillment of the Requirements for the Degree of 

Master of Public Health Management, Faculty of Graduate Studies, An-Najah National 

University, Nablus - Palestine. 

2024 





III 

 

Dedication 

I dedicate the harvest of my effort to my family, father, mother, brothers and sisters.  

To my in-law, husband and daughters 

To my friends, teachers, colleges and every one supported me during my study directly 

or in directly. 

  



IV 

 

Acknowledgements 

Praise is to Allah, who helped me to complete this research, and made use of all means 

of assistance and facilitation. 

I would like to sincerely thank my supervisor, Dr. Raya sawallha, for her continued 

understanding, positive words of encouragement and constant encouragement, and 

insightful advice in guiding me through this study.   

My teachers in this study trip, thank you for your efforts you made.  

Finally, I would like to thank Palestinian Association of Medical Radiation Technologists 

(PAMRT) for their facilitation for this research and information. 

 

 

 

 

 

 

 

 

 

 

 

 

 





VI 

 

List of Contents  

 

Dedication .......................................................................................................... III 

Acknowledgements ............................................................................................ IV 

Declaration ........................................................................................................... V 

List of Contents .................................................................................................. VI 

List of Tables ................................................................................................... VIII 

List of figures ..................................................................................................... IX 

List of Appendices ............................................................................................... X 

Abstract .............................................................................................................. XI 

Chapter One: Introduction and Theoretical Background ..................................... 1 

1.1 Background ................................................................................................................ 1 

1.1.1 Health information technology ................................................................................ 2 

1.1.2 Electronic health record ........................................................................................... 2 

1.1.3 Health information system ...................................................................................... 3 

1.1.4 Picture archiving and communication system (PACS) ........................................... 5 

1.1.5 PACS main components .......................................................................................... 9 

1.1.6 PACS scope in Palestine ....................................................................................... 16 

1.1.7 Research problem .................................................................................................. 16 

1.1.8 Study aim ............................................................................................................... 17 

1.1.9 Study objectives .................................................................................................... 17 

1.1.10 Study Questions ................................................................................................... 18 

1.2 International studie .................................................................................................. 18 

1.2.1 Study at Regional level .......................................................................................... 21 

Chapter Two: Method ........................................................................................ 30 

2.1 Study design ............................................................................................................. 30 

2.2 Study population ...................................................................................................... 30 

2.3 Study sample ............................................................................................................ 30 

2.4 Study instrument ...................................................................................................... 31 

2.5 Study validation ....................................................................................................... 32 

2.6 Reliability of the Questionnaire ............................................................................... 32 

2.7 Study procedures ..................................................................................................... 33 

2.8 Statistical Procedures ............................................................................................... 34 



VII 

 

2.9 Study analysis .......................................................................................................... 34 

2.10 Ethical approval ....................................................................................................... 34 

Chapter Three: Result ........................................................................................ 35 

3.1 Sample Demographics ............................................................................................. 35 

3.2 Perception of users toward impact of PACS ........................................................... 37 

3.3 Correlation between impact variables and user’s characteristic .............................. 40 

Chapter Four: Discussions, Conclusions and Recommendation ....................... 42 

4.1 Discussions .............................................................................................................. 42 

4.1.1 Socio-Demographic indicators from the respondents' response about adopting 

PACS ..................................................................................................................... 42 

4.1.2 External environment indicators toward the adaptation of PACS ........................ 44 

4.1.3 Expected outcome indicator toward the adaptation of PACS ............................... 44 

4.1.4 Expected challenges indicator towered the adaptation of PACS .......................... 45 

4.1.5 Satisfaction indicators toward the adaptation of PACS ........................................ 46 

4.2 Conclusion ............................................................................................................... 47 

4.3 Recommendations .................................................................................................... 47 

References .......................................................................................................... 48 

Appendices ......................................................................................................... 53 

 ب ................................................................................................................... الملخص 

 

 

 

 

 

 

 

 

 

 

 

 

 



VIII 

 

List of Tables  

Table 1: The list of previous studies ............................................................................... 29 

Table 2: Cronbach Alpha test for the study tools ........................................................... 32 

Table 3: Cronbach alpha Internal Consistency ............................................................... 33 

Table 4: Scale for representing the estimation level of sample responses ...................... 34 

Table 5: Distribution of Sample responses on users’ demographics .............................. 36 

Table 6: The response rate of the External environment impact variables in Palestinian 

hospitals in descending order ........................................................................... 37 

Table 7: Response rate to the Expected outcomes impact variable in Palestinian hospitals 

in descending order ........................................................................................... 38 

Table 8: the response rate to the Expected challenges impact variable in Palestinian 

hospitals in descending order ........................................................................... 39 

Table 9: The response rate to the Satisfactions impact variable in Palestinian hospitals in 

descending order ............................................................................................... 39 

Table 10 : ANOVA results showing variance between impact variables and user 

characteristics ................................................................................................... 41 

 

 

 

 

 

 

 

 

 

 

 

 



IX 

 

List of figures  

Figure 1: PACS main component ..................................................................................... 9 

Figure 2: Regional PACS Component ............................................................................ 14 

Figure 3: Structure of realization of data records for the same patient from different 

facilities .......................................................................................................... 15 

Figure 4: Structure of Regional PACS ........................................................................... 15 

Figure 5: Study Procedure: The Procedures of Study Showed in Figure (1) ................. 33 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



X 

 

List of Appendices 

Appendix A: The List of Researchers ............................................................................. 53 

Appendix B: Questionnaire ............................................................................................ 54 

Appendix C: Institutional Review Board (IRB) ............................................................. 69 

Appendix D: Explanatory Litter ..................................................................................... 70 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



XI 

 

THE PERCEPTION OF RADIOGRAPHERS IN RADIOLOGY 

DEPARTMENT TOWARDS THE IMPLEMENTATION OF 

PICTURE ARCHIVING AND COMMUNICATION (PACS) IN 

PALESTINIAN HOSPITALS  

By  

Nada “ Joul Jamal” Saleem Shalabi  

Supervisor 

Dr. Raya Sawalha 

Abstract  

Introduction: Picture Archiving and Communication System (PACS), is one of the most 

necessary systems recured in radiology department for archiving and retrieving medical 

imaging. The perception of its users considered as one of the important impacts on its 

adaptation. The aim of this study is to measure the acceptance of PACS in Palestinian 

public hospitals.  

Method: in 2023 a cross-sectional study was conducted at Palestinian general hospitals. 

The targeted population was all radiographers working in radiology department at general 

hospitals. Out of (170) participant only (151) answered the distributed questionnaire. The 

questionnaire consisted of five inter- related variables i.e., socio-demographics factor, 

external environment, expected outcome, expected challenges and satisfaction. These 

factors were designed to measure the acceptance of PACS in radiology department.  

Results: this study showed a significant relationship between the acceptance of PACS and 

the related variables i.e., socio-demographics factor, external environment, expected 

outcome, expected challenges and satisfaction. It also explained the positive impact of 

PACS.  

Conclusion: this study showed the positive perception of users toward PACS in 

Radiology department. Also, the effect of PACS on users’ productivity and the ability to 

adopt the system in radiology department. The result of this study aims to provide health 

care worker a better understanding to increase the adaptation of PACS from radiographers 

in radiology department.  



XII 

 

Keyword: Picture Archiving and Communication System (PACS); Radiology 

Department; Socio-demographics Factor; External Environment; Expected Outcome; 

Expected Challenges and Users’ Satisfaction. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



1 

 

Chapter One 
Introduction and Theoretical Background  

1.1 Background 

Healthcare systems around the world aim to serve people well by providing the most 

appropriate healthcare services. Health systems, whether in developed or developing 

countries, struggle to manage healthcare delivery under resource-constrained conditions. 

Healthcare organizations are expected to provide more consumer-oriented services. In 

order to achieve this goal, improving service quality is an absolute necessity, which 

requires timely access to high-quality information. Health care primary task is to maintain 

the health of the population in order to achieve this it’s important to improve and reserve 

the intellectual capital and the labor potential. Therefore, the most important evaluation 

and analytical categories for healthcare facilities is the quality of costumer cervices 

provided. The quality of healthcare services describes the accuracy of healthcare 

organization in delivering their processes to meet the needs for the patients. On the other 

hand, it also describes the properties available at health care organization that focuses on 

achieving the desired results at the appropriate level for consumers   (Dudin, Sertakova et 

al. 2017) . 

There are two main key factors that largely influence the level of quality of health care 

services. At first, competences of health institution, professionalism and competencies of 

healthcare professionals  (doctors, nurses, laboratory, etc.). the second factor, on the 

sufficiency and completeness of healthcare facilities (healthcare organization). In other 

words, the provision of healthcare services requires both staff and certain material and 

technical resource. This shows the need for urgent development of scientific and 

methodological approaches to improve the quality of healthcare services  (Abbasi, Jabali 

et al. 2020)   . The shaping of healthcare domain affected by Information and 

Communication Technology (ICT). ICT makes significant new opportunities to many 

areas, including many benefits for health sector, and the quality of healthcare services 

delivered by increasing efficiency and quality. The usage of health ICT in healthcare 

developed a new term e-health which is referred to the usage of ICTs in healthcare. Due 

the growing population the demand on healthcare services is in an increasing manner that 

requires update in the dealing with health information and Health institutions, which are 

complex organizations, naturally need sophisticated information management systems for 



2 

 

effective and efficient health service delivery. this leads to the Health Information 

Technology (HIT) (Aceto, Persico et al. 2018) . 

1.1.1 Health information technology 

Health Information Technology (HIT) has for both patients and service providers in terms 

of quality in health services. Healthcare information technology (HIT) is defined as “the 

is the processing of information and data of health involving both computer hardware and 

software that deals with the storage, sharing, retrieval, and use of data, information, and 

knowledge for decision making and communication”. the HIT includes various 

technology’s that support decision making and integration with medical technology. This 

facilitates the improving and transforming healthcare services such as; improving clinical 

outcomes, facilitating care, reducing human errors, improving practice efficiencies, 

tracking data, and coordination over time (Alotaibi and Federico 2017). One of the 

important technology’s that HIT affected more is Electronic Health Record (HER).  

1.1.2 Electronic health record 

Electronic Health Record (HER) is “a documentation tool that yields data useful in are 

corporate systems that have the potential to overcome inefficiencies and contain 

costs”(Lavin, Harper et al. 2015). And Electronic health record (EHR) is “data collected 

from millions of patients are now routinely collected across diverse healthcare 

institutions. They consist of heterogeneous data elements, including patient demographic 

information, diagnoses, laboratory test results, medication prescriptions, clinical notes, 

and medical images (Xiao, Choi et al. 2018). Also, EHRs “represent longitudinal data (in 

electronic format) that are collected during routine delivery of health care. it generally 

contains demographic, vital statistics, administrative, claims (medical and pharmacy), 

clinical, and patient-centered (e.g., originating from health-related quality-of-life 

instruments, home-monitoring devices, and frailty or caregiver assessments) data” 

(Cowie, Blomster et al. 2017). 

EHR improves the performance and service delivery of health services. Electronic health 

records have the potential to strengthen the quality of the relationship between physicians 

and patients, as well as providing access to complete and up-to-date patient information 

from practices or remote locations, it also has the functions to keeping patient records, 

reducing errors, saving administrative costs, increasing productivity and improved patient 



3 

 

satisfaction  (Cowie, Blomster et al. 2017). The spread of EHR and HIT requires more 

efficient sharing of patient information, which require more efficient patient 

documentation quality to enhance patient safety, quality of care and reducing the cost of 

health system. the result of the transitions from paper-based to electronic health record 

will lead to decrease staff documentation time and increase time for patient direct care  

(Baumann, Baker et al. 2018). Despite all these advantages but there is low adaptation of 

the system. 

According to the third global research report of the World Health Organization (WHO) 

E-Health Global Observatory (2016), there has been steady growth in the adoption of 

national HIT systems in the last 15 years, with )46%( of the global increase in the last 

five years.  )50%( of upper-middle and high-income countries have adopted national HIT 

systems. However, the rate of adoption is much lower in low-middle-income countries 

(35%) and low-income countries (15%). Moreover, the majority of the member countries 

with national IHC systems have integrated HIT systems with laboratory (77%) and 

pharmacy (72%) information systems, which means integration with picture archiving 

and communication systems (56%).  

1.1.3 Health information system 

Health information system (HIS) is “an integrated electronic system which is used in 

collecting, storing, retrieving, and displaying patient data and information for example: 

patient history, laboratory result, diagnosis, billing and hospital related procedures”. 

Also” The Hospital Information System (HIS) is a computer system aimed at providing 

a paperless environment that covers all aspects of the hospital's operation such as clinical, 

administrative, and financial systems (Nilashi, Jannach et al. 2016). The system includes 

several components, such as Laboratory Information System (LIS), Financial Information 

System (FIS), Radiology Information System (RIS), Picture Archiving Communication 

System (PACS) these component can be linked together with the different characteristics 

(Ismail, Abdullah et al. 2015). In the resent years the HIS had a crucial role in healthcare 

delivery, safety of patient, and the clinical practices. The appropriate usage and 

implementation of this system will increase health care worker satisfaction which intern 

will enhance the level of engaging with these systems (Cohen, Coleman et al. 2016). So 

to enable decision-making process in building health system that accounts on the reliable 

information which is necessary for building strategy, policy and implementation, health 



4 

 

research, health education and training, human resources and financing the proper 

understanding and usage of system functionally is required (WHO 2009). 

Many research shows that HIS system rapidly increases the efficiency and reduce the 

expenditure of health cost. Using effective technology such as HIS system will eventually 

reduce clinical errors, increase patients access to health services, support clinicians, 

support remote care, improve information management, and enhance the continuity of 

health services. HIS is expected to affect the social and economic benefit for families, 

patient and healthcare provider. Despite all technology in healthcare sector, there’s a slow 

adaptation of new technology compared to other industries. The implementation of any 

HIS system suggest to enhance the safety of patient and also reduce the expected cost for 

health services (Inamura and Kim 2011).  

Many challenges may be an obstacle in implementing the HIS system, these challenges 

may include technology such as poor product and insufficient planning. Innovation 

characteristic as safety, risk, and performance. Resistant of change is phenomenon widely 

recognized because users consider new technology as time-consuming, not aware for the 

benefit, patient privacy and confidentiality, legal responsibility, and fear from facing new 

kind of errors because of new system. On the other hand, the successful implementation 

of HIS requires IT infrastructure that includes different types of devices and technology, 

the technology should be easy to use, requires small or no training, flexible, clear and 

understandable, also it requires on-set training and ongoing support to implementation to 

occurs, effective communication between technological staff and the clinical and 

managerial staff  is considered crucial (Sligo, Gauld et al. 2017).   

The health information system is a highly complex system that includes complex 

hardware and software, so its users (healthcare professionals) must have a certain level 

of Health Information usage skilled. In addition, Health Information System has a number 

of capacity (technical) problems that are the subject of the complaints of healthcare 

professionals which need to be solved and developed. There are many studies pointing 

out the deficiencies of healthcare professionals in computer use skills, technical training 

and support, and guidance for the use of the HIS. The reason for this is the obstacles that 

exist between the capacity of healthcare professionals and the capacities of the systems 

(Juris Bennett, Walston et al. 2015). 



5 

 

The hospital information system (HIS), cardiovascular information systems 

(CVIS)picture archiving communication system (PACS), clinical information system 

(CIS), radiology information system (RIS), and electronic health record (EHR) are the 

integral components of a hospital.  

1.1.4 Picture archiving and communication system (PACS) 

All the technologies aim in the first place to increase the efficiency and quality of health 

care system, including PACS as integrated part from HIS system. There is a need for a 

systematic entity for processing images in radiology department as it cannot be processed 

like other hospital data (Goodarzi, Khatami et al. 2016). 

medical images require routing, storing, and retrieving for which the invention of a 

specialized system such as a picture archiving and communication system (PACS) 

(Aldosari, Saddik et al. 2018). PACS defined as “the system allows the medical imaging 

to be stored, transmitted, retrieved, and displayed in several location of health system and 

hospitals” (Goodarzi, Khatami et al. 2016). It also defined as “is a subsystem of the health 

information system that aims to facilitate the storing, archiving, and managing of digital 

images as well as their transmission” (Hamta, Mohammadzadeh et al. 2020). Also “is 

system is required to fetch, archive, and process images from one or many sources. The 

main purpose of the system is to improve image routing, retrieval, and display capabilities 

among a healthcare facility, specifically the radiology department. PACS is integrated 

with more than one imaging modalities such as X-Ray, magnetic resonance imaging 

(MRI), computed tomography (CT), ultrasound and nuclear medicine (NM), and other 

similar technologies (Aldosari, Saddik et al. 2018). PACS is” an electronic information 

system (IS) used to acquire, store, transmit, and display medical images (Buabbas, Al-

Shamali et al. 2016). Was first introduced in the 1980s (Inamura and Kim 2011). It has 

an important role in transmission from paper-based imaging to digitalized imaging 

although the transition from paper-based to electronic based increased complexity while 

simplifying documentation. documentation has always been an essential component of 

professional care services (Haux 2006). The users of PACS include technologist, 

physicians, radiologist, nurse and image library personals (Aldosari and making 2012). 

The concept of digital image communication and display is first introduced in 1979’s in 

Europe (Lemke 2011). Due to the lack of technology at that time the first implementation 

of PACS were in the early 1980s in different part of the world starting from the USA 



6 

 

(Huang 2011). In the late 1980’s there were a start to integrate the PACS with HIS system 

and radiology information system (RIS), And with digital imaging and communication in 

medicine (DICOM) (10). At first the systems only focused on single department or 

section within the organization. In the early 1990s the PACS were introduced at the 

hospital level including the whole department. After that at the late 1990s the PACS 

covered a wide-area including several hospital or health institution. the implementation 

of the PACS affected by the socioeconomical state of the country, the industries in health 

sector, and the political condition of the country. Therefor the implementation of PACS 

rolled in developing countries in Asia and Europe. On the other hand, the concept of IHE 

(integrating healthcare enterprise) aligned with RIS and HIS contributed to effective 

implementation of PACS (Huang 2011, Inamura and Kim 2011, Lemke 2011). In these 

days PACS is used widely used in both developing and developed countries. In fact, it’s 

becoming one of the most used digital imaging tools (Alhajeri and Shah 2019). 

PACS offers several important uses. At first replacing hard-copy-images in processing 

images. It also decreases the price of radiology images, decreasing the cost of storing and 

archiving images, it provides off-set image reviewing. Furthermore, it provides electronic 

platform to allow images to integrate with other modalities (Khaleel, Rahmat et al. 2018). 

PACS consists from four major parts: image acquisition devices (imaging modalities), 

communication networks, PACS archive and server, and integrated display workstations 

(WS). It’s connected to healthcare system through communication networks. Image 

acquisition devices consisted from device imaging modalities such as magnetic resonance 

imaging, computed tomography, PET, X-ray angiography and others. And acquisition 

gateway computers that connects between imaging modalities and PACS servers. It also 

converts image data from the format of manufacture modalities to the PACS standard 

format that called DICOM, and also execute some prepressing function such as, resizing, 

background removal and orientation calibration. The communication network is the way 

of transition medical data from PACS component and other systems parts such as 

communication between gateway computer, imaging modalities, display and review 

WSs, PACS server, HIS/RIS systems and any other remote medical locations. PACS 

archive, is where all patients imaging examination and information are sent from for 

saved. server from the acquisition gateway computers and from HIS/RIS systems. the 

PACS server, is the engine, has two main parts: archive system and storage media 



7 

 

(database). There is two level of archiving: short term that retrieve data (image) in 2 

second. and long term that retrieve image in 3 minutes. integrated display workstations 

(WS) are an important role in the acceptance of PACS, it plays role in the acceptance of 

PACS. It’s the replacement of the manual light box of radiology system (Khaleel, Rahmat 

et al. 2018). 

Many advantages have been noticed from using the PACS, mainly it has been an 

alternative for film-based imaging. It had an effect in increasing the productivity and 

efficiency of physicians which in turn reduce reporting time, lowering number of lost 

images, enhance the communication between radiology department and clinical unite, 

increase image quality and accessibility, decrease re-imaging and exposure patient to 

harmful x-rays, and reducing patient waiting time (Abbasi, Jabali et al. 2020).  

Recently the PACS are being applied in an increasing manner in all country due to its 

effect on the managerial, departmental, and clinical level. At the first the adapting of 

PACS had an effect of reducing the cost results from process of producing films including 

material cost, storing space, and labor for traditional film (Alhajeri and Shah 2019). 

secondly, this technology had a role in increasing the productivity of radiology 

department due to digitally performing tasks though enhancing the satisfaction on the part 

of physicians and radiology staff and also for the patent, thirdly the clinical level which 

enhance the diagnosis and interpretation of images (Buabbas, Al-Shamali et al. 2016). On 

the other hand, PACS also facilitate the accesses to medical image anywhere at any time, 

reducing the time of retrieving and turn-over time for clinical report. Otherwise, it 

attached the scans to the patient electronic health record which enhance the long-distance 

consultations, and improve the scheduling for radiology equipment while enhancing the 

work flow (Aldosari and making 2012). 

In spite of the high potential benefit of the PACS there still a low implementation rate of 

the system due to some significant changes, such as the cost, the need for adequate 

capacity to handle with the necessary computer infrastructure, the requirement for 

changes in healthcare personals, and the shortage in user’s accreditation. But the lake of 

acceptance of the new technology’s remains the main obstacles that must be eliminated 

to adapt these technology’s such as PACS (Abdekhoda and Salih 2017). In order to meet 

a successful implementation for PACS its necessary to adopt strategy that take into 

consideration all technical, organizational, human, and financial challenge.  



8 

 

The user acceptance of new technology is considered one of the main challenges in the 

success of their technology. the user acceptance is defined by Esmaeilzadeh et al. as the 

willingness to adopt information technology to support task. It is also defined as the 

willingness of user group to use information technology to support task. Moreover, it’s 

important to take into consideration all users point of view within group, because the 

resistance of one member within group may delay the adaptation of the technology. 

Additionally, it’s important to motivate users and discover the source of resistance for 

new systems. The proper IT technology, continuous training, and well-trained radiologist 

well have an effect on the implementation of PACS (Abdekhoda and Salih 2017). 

For many years Technology acceptance model (TAM) has been the most used models in 

projects in the field of information system comfort munity. It’s considered as the most 

commonly used theory to measure individual acceptance for information system. TAM 

assume that individual acceptance is decided by two variables, Perceived Usefulness (PU) 

and Perceived Ease of Use (PEOU) (Rahimi, Nadri et al. 2018). 

In addition to the TAM, Technological, Organizational and Environmental model (TOE) 

also used for measuring the effect of new technology introduction. The TOE model 

explains the three element of model that influence the adaptation decision. These three 

elements are technological, the organizational, and the environmental context. The 

technological model includes the relevant technology already used and as well the 

technologies are available in the marketplace but not currently in use. Determining these 

technology play roles in the set of scope of technological change adoption. On the other 

hand, the organizational model reflects the effect of resources and characteristics of 

organizational firm on the adaptation and implementation decision. The firms include the 

linking structures between employees, communication process, number of slack 

resources, and firm size. Additionally, the environmental model, which influence the 

adaptation of innovation. It includes the presence or absence of technology service 

providers, the regulatory environment, and the structure of the industry (Baker 2012). 

 

 

 



9 

 

1.1.5 PACS main components 

The development of PACS has evolved through several stages. A key feature of all these 

stages is that the systems were designed to align with nearly identical infrastructure 

architectures. This trend of maintaining similar infrastructure persists, even with the 

growing adoption of newer programming technologies and advanced types of medical 

devices. At present, the infrastructure on which PACS is based has a number of physical 

components (Fig. 1):  

 First side – devices generating digital medical images that are distributed and stored 

by PACS. 

 Second side – all images viewing infrastructure . 

A primary characteristic used to evaluate modern PACS is its capability to modify the 

underlying infrastructure by adding or removing nodes and communication buses. 

Figure 1 

PACS main component 

 

 

1.1.5.1 Medical Imaging Equipment 

Digital imaging devices encompass a range of technologies, including computerized 

tomography (CT) scanners, magnetic resonance imaging (MRI) machines, 

ultrasonography, digital radiography, digital angiography, digital fluoroscopy, and digital 

mammography. Typically, these devices operate independently, with each component 



10 

 

connected to a shared system via an internal network (intranet). Additionally, there are 

devices that convert traditional projection radiography, which previously relied on analog 

screen-film detectors and recorded images on film or plates, into digital formats. 

Most commonly, devices within departments connect to a gateway that facilitates access 

to the internal network, while direct connections to the internal network are less frequent. 

If a device does not support the PACS storage format, a local server is utilized to convert 

data into the PACS-compatible format. 

In terms of interfaces and direct integration capabilities with PACS, digital devices of this 

nature should offer the following features: 

 Receiving demographic information: Ability to obtain patient data from Regional 

Information Systems. 

 Quality control: Capability to check and adjust images for quality assurance. 

 DICOM descriptions: Provision of DICOM (Information Object Definition) 

parameters for transmitting device specifications, such as cathode tube voltage in X-

ray machines (kVp), exposure time, and more. 

 Study-specific image processing: Implementation of image processing tailored to 

specific studies. 

1.1.5.2 Image Server 

The image server functions as a database management system for images, incorporating 

additional textual information. It is one of the two primary components of PACS. Modern 

implementations typically focus on a technical solution that includes a central computer 

equipped with multiple high-speed processors, extensible HDD storage (potentially 

structured as RAID), substantial RAM, and multi-layer cache memory. 

The software installed on this computer must ensure the monitoring of information, 

images, and their formats, as well as tracking image attributes, source information, and 

timestamps for image modifications. In cases where very large volumes of data are 

anticipated, some PACS implementations utilize a broker as an intermediary layer 

between two or more databases of this type. 

A less common architecture is the decentralized or distributed PACS, where server 

functionality and image repositories (local databases linked to components of the 

decentralized or distributed system) are distributed across the network. 



11 

 

1.1.5.3 Archiving System 

The archiving system is a crucial component of PACS, responsible for the electronic 

storage of images and their associated data. Advances in storage devices, coupled with 

intelligent data search and extraction software, have alleviated the primary challenges 

associated with expanding this functionality. Hard drives serve as the main storage 

medium, with their capacity continually increasing; creating repositories of hundreds of 

terabytes is now more of an economic and infrastructure challenge than a technical one. 

Typically, the technical solution involves a quick access archive and a long-term archive, 

with significantly different access times. This division is primarily an economic strategy, 

as the rapid access technology required for recently archived images tends to be more 

costly. To safeguard against data loss from disasters, a duplication of the archive is often 

implemented for recovery purposes. It’s important to note that rapid advancements in 

storage technologies can lead to a reduction in device prices by half over a five-year span. 

Consequently, scalability and workload assessments are essential considerations when 

acquiring a PACS archiving system. Realistic estimates of expected data and image 

volumes, workload (i.e., transfer rates to and from the repository), annual data growth, 

and access points to PACS should be made, as these factors can initiate archive access 

procedures. Additionally, it is vital to determine whether the archiving process will be 

automated or require manual activation each time. 

1.1.5.4 Broker for Communication with RIS and Other Information Systems of 

Image Generating Departments 

A vital component of PACS infrastructure is the communication broker that connects 

with other information systems. Successful integration with these systems and the ability 

to present relevant data are crucial for the effective use of PACS. At the workstation level, 

images can only be utilized if they are linked to patient information. Current technological 

solutions provide various ways to address these challenges. The relationship between the 

Radiology Information System (RIS) and PACS is particularly significant. This 

importance arises from the growing prevalence of RIS-based architectures, which connect 

with other information systems within hospitals or healthcare facilities. The increase in 

digital image sources and the volume of images necessitate efficient data transfer, as 

transferring raw images to a central server and then back to the medical investigation is 

often inefficient. Most modern RIS are developed, installed, and operated independently 



12 

 

of PACS but can be integrated with it. Manufacturers typically utilize the HL7 standard 

to facilitate the connection between RIS and PACS.  

To minimize redundant data and discrepancies across different server archives, many 

PACS systems rely on RIS as the primary source of patient information. This dependence 

requires a stable connection between PACS and RIS, usually facilitated by a “broker” 

that converts relevant data from HL7 to DICOM or vice versa. Radiology is not the only 

department producing medical images; other departments such as endoscopy, cardiology, 

Doppler imaging, pathology, and ultrasound diagnostics also generate significant 

amounts of data. Many of these devices produce large and complex single images or sets 

of images, as well as high-resolution videos. Clinicians often integrate information from 

these images with other clinical data to make informed decisions for patients. This results 

in substantial data streams and images that must be effectively managed within the PACS. 

1.1.5.5 Terminal Workstations 

The terminal workstation, which serves as the computer viewer for medical images, is a 

critical component of the PACS infrastructure. It is arguably the most visible aspect of 

PACS, as this is where medical staff interact with images managed by the system. 

Displaying images in PACS is a flexible and dynamic process, allowing medical 

personnel to engage directly with the images on their workstations. Each workstation 

comprises two main components: software and hardware. The effectiveness of a 

workstation is dependent on the specific combination of these two elements. At the 

hardware level, a significant challenge lies in ensuring that monitors can display images 

of consistent quality, regardless of the device used. This issue is prevalent in many PACS 

systems, which often operate with default settings based on the configuration of the 

installed operating system and the medical imaging visualization module. In practice, 

specialized and finely-tuned imaging monitors are seldom found in radiology 

departments. In a PACS environment, workstations serve various purposes, including 

primary reading, consulting, and reviewing images. To determine the requirements for 

these devices, it is helpful to categorize them based on their intended use: 

 Primary Class Device: Used primarily in radiology departments. 

 Secondary Class Device: Utilized in the medical practices of other specialists. 

 



13 

 

The main specifications for display workstations can generally be grouped into three 

categories: 

1. Ergonomics: Positioning (on a stand or wall-mounted), Angle and height adjustment 

options, Screen dimensions, Distance from the user, Room lighting conditions. 

2. Physical Characteristics: Resolution, Inter-pixel distances along both axes, Refresh 

rate, Geometric distortion, Anti-reflective coating. 

3. Optical Characteristics: Contrast, Maximum illumination, Illumination uniformity, 

Depth of gray (number of shades of gray), Chromaticity, Number of defective pixels, 

Angular variation of illumination, Contrast at the pixel level. 

These specifications are essential for ensuring that terminal workstations meet the needs 

of medical professionals in their imaging tasks. It is also important to know if additional 

workstations have additional functions such as brightness stabilization, image shape 

recognition, image mapping, autocalibration, remote calibration, ambient light sensor 

(external or internal), brightness remote control and contrast. A critical aspect of PACS 

evaluation is the ability to incorporate user functionalities through the use of an API or 

an internal command scripting language. This capability allows for customization tailored 

to specific user needs, thus increasing the overall effectiveness of the PACS system. 

1.1.5.6  Remote Access to PACS Resources 

From the early implementations of PACS, it has been recognized that the economic 

justification for installing PACS is contingent upon its ability to ensure effective 

dissemination and utilization of images across the entire hospital or medical organization, 

rather than being limited to the radiology department or other imaging departments. The 

distribution of medical imaging throughout the hospital or organization presents unique 

challenges that are significantly more complex than those faced by traditional PACS 

designed for radiology wards. Users outside the radiology department may have 

unpredictable needs regarding: 

 Image Requirements: What images they need . 

 Viewing Locations: Where they should access these images . 

 Timing: When they need to view them . 

These users can often be more demanding than radiologists concerning image 

transmission performance, which creates a substantial technological challenge. Over the 

past decade, the challenges associated with remote access to PACS have become 



14 

 

significantly more complex due to the rise of remote work. This capability has now 

become a standard requirement for any serious PACS product. Typically, remote access 

is facilitated through: Web Servers and Specialized PACS Client Software installed at 

remote locations. 

The primary issue involves accessing medical information outside the medical center via 

the Internet, which raises several concerns: 

 Data Security: Ensuring patient confidentiality (encryption is essential) . 

 Speed: Limited bandwidth can affect performance. 

 Image Quality: Potential degradation due to compression and display issues. 

 Legal Implications: Medical-legal consequences related to telemedicine . 

These challenges must be effectively managed to ensure the secure and reliable use of 

PACS resources in a remote access environment. 

1.1.5.7 Structure of regional PACS and Hospital PACS  

The structural development of PACS were designed as:  

 Hospital PACS Structure: connect hospital department.  

 Regional PACS Structure:  connect several hospitals together. 

A principal scheme illustrating the connection of regional PACS to hospital systems is 

presented in Figure 2.  

Figure 2 

Regional PACS Component 

 

 

 

 

 

 

 



15 

 

 

This scheme provides a basic understanding of the overall structure that needs to be 

maintained. It serves as the foundation for developing a principal scheme for accessing 

patient data from various hospitals connected to the regional PACS. This scheme is 

illustrated in Figure 3. 

Figure 3 

Structure of realization of data records for the same patient from different facilities 

 

 

 

 

 

 

 

 

In response to the need for external access to PACS (beyond the hospital infrastructure), 

hospital staff can access PACS through a DICOM WEB Browser, which is part of the 

installed PACS system. Access is secured by personal accounts and passwords. Similar 

to internal access to images, users have read-only access to PACS and work with local 

copies of the images. The original content cannot be modified (Ivanov, Gueorguiev et al. 

2021). 

The detailed structure of the regional PACS is illustrated in Figure 4 

Figure 4 

Structure of Regional PACS 

 



16 

 

1.1.6 PACS scope in Palestine 

The Palestinian ministry of health start working in the 1994 after entering the Palestinian 

authority as considered the main health provider for the Palestinian The health system in 

Palestine Lack of infrastructure to support population in need for the health services. A 

critical lake of infrastructure in the Palestinian hospital due to the restriction on the 

imports and the medical supply. Despite the difficulties faced by the Palestinian Ministry 

of Health, it was able to fulfill many of its roles in providing health care as well as 

promoting its institutions at a high level, including at the software level and the 

application of highly professional systems such as health information system (HIS) 

(anear). 

In September 2012, the first HIS implementation in the Palestinian medical complex 

hospital were conducted as AviCenna Hospital Information Management Platform. After 

the adaptation in this hospital, it was implemented in four other Palestinian governmental 

hospitals. The target of the system included the education of medical staff in hospitals by 

the AviCenna HIS engineers. In the model train-the-trainer, the head of each department 

was responsible for teaching his staff. Unlike other developing countries, Palestine faces 

more difficulties in adaptation of HIS due to the limits of accessing outside the country 

for learning new technology (Salameh, Eddy et al. 2019). 

1.1.7 Research problem 

The purpose of the study is to assess the current situation of PACS and HIS system 

implementation and factors facilitate of prevent their implementation in Palestinian public 

hospitals. And to develop an extension of TAM, which includes five structures: 

demographic (personal), literacy level, technological, organizational, and environmental 

factors, based on the perceptions of healthcare professionals. No previous study has been 

found that handles these factors comprehensively in Palestine. The main motivation 

behind this study is to clearly identify and examine the factors affecting the acceptance 

of the HIS and PACS in Palestinian public hospitals. In addition to the capacity utilization 

of the system. 

In the study we aim to study the perception of healthcare professionals towards the 

implementation of PAC in Palestinian public hospitals, we included all Palestinian public 



17 

 

hospital in West Bank (18 hospital). The problem to discuss focus on the effect of 

implementing PACS on staff at radiology department.  

1.1.8 Study aim 

In this study we aim to study the perception of healthcare professionals towards the 

implementation of PAC in Palestinian public hospitals. The problem to discuss focus on 

the effect of implementing PACS on staff at radiology department. This research provides 

a great important in the Palestinian public hospital, as it focus on the implementation of 

PASC in different factors. This study will explain the effect of employee demographics 

such as age, gender, education degree, computer skill, and work experience on the 

implementation of PACS Also, the effect on the expected outcome such as department 

management, number of repeated images, patient registration, time in radiology 

department, reporting time, the quality of images, the quality of reports and reducing 

errors. Another factor is the external environment of the organization such as the ease of 

access to radiology image, the effect on enhancing the communication between different 

department, and the improve the transition of radiology images. The next factor affected 

by PACS is patient care delivery such as patient satisfaction, reduce medical error, and 

reduce time in radiology department. Additionally, this research results will enhance the 

dealing with PACS and affect the future implementation of different projects in the 

Palestinian public hospitals. On the other hand, it will explain the challenges in 

implementation PACS in order to reduce these challenges in future event.  

1.1.9 Study objectives 

This descriptive study will be carried out to assess the perception of radiographers 

toward the use of PACS in west bank, Palestine.  

1. To assess the impact of PACS on its users. 

2. To determine the relationship between PACS implementation and users’ 

demographics. 

3. To measure the effect of PACS implementation on the external environment. 

4. To assess the relationship between PACS implementation and the quality of service.    

5. To determine the relationship between PACS implementation and the expected 

outcome.   

6. To measure the acceptance of PACS from its users.  



18 

 

1.1.10  Study Questions  

The study tries to answer the following main questions: 

 What are the factors affecting the adoption of Picture archiving and communication 

system (PACS) in Palestinian public hospitals? 

 Are there significant statistical differences at the level of (α≤0.5) in the study sample 

perspectives towards factors affecting the adoption of Picture archiving and 

communication system (PACS) in Palestinian hospitals due to the variables of gender, 

qualification, age, English language level, years of experience and knowledge about 

electronic health? 

1.1.10.1 Literature Review 

In this literature review these key words were used PASC, Radiology, health information 

system and users. Search were done between (2015-2022), using searching engines 

PubMed and google schooler. In this proposal 12 article were analyzed. The studies 

focused on the benefits and challenges in the process of implementing PACS.  

1.2 International studie 

article published by (Song, Mango et al. 2017) on the implementation of PACS in the 

period between 2012-2014 (Successful Implementation of a PACS in Tanzania). The 

PACS implementation started from the Muhimbili Orthopaedic Institute (MOI). The 

implementation experiment had four phases: planning, installation, expansion, and 

maintenance phases. The planning phase lasted for 2 years in order to reach the needs and 

requirements of PACS and radiology department to address a budget. This included 

assessing the inventory of infrastructure and the workflow in the radiology department. 

The installation phase duration was 3 months long to proof the compatibility between the 

workflow and proposed PACS. Open-resource PACS software were selected for structure 

the test server and workstation. The expansion phase was 6 months long to expand the 

storage capacity, server memory, and PACS workstation.  

Maintenance phase lasted for one year after the first installation. It included the 

maintenance and expanding the PACS. There was a successful implementation of PACS 

o lower the cost and improve access to x-ray images as a result there was a financial 

saving. The result explains that benefit of PACS exceeded the disadvantage and the ability 

to zoom, retrieve, pan, save, and compare images on PACS workstations has improved 



19 

 

the radiology resident learning experience. There was a successful implementation of 

PACS and the effort of lowering the cost and improving the access for x-ray images  

(Song, Mango et al. 2017). 

A study conducted in South Africa country in 2019 (PACS implementation challenges in 

a public healthcare institution: a South African vendor perspective). the aim of the study 

identifies and describe the challenges endured by PACS vendors during PACS 

implementation. A qualitative research approach used in this study using an interpretive. 

this enabled an information rich narration of a population of PACS vendor employees to 

collect data from their live experiences and to report on their meanings and 

understandings. The data collected using methodology approach qualitative in nature 

throw semi structured interview for 10 PACS expert and then analyzed. The study found 

countless challenges related to the vendor the lake of space to position the PACS 

workstations was the major. Also, the related peripheral devices were a challenge due to 

the lake of proper furniture. Another concern was about the minor system changes such 

as uncomfortable ergonomic positioning of equipment.  

Moreover, respondents note about the x-ray darkroom was being converted to unsafe 

server room which will affect the equipment. In South Africa they have faced the lake of 

working room such as offices and general space. The power and electricity also were a 

general problem, in South Africa there was a lack of the needed power and electricity that 

affects all sectors, including business and healthcare. This clearly pose a challenge to 

provide the stable power for the system. Another barrier was related to the financial 

support, funds are available, but the concerns was about the space modification, 

maintenance of the system and replacement for theft of equipment, and budgets for future 

upgrades. A widespread deficiency in IT knowledge has been identified as a significant 

obstacle to the implementation of PACS systems, as effective training for PACS software 

depends on a foundational understanding of IT. This issue has also been documented 

within the healthcare sector. Another obstacle related to the absence of specialized 

training, insufficient manpower for large projects, and delays in professional support from 

international manufacturers are key issues.  

These factors can result in implementation delays and dissatisfied customers, which in 

turn contribute to resistance against the implementation of PACS. 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 



20 

 

aware of these challenges to mitigate their effects and Vol. 25 • No. 4 • October 2019 

www.e-hir.org 331 PACS Implementation Challenges to aid in a successful 

implementation (Abbas and Singh 2019). 

Recently a study was made in Bulgaria in 2021 (Design and implementation of a regional 

PACS), the study shows that offered on market of PACS had increased more than 10 

times in the period between 2005-2020 due to offering varies capabilities and function. 

according to this study, many advantages cased this rapid increase for example, Enhanced 

usage scenarios and simplified operations Improved capacity for input-output requests 

related to image handling, leading to faster electronic archiving, reduced response times 

for processing requests, an increased variety of image manipulation options available 

within the system, enhanced performance in image processing, remote and simultaneous 

access to image data, better computer archiving through new algorithms for indexing and 

searching by various features, capability to handle images from both digital and analog 

radiological machines, cost reductions and extended operational time due to a modular 

development approach, which lowers the expenses associated with upgrading medical 

imaging equipment in radiology departments, improved cost-effectiveness resulting from 

decreased expenses for computers and communication infrastructure, as more operating 

systems and general-purpose protocols are being utilized. PACS systems are susceptible 

to technical issues and operational drawbacks. Problems can occur due to improper or 

incomplete installation or configuration, especially when they exceed the initially 

intended resources and tasks, or when new image-generating devices are added or images 

are displayed. Specific challenges for hospital and interhospital networks include 

compliance with DICOM protocol requirements.  

Many communication devices do not support all the protocols mandated by DICOM. The 

security of local and regional PACS relies on several fundamental requirements: 

Complete protection of the main database, Prohibition of any HTTP exchanges with the 

main PACS, Anonymization/ deanonymization, Transport of anonymized data, 

Identification of DICOM viewers, Exported DICOM viewers, HTTP exchanges. 

Moreover, the system improves the use and operation of data, increase the input and 

output capacity required for work, reducing processing time, increase number of 

processed images, improve image processing, referment the remote access to images data, 

improve searching and indexing data by using new algorithms technology, increasing 

operation time and reducing the cost, and reducing the cost of infrastructure in order to 



21 

 

increase cost-effectiveness. Within the activities carried out by the National Scientific 

Program “е-Health in Bulgaria”, PACS was selected and an installation of local hospital 

PACS and regional PACS was made (Ivanov, Gueorguiev et al. 2021). 

1.2.1 Study at Regional level 

In 2017 in Saudi Arabia at King Saud bin Abdul-Aziz University for Health Sciences 

research in systematic review (Evaluating latest developments in PACS and their impact 

on radiology practices: A systematic literature review) (Alhajeri, et al,.2017). A 

systematic review to analyze the empirical literature examining various features of PACS 

and evaluate the impact of recent developments in PACS. 17 articles from different 

regions of the world were included in the review. This review aimed to conduct a 

systematic review to assess the evidence surrounding the technical characteristics of the 

most effective PACS and to evaluate the impact of recent developments in PACS on 

radiology practices from 2004 to 2015. During this decade, information technology has 

advanced rapidly, providing an opportunity to explore the latest developments and trends 

in PACS. A wide range of studies addressing various aspects of PACS exists. However, 

a comprehensive systematic review that identifies the shortcomings of current PACS used 

by radiologists globally, examines the new features needed to meet future user 

requirements, and enhances functionality, accessibility, and maturity has not been found. 

Additionally, existing studies have not explored how the latest developments in PACS 

will impact radiology practice and its users. Despite the increasing global use of PACS, 

a database search for papers published in the last decade yielded only 17 relevant studies, 

with US research groups contributing eight and European researchers four. This scarcity 

limits the ability to draw definitive conclusions about PACS's impact across different 

healthcare scenarios. Furthermore, most studies have focused on only a few PACS-related 

aspects, which restricts a comprehensive understanding of PACS's effects within specific 

organizations. Although various PACS platforms are commercially available, only one 

study was identified that examined different PACS platforms in detail. This review 

summarized the successful themes for PACS implementation: best characteristics of 

selected PACS, PACS influence on radiologist and radiograph workplace, user 

acceptance of PACS, and satisfaction of users (Alhajeri, et al,.2017).   

Another study in Saudi Arabia at Riyadh region in King Abdulaziz Medical City in 2018 

(Impact of picture archiving and communication system (PACS) on radiology staff) 



22 

 

(Aldosari, Saddik et al. 2018). This study aimed to discussed the effect of implementing 

PACS on the radiology staff and its advantages in improving the quality of health system. 

And the relationship between user’s characteristic and the acceptance of the system in 

hospitals facilities in Saudi Arabia. This quantitative study employs an exploratory 

descriptive approach as its overarching framework and relies on distributed 

questionnaires to collect the necessary data.  

The study focuses on five variables that describe the impact of the health information 

system: External Communication, Service Outcomes, Personal Intentions, Personal 

Hassles and Increased Blame. Investigating radiologists' responses to these variables will 

enhance our understanding of the impact of PACS on their work. Additionally, by 

analyzing the relationship between user characteristics and the study's impact variables, 

it identified which user characteristics correlate most significantly with these variables. 

Given that the study examines the impact of PACS on radiologists, this design is 

particularly suitable for gathering information and establishing a foundation to 

comprehend the limitations and scope of the research questions. The systematic literature 

review highlights several themes essential for the successful implementation of PACS: 

Features for Selecting the Best PACS,  User Acceptance of PACS,  Teleradiology and 

PACS,  Impact of PACS on the Work Environment of Radiologists and Radiographers,  

User Satisfaction with the Virtual Organization of the Medical Imaging Department, 

PACS Success Model,  Image Viewing Platforms, and PACS Maturity Framework. 

Despite numerous advancements in PACS that have aided clinicians in enhancing 

radiology practices, several areas of concern for PACS users still require attention.  

These issues must be addressed in the development of more sophisticated and integrated 

technologies for the next generation of PACS. The study showed that there is a positive  

effect of PACS on its users and there were well perceiving for PACS benefits among the 

physicians and radiologists. Also, there were a disadvantage in PACS as insufficient 

training, difficulty in finding images, and recruitment downtime (Aldosari, Saddik et al. 

2018). 

In Saudi Arabia a study was conducted to assess the clinician’s perception of PACS in 

2021 (Clinicians’ Perceptions of Picture Archiving and Communication System (PACS) 

Use in Patient Care in Eastern Province Hospitals in Saudi Arabia) (Al-Kahtani, Al-Dhaif 

et al. 2021). The primary aims of this study were to investigate clinicians’ perceptions of 



23 

 

PACS, examine how they utilize the system, assess the advantages and disadvantages of 

its use, and gather their suggestions for improving its implementation. Additionally, the 

study sought to identify the factors that influence clinicians’ perceptions and use of PACS 

to provide insights into ways to enhance its utilization.  

The following research questions were addressed: Do hospital clinicians use PACS in 

their practice? What are the perceived advantages of PACS use? What are the perceived 

disadvantages of and/or barriers to PACS use? What are clinicians’ recommendations for 

improving PACS use? This study utilized a qualitative research approach grounded in 

theory to explore the use of PACS from a clinician's perspective in three hospitals located 

in the Eastern Province of Saudi Arabia. Qualitative research aims to "discover the world 

from the participants’ perspective." Data were collected through semi-structured 

interviews and analyzed using grounded theory methods. A grounded theory study is an 

inductive approach that develops abstractions, concepts, hypotheses, and theories based 

on participants’ words. The data gathered from the interviews were used to formulate a 

theory regarding the phenomenon of PACS use in patient care within hospitals.  

The sample consisted of 18 participants contained radiologist, resident and consultants. 

the result of the study shows the Clinicians’ acceptance of PACS is crucial for the 

successful implementation of the system, and this acceptance is influenced by their 

perceived advantages and disadvantages of the system and its usage. The theoretical 

model developed in this study identifies three key factors that shape clinicians’ 

perceptions: Demographic Factors, System-Related Factors and Hospital-Related 

Factors. These factors can help pinpoint areas for improvement to ensure effective PACS 

implementation in hospital settings. It also reviled the barriers included low-speed 

internet connections and technical problems (Al-Kahtani, Al-Dhaif et al. 2021). 

A study conducted in Iran in 2017 titled (Acceptability of picture archiving and 

communication system (PACS) among hospital healthcare personnel based on a unified 

theory of acceptance and use of technology) to investigate the influence of PACS on its 

users. Various theories address the use and acceptance of technology, aiming to describe 

the behaviors and attitudes of end users toward information technologies. This study 

explored the factors influencing users’ acceptance of PACS in military hospitals in 

Tehran. This study applied analytical and cross-sectional study conducted in 2016, 

involving a population of 151 healthcare personnel who utilized PACS in five military 



24 

 

hospitals in Tehran. They employed the Unified Theory of Acceptance and Use of 

Technology to identify the factors influencing users’ acceptance of PACS. Data were 

collected using a researcher-designed questionnaire. To ensure the questionnaire was 

suitable for this research, we reviewed articles related to the Unified Theory of 

Acceptance and Use of Technology model. The study considered the following variables: 

Performance Expectancy, Effort Expectancy, Social Impact, Facilitating Conditions, and 

Behavioral Intention. The questionnaire was divided into two parts. The first part gathered 

demographic information, including age, sex, education, work experience, and the names 

of the organization and hospital (seven items).  

The second part consisted of six sub-sections: performance expectancy, effort 

expectancy, social influence, facilitating conditions, behavioral intention, and actual use. 

In total, 27 items were adapted from Davis's questionnaire and other resources related to 

the integrated model of acceptance and use of information technologies. Responses were 

rated on a 5-point Likert scale (from completely disagree to completely agree). Before 

distributing the questionnaire to participants, its validity was confirmed by a panel of 

experts, and its reliability was assessed through a pilot study involving 30 hospital 

healthcare personnel, yielding a Cronbach’s alpha of (α = 0.91). The data were analyzed 

using both descriptive and inferential statistics. Results had showed efforts expectancy, 

social impact, expected performance and facilitating conditions affect directly on the 

behavior’s intention toward the acceptance of PACS.  

The behavioral intention among hospital healthcare employees has a significant 

association with social influence, effort expectancy, Performance expectancy, and 

facilitating condition. Each of the studied variables is influential in the decision to use 

PACS and should be considered by medical centers’ authorities to successfully 

implement PACS. Training healthcare personnel in the use of PACS appears to be 

essential. Additionally, it is recommended that future studies explore the acceptance of 

healthcare technology systems, such as PACS, using structural equation models and 

technology acceptance models (Ahmadi, Mehrabi et al. 2017). 

Another study published in Iran in 2019 titled (Effect of implementation of picture 

archiving and communication system on radiologist reporting time and utilization of 

radiology services: a case study in Iran.)  In this study the aim was to study the effect of 

PACS on radiology reporting time and service utilization. A cross-sectional approach was 



25 

 

condeucted in 2018 in Nohome Dey Hospital in Torbat Heidaryeh city, Khorasan, Iran. 

Which is a general hospital, governmental and non-teaching. It consisted from 190 beds. 

the study used data collected from a (5074) patients with (6613) exam was collected in 

three period of 6 months. These periods included before implementation, immediately 

after implementation, and 1 year after implementation. To avoid possible seasonal impact 

the data collected from similar months in the three period. the data were collected from 

the early July 2015 to the end of December 2015 (6 months period before the system 

implementation), the early July 2016 to the end of December 2016 as the period of 

immediately after PACS (the first 6 months after system implementation) and early July 

2017 to the end of `December 2017 as the period of 1 year after PACS implementation. 

The data collected from CT examination and radiographers.  

The reporting time were calculated throw estimating the time between patient order and 

physicians report and the utilization rate was calculated throw these variables: the average 

number of examinations per patients with an examination, the average number of 

examinations per all admitted, and the average number of examinations per patient day, 

respectively. This study showed a significance decrease in reporting time after 1 year of 

implementation. Besides, increasing in utilization rate in the long and short-term in 

radiography and CT scan in radiology department. which suggest that radiology 

department  use the system to increase utilization of radiology services and to improve 

the reporting time of radiologists (Hasani, Hosseini et al. 2020). 

In Kerman city in Iran in 2020 titled (Investigating the satisfaction level of physicians in 

regards to implementing medical Picture Archiving and Communication System 

(PACS)). The study conducted to measure the physician satisfaction of PACS and 

compare the features of traditional film-based system. as it’s important criteria in the 

acceptance of the model in hospitals of Kerman city in Iran. In this study the author’s see 

user satisfaction is a critical factor influencing the successful implementation of 

information systems. When users feel satisfied with a system, they are more likely to 

engage with it effectively, leading to improved overall performance. Conversely, user 

resistance to these systems can create significant inefficiencies, which can hinder 

organizational productivity and effectiveness.  

This resistance may stem from various factors, including usability issues, lack of training, 

or inadequate support. Over time, persistent dissatisfaction can lead to system withdrawal, 

where users abandon the system altogether in favor of alternative solutions. given that 



26 

 

user satisfaction with an information system directly correlates with employees’ 

productivity and their likelihood of continued use, it becomes essential for organizations 

to prioritize understanding and addressing the factors that contribute to users’ 

dissatisfaction. Identifying these issues not only helps to enhance user experience but also 

fosters a more productive work environment.  

Therefore, organizations should actively seek feedback from users and implement 

strategies to resolve any concerns, ensuring that the information systems in place 

effectively meet the needs of their users. A cross-sectional approach was applied on 59 

resident seniors using a questioner consisted of three parts. The first part measures the 

demographics information such as: gender, age, computer skill, PACS experience, 

specialty, and the number of images interrupted by physicians using PACS. second part 

measure the satisfaction of the system using 14 question of 7-choice on Likert scale (from 

“completely disagree” to “completely agree”).  

The third part questions compared features between digital and traditional film-based 

using 8 questions of 5-chioces on Likert scale (from score1 to 5). This study showed that 

The Physicians satisfaction was at moderate level, problems were found in the 

implementation of PACS. It hasn’t met all the demands in radiology department. most of 

physicians and radiologist are satisfied with using PACS. Although the users with high 

computer skills are more satisfied than low computer skills, those see PACS as a time-

wasting system.  

The study results indicated that, although physicians’ satisfaction with PACS was rated 

as moderate to high, challenges remain in successfully implementing the system and 

achieving interoperability across different treatment centers. PACS have not fully met 

physicians' needs, and some healthcare facilities have not realized their intended 

objectives, such as access from various locations. To address these issues, the study 

recommends increasing the number of workstations for PACS and utilizing personal 

digital assistants (PDAs) to reduce the time spent accessing the system at patients’ 

bedsides. User-specific training is also crucial for effective implementation. Additionally, 

adding a printing feature could facilitate sharing images with external centers, enhancing 

collaboration and patient care (Abbas and Singh 2019). 

Another study conducted in Iran in 2022 (Determining the Effect of the Picture Archiving 

and Communication System (PACS) on Different Dimensions of User). the study aims 



27 

 

to discover and enhance the effect of PACS on users work at Kerman University of 

Medical Sciences. The impact of (PACS) on various aspects of healthcare, including 

costs, information access, image quality, and user workflow, has been the subject of 

extensive research. These studies have provided valuable insights into how PACS can 

enhance efficiency and effectiveness in medical imaging and patient care. However, 

despite this wealth of information, there remains a notable lack of evidence regarding the 

effects of PACS on different dimensions of users' work experiences.  

Recognizing this gap, the objective of the present study was to thoroughly evaluate the 

impact of PACS on several critical dimensions of users' work. Specifically, the study 

focused on external communication, service quality, user intention to utilize PACS, the 

influence on daily routines, and the nature of complaints reported by users. By examining 

these factors, the study aimed to provide a comprehensive understanding of how PACS 

affects the daily operations of healthcare professionals. Furthermore, the research sought 

to compare the opinions and experiences of various user groups regarding the PACS. This 

comparison is essential, as different users—such as radiologists, technicians, and 

administrative staff—may interact with the system in distinct ways and have varying 

perceptions of its effectiveness.  

By gathering and analyzing feedback from these diverse groups, the study aims to 

highlight potential areas for improvement and inform future implementations of PACS in 

healthcare settings. A cross sectional approaches a questionnaire was used for collecting 

data from 72 of radiology staff include, radiologists, radiology staff, ward heads, and 

physicians. This study showed that the PACS has a positive effect on users’ work, 

especially on user intention to use the system, external communication, and service 

quality. It also measured the negative impact of PACS such as complaints and pressure 

on the radiology department. The author recommended that medical centers implement 

PACS to effectively support users' work. This implementation is crucial for maintaining 

and enhancing the capabilities and functions of radiology departments, ensuring they can 

deliver high-quality imaging services efficiently (Montazeri, Khajouei et al. 2022). 

A study in Kuwait in 2016 (Users’ Perspectives on a Picture Archiving and 

Communication System (PACS): An In-Depth Study in a Teaching Hospital in Kuwait). 

This study aims to thoroughly explore the various factors that contribute to the success or 

failure PACS in determining their clinical value. By focusing specifically on the 

experiences and perspectives of the direct users of this system—such as radiologists, 



28 

 

technicians, and administrative staff—the research seeks to provide a comprehensive 

understanding of how PACS impacts daily operations in a healthcare setting. The 

conceptual basis of this study is centered on assessing the impact of PACS within a 

regional hospital in Kuwait. The evaluation is conducted using specific criteria designed 

to measure various dimensions of the system's effectiveness, including user satisfaction, 

workflow efficiency, and the quality of patient care. This approach allows for a nuanced 

analysis of how PACS functions in a real-world environment and its implications for 

clinical practice. Importantly, this study is groundbreaking in the context of Kuwait, as it 

represents the first research of its kind in the region.  

There is a notable scarcity of literature addressing the implementation and impact of 

PACS in Kuwaiti healthcare facilities, making this study a significant contribution to the 

field. By filling this gap, the research not only enhances the understanding of PACS in a 

local context but also provides valuable insights that can inform future implementations 

and improvements of such systems in Kuwait and similar healthcare environments. An 

in-depth study Data collected from 60 radiologist and technologist, both quantitative and 

qualitative methods through a mixed-methods approach, comprising: Survey 

Questionnaires: Distributed to radiologists and technologists at Mubarak Al-Kabeer 

Hospital to gather information on PACS usage and Semi-Structured Interviews: 

Conducted with PACS administrators for insights into the system's implementation. A 

validated questionnaire, translated from French to English, was pretested for clarity and 

relevance, simplifying a 7-point Likert scale to 5 points. 

The evaluation of PACS success was based on a model derived from DeLone and 

McLean, enhanced with constructs for system continuance intention and confirmation 

oexpectations. The questionnaire assessed users' perspectives across eight dimensions, 

including system quality, information quality, service quality, usage, satisfaction, net 

benefits, continuance intention, and confirmed expectations. Additionally, interviews 

with PACS administrators provided valuable insights into the clinical environment, 

focusing on the experiences of technologists managing PACS and RIS operations, thereby 

enriching the study's findings. The study finds that almost three quarter of the participants 

rate PACS positively productive impact of PACS on the performance of radiologist and 

technologist (Buabbas, Al-Shamali et al. 2016). 

A study in Egypt 2021 (Implementations of PACS and Teleradiology Systems in Sohag 

University Hospital). This study aimed to evaluate, enhance current use and acquire 



29 

 

experience of implementation of PACS and teleradiology in the period (2015-2017) in Suhag, 

Egypt. Descriptive analytical model was applied. the data collected and analyzed from 57453 

patients in period between 2015-2017. The result showed the impact of implementation of 

PACS such as, rapid access to images, reduction of images loss, reduction on cost, increase 

productivity, and improve patient care (Abodahab, Alhewaig et al. 2021). 

Table 1 

The list of previous studies 

Country Study Author, year 
Collection 

tool 
Population 

International studies 

Tanzania 
Successful Implementation of a PACS in 

Tanzania 

Song, Mango 

et al. 2017 

Cross 

sectional 

survey 

Radiology 

department at 

Muhimbili 

Orthopaedic 

Institute in 

Tanzania 

South 

Africa 

Pacs implementation challenges in a public 

healthcare institution: a South African 

vendor perspective 

Abbas & 

Singh, 2019 

semi 

structured 

interview 

10 PACS expert 

Bulgaria 
Design and implementation of a regional 

PACS 

Georgieva,& 

Ivanov, 2021 

Self-data 

collection 
 

Regional studies 

Saudi 

Arabia 

Evaluating latest developments in PACS 

and their impact on radiology practices: A 

systematic literature review 

Alhajeri, et 

al,.2017 

Systemati

c review 

of 

previous 

studies 

 

Impact of picture archiving and 

communication system (PACS) on 

radiology staff 

Aldosari et al., 

2018 

Questionn

aire 

200 radiology 

department 

users. 

Clinicians’ Perceptions of Picture Archiving 

and Communication System (PACS) Use in 

Patient Care in Eastern Province Hospitals 

in Saudi Arabia 

Kahtani, Al-

Dhaif et al. 

2021 

semi-

structured 

interviews 

18 residents, 

radiologists, and 

consultants. 

Iran 

Acceptability of picture archiving and 

communication system (PACS) among 

hospital healthcare personnel based on a 

unified theory of acceptance and use of 

technology 

Ahmadi, et 

al.,2017 

Questionn

aire 

151 healthcare 

employees 

Effect of implementation of picture 

archiving and communication system on 

radiologist reporting time and utilization of 

radiology services: a case study in Iran 

Hasani, 

Hosseini, & 

Sheikhtaheri, 

2020 

Patient 

data 

collection 

5074 patients 

Investigating the satisfaction level of 

physicians in regards to implementing 

medical Picture Archiving and 

Communication System (PACS 

Abbas & 

Singh, 2019 

Questionn

aire 
59 residents 

Determining the Effect of the Picture 

Archiving and Communication System 

(PACS) on Different Dimensions of User 

Montazeri, 

Khajouei, & 

Practice, 2022 

Questionn

aire 

72 of radiology 

staff 

Kuwait 
Users’ Perspectives on a Picture Archiving 

and Communication System (PACS 

Buabbas et al., 

2016 

Questionn

aire 

60 radiologist 

and technologist 

Egypt 

(Implementations of PACS and 

Teleradiology Systems in Sohag University 

Hospital 

(Abodahab, 

Alhewaig, 

Alserafi, & 

Fawzy, 2021 

Patient 

data 

collection 

57453 patients 



30 

 

Chapter Two 

Method 

2.1 Study design 

According to the study problem and its objectives, and through the questions that this 

study seeks to answer, the cross-sectional descriptive study has been relied upon, which 

provides data for describing the status of phenomena or relationships among phenomena-

related variables at a fixed point in time. 

2.2 Study population 

This study will include all radiology staff, using PACS working in governmental hospitals 

in the population refers to all the elements of the study, or elements being investigated, 

the research population included all hospital in west bank who were (170) at the time of 

the study. 

2.3 Study sample 

Since the study population is relatively small and very stratified, this research study 

utilized a comprehensive sampling approach by inviting all the (170) employees of 

hospitals to participate in the survey. Employees-related information was provided by the 

Palestinian medical imaging associations. The questionnaire (Appendix B) was 

distributed to the study sample through on the site of the Palestinian medical imaging 

associations. 

 Inclusion criteria: all radiographers working in the Palestinian governmental hospitals 

registered in the Palestinian Association of Medical Radiation Technologists. 

 Exclusion criteria: radiographers working in clinicals and privet center.  

The sample consisted of 151 PACS users in Palestinian hospitals. The sample is a 

stratified random sample. The background of the study sample is varied in terms of 

gender, qualification, age, English level  and  years of experience. 

 

 

 



31 

 

2.4 Study instrument 

Data resources in this study can be divided into primary (direct) and secondary (Indirect) 

resources. 

 Primary data: Questionnaire were the main instruments of this study; the 

questionnaire was designed keeping in view the study’s objective. It was kept as 

concise as possible as a short questionnaire with conceptually clear and concise 

statements desired by both respondents and the researcher. 

A questionnaire was prepared by reviewing several studies that dealt with the same topic 

as our current study. Questioner structured, close-ended, and design in Arabic  language 

to ensure completely understand of the questionnaire because we have old radiographers. 

comprising (35) questions. A 5-point Likert-type scale was used to assume that the 

strength/intensity of the experience is linear, i.e., on a continuum from strongly disagree 

to agree strongly. To achieve the objectives of the study, we used a 35-item of factors 

affecting the adoption of Picture archiving and communication system (PACS) in 

Palestinian hospitals by using previous literature and the researcher's own experience in 

the field of studying public health management At Al Najah National University. 

Respondents were offered a choice of one to five, were responses to the neutral point 

being neither agree nor disagree; whereby one refers to strongly disagree, two refers to 

disagree, three refers to neutral, four refers to agree, and finally, five refers to strongly 

agree. The questionnaire consisted of five main sections (appendix B).  

 Section 1. It covers socio-demographic related to gender and type of practice, it 

consists of (9) questions (i.e., age, gender, region of work, computer skills and level 

of education.)  

 Section 2. It covers the effect of PACS on the external communication it consists of 

(4) questions (i.e., the ease access to images, the communication between different 

department, and the benefit between the clinical and radiology department).  

 Section 3. This section will cover the expected outcome from using the PACS, it 

consists of (10) questions (i.e., repeated images, reporting time, reducing the cost and 

improving overall quality)  

 Section 4. It will discuss the challenges in using the PACS, it consists of (6) questions 

(i.e., technical challenges and poor computer skills.). 



32 

 

 Section 5. it will discuss the user’s satisfaction in using PACS, it consists of (6) 

questions 

The scores of responses to each item were calculated according to a five-point Likert scale 

for the first three domains’ responses in which strongly agree =5 points, agree =4 points, 

neutral   = 3, disagree = 2 points and strongly disagree = 1 point.  

2.5 Study validation 

The questionnaire was developed paced on previous study in the field of PACS, the data 

was collected and reviewed by (5) researchers in health management and medical 

imaging. The response was viewed from (3) researchers Appendix (A) The respondents’ 

comments and the jury's suggestions were taken into consideration to modify and improve 

the questionnaire's content and wordings by omitting, adding or rephrasing items bringing 

the number of items remained 35 items. it was modified and addition as possible.  

2.6 Reliability of the Questionnaire 

The reliability of the questionnaire was calculated through Cronbach Alpha formula and 

the following table illustrates the results: 

Table 2 

Cronbach Alpha test for the study tools 

Study Tool/ Domains  Items Cornbach Alpha 

External environment 4 0.966 

Expected outcomes 10 0.969 

Expected challenges 6 0.961 

Satisfactions   6 0.944 

Total 26 0.985 

 

Results in table (3) illustrate that Cronbach Alpha coefficient for the total degree was 

(0.985) which is Excellent and acceptable for the purpose of the study. The Cronbach 

Alpha coefficient of the domains ranged between (0.961) for Expected challenges and 

(0.969) for Expected outcomes among PACS users in Palestinian hospitals.  In order to 

evaluate the results of Cronbach Alpha, the following scale is used as demonstrated in the 

following table:  



33 

 

Table 3 

Cronbach alpha Internal Consistency 

 Cronbach alpha  
Internal Consistency 

α ≥ 0.9 
Excellent 

0.7≤ α < 0.9 
Good 

0.6≤ α < 0.7 
Acceptable 

 

2.7 Study procedures 

Figure 1 

Study Procedure: The Procedures of Study Showed in Figure (1)  

 

 

 

.

• initially, a research proposal for this study was prepared, and 
the study tool (a questionnaire) was presented to a group of 
expert befor beind subbmitted 

.

• the approval on the proposal were obtaiened from the 
Faculty of Graduate Studies and IRB at Al-Najah National 
University and from the PAto initiate the distribution of 
Quastionnaiers to collect data.

.

• a pilot study was conducted to ensure the validity and 
realability of the study.

• the study tool was applied to the study sample , and the data 
was collected and converted to a spicial tables. the total 
number of questonnaires was 151 employee.

• the data was analyezed by using SPSS to have the final 
results 



34 

 

2.8 Statistical Procedures    

The data collected were analyzed using SPSS version 17.0 in order to provide answers 

the questions of the study, the researcher used the following:  Means, frequencies, 

standard deviations, percentages-tests for Independent Samples, One-Way Analysis of 

Variance (ANOVA), Cronbach Alpha is used, and Post hoc test. 

2.9 Study analysis 

Accordingly, the researcher used the following scale to represent the estimation level of 

sample   responses. In order to limit the length of the cells of the five-point Likert scale 

(minimum and maximum limits, range has been calculated (5-1=4), divided on the correct 

length of the cell (4/5=0.80) and added to the lowest value of the scale (1) in order to 

reach the highest limit of this cell. Cell limits became as in Table (4): 

Table 4 

Scale for representing the estimation level of sample responses 

Mean Percentage % Estimation Level 

4.20 and more 84.0 % and more Very High 

3.40-4.19 68.0 – 83.8   % High 

2.60-3.39 52.0 – 67.8 % Moderate 

1-80- 2.59 36.0 – 51.8   % Low 

Less than 1.8 35.9% and less Very Low 

 

2.10 Ethical approval  

The Institutional Review Board (IRB) at An-Najah National University and the scientific 

research committee of the Public Health Management Department (Appendix c) approved 

the study proposal. An explanatory letter was attached to each questionnaire for all 

participants to explain the aim, importance, and privacy, with optional participation 

(Appendix D).  In addition, a permission taken from the Palestinian Association of 

Medical Radiation Technologists to publish this questioner on their website. 

 

 

 



35 

 

Chapter Three 

Result 

This study aimed at identifying factors affecting the adoption of Picture archiving and 

communication system (PACS) in Palestinian hospitals. It also aimed at identifying the 

effect of several variables on the responses. To accomplish the aims of the study, the 

researcher analyzed the data of the questionnaire in the accordance with the study 

questions and hypotheses. The sample consisted of (151) respondent constants collected 

with a response rate of  )88%( from PACS users in Palestinian hospitals. The sample is a 

stratified random sample.   

3.1 Sample Demographics 

The demographic distribution of the study sample is varied in terms of gender, qualification, 

age, English languge level,  years of experience, area of occupation, computer skills, 

knowledge in electronic health record and PACS training in department. In this study (77.5%) 

of the study sample was male, (67.5%) having B.A degree, the highest age group with 49.9% 

was (31-40) years old, (41.7%) had a faire English language level, (6-11) years of experience 

was (47%) of sample, (47.0%) of the study sample working in general radiology and 

Computed Tomography. (CT), (51.0%) of the study sample has adequate computer skills, 

(81.0%) has excellent knowledge about electronic and health record system and PACS have 

not provided 82.8% training as showed in table (5). 

 

 

 

 

 

 

 

  



36 

 

Table 5 

Distribution of Sample responses on users’ demographics 

V
ar

ia
b

le
 

C
la

ss
 

F
re

q
u

en
cy

 

P
er

ce
n

ta
g

e 

%
 

Gender 
Male 117 77.5 

Female 34 22.5 

Qualification 

Bachelor degree 102 67.5 

Master degree 44 29.2 

Ph.D. or more 5 3.3 

Age 

From (22-30) Years Old 57 37.7 

From (31-40) Years Old 75 49.7 

From (41-50) Years Old 17 11.3 

Older than 51 years 2 1.3 

English level  

Poor 20 13.3 

Fair 63 41.7 

Good 52 34.4 

Excellent 16 10.6 

Years of experience  

≤ (5) Years 53 35.1 

From (6-11) Years Old 71 47.0 

From (12-19) Years Old 25 16.6 

≥ (20) Years 2 1.3 

What is the area in radiology department 

 that describe your current position 

General radiography 39 25.8 

Computed Tomography. (CT) 21 13.9 

Magnetic Resonance image (MRI) 15 9.9 

Nuclear Medicine 2 1.3 

Others 3 2.0 

General radiography and Computed 

Tomography. (CT) 
71 47.0 

Computer skills 

Poor 57 37.7 

Adequate 78 51.7 

Excellent 16 10.6 

Knowledge about electronic health  

record system 

very little 17 11.3 

A little 5 3.3 

Good 6 4.0 

Excellent 123 81.5 

Which of the following describe the  

PACS training that was provided to you 

I was trained with a group 3 2.0 

I was trained individually 8 5.3 

I was trained using web-based tutorial 

training 
15 9.9 

I have not been trained 125 82.8 

Total 151 100.0 

 



37 

 

3.2 Perception  of users toward impact of PACS 

Based on the questionnaire used in this study, the factor divided into four variables. The 

responses to the impact of the four variables of the questionnaire are described explicitly 

in table (6-9) 

Table (6) shows that the total degree for of the items of factors affecting the adoption of 

PACS in External environment domain, according to users was (4.17) which suggests 

high level of estimation. The highest mean was given to the item (PACS affects the ease 

of access to radiology images and data). The lowest was for the item (Communication 

with other clinical departments has enhanced since PACS was installed). 

Table 6 

The response rate of the External environment impact variables in Palestinian hospitals in 

descending order 

R
an

k
 

N
o

. 
in

 t
h

e 

Q
u

es
ti

o
n

n
ai

re
  

D
o

m
ai

n
 

M
ea

n
s 

st
an

d
ar

d
 

d
ev

ia
ti

o
n

s 

P
er

ce
n

ta
g

e 
%

  

E
st

im
at

ed
 

le
v

el
 

1 1 
PACS affects the ease of access to radiology images and 

data 
4.21 0.86 84.2 Very High 

2 2 
PACS enables easy access and sharing of radiology data and 

images with other clinical departments. 
4.19 0.91 83.8 High 

3 4 PACS facilitates patients file sharing between hospitals 4.14 0.84 82.8 High 

4 3 
Communication with other clinical departments has 

enhanced since PACS was installed 
4.13 0.94 82.6 High 

Total 4.17 0.82 83.4 High 

 

Table (7) shows that the total degree for of the items of factors affecting the adoption of 

PACS) in Expected outcomes according to users was (3.99) which suggests high level of 

estimation. The highest mean was given to the item (PACS reduces errors in patient 

registration). The lowest was for the item (PACS improves and helps reserve the quality 

of image). 

 

 

 

 



38 

 

Table 7 

Response rate to the Expected outcomes impact variable in Palestinian hospitals in descending 

order 
R

an
k

 

N
o
. 

in
 t

h
e 

Q
u
es

ti
o
n
n
ai

re
 

D
o
m

ai
n
 

M
ea

n
s 

st
an

d
ar

d
 

d
ev

ia
ti

o
n
s 

P
er

ce
n
ta

g
e 

%
 

E
st

im
at

ed
 

le
v
el

 

1 3 PACS reduces errors in patient registration 4.11 0.84 82.2 High 

2 1 PACS affected better management for radiology department. 4.03 0.86 80.6 High 

3 2 PACS reduced the number of repeated images 4.02 0.84 80.4 High 

4 7 PACS provides the ability to view pictures from different angles 4.01 0.83 80.2 High 

5 4 PACS reduces waiting time for patients in radiology department. 4.00 0.79 80.0 High 

5 5 PACS had reduces reporting time for images. 4.00 0.79 80.0 High 

5 8 PACS allow to attach patient reports to the images 4.00 0.82 80.0 High 

5 10 PACS allow remote diagnosis 4.00 0.87 80.0 High 

6 9 
PACS helps in reducing medical errors by providing better and 

accurate diagnoses 
3.88 0.94 77.6 High 

7 6 PACS improves and helps reserve the quality of image 3.84 .94 76.8 High 

Total 3.99 0.74 79.8 High 

 

Table (8) shows that the total degree for of the items of factors affecting the adoption of 

PACS) in Expected challenges, according to users was (4.01) which suggests high level 

of estimation. The highest mean was given to the item (PACS increase the technical 

problems that may occur). The lowest was for the item (There was a difficulty in logging 

in to the system from different departments). 

 

 

 

 

 

 

 

 

 



39 

 

Table 8 

the response rate to the Expected challenges impact variable in Palestinian hospitals in 

descending order 
R

an
k

 

N
o
. 

in
 t

h
e 

Q
u
es

ti
o
n
n
ai

re
  

D
o
m

ai
n
 

M
ea

n
s 

st
an

d
ar

d
 

d
ev

ia
ti

o
n
s 

P
er

ce
n
ta

g
e 

%
  

E
st

im
at

ed
 

le
v
el

 

1 1 PACS increase the technical problems that may occur.                   4.17 0.85 83.4 High 

2 2 People with lake computers skill effect on PACS use.  4.14 0.87 82.8 High