The results showed that most of those using the Picture Archiving and Communication System, were satisfied with this system. In this study, radiologists and also those who had higher computer literacy were more satisfied with PACS. Physicians believed that because of having different features such as edit, ability to apply different changes to the images and also the ability to compare patients’ previous and new images, this system, and its findings are more reliable. Despite all of PACS’s advantages, several physicians believed that this system somewhat wastes their time. Currently, considering the inability to use PACS images at imaging centers outside the hospital, this system can increase patients’ costs for re-imaging and also the risk of being re-exposed to x-ray.
Optimization in work process, efficiency and quality of service
The results of the present study showed that more than half of the physicians believed using PACS led to the optimization of the work process, quality of treatment care and also training. In line with this finding, Tan’s  study also revealed that more than two-thirds of users believed that the PACS had led to optimization in their performance and compared to the traditional system of hard copies, this system has improved physicians’ performance. The findings of two other studies [7, 10] also showed that users consider PACS to be effective in improving the quality of their services and believed that this system has led to an improvement in productivity, efficiency, and quality of their services.
System’s Ease of Use
More than half of the physicians in this study believed that reviewing images with this system is easy and the PACS has met their expectations. A study by Buabbas and colleagues , findings showed that more than three-quarters of the radiologists and technologists, consider using PACS as positive and being user-friendly. Also, Jorwekar and colleagues  in their study addressed the easiness in using PACS in users’ viewpoints and reported that 85% of the users believed that PACS was very easy to use for them. The results of the mentioned studies are consistent with the present study. The PACS ease of use is one aspect that is addressed in many studies and therefore we can say that most likely, PACS is a system that despite its variety of tools and menus, it is highly easy to learn for users and can meet users’ expectations for this matter.
Reducing hospital-stay time
In this study, more than half of the physicians believed that PACS had no influence in reducing the patients’ length of hospital stay . Despite these results, Al-Alawi’s study showed that about two-thirds of PACS users agreed that this system leads to reducing patients’ hospital stay . Some studies have reviewed the impact of PACS on the patients’ hospital stay time. The findings of these studies [37-39] showed that this system has been able to lead to reducing patients’ hospital stay time. However, a study in Australia  showed PACS not affecting the patients’ length of stay in the hospital.
The reason for different findings amongst studies can be due to a variety of reasons. However, one of the most important reasons may be the difference in the population of studies. The difference among patients in different wards or hospitals can present different findings. Also, users with different standpoints that are being studied can lead to different results. Leastwise, all being said that in Iran the PACS is still considered a relatively new system and maybe physicians’ approach towards this system’s clinical advantages has not fully developed yet and they may need more time.
According to the present study's findings, more than half of the physicians believed that using PACS leads to a reduction in costs. PACS-related costs are divided into two categories of direct and indirect costs. Direct costs are expenses related to implementing the PACSs such as system purchase cost, maintenance, and equipment purchase. While the indirect costs include increasing patients’ hospital stay, repeating similar imaging, reducing productivity and physician’s performance for the lack of access to images and reports .
Regarding PACS-related costs, there are different perspectives. While some studies address the high cost of purchase, implementation, and maintenance of the PACS [42-45], other studies suggest the effectiveness of this system and also consider the reduction of indirect costs as PACS's advantages [12, 46].
When launching the PACS, indirect costs reduce and can compensate for the direct expenses inflicted on the hospital and can even lead to the reduction of general expenses .
Fang et al. study  showed that an appropriately designed PACS can save and reduce costs compared to film-based imaging due to the increasing productivity of devices and technicians, ability for online phone consultation, ability to save time for physicians and radiologists and the decreasing need for more personnel all of which are indirect costs.
Physicians’ different approaches towards the PACS maybe for their different standpoints regarding direct and indirect costs . Presumably, some physicians fail to take into consideration the reduction in PACS’s indirect costs in the long-term, and therefore they believe that PACS leads to an increase in costs. This is while indirect costs in the PACS are significantly lower compared to the traditional system.
According to 10% of physicians, because of the inability to print images or use these images at other treatment centers outside the hospital such as physicians’ offices, the patients are forced to go through the imaging again, which this matter leads to patients’ further exposure to rays and finally decreases safety for patients. Despite the findings of the present study, Modrak and colleagues  conducted a study that showed after implementing PACS, patients’ exposure to x-rays reduces, considering the decrease in repeat imaging. Also, other studies have shown that implementing the PACS can lead to a reduction in re-imaging and patients’ dose of x-rays and increase patient safety [48, 49].
This difference could be because of the different network infrastructure used. In Iran, images are only transmitted within an organization and there is no communication among different organizations. In Iran, interoperability of information among health information systems such as hospital information systems does not exist with the PACS. For this reason, physicians believe that patients will have to go through imaging and exposure to x-rays again at other treatment centers. However, if the capability of establishing communication and transferring images between health information systems used at governmental and private health care centers develops, while reducing repeated imaging, the PACS can lead to decreasing patients’ exposure to rays and finally increase patient safety.
PACS versus Traditional Radiology
The results of the present study show that most physicians believe that because the PACS has different features such as image edit, ability to apply changes to images such as contrast, clarity, and zoom, and also the ability to present details, this system is more satisfying for them compared to traditional radiology. However, there was no significant difference in the ease of use in both systems. In Abuabbas and colleagues’ study, most participants suggested that the system was user-friendly. Also, Al Yafei and colleagues  in their study reported 90% user-friendliness for the PACS. The results of the mentioned studies are consistent with the present study’s findings. However, the present study’s results about comparing the ease of use in PACS and the traditional system differ somewhat from Jorwekar and colleagues’ study in which system users described the PACS as being very user-friendly. Perhaps this level of difference in opinions about the easiness in using PACS compared to traditional film-based systems is related to the computer literacy level of the users and or the lake of interoperability of PACS with other health information systems. Probably the more users are computer literate and the more proper the system’s interoperability with other systems the system’s ease of use and users’ satisfaction level increase.
Also, another reason for the difference in opinions about the system’s user-friendliness and its ease of use could be the users’ level of involvement during the system analysis phase before the design phase. If users’ needs are properly assessed, and the system is accordingly designed, then the system would probably meet users’ satisfaction.
Relationship between Satisfaction Level and Demographic Information
The results showed that factors such as age, experience in using PACS, and physicians’ type of specialty had no significant relationship with the level of satisfaction; however, physicians’ computer literacy affected the level of their satisfaction. In line with these findings, Buabbas’s study  showed that none of the demographic information and also users’ computer literacy does not affect their level of satisfaction.
One reason for the differences amongst studies in terms of the relationship between satisfaction and computer literacy is probably because the computer literacy variable was measured in the form of self-report. We suggest that for a more precise investigation of the relationship between these two variables, a standard computer literacy questionnaire along with the satisfaction questionnaire to be used.
Although the sample size in the present study is not very large, this study is the first study in Iran conducted that concerns the assessment of users’ satisfaction with PACS, and those physicians who took part in this study had experience in working with PACS and were interested in completing the questionnaire. These findings can help those healthcare centers' directors who are considering purchasing or implementing the PACS, that besides considering the strong and weak points of this system, to attempt resolving some issues. Also, communications technology policymakers with the aid of information system developers can attempt to develop data communication standards for inter-informational systems so that the communication between these systems could be possible from anywhere.