Picture archiving and communication systems and vascular surgery: Clinical impressions and suggestions for improvement

The purpose of this study was to determine the acceptance and clinical utility of a large scale picture archiving and communication system (PACS) for vascular surgery. Questionnaires and one-on-one interviews were conducted with physicians and nurses in the department of vascular surgery at the Baltimore VA Medical Center where PACS has been in routine, hospital-wide use for more than 21/2 years. The perceptions of the clinical staff were assessed to determine the efficacy of PACS in comparison to the conventional film based alternative for the practice of vascular surgery and suggestions for improvements were solicited. There was consensus among the vascular surgery staff members that the use of PACS enhanced their clinical practices, both in and out of the operating room (OR). Vascular surgeons heavily rely on image display in the OR as a “road map” to help determine their operative approach and to guide their surgery. PACS offers unique intraoperative imaging capabilities including rapid image retrieval and improved archival, cine review, the ability to modify image contrast, and the ability to obtain direct quantitative measurements of the degree of vascular stenosis. The increased accessibility and availability of images throughout the hospital enables improvements in time management and in patient care.     

A cost analysis of film image management and four PACS based on different network protocols

Picture Archive and Communication Systems (PACS), which allow the electronic acquisition, storage, transportation, and viewing of medical images, hold the eventual promise of reduced costs, improved imagemanagement logistics, and ultimately, improved patient care. But at what point in the future will PACS really cost less than film-based image management for a given hospital size; and how are these costs affected by the choice of the digital communication network? To address these questions, a static differential cost model has been constructed. PAC systems based on two high-speed networks (less than 150 megabytes per second Mbps) and two lowspeed networks, as well as film, were considered for five different sized hospitals (ranging from 15,000 to 125,000 procedures per year) and two time periods (1995 and 2000). PACS equipment was assumed to have a payoff of five years. The model considered all capital and supply costs and personnel costs for the PACS and for film storage and retrieval. It did not consider any possible cost savings from logistics improvement likely to result from the adoption of a PACS. Based on the assumptions outlined, high-speed-network PACS are less costly than those based on low-speed networks for all scenarios considered. Further, even though all possible PACS cost savings were not considered, high-speed network PACS appear to be less costly than film for hospitals larger than 60,000 procedures in 1995 and larger than 15,000 in 2000, while low-speed-network PACS should cost less than film for 60,000 and 30,000 procedure hospitals in 1995 and 2000 respectively.     

How to satisfy both clinical and information technology goals in designing a successful picture archiving and communication system

Designing and operating a PACS system requires an integrated focus to maintain peak performance of the system from an information technology (IT) perspective and to ensure that all clinical and financial requirements are met. An IT-based picture archiving and communication system (PACS) manager is in the best position to satisfy these sometime conflicting audiences. This report will describe how an institution moving towards PACS can unite radiologists, hospital administrators, and information systems (IS)/IT specialists into one cohesive team to ensure the highest levels of success with their future PACS. There are several keys to success: (1) Designing and selecting PACS requires a dedicated team, with representatives from radiology, as well as IS/IT and administration. (2) Each group needs to thoroughly outline their specific needs, so that the final PACS solution is relevant from all perspectives. This needs assessment needs to be made before issuing a request for proposal (RFP) and interviewing vendors. (3) The team needs to be small to be effective. Each group should have one or at most two representatives that collect input from, and report to, a group of his or her peers. (4) Plans need to be made to determine how to integrate current and future hospital information systems (HIS), in order to ensure a smooth pathway to the electronic medical record. (5) All team members should agree on the overall objectives for PACS and participate in its design and installation. (6) Each team member is charged with motivating, and helping to educate, his or her peers. (7) Training should be tailored to the needs of each audience. Explain how each staff member benefits from the PACS. Training should be ongoing to accommodate the addition of new system features and new users. This report will describe the importance of recognizing PACS as being an IT system with a clinical focus. The importance of designing goals of the PACS system from various perspectives, including clinical, technical, and financial, will be addressed. More importantly, this presentation will high-light the benefits a medical institution will receive if the various groups can work together, while at the same time outlining some pitfalls they can expect to encounter if the groups take an adversarial approach.     

Comparison of a PACS Workstation with Laser Hard Copies for Detecting Scaphoid Fractures in the Emergency Department

Picture archiving and communication systems (PACS) for imaging studies is rapidly being adopted in hospitals throughout the UK. However, very little comparison has been made between PACS and laser hard copies for assessing the diagnostic accuracy of detecting fractures by emergency physicians. A prospective paired comparison study was undertaken looking at correct reporting of scaphoid X-rays on PACS and conventional film by emergency department medical staff. A total of 34 imaging studies were reported by 38 physicians using both PACS workstations and laser-printed films. The percentage of emergency physicians correctly reporting imaging studies was similar when comparing PACS images to laser film copies (80.7% versus 81.0%). The sensitivity and specificity of PACS for diagnosing scaphoid fractures was 79.5% and 81.6%, versus 78.1% and 83.8% for conventional films. There is no significant difference in accuracy of diagnosis between PACS and laser film copies when scaphoid X-rays are reported by emergency physicians.     

The importance of a picture archiving and communications system (PACS) manager for large-scale PACS installations

Installing a picture archiving and communication system (PACS) is a massive undertaking for any radiology department. Facilities making a successful transition to digital systems are finding that a PACS manager helps guide the way and offers a heightened return on the investment. The PACS manager fills a pivotal role in a multiyear, phased PACS installation. PACS managers navigate a facility through the complex sea of issues surrounding a PACS installation by coordinating the efforts of the vendor, radiology staff, hospital administration, and the information technology group. They are involved in the process from the purchase decision through the design and implementation phases. They can help administrators justify a PACS, purchase and shape the request for proposal (RFP) process before a vendor is even chosen. Once a supplier has been selected, the PACS manager works closely with the vendor and facility staff to determine the best equipment configuration for his or her facility, and makes certain that all deadlines are met during the planning and installation phase. The PACS manager also ensures that the infrastructure and backbone of the facility are ready for installation of the equipment. PACS managers also help the radiology staff gain acceptance of the technology by serving as teachers, troubleshooters, and the primary point-of-contact for all PACS issues. This session will demonstrate the value of a PACS manager, as well as point out ways to determine the manager’s responsibilities. By the end of the session, participants will be able to describe the role of a PACS manager as it relates to departmental operation and in partnership with equipment vendors, justify a full-time position for a PACS manager, and identify the qualifications of candidates for the position of PACS manager.     

Clinical input into designing a PACS

The purpose of this study was to evaluate clinical attitudes and expectations in the implementation of a neuroradiology picture archiving and communication system (PACS). A 1-page survey of expectations and clinical attitudes toward a neuroradiology mini-PACS was distributed to 49 full-time faculty members in the departments of neurosurgery, neurology, and otorhinolaryngology at an academic center. Interest in viewing soft-copy images was moderate to very high for over 89% of clinicians. All clinicians were comfortable with phone consultations with radiologists while viewing soft-copy images. Clinicians preferred retrieving images from personal computers over workstations and film libraries by 72.9%, 27.1%, and 0%, respectively. However, 38.5% of surgeons felt the need for hard copy in the operating room. Clinicians estimated that in 18.3% of cases, patients took their in-house films to outside institutions for consultations. Clinicians were enthusiastic about implementing PACS. Although acceptance of soft-copy viewing among clinicians is high, some provision for supplying hard-copy images appears to be necessary.     

Evaluation of teleradiology for interpretation of intravenous urograms

The diagnostic yield of a commercial teleradiology/picture archiving and communication system (ATT-Philips Comm View T/PACS) was evaluated for 100 urograms. A single image from each examination was digitized (2048 x 1684 x 12-bit pixels) and transmitted from a satellite hospital over a T-1 line using the T/PACS system. The video display of each digitized image was reviewed independently by four radiologists. The same four radiologists reviewed the original film images at a different time without knowledge of their T/PACS interpretation. There was no statistically significant difference in the sensitivity for clinical findings between T/PACS (86%) and film (89%). The false positive rate, however, was significantly higher with T/PACS than with film (44 versus 32 false positive findings per 100 films). We conclude that T/PACS of the type studied here demonstrates sufficient sensitivity for the detection of clinically important urographic findings in the emergency setting. A final reading of the original films is still necessary, however, to assure appropriate specificity.     

Women in academic general surgery.

PURPOSE: To portray the professional experiences of men and women in academic general surgery with specific attention to factors associated with differing academic productivity and with leaving academia. METHOD: A 131-question survey was mailed to all female (1,076) and a random 2:1 sample of male (2,152) members of the American College of Surgeons in three mailings between September 1998 and March 1999. Detailed questions regarding academic rank, career aspirations, publication rate, grant funding, workload, harassment, income, marriage and parenthood were asked. A five-point Likert scale measured influences on career satisfaction. Responses from strictly academic and tenure-track surgeons were analyzed and interpreted by gender, age, and rank. RESULTS: Overall, 317 surgeons in academic practice (168 men, 149 women) responded, of which 150 were in tenure-track positions (86 men, 64 women). Men and women differed in academic rank, tenure status, career aspirations, and income. Women surgeons had published a median of ten articles compared with 25 articles for men (p <.001). Marriage or parenthood did not influence numbers of publications for women. Overall career satisfaction was high, but women reported feeling career advancement opportunities were not equally available to them as to their male colleagues and feeling isolation from surgical peers. Ten percent to 20% of surgeons considered leaving academia, with women assistant professors (29%) contemplating this most commonly. CONCLUSION: Addressing the differences between men and women academic general surgeons is critical in fostering career development and in recruiting competitive candidates of both sexes to general surgery.     

Criteria of interface evaluation for computer assisted surgery systems

OBJECTIVES: The evaluation of computer assisted surgery (CAS) systems in terms of clinical outcomes and ergonomic features is more and more relevant. The goal of this paper is to provide criteria to define effective evaluation protocols of HCI for CAS systems. METHOD: The proposed criteria include the use of two questionnaires prepared by the authors, aimed at analyzing the subjective feeling of the surgeons in using the system's tools, and objective aspects of the system. These questionnaire have to be submitted to system's end-users and to experts in HCI development iteratively during the system development or once at the end. A quantitative evaluation of the main parameters related to the surgical application is also required as an index of system efficacy. The demonstration application was planning software developed for the total knee replacement (TKR). RESULTS AND CONCLUSIONS: In our TKR planning software the proposed evaluation procedure provided useful indications about the efficacy of HCI and also about further developments of its design and functionality. Moreover, since surgical training systems and surgical navigation platforms also share data treatment and layout similar to the presented TKR planner, these kinds of applications can benefit directly from the proposed approach to HCI design and evaluation.     

Does the use of shared decision-making consultation behaviors increase treatment decision-making satisfaction among Chinese women facing decision for breast cancer surgery?

Objective

To assess the extent to which breast surgical consultations used shared decision making (SDM), identify factors associated with use of SDM, and assess if using SDM increases decision-making satisfaction.

Methods

Two hundred and eighty-three video-recorded diagnostic-treatment decision consultations between breast surgeons and women with breast cancer were assessed using the Decision Analysis System for Oncology (DAS-O) coding system designed for assessing SDM behaviors. Women completed a questionnaire at pre-consultation, one-week post-consultation and one-month post-surgery. Patient outcomes included decision conflict, patient satisfaction with medical consultation, and decision regret.

Results

Overall, the level of SDM behaviors was low. The extent of SDM behavior within consultation was related to greater consultation duration (p < 0.001), more than one treatment being offered (p < 0.001), and fewer questions raised by patients/companions (p < 0.05). While use of SDM consultation did not influence post-consultation decision conflict, it increased satisfaction with information given and explained, patients’ feelings of trust and confidence in their surgeons, and reduced post-surgical decision regret.

Conclusion

These breast surgical consultations mostly adopted informed treatment decision-making approaches. Using SDM improved patient consultation and decision satisfaction.

Practice implications

The study findings highlight a need to reinforce the importance of SDM in consultations among breast surgeons.     

Four-Year Enterprise PACS Support Trend Analysis

While health care facilities recognize the need for dedicated picture archiving and communication system (PACS) staff at the time of the initial implementation of PACS, they often do not plan accordingly for ongoing or increasing PACS support needs as a PACS matures. This article reviews trends in a health care system’s PACS support data over 4 years to show how PACS support needs evolve over time. PACS support items were logged and categorized over this period and were used by the health care system to become more proactive in system support and adjust staffing levels accordingly. This article details how PACS support needs change over the life of a PACS installation and can be used as a model for health care facilities planning for future PACS support needs.     

Initial data-element selection for the evaluation of picture archiving and communication system performance

The completely new, hospital-wide picture archiving and communication system (PACS) now being implemented at Osaka University Hospital is described elsewhere in this issue.¹ This paper lists the many studies of the department and hospital that were performed before the PACS for the purpose of identifying data elements for use in evaluating a PACS system. A second purpose of the initial data-element collection was to assist in the overall Osaka University PACS design. Selected studies from this work are presented here.     

Budgeting for PACS

There are a number of models for the acquisition of digital image management systems. The specific details for development of a budget for a PACS/RIS acquisition will depend upon the acquisition model - although there are similarities in the overarching principles and general information, particularly concerning the radiology service requirements that will drive budget considerations.While budgeting for PACS/RIS should follow the same principles as budgeting for any new technology, it is important to understand how far the implementation of digital image management systems can reach in a healthcare setting. Accurate identification of those elements of the healthcare service that will be affected by a PACS/RIS implementation is a critical component of successful budget formation and of the success of any business case and subsequent project that relies on those budget estimates.A budget for a PACS/RIS capital acquisition project should contain capital and recurrent elements. The capital is associated with the acquisition of the system in a purchase model and capital budget may also be required for upgrade - depending upon a facility's financial management processes.The recurrent (or operational) cost component for the PACS/RIS is associated with maintaining the system(s) in a sustainable operational state.It is also important to consider the service efficiencies, cost savings and service quality improvements that PACS/RIS can generate and include these factors into the economic analysis of any proposal for a PACS/RIS project.     

PACS Training Modules at Texas Children’s Hospital

In 1999, the Performance Improvement Committee of the Diagnostic Imaging Services of Texas Childrens Hospital identified the need for smoother integration of the picture archiving and communications system (PACS) technology into the workflow of the rest of the department. An effort was then launched to document prevalent issues, as well as to define the processes needed to implement a department-wide program to acquaint the staff with this new technology. The departments application trainer, with the guidance of the Performance Improvement Committee, spearheaded the design and implementation of the PACS training program and has continued to develop it during the past 2 years. This article describes the format and components of the PACS training modules now in use, and details some of the positive effects of this effort.     

How much do surgeons like their patients?

OBJECTIVES: Physicians experience feelings of caring and sometimes frustration toward patients during routine visits. To date, no studies have explored surgeons' feelings toward patients. Our objectives were: (1) to examine how much surgeons like their patients and (2) to assess the relationship of surgeons' liking to patient and surgeon characteristics and to patient satisfaction. METHODS: Participants included 66 surgeons (orthopaedic and general surgeons) in community practice in Colorado and Oregon, and 701 of their patients. Exit questionnaires asked surgeons how much they liked the patient on a 1-5 scale ranging from "not at all" to "very much". Patients scored satisfaction with the visit on a 1-5 scale. Logistic regression was conducted with surgeon liking and patient satisfaction as dependent variables. RESULTS: Surgeons' ratings of liking ranged across all five categories. Patient characteristics including age over 65 years, higher education and income, and better health were associated with higher liking scores. Surgeon characteristics hours worked per week, practice setting and surgeons' self-rating of their own health were associated with liking. Patient satisfaction were associated with "liking". CONCLUSION AND PRACTICE IMPLICATIONS: These findings shed light on a rarely addressed issue-surgeons' feelings toward their patients. We found that surgeons do not like their patients equally. Their feelings are associated with surgeon and patient characteristics, and with patient satisfaction. Our findings have important implications for surgeons seeking to improve care striving to enhance or maintain their own career satisfaction.     

Data Management Solution for Large-Volume Computed Tomography in an Existing Picture Archiving and Communication System (PACS)

Multidetector row computed tomography (MDCT) creates massive amounts of data, which can overload a picture archiving and communication system (PACS). To solve this problem, we designed a new data storage and image interpretation system in an existing PACS. Two MDCT image datasets, a thick- and a thin-section dataset, and a single-detector CT thick-section dataset were reconstructed. The thin-section dataset was archived in existing PACS disk space reserved for temporary storage, and the system overwrote the source data to preserve available disk space. The thick-section datasets were archived permanently. Multiplanar reformation (MPR) images were reconstructed from the stored thin-section datasets on the PACS workstation. In regular interpretations by eight radiologists during the same week, the volume of images and the times taken for interpretation of thick-section images with (246 CT examinations) or without (170 CT examinations) thin-section images were recorded, and the diagnostic usefulness of the thin-section images was evaluated. Thin-section datasets and MPR images were used in 79% and 18% of cases, respectively. The radiologists’ assessments of this system were useful, though the volume of images and times taken to archive, retrieve, and interpret thick-section images together with thin-section images were significantly greater than the times taken without thin-section images. The limitations were compensated for by the usefulness of thin-section images. This data storage and image interpretation system improves the storage and availability of the thin-section datasets of MDCT and can prevent overloading problems in an existing PACS for the moment.Key words: CT, MDCT, PACS, computer applications     

Clinical experience with a second-generation hospital-integrated picture archiving and communication system

In a previous report we described a second-generation hospital-integrated picture archiving and communication system (HI-PACS) developed in-house. This HI-PACS had four unique features not found in other PAC systems. In this report, we will share some of our clinical experiences pertaining to these features during the past 12 months. We first describe the usage characteristics of two 2,000-line workstations (WSs), one in the in-patient and the second in the out-patient neuroradiology reading area. These two WSs can access neuro-images from 10 computed tomographic and magnetic resonance scanners located at two medical centers through an asynchronous transfer mode network connection. The second unique feature of the system is an intensive care unit (ICU) server, which supports three WSs in the pediatric, medical surgery, and cardiac ICUs. The users’ experiences and requests for refinement of the WSs are given. Another feature is physician desk-top access of PACS data. The HI-PACS provides a server connected to more than 100 Macintosh users for direct access of PACS data from their offices. The server’s performance and user critiques are described. The last feature is a digital imaging and communication in medicine (DICOM) connection of the HI-PACS to a manufacturer’s ultrasound PACS module. The authors then outline the interfacing process and summarize some of the difficulties encountered. Developing an in-house PACS has many advantages but also some drawbacks. Based on experience, the authors have formulated three axioms as a guide for in-house PACS development.