Efficient radiologic reading environment by using an open-source macro program as connection software

Purpose

The objectives are (1) to introduce an easy open-source macro program as connection software and (2) to illustrate the practical usages in radiologic reading environment by simulating the radiologic reading process.

Materials and methods

The simulation is a set of radiologic reading process to do a practical task in the radiologic reading room. The principal processes are: (1) to view radiologic images on the Picture Archiving and Communicating System (PACS), (2) to connect the HIS/EMR (Hospital Information System/Electronic Medical Record) system, (3) to make an automatic radiologic reporting system, and (4) to record and recall information of interesting cases. This simulation environment was designed by using open-source macro program as connection software.

Results

The simulation performed well on the Window-based PACS workstation. Radiologists practiced the steps of the simulation comfortably by utilizing the macro-powered radiologic environment. This macro program could automate several manual cumbersome steps in the radiologic reading process. This program successfully acts as connection software for the PACS software, EMR/HIS, spreadsheet, and other various input devices in the radiologic reading environment.

Conclusion

A user-friendly efficient radiologic reading environment could be established by utilizing open-source macro program as connection software.     

High availability web-based image distribution

When a health system implements a picture archiving and communication system (PACS), film is no longer the preferred medium of image distribution from a radiology department's perspective. The goal is for the department to be 100% filmless sometime after the installation. However, implementing change can be difficult, and getting to that goal of 100% is sometimes never achieved. Sutter Health has come close, with 90% of studies being filmless. A primary reason lies with the distribution method of providing access to images.     

A hospital-wide picture archiving and communication system (PACS): the views of users and providers of the radiology service at Hammersmith Hospital

OBJECTIVE: To obtain users' views of the new picture archiving and communication system (PACS) from clinical and radiological staff at Hammersmith Hospital, UK. METHODS: Semi-structured interviews were used to ascertain the views of staff, following an interview schedule which covered aspects of: (1) their use of PACS, (2) facilities available, (3) the perceived quality of images, (4) reporting, (5) image availability, (6) image accessibility, (7) training, and (8) ease of use of PACS. RESULTS: Interviews were carried out with 34 key users and providers of the radiological service at Hammersmith Hospital. Overall, staff were very satisfied with PACS particularly in terms of image availability. All staff said that they preferred PACS to the previous, conventional radiology service. CONCLUSIONS: The key implications of issues raised by staff were: the impact of 'down-time' and the importance of an efficient back-up system, the requirement for sufficient short-term storage to prevent images being off-line during clinical situations, the usefulness of the folder system for management of the images, the need to access images for teaching purposes, the advantage of having a default display protocol to facilitate radiological reporting, and the requirement for flexible, yet effective, training to ensure that the system is utilised to its full potential by users.     

Three methods of implementing a picture archiving and communication system.

A picture archiving and communication system (PACS) is a system integration of many components, including radiologic image acquisition devices, computers, communication networks, image display workstations, and data base management systems. The author describes three general approaches to implementing a PACS. In the first approach, the department or institution acts as a systems integrator, designing and implementing the PACS. In the second approach, the PACS is planned on the basis of the department's operations and environment and then a manufacturer is contracted to design and build the system. The third approach is to purchase a turnkey system, with some modifications provided by the manufacturer for a specific clinical application. The author provides examples of each approach in the clinical environment and presents the disadvantages and advantages of each.     

PACS for imaging centers

PACS can be a difficult and confusing decision for any radiology provider, but it can be an even more dynamic question for an outpatient imaging center. Every center represents a unique situation and requires a specialized solution. Typically, most of what is said and discussed about PACS concentrates on solutions and requirements for hospital radiology facilities. Administrators of imaging centers have different problems from hospital administrators, and they need different answers. For imaging centers, the financial justification for PACS may be less immediate than for hospitals. The first thing that must be understood is that no PAC system can make a typical imaging center completely filmless, at least not for quite a while. A hospital has the ability to dictate to its internal referring physicians how a radiological study is delivered, whereas in an imaging center environment, the roles are very much reversed. Once the justification are made for the financial viability of PACS in an imaging center, the next question is how to finance the acquisition of PACS. The decision will depend on how you cost justify your PACS, as well as the shape of your business model, and it will come to a decision between capital purchase or contracting with an application service provider, or ASP. Historically, in the hospital-dominated marketplace, PAC systems have been treated as capital acquisitions. However, for most imaging center, owning the system is more of a problem than a benefit. ASPs increasingly represent a successful alternative for imaging centers. One of the biggest things to consider with PACS is how to store all of those images. There are typically two options, on-site and off-site, with a new "hybrid" option surfacing more recently. Each option has benefits for the user, but the benefits of off-site storage are increasing as the technology advances. Some of the benefits are data security and access. Other issues to address are HIPAA compliance, standardized interfaces such as HL-7, Web access and the choice of view stations.     

Medical archiving: solutions for medical image management

Within the field of radiology, innovations in digital imaging have led to the development of the picture archival and communication system (PACS), which is now a part of the fundamental technological infrastructure supporting radiology practice in the digital age. Healthcare providers like hospitals, outpatient centers, and clinics are facing an explosion of medical imaging content as the industry continues the transfer from film to digital format. As a result, providers need to rethink their storage architecture strategies to better address the varied applications of the modern healthcare organization. Digital medical images are typically very large and technological advances are constantly increasing the rate at which such data is being recorded, image volume can present a storage capacity challenge. In addition, the images must be safely stored for a long time and easy to access. Regardless of strategy, the continued deployment of PACS as the primary vehicle to streamline medical imaging workflow, manage image access and increase user productivity is important. Grid computing, typically associated with the capture of idle computational cycles on heterogeneous servers, employs computing techniques that can offer providers unique solutions to their storage problems.     

PACS图像显示器质量控制的初步研究

目的探讨放射科PACS系统中图像显示器的质量保证(QA)、质量控制(QC)问题。方法参考美国医学物理学会第18工作组(AAPMTG18)制定的测试图和质量评估标准,利用光度计、显示器校正软件,对3种型号的BARCOCRT灰阶显示器进行季度性定量检测。内容包括:DICOM灰阶标准显示函数校正、最高亮度和最低亮度检测、亮度均一性检测、显示器分辨率、几何失真校正。结果显示器的各项性能指标都符合AAPMTG18规范。放射科95%的医学图像依靠PACS显示器做出了诊断。结论PACS图像显示器的质量控制是确保数字化医疗环境优质性的重要措施。     

Development of an automated patient-recognition method for digital chest radiographs using edge-enhanced images

It is important that all images in a picture archiving and communication system (PACS) environment should be stored in the correct location, e.g., in the proper patient's folder. However, if patient information, such as identification number or patient name, has been entered incorrectly, the image may be stored in the wrong place. We are developing an automated patient recognition method for chest radiographs based on a template-matching technique to prevent such filing errors. To further improve the performance of our method, we investigated the usefulness of a new automated patient-recognition method based on a template-matching technique by using edge-enhanced and smoothed images. We found that the relationship between the correlation values obtained with and without the edge-enhancement technique tended to provide different criteria for identifying correct or incorrect patients. When we combined the two methods to distinguish the images by a rule-based method, 67.1% of wrongly identified patients in our database could be identified as wrongly identified, without any false warnings for correctly identified patients. We consider that this automated method for patient recognition based on edge-enhanced images would be useful in preventing "wrong" images from being stored in a PACS environment.     

APPC—A new standardised coding system for trans-organisational PACS retrieval

Objectives

As part of a general strategy to integrate the health care enterprise, Austria plans to connect the Picture Archiving and Communication Systems (PACS) of all radiological institutions into a nationwide network. To facilitate the search for relevant correlative imaging data in the PACS of different organisations, a coding system was compiled for all radiological procedures and necessary anatomical details.

Results

This code, called the Austrian PACS Procedure Code (APPC), was granted the status of a standard under HL7. Examples are provided of effective coding and filtering when searching for relevant imaging material using the APPC, as well as the planned process for future adjustments of the APPC.

Discussion

The implementation and how the APPC will fit into the future electronic environment, which will include an electronic health act for all citizens in Austria, are discussed. A comparison to other nationwide electronic health record projects and coding systems is given. Limitations and possible use in physical storage media are contemplated.     

The benefits of hospital-wide picture archiving and communication systems: a survey of clinical users of radiology services.

This paper describes one element of a broad evaluation of a hospital-wide picture archiving and communication system (PACS): an assessment of the views of users of the radiology service, their major causes of dissatisfaction with the service, the incidence of image unavailability, and the consequences of images being unavailable. The principal research design was a "before and after" comparison at Hammersmith Hospital, as the hospital site introducing PACS. Several other hospitals were included in this survey, for comparison. Questionnaires were distributed several times before PACS was operational at Hammersmith, and on one occasion after. The overall response rate was 54%. The main pre-PACS radiology-related problem areas were: the non-availability of images, the non-availability of written reports when clinically required, and the time devoted by junior staff to image searching. PACS greatly reduced the perceived problem of image non-availability. But Hammersmith's problems with the availability of radiological reports still remained when PACS was operational. The time junior doctors spent in image-searching was dramatically reduced by the introduction of PACS.     

Integrating digital ICU viewing into the global working environment

We illustrate that to benefit from the advantages of Picture Archiving and Communication Systems (PACS) for the Intensive Care Unit (ICU), the PACS must be strongly integrated within the overall working environment. This includes adaptation of the PACS toward specific working patterns and integrating it with the Hospital Information System (HIS). This is reflected in our prototype system in different ways. The user interface of the viewing station is centered around often used patterns in ICU viewing. Information about bed occupancy is retrieved from the HIS and exploited in the viewing station. A digital connection between the phosphorplate scanner and the HIS ensures that images are correctly related to other patient information and to previous images. Using minor adaptations to the existing HIS, PACS and HIS have been made to cooperate in integrated presentation of images and radiological reports, as a step towards a multimedia medical information system. We discuss the relation between PACS and the global information environment, emphasizing organizational issues rather than technological aspects.     

Film-free efficiency systems: a new cost-effective approach

Pressure is on healthcare providers to make their services more affordable. Streamlining operations to improve efficiency is one means of achieving that goal. PACS has been touted as the technology to improve radiologic services. Sold as a way to eliminate lost records and lower operations costs, in reality, PACS has raised costs and slowed work flow in many cases. Perhaps PACS that raise operations costs are more properly named digital overhead generating systems (DOGS). There is an alternative solution--film-free efficiency systems (FFES), defined as the technological tools required to lower radiologic costs and improve services. A new type of image and information management technology and distinct from traditional PACS in a number of ways, film-free efficiency systems are immediately cost effective. They improve personnel efficiency, reduce costs per RVU, provide an alternative to film and exclude the use of any technology that is not cost effective. Implementation of these systems must begin with a clearly stated mission, a leadership statement and financial accountability. To guarantee an immediate financial gain in your department, you'll want to finance the system through material cost savings. Implementation should start with the digital modalities. The next step is to retrain staff and reengineer the workplace, followed by creating the necessary infrastructure of PCs in referring physicians' offices. Lastly, implement CR or digital radiography as prices drop and technologies improve in speed.     

Why PACS is no longer a four-letter word

The real value of PACS is not realized until widespread adoption exists among physicians other than interpreting radiologists. Referring physicians at the office level, in the operating room and in other departments must be willing to embrace the reading of images on monitors. That takes time. The payoff for a PACS system is therefore not realized until sometime in the future. Given the huge up-front capital expenditure required of PACS solutions, it is no wonder that the decision has historically been a difficult one to make. Enter the application service provider (ASP). The marriage of the ASP model to PACS seems to be one of the true "killer apps" currently available in the healthcare technology space. An ASP can host and maintain the software inherent in PACS solutions. Images are centrally archived over the short-, medium-, and long-term timeframe, utilizing state-of-art data management facilities. Some ASPs also provide the necessary bandwidth to office sites and the small amount of hardware that is required onsite, such as viewing stations or monitors. Costs for Internet-based image management under the ASP model rely on a pay-as-you-go formula, which may include all software, support, required hardware and bandwidth as part of the service. There may be a minor up-front fee for installation. The ASP pricing model eliminates the huge gamble an organization takes on "big iron" PACS purchases. Those benefits rely on the first rule of finance: a dollar today is worth more than a dollar tomorrow. PACS and ASPs were made for one another. Because the financial benefits of PACS are realized over time, the timing of cash flows is extremely important. Other benefits inherent in the ASP model such as scalability, diminished need for IT personnel, software version integrity and better pricing because of economies of scale are attractive also.     

Assessment of a neuroradiology picture archiving and communication system in clinical practice.

The goal of this study was to determine if our neuroradiology picture archiving and communication system (PACS) is capable of improving the efficiency and function of the management and review of neuroradiologic images. A neuroradiology PACS module developed in our department was evaluated in the clinical environment from February 1990 through July 1991. The overall evaluation focused on three aspects: (1) image delivery performance, (2) system availability, and (3) user acceptance. Image delivery performance was evaluated by analyzing the time spent on each modularized task with both the film-based system and the PACS system. The system availability was examined by observing the downtime occurrence and uptime probability of individual hardware components in the PACS module. User acceptance was evaluated through a survey done with the display workstation. Under regular operating conditions, the PACS outperforms the current film-based operation. The overall PACS module availability is more than 92%, with the display workstation available more than 99% of the time. The overall user acceptance of the system is 3.4 on a four-point ranking scale. This study has demonstrated the full functionality and clinical usefulness of our neuroradiology PACS. On the basis of the results of this study, a large-scale PACS has been designed and implemented in our department.     

Adult Fingers Visualized on Neonatal Intensive Care Unit Chest Radiographs: What You Don’t See

Purpose

In a previous publication, it was revealed that a disturbingly high incidence of adult fingers were seen on pediatric intensive care unit radiographs, an example of inappropriate occupational exposure to diagnostic radiation. The present study examined adult fingers seen on neonatal intensive care unit (NICU) radiographs to assess the frequency of this occupational radiation exposure. During this study, we encountered an unexpected issue. The inappropriately exposed fingers appeared on the raw images but were sometimes cropped during technologist image processing before being sent to the picture archiving and communication system (PACS) for interpretation. Our audit describes the frequency of cropping adult fingers from images before display on PACS, with the intent of unmasking this source of occupational radiation exposure, of which quality assurance personnel may not be aware.

Methods

At the x-ray workstation, the raw NICU source x-ray images were analysed for the visibility of adult fingers and then were compared with the final processed images sent to PACS by the x-ray technologist.

Results

Of 230 radiographs audited, 30 (13%) contained fingers directly in the x-ray beam that remained visible on PACS, 22 (10%) contained fingers in the direct beam that were cropped before being sent to PACS for analysis, and 44 (19%) contained fingers in the coned area.

Conclusions

A significant number of adult fingers are being exposed to radiation during the acquisition of NICU radiographs. Cropping NICU radiographs before sending them to PACS can conceal a significant source of occupational radiation exposure.     

Medical image security in a HIPAA mandated PACS environment.

Medical image security is an important issue when digital images and their pertinent patient information are transmitted across public networks. Mandates for ensuring health data security have been issued by the federal government such as Health Insurance Portability and Accountability Act (HIPAA), where healthcare institutions are obliged to take appropriate measures to ensure that patient information is only provided to people who have a professional need. Guidelines, such as digital imaging and communication in medicine (DICOM) standards that deal with security issues, continue to be published by organizing bodies in healthcare. However, there are many differences in implementation especially for an integrated system like picture archiving and communication system (PACS), and the infrastructure to deploy these security standards is often lacking. Over the past 6 years, members in the Image Processing and Informatics Laboratory, Childrens Hospital, Los Angeles/University of Southern California, have actively researched image security issues related to PACS and teleradiology. The paper summarizes our previous work and presents an approach to further research on the digital envelope (DE) concept that provides image integrity and security assurance in addition to conventional network security protection. The DE, including the digital signature (DS) of the image as well as encrypted patient information from the DICOM image header, can be embedded in the background area of the image as an invisible permanent watermark. The paper outlines the systematic development, evaluation and deployment of the DE method in a PACS environment. We have also proposed a dedicated PACS security server that will act as an image authority to check and certify the image origin and integrity upon request by a user, and meanwhile act also as a secure DICOM gateway to the outside connections and a PACS operation monitor for HIPAA supporting information.     

New direction in PACS education and training.

The picture archiving and communication system (PACS) is an image information system that has become widely installed. For its successful implementation, training has been found indispensable. A review of PACS training thus far shows major emphasis was placed on the use of display workstations. As an integrated system, the PACS is much broader than the display workstations, having many components that need connectivity and customization. With the many potentials of further development, a more comprehensive education program on PACS is called for and a PACS simulator as a standalone training and research tool is deemed necessary.     

PACS实现方案及策略探讨

目的 探讨国内医院实现PACS的方案和策略。材料与方法 系统采用菲特公司最新的多服务器PACS软件－MiNet系列,全面支持DICOM 3．0标准,其中连接CT和MR设备、2台服务器、个光盘库、5个工作站、2个登记站,系统采用100M Internet网。结果 成功的实现了数字图像在放射科的PACS内传输、存储、管理和备份,而且可以方便地编辑、打印全中文报告。结论 在医院组建PACS系统是实用、可行的,但是同时要有策略的选择合作伙伴和有步骤的实施。     

Integration of a multimedia teaching and reference database in a PACS environment.

In one radiology department, a computerized authoring and editing environment was developed and integrated with the picture archiving and communication systems (PACS) for creation of image-based electronic teaching files to replace a collection of printed film images. This multimedia database and authoring environment allows physicians to create reference databases for teaching and research directly from clinical cases being reviewed on PACS diagnostic workstations. The database engine allows users to generate stand-alone CD-ROMs (compact disks, read-only memory) and World Wide Web-based teaching files. The system is fully compliant with the Digital Imaging and Communications in Medicine (DICOM) standard and supports a large number of standard multimedia image file formats. The focus of the development was on convenience and ease of use of a generic system adaptable to all users. The software was integrated on the PACS workstations to allow users to add new cases to the database at any time and anywhere in the department. A pilot system was implemented in clinical operation, with a central server and several client units.