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.     

A comparison of the time required by radiologists for the preparation of clinico-radiological meetings when film and PACS are used

The hypothesis was that when a hospital-wide Picture Archive and Communications System (PACS) is used, preparation for clinico-radiological meetings is faster, and more images are available, than when a conventional film system is used. This paper reports a study which compared the preparation time by radiologists when film was used with the time for the same activity when a hospital-wide PACS was used at Hammersmith Hospital for the preparation of the respiratory medicine and hepato-biliary meetings. It was found that when PACS was used the time per patient to prepare for the respiratory medicine session was reduced by 11.1 min and that similarly, 16 min per patient was saved in the preparation of the hepato-biliary sessions. The number of images which were unavailable for the session was reduced when PACS was in operation, but this reduction was not shown to be statistically significant. The introduction of PACS at Hammersmith Hospital has significantly reduced the time spent by radiologists in preparing for the two clinico-radiological sessions studied and, if this is extended to the other numerous sessions held each week, contributes to a considerable saving of staff time within the radiology department. Received: 1 April 1999; Revised: 24 June 1999; Accepted: 9 August 1999     

The impact of a picture archiving and communication system (PACS) upon an intensive care unit

OBJECTIVE: The aim of the study was to assess the effect of the introduction of PACS (Picture Archiving and Communication System) upon image availability in an Intensive Care Unit (ICU) and the consequent impact upon the behaviour of the ICU physicians, in terms of the initiation of image-based clinical actions. DESIGN: A before and after study was used to compare the speed of image availability prior to, and following, the implementation of a hospital-wide PACS. SETTING: The research was part of an economic evaluation of PACS at Hammersmith Hospital, West London. PATIENTS AND PARTICIPANTS: All ICU patients who were X-rayed during two pre-PACS and one post-PACS data collection periods were included within the study. MEASUREMENTS: The times of: the X-ray request; acquisition; availability on ICU; and of any image-based clinical action taken by the ICU physician were recorded by radiographers and ICU physicians. RESULTS: PACS significantly reduced the time between request and image availability on ICU for routine X-rays but did not have any measurable impact upon the time clinical actions were initiated by ICU physicians. The data on non-routine images were statistically inconclusive. CONCLUSIONS: This study shows that PACS significantly improves the speed of delivery of routine images to the ICU, but it appears that the instigation of image-based clinical actions is determined by other organisational factors in ICU, such as ward rounds, rather than the availability of the image for viewing. Further work is required on non-routine X-rays to clarify the impact of PACS on physician behaviour in clinically urgent situations.     

A comparison of image reject rates when using film, hard copy computed radiography and soft copy images on picture archiving and communication systems (PACS) workstations

A comparison has been made of the reject rates of plain images for three separate periods when film, computed radiography (CR) and PACS systems were in operation throughout the Hammersmith Hospital, London. There was a statistically significant reduction in the overall percentage reject rate across all examinations from 9.9% to 8.1% when the hospital changed from using a conventional film based system to a CR system. There was a further reduction in the reject rate to 7.3% when the hospital moved to a hospital-wide PACS system, but this change was not statistically significant. Using estimations of the total number of images used, the percentage reject rates were 6.6% for film, 5.5% for CR and 5.5% for PACS. Thus, if the radiation dose for each image is unchanged, and the same types of images are used for the examination of each body area, a move from conventional film imaging to phosphor plate imaging provides the potential to reduce the patient population dose.     

Modular project of the Picture Archiving and Communication System (PACS). Preliminary operational experience. I

Since september 1988 a PAC System (Comm View by AT & T and Philips) has been operating in the Radiology Department of the University Hospital, Trieste. A research project is presently in progress aiming at providing factual evidence for the evaluation of this kind of systems as far as operational, technical, clinical and economic aspects are concerned. The general approach to this research consists in implementing and monitoring a PACS in a stepwise way, starting with a small system connected to some digital modalities only, in order to test the feasibility and effectiveness of the system within a Radiology Department, and to test the possibility of matching the PACS to the Radiological System. The present paper describes in detail the present configuration of this entry-level system and its technical features. The planned development (october 1989) is also depicted. Further developments devise at managing in an integrated way all the radiological images of the four hospitals of Trieste. At present, the PACS is currently used to manage and store on optical disks all the images acquired from the connected modalities plus the related reports, and to perform the reporting sessions for CT examinations (brain and abdomen). The present research effort is devoted to two main areas: clinical evaluation and operational analysis. The object of the operational analysis was the assessment of the impact of PACS on the operations of a Radiology Department. The general approach followed for this research consists in analysing the procedures as they are performed in the conventional way (manual operations), and comparing them to the way they are, or could be, performed using a PACS System (automatic operations). This stage of the project is divided into three phases, concerning respectively the analysis of the organization and operations before PACS, the analysis of the impact of PACS in its initial configuration and the forecast of the influence of PACS in its future setting. A first evaluation concerned the activities carried out from the moment the images are generated to the moment they are ready to be achieved. They include image acquisition, reporting, delivering and returning of images from the departments. The time required to carry out each of the activities involved was recorded, both in the manual and in the automatic version; furthermore, a more detailed analysis was performed on the reporting procedure. The conclusions reached through this analysis are that this kind of operation is mostly affected by the way the Radiology Department is managed, rather than by the tools employed.(ABSTRACT TRUNCATED AT 400 WORDS)     

Radiological reporting system developed with FileMaker-Pro: cooperation with HIS, RIS, and PACS

This article briefly describes our original radiological reporting system. This system was developed with the widely used database software FileMakerPro (ver 5.5). The reporting system can obtain information about patients and examinations from a radiology information system(RIS) by the Open DataBase Connectivity(ODBC) technique. By clicking the button on the reporting system, the corresponding DICOM images can be displayed on a picture archiving and communication system(PACS) workstation monitor. Reference images in JPEG format can be easily moved from PACS to the reporting system. Reports produced by the reporting system are distributed to the hospital information system(HIS) in Portable Document Format(PDF), through another web server. By utilizing the capacity of FileMakerPro, the human-machine interface of the system has been able to be improved easily. In addition, cooperation with HIS, RIS, and PACS could be constructed. Therefore, this original system would contribute to increasing the efficiency of radiological diagnosis.     

Integrating digital systems: commitment and collaboration

One year ago, the radiology department at Ball Memorial Hospital, a 350-bed facility in Muncie, IN, was completely film-based. The need to support a new all-digital, 35-room emergency department (ED) hastened the facility's transition to a digital environment. Today, with the exception of mammography, the hospital's imaging services are now digital. To develop and implement the project, the hospital formed an internal implementation team. An independent consultant was also hired to evaluate the impact of these new technologies and to provide an estimated cost payback. After research, site visits, and vendor demonstrations, the hospital selected a single vendor for its picture archiving and communication system (PACS), digital radiography (DR), computed radiography (CR), and overall project management. The DR system was installed in the ED to provide digital image capture for a full range of trauma exams. The ED also initially began utilizing a Web-based PACS distribution originally implemented for after-hours teleradiology. The majority of the hospital's imaging studies are captured with 2 multi-cassette CR systems that serve 7 exam rooms in the radiology department. The hospital also installed remote operations panels to expedite entry of patient and exam information. Technologists readily embraced both CR and DR systems. The Web distribution system now transmits images to hospital-based computers and to 150 remote referring physicians. The PACS platform automatically e-mails key images and radiology reports to referring physicians. Authorized physicians can also request reports and images on an as-needed basis. The PACS vendor had previously performed multiple integrations with the radiology information system (RIS) vendor; the integration of PACS and RIS was extremely smooth. One of the critical components of a successful conversion is experienced, dedicated management. The hospital retained professional project management services to facilitate implementation and to ensure adequate training for all users.     

Wunsch und Wirklichkeit bei der Installation einer abteilungsübergreifenden Bild- und Befunddistribution

PROBLEM: This report describes the problems that can occur in the representation of the radiological workplace in a digital environment. On one hand the radiologist can sometimes access good equipment in "stand-alone" surroundings (CT, laser printer, workstations,...); on the other hand, the existing insufficient communication between different components is only rarely qualified to support the radiological workflow. This unsatisfactory framework handicaps the required clinic-wide distribution of radiological information. METHODS: From the beginning we defined user groups requiring different radiological data closely associated with specific hard- and software: The radiological workstation in the department for reporting and image processing. The demonstration workstation in wards/outpatient departments for clinicians involved in treatment. Standard PCs with access to the digital medical document for clinicians involved in treatment. At all workstations the medical as well as the legal unity of digital radiological images and the corresponding report is ensured. RESULTS: Only the first two user groups have unrestricted access to the RIS database and to the PACS archive. We have decided that the RIS should be the master of the RIS/PACS-System. For an effective master/slave relationship between RIS and PACS archive and PACS workstations we suggest to mark images and/or series of images. CONCLUSION: The third user group depends on the information exported by the radiologist from PACS. After the report is written and signed by the radiologist, the digital report is transferred from the RIS to the HIS. The report is automatically attached to these images. Authorized personnel at the wards and outpatient are able to read the combination of validated report and exported radiological images as part of the digital medical record with an intranet browser on standard PCs.     

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.     

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.     

Picture archiving and communication systems: A multicentre survey of users experience and satisfaction

A multicentre study was undertaken to assess user's impressions of picture archiving and communication systems (PACS). A questionnaire was sent to 1518 clinicians in 7 UK trusts. Half of the 286 responders used PACS alone for looking at radiological images, having used the system between 2 and 5 years. 83% felt PACS benefited their work, 79% felt PACS was better than hard copies and 83% would recommend it. Several potential problems were highlighted. Half of responders had no training to use PACS. Of those, 50% stated that no training had been offered. A second concern was unreliability, with 20% feeling that the system was unable to be used at least 1 week every year. Third was the poor quality of images, due to the poor quality of the monitors. All these problems will need to be addressed by any trust intending to implement a reliable and useful system.     

Evaluation of radiological workstations and web-browser-based image distribution clients for a PACS project in hands-on workshops

The methodology and outcome of a hands-on workshop for the evaluation of PACS (picture archiving and communication system) software for a multihospital PACS project are described. The following radiological workstations and web-browser-based image distribution software clients were evaluated as part of a multistep evaluation of PACS vendors in March 2001: Impax DS 3000 V 4.1/Impax Web1000 (Agfa-Gevaert, Mortsel, Belgium); PathSpeed V 8.0/PathSpeed Web (GE Medical Systems, Milwaukee, Wis., USA); ID Report/ID Web (Image Devices, Idstein, Germany); EasyVision DX/EasyWeb (Philips Medical Systems, Eindhoven, Netherlands); and MagicView 1000 VB33a/MagicWeb (Siemens Medical Systems, Erlangen, Germany). A set of anonymized DICOM test data was provided to enable direct image comparison. Radiologists (n=44) evaluated the radiological workstations and nonradiologists (n=53) evaluated the image distribution software clients using different questionnaires. One vendor was not able to import the provided DICOM data set. Another vendor had problems in displaying imported cross-sectional studies in the correct stack order. Three vendors (Agfa-Gevaert, GE, Philips) presented server-client solutions with web access. Two (Siemens, Image Devices) presented stand-alone solutions. The highest scores in the class of radiological workstations were achieved by ID Report from Image Devices (p<0.005). In the class of image distribution clients, the differences were statistically not significant. Questionnaire-based evaluation was shown to be useful for guaranteeing systematic assessment. The workshop was a great success in raising interest in the PACS project in a large group of future clinical users. The methodology used in the present study may be useful for other hospitals evaluating PACS.     

Modular project of the Picture Archiving and Communication System (PACS). Preliminary clinical experience. II

In the previous paper in this volume the PAC System installed in the Radiology Department of the University of Trieste has been described and its advantages and limitations have been analyzed, mainly from an operational point of view. This paper deals with the clinical evaluation of the system in ordinary operative conditions. A series of cases with specific characteristics was monitored in order to reveal different performances in both diagnostic process and conclusions using the PACS viewing console (DW) vs. conventional CRT film images on alternators. In a first test, 100 routine (not pre-selected) brain CT cases were independently analyzed by 4 radiologists, each of them giving 2 interpretations of the same case, one based on film and the other on PACS. The data were analyzed by conventional statistical methods, showing a substantial agreement of the results obtained with the 2 modalities. A second test concerned the evaluation of 100 lumbar intervertebral disks by CT, with the same procedure as above. Four radiologists were again asked to decide on film and PACS images about normality, protusion, or herniation of the disks. The results demonstrate the possibility of adequately reporting on the PACS monitor and stress the need of an adequate training period and the efficacy of the image processing capabilities of the system.     

PACS and Web-based image distribution and display.

Picture archiving and communication system (PACS) delivers images to the display workstations mostly through digital image communication in medicine (DICOM) protocols in radiology departments, and there are lots of medical applications in healthcare community needing to access PACS images for different application purposes. In this paper, we first reviewed a hospital-integrated PACS image data flow and typical diagnostic display software architecture, and discussed some Web technologies and Web-based image application server architectures, as well as image accessing and viewing methods in these architectures. Then, we present one approach to develop component-based image display architecture and use image processing and display component to build a diagnostic display workstation, and also, give a method to integrate this component into Web-based image distribution server to enable users using Web browsers to access, view and manipulate PACS DICOM images as easy as with PACS display workstations. Finally, we test and evaluate the performance of image loading and displaying by using the diagnostic display workstation and the component-based Web display system, the experimental results show that the image distribution and display performance from the Web server to browser clients is similar with that of the image loading and displaying procedure of the diagnostic workstation as more browser clients accessing the Web server at same time. We also discuss the advantages and disadvantages of the Web-based image distribution and display in different medical applications.     

PACS--and beyond. A journey to the digital promised land

A successful picture archiving and communication system (PACS) integration depends on much more than the technology; marketing also plays a large role. This fact was evident from the inception of the PACS project at Boca Raton Community Hospital (BRCH). Strategic and effective marketing efforts should target technologists, nurses, physicians (including radiologists), administration, and colleagues in other departments. The buy-in of these users is critical to the project's success. BRCH's first marketing effort took place during the initial PACS presentation made to the hospital's board of directors. Once approval was given and a 6-month implementation target was set, a strategic and effective marketing/education plan commenced. Posters, brochures, t-shirts, and promotional items were distributed in a coordinated effort to target hospital staff and referring physician offices. Through its "Got PACS?" branding and other identity materials, BRCH implemented a marketing plan that informed, educated, and engaged PACS users.     

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。     

Hanging protocol and viewers for a dental full picture [corrected] archiving and communication system (PACS) [corrected

OBJECTIVES: Study objectives were: to develop a hanging protocol for displaying digital transmission radiographic images of oral and maxillofacial regions using a dental DICOM (digital imaging and communication in medicine) viewer and a dental Web viewer; and to give information on a system that allows patients and health professionals to share image information. METHODS: For the hanging protocol, alphanumeric tags were defined and used in a DICOM modality worklist. These tags consisted of layout information to display images on monitors by the type of projection method and assignment information to display images of template for intraoral full-mouth survey that were numbered and slotted according to tooth position. Tooth code and algorithm for assignment of images for intraoral full-mouth survey were determined. Expanded correspondence for viewers was used for modalities without tags. Images could be edited by quality control system. An electronic medical record (EMR) system, a radiological information system (RIS) and a picture archiving and communication system (PACS) with servers, terminals and viewers were set up in a patient-centred hospital environment. RESULTS: Using the hanging protocol, the viewers displayed digital transmission radiographic images automatically on display areas on one or multiple monitors showing intraoral, panoramic and extraoral views produced during various examinations. The images were also displayed using the coupling function of EMR and RIS. Users can compare the images taken at various times more efficiently. CONCLUSION: The new system using a dental DICOM viewer and a dental Web viewer is the most advanced for examining oral and maxillofacial regions compared with medical viewers. Our local but clinically operational hanging protocol should be a good model for DICOM Working Group 22.     

PACS strategy for imaging centers

Picture archiving and communications systems (PACS) have been available in imaging centers for many years, but they often were less functional, were not well integrated into patient information systems, and lacked the network backbone to implement a system. As modalities are replaced and technology improves, the ability and time for an imaging center to acquire, integrate, and utilize PACS has arrived. However, each imaging center must determine why it should invest in PACS. A business plan is the fundamental need. Each imaging center must understand its target market, growth rate, and staffing plans. Additional considerations lie in current and future modality availability, the need for offsite delivery of images and reports, and the potential need for remote transmission of images. These issues must be identified and prioritized. A multidisciplinary team is essential. The most successful PACS implementation begins with complete involvement from all levels. The team should be comprised of people with complementary skills who are committed to a common purpose, set of performance goals, and approach for which they hold themselves mutually accountable. The team must jointly decide on the project's objectives. These objectives fall under 4 categories: clinical, service, financial, and performance. PACS must be considered a tool to help accomplish each objective. The imaging center must determine its top priorities, then translate them into a technology "wish list." The center can then list those pieces of technology that are most important and prioritize them. There are even more considerations for connecting multiple imaging centers. The team must create a comprehensive request for proposal (RFP) and determine the vendors that will receive the document. Once the RFP responses have been received and the vendor has been selected, an effective training plan must be executed. Training plans should be competency-based, ensuring comfort and competency among all staff. Upon the project's completion, it is essential for the imaging center to evaluate PACS' effect upon its services and relationships with patients, staff, and referring physicians. Marketing and demonstrating the latest technology can positively impact all these areas.     

Integrating images into the electronic patient record of the hospital authority of Hong Kong.

Over a period of 10 years the Hospital Authority has developed an integrated clinical information system (The Clinical Management System-CMS), including a territory-wide longitudinal electronic patient record (ePR). The CMS and ePR are used by over 4000 doctors and 20,000 other clinicians to document and review care. The ePR currently has nearly 3TB of data covering 44 million episodes for 6.4 million patients. To date the CMS has largely dealt with textual data. However, PACS technology is increasingly being adopted in the HA. This paper describes our strategy for taking the hospital image archives and making them available throughout the Authority as part of the longitudinal patient record, leveraging the ePR to distribute radiological and other images in a manner which is integrated, affordable and sustainable.