The future of PACS

How will the future of picture archiving and communication systems (PACS) look, and how will this future affect the practice of radiology? We are currently experiencing disruptive innovations that will force an architectural redesign, making the majority of today's commercial PACS obsolete as the field matures and expands to include imaging throughout the medical enterprise. The common architecture used for PACS cannot handle the massive amounts of data being generated by even current versions of computed tomography and magnetic resonance scanners. If a PACS cannot handle today's technology, what will happen as the field expands to encompass pathology imaging, cone-beam reconstruction, and multispectral imaging? The ability of these new technologies to enhance research and clinical care will be impaired if PACS architectures are not prepared to support them. In attempting a structured approach to predictions about the future of PACS, we offer projections about the technologies underlying PACS as well as the evolution of standards development and the changing needs of a broad range of medical imaging. Simplified models of the history of the PACS industry are mined for the assumptions they provide about future innovations and trends. The physicist frequently participates in or directs technical assessments for medical equipment, and many physicists have extended these activities to include imaging informatics. It is hoped that by applying these speculative but experienced-based predictions, the interested medical physicist will be better able to take the lead in setting information technology strategies that will help facilities not only prepare for the future but continue to enjoy the benefits of technological innovations without disruptive, expensive, and unexpected changes in architecture. A good PACS strategy can help accelerate the time required for innovations to go from the drawing board to clinical implementation.     

Growth of the anti-plague system during the Soviet period

The Anti-plague system experienced a dramatic expansion in Soviet times. From the dozen facilities created in the Russian Empire, it grew during the Soviet period to include over 100 facilities engaged in public health activities as well as BW-related work. This article describes how this highly responsive public health system, created to respond to natural outbreaks of dangerous diseases, became a critical adjunct to the Soviet BW program.     

Enterprise-Wide CR Implementation: The Shands Healthcare System Experience

Major healthcare systems are comprised of hospitals and clinics of different sizes and locations. Many such enterprises are already using picture archiving and communication systems (PACS) and computed radiography (CR) in their main hospitals. The integration of other hospitals and clinics into PACS is a more complex problem. The introduction of CR in remote facilities presents problems, as patient populations, department sizes, and work flow patterns may differ among facilities, and inadequate implementation programs may lead to disruption of patient care services. Although the University of Florida has had an operating PACS for years, facilities affiliated with the Shands Healthcare System (SHS) had not been incorporated into PACS until recently. This article presents the 5-year process to convert all film-screen radiological services to CR in the main hospital, five affiliated community hospitals, and four clinics. The article shows the importance of leadership by the medical physicist from inception of the project through installation and clinical implementation.     

A comparison between digital images viewed on a Picture Archiving and Communication System diagnostic workstation and on a PC-based remote viewing system by emergency physicians

Picture Archiving and Communication Systems (PACS) make possible the viewing of radiographic images on computer workstations located where clinical care is delivered. By the nature of their work this feature is particularly useful for emergency physicians who view radiographic studies for information and use them to explain results to patients and their families. However, the high cost of PACS diagnostic workstations with fuller functionality places limits on the number of and therefore the accessibility to workstations in the emergency department. This study was undertaken to establish how well less expensive personal computer-based workstations would work to support these needs of emergency physicians. The study compared the outcome of observations by 5 emergency physicians on a series of radiographic studies containing subtle abnormalities displayed on both a PACS diagnostic workstation and on a PC-based workstation. The 73 digitized radiographic studies were randomly arranged on both types of workstation over four separate viewing sessions for each emergency physician. There was no statistical difference between a PACS diagnostic workstation and a PC-based workstation in this trial. The mean correct ratings were 59% on the PACS diagnostic workstations and 61% on the PC-based workstations. These findings also emphasize the need for prompt reporting by a radiologist.     

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.     

A Mobile Phone Integrated Health Care Delivery System of Medical Images

With the growing computing capability of mobile phones, a handy mobile controller is developed for accessing the picture archiving and communication system (PACS) to enhance image management for clinicians with nearly no restriction in time and location using various wireless communication modes. The PACS is an integrated system for the distribution and archival of medical images that are acquired by different imaging modalities such as CT (computed tomography) scanners, CR (computed radiography) units, DR (digital radiography) units, US (ultrasonography) scanners, and MR (magnetic resonance) scanners. The mobile controller allows image management of the PACS including display, worklisting, query and retrieval of medical images in DICOM format. In this mobile system, a server program is developed in a PACS Web server which serves as an interface for client programs in the mobile phone and the enterprise PACS for image distribution in hospitals. The application processing is performed on the server side to reduce computational loading in the mobile device. The communication method of mobile phones can be adapted to multiple wireless environments in Hong Kong. This allows greater feasibility to accommodate the rapidly changing communication technology. No complicated computer hardware or software is necessary. Using a mobile phone embedded with the mobile controller client program, this system would serve as a tool for heath care and medical professionals to improve the efficiency of the health care services by speedy delivery of image information. This is particularly important in case of urgent consultation, and it allows health care workers better use of the time for patient care.     

The design and development of a physician-oriented PACS for the enhancement of e-hospital facilities

Recent advancements in modern medical diagnoses have required a huge increase of the use of equipment such as CT and ultrasound machines. Correspondingly, the storage and dissemination of these medical images have become an important issue to medical professionals. Unfortunately, management of these images has traditionally been slow and cumbersome. With the prevalence of the personal computer, however, along with increased network bandwidth, it is now possible to handle this information electronically as well as wirelessly. The Picture Archiving and Communication System (PACS) is at the forefront of this revolution. Yet, commercially available PACS software is generally prohibitively expensive for hospitals with limited financial resources. A dilemma among many hospitals is deciding how to acquire and implement the proper PACS system without unduly affecting the budget. In this paper, a full function, efficient, and economical PACS system is presented as a viable, non-compromising option for many small and medium-sized hospitals. This system, designed and developed mainly by the physicians and technicians of Puli Christian Hospital (PCH), with the assistance from academia, allows for customization to fit the needs of individual hospitals. This system can be used as the foundation of a hospital's health information infrastructure and to enhance e-hospital service.     

Enhancing integrated palliative care: what models are appropriate? A cross-case analysis

Background

Effective integration between hospices, palliative care services and other local health care services to support patients with palliative care needs is an important international priority. A previous model suggests that integration involves a cumulative stepped process of engagement with other organisations labelled as ‘support, supplant or supplement’, but the extent to which this model currently applies in the United Kingdom is unknown. We aimed to investigate accounts of hospice integration with local health care providers, using the framework provided by the model, to determine how service users and healthcare professionals perceived palliative care services and the extent of integration experienced.

Methods

Longitudinal organisational case study methods were employed using qualitative serial interviews (interval 3 months) with patients and family carers focusing on how services responded to their needs; and group interviews with health professionals. Data were audio-recorded, transcribed verbatim, and analysed by qualitative content analysis and combined across data sources.

Results

The study focused on four hospices in northern England, including 34 patients (diagnosis: 17 cancer, 10 COPD, 7 heart failure), 65% female, mean age 66 (range 44–89), 13 family carers of these patients (48% partners), and 23 health care professionals. While some care fell short of expectations, all patients reported high levels of satisfaction and valued continuity of care and efficient information sharing. All hospices supported and supplemented local providers, with three hospices also supplanting local provision by providing in-patient facilities.

Conclusion

UK hospices predominantly operate in ways that support and supplement other providers. In addition, some also supplant local services, taking over direct responsibility and funding in-patient care. They all contributed to integration with local services, with greater blurring of boundaries than defined by the original model. Integrated care offers the necessary flexibility to respond to changes in patient needs, however, constraints from funding drivers and a lack of clear responsibilities in the UK can result in shortfalls in optimal service delivery. Integrating hospice care with local healthcare services can help to address demographic changes, predominantly more frail older people, and disease factors, including the needs of those with non-malignant conditions. This model, tested in the UK, could serve as an example for other countries.

     

Patients’ challenges,competencies, and perceived support in dealing with information needs – A qualitative analysis in patients with breast and gynecological cancer

ObjectivesThis study aimed to investigate challenges, competencies, and support in breast and gynecological cancer patients when dealing with information needs and how health literacy as an interplay of these factors might be improved.MethodsSemi-structured interviews were conducted with patients in acute care (n = 19), undergoing rehabilitation (n = 20) or attending self-help groups (n = 16). Interviews were analyzed using content analysis.ResultsChallenges: gain information according to own needs, internet as information source, information evaluation and decisions, doctor-patient communication, situationally limited information processing, difficult access to information. Competencies: self-regulation of information needs, media and social competencies, communication skills in the doctor-patient conversation, internet competencies, self-directed decisions according to own needs, interest/self-efficacy, previous knowledge, trust in the doctor. Support: by professionals (e.g., patient-centered communication), relatives (e.g., support during consultations), peers (e.g., exchange), facilities (e.g., clinics).ConclusionsOur findings provide insight into challenges and competencies relevant to patients’ health literacy and the influence of support. The individuality of the interplay highlights the relevance of an active patient role and patient-centered care.Practice implicationsPatients’ health literacy should be improved in (psycho)oncological work by both reducing challenges (e.g., by communication skills training, involving relatives) and promoting competencies (e.g., by needs- and competence-oriented information offers).     

Right-Sizing Technology in the Era of Consumer-Driven Health Care

Technology for modern clinical and public health microbiology laboratories has evolved at an impressive rate over the last two decades. Contemporary diagnostics can rapidly provide powerful data that can impact patient lives and support infectious disease outbreak investigations. At the same time, dramatic changes to health care delivery are putting new pressures on a system that is now focusing on patient-centric, value-driven, convenient care. For laboratories, balancing all these demands in a cost-contained environment remains a challenge. This article explores the current and future directions of diagnostics in our dynamic health care environment.     

Picture archiving and communication system training for physicians: Lessons learned at the Baltimore VA Medical Center

Physicians practicing at the “filmless” Baltimore VA Medical Center need to be proficient in the use of the picture archiving and communication system (PACS) to be able to view radiologic images and accompanying reports. PACS training is necessary to assure optimal patient care and to satisfy potential medicolegal requirements. Providing such training is the responsibility of both the Imaging Department and the hospital. Training in the use of the PACS at the Baltimore VA is conducted by an on-site application specialist. Data were collected from interviews with the trainer, training log sheets, and physician surveys. Although 100% of radiologists received formal training, only 22% of nonradiologists were formally trained; 32% of these physicians identified themselves as having been trained by their peers and 41% stated they were self-trained. We identified two goals of a PACS training program. The first is to teach physicians how to retrieve images and reports from current as well as prior studies and display them on a computer workstation. Secondly, the training should include instruction on the use of the various workstation tools to enhance image interpretation. Imaging requirements and usage by different physician groups vary, and PACS training should be tailored accordingly. Difficulties in the scheduling of training sessions during working hours and the widespread use of a “generic” log-on identification have contributed to the low (22%) compliance of nonradiologists with the formal training program. Although we believe that one-on-one training is most effective and can be best tailored to the needs and computer expertise of an individual particular physician, computer based training (both on and off-line) may provide an acceptable, and in some cases, a preferred alternative.     

Picture Archiving and Communication Systems and related developments in Sweden

Large PACS (Picture Archiving and Communication Systems) installations do not yet exist in Sweden, but some hospitals have had experience with limited PACS activities. At present there are four mini PACS installations in radiology departments and about 12 teleradiology systems in use in Sweden. A couple of small Swedish enterprises work in the market segment of digital imaging including PACS and teleradiology, although the radiology market is dominated by the large international companies. Interest in PACS and teleradiology in Sweden has increased during the last few years, along with advancements in technology and international experience. However, radiology is organized very differently in the United States, Japan, Southern Europe, and Scandinavia. Because of this, PACS will be introduced in different ways, and experience with PACS gained in one health care system may differ from that gained from other health care systems. This article reviews the status of PACS and related developments in Sweden.     

“Do no harm”: Fortifying MDT collaboration in changing technological times

PurposeTo examine the changes in multidisciplinary medical team activity and practices, with respect to the amount of patient cases, the information needs and technology used, with up to 10 multidisciplinary teams (MDTs) in a large teaching hospital over a 10-year period.MethodsAn investigation of MDT meeting activity was undertaken in November 2005 and repeated in November 2012 for the MDTs at a large university teaching hospital. Analysis of data from 8 MDTs was informed through long-term ethnographical study, and supplemented with 38 semi-structured interviews and a survey from 182 staff members of MDTs.ResultsWork rhythms change over time as a function of the volume of work and technology changes, such as the use of a picture archive and communication system (PACS), videoconferencing and an electronic patient record (EPR). Maintaining cohesive teamwork, system dependability, and patient safety in the context of rapid change is challenging.ConclusionsBenefits of MDT work are in evidence, but the causes are not fully understood. Instead of asking ‘how can technology support more MDT activity?’, we ask ‘how can we preserve the benefits of human–human interaction in an increasingly technological environment?’ and ‘how can we ensure that we do no harm?’ when introducing technology to support an increasingly demanding collaborative work setting.Introducing technology to streamline work might instead threaten the experienced improvement in patient services.     

Health facilities at the district level in Indonesia

Background

At Independence the Government of Indonesia inherited a weak and unevenly distributed health system to which much of the population had only limited access. In response, the government decided to increase the number of facilities and to locate them closer to the people. To staff these health facilities the government introduced obligatory government service for all new graduates in medicine, nursing and midwifery. Most of these staff also established private practices in the areas in which they were located. The health information system contains little information on the health care facilities established for private practice by these staff. This article reports on the results of enumerating all health facilities in 15 districts in Java.

Methods

We enumerated all healthcare facilities, public and private, by type in each of 15 districts in Java.

Results

The enumeration showed a much higher number of healthcare facilities in each district than is shown in most reports and in the health information system which concentrates on public, multi-provider facilities. Across the 15 districts: 86% of facilities were solo-provider facilities for outpatient services; 13% were multi-provider facilities for outpatient services; and 1% were multi-provider facilities offering both outpatient and inpatient services.

Conclusion

The relatively good distribution of health facilities in Indonesia was achieved through establishing public health centers at the sub-district level and staffing them through a system of compulsory service for doctors, nurses and midwives. Subsequently, these public sector staff also established solo-provider facilities for their own private practice; these solo-provider facilities, of which those for nurses are almost half, comprise the largest category of outpatient care facilities, most are not included in official statistics. Now that Indonesia no longer has mandatory service for newly graduated doctors, nurses and midwives, it will have difficulty maintaining the distribution of facilities and providers established through the 1980s. The current challenge is to envision a new health system that responds to the changing disease patterns as well as the changes in distribution of health facilities.

     

Issues Surrounding PACS Archiving to External, Third-Party DICOM Archives

In larger health care imaging institutions, it is becoming increasingly obvious that separate image archives for every department are not cost effective or scalable. The solution is to have each department’s picture archiving communication system (PACS) have only a local cache, and archive to an enterprise archive that drives a universal clinical viewer. It sounds simple, but how many PACS can truly work with a third-party Integration of the Health Care Enterprise Compliant Image Archive? The answer is somewhat disappointing.Key words: PACS, IHE Actors, enterprise archiving     

Impact of the mental health and dynamic referral for oncology (MHADRO) program on oncology patient outcomes,health care utilization,and health provider behaviors: A multi-site randomized control trial

ObjectiveThe MHADRO assesses psychosocial and medical needs, provides tailored feedback reports, and connects patients to mental health providers. This study examined the MHADRO’s effect on patient outcomes, health care utilization, and oncology provider documentation and behaviors.Methods836 patients were part of a multi-site RCT and assessments were conducted at baseline, 2, 6 and 12 months.ResultsThe intervention group engaged in less emergency calls to providers. There were no differences in psychosocial outcomes at follow up assessments. Providers of patients in the intervention group were more likely to: document psychosocial symptoms and history; refer to psychosocial services; encourage support groups; seek psychological evaluations during visits. Patients who agreed to a mental health referral had decreased hospitalizations, increased mental health care interactions, and stronger ratings of counseling potential benefits. This group also reported increased psychosocial distress at all follow-up assessments.ConclusionThe MHADRO may increase access to mental health care, lessen utilization, and improve providers’ management of psychosocial needs, but does not appear to impact overall functioning over time.Practice ImplicationsProviders are encouraged to consider incorporating programs, like the MHADRO, into patient care as they may have the potential to impact screening and management of patients’ psychosocial needs.     

A case for automated tape in clinical imaging

Electronic archiving of radiology images over many years will require many terabytes of storage with a need for rapid retrieval of these images. As more large PACS installations are installed and implemented, a data crisis occurs. The ability to store this large amount of data using the traditional method of optical jukeboxes or online disk alone becomes an unworkable solution. The amount of floor space, number of optical jukeboxes, and off-line shelf storage required to store the images becomes unmanageable. With the recent advances in tape and tape drives, the use of tape for long term storage of PACS data has become the preferred alternative. A PACS system consisting of a centrally managed system of RAID disk, software and at the heart of the system, tape, presents a solution that for the first time solves the problems of multi-modality high end PACS, non-DICOM image, electronic medical record and ADT data storage. This paper will examine the installation of the University of Utah, Department of Radiology PACS system and the integration of automated tape archive. The tape archive is also capable of storing data other than traditional PACS data. The implementation of an automated data archive to serve the many other needs of a large hospital will also be discussed. This will include the integration of a filmless cardiology department and the backup/archival needs of a traditional MIS department. The need for high bandwidth to tape with a large RAID cache will be examined and how with an interface to a RIS pre-fetch engine, tape can be a superior solution to optical platters or other archival solutions. The data management software will be discussed in detail. The performance and cost of RAID disk cache and automated tape compared to a solution that includes optical will be examined.     

Perspective: Leveraging the health care workforce: what do we need and what educational system will get us there?

Shortages of 100,000 physicians and up to one million nurses are projected in the next 10 years. If these statistics are close to true, medical schools would need a 100% increase in graduates over the next 4 years, and nursing schools a 100% increase over the next 13 years. These calculations are instructive in that they demonstrate the absurdity of expecting schools to provide these sorts of increases in that time frame. Other solutions must be considered. For instance, do doctors and nurses need to do everything they are currently called on to do? Could not other members of the health care workforce, such as well-trained lay workers, be leveraged to do some of the more routine work, freeing medical professionals to perform their unique roles? How is such a workforce built, and how shall learners be educated to fill those needs? This article presents a hypothetical model that could be implemented based on carefully researched pilots to meet health care education needs. The model features three essential components: (1) a school for the public in which lay teachers develop curricula with members of the public, for example, about how to incentivize healthy behavior, (2) a college for health as part of a university with interdisciplinary teaching, where patients, faculty members, and students interact in each of the schools and learn together, and (3) the most effective and efficient nursing and medical school curricula, developed together based on evidence of what the student needs to know.