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.     

CR/DR systems: what each technology offers today; what is expected for the future

Computed radiography (CR) is considered by some to be the work-horse for digital image capture of general radiography exams because it is affordable, offers excellent image quality and exposure latitude and utilizes existing x-ray systems. CR systems deliver digital imaging to general radiology departments and lower-volume areas that can include hospital floors and outpatient imaging centers. Digital radiography (DR) technology is more expensive, but some believe it earns its keep with significant productivity gains and the capacity for higher image quality or lower dose. DR systems are especially appropriate for emergency room settings and high-volume areas in general radiology departments, orthopedic clinics, imaging centers and other facilities. Facilities with growing patient volumes and limited space often choose to install DR systems in one or 2 exam rooms to double the productivity of those rooms, while one or more CR systems serve the remaining rooms or remote areas. Patients benefit from both faster image capture (it takes less time for each imaging exam) and hospitals achieve a digital distribution process that speeds delivery of radiology reports to referring physicians and a more efficient imaging workflow that can lead to increased revenues.     

数字X线摄影系统中低剂量应用的探讨

目的 通过数字X线摄影系统（DR）在胸部摄影检查中的应用评价DR的低剂量的优越性。方法 利用CDRAD 2.0低对比细节体模评价计算机X线摄影（CR）和DR的影像质量和表面空气吸收剂量（ESD）关系,分别利用两个系统（DR使用ESD约为CR的1/3）得到成人胸部30幅影像。由6位影像科医生来评价以上两者的影像系统对于肩胛骨内侧边缘等胸部结构的清晰程度。结果 CR影像和减少ESD的DR影像在影像诊断质量上差异没有统计学意义（P＞0.05）。结论 DR的较好的分辨率和低噪声特性,以及高DQE有助于减少患者接受的辐射剂量,而不影响诊断质量。     

通过工作列表实现数字化网络各系统之间患者信息的一致性

目的 实现图像存储与传输系统(picture archiving and communication system，PACS)、放射学信息系统(radiology information systems，RIS)、影像设备之间患者检查信息的一致性。方法 我院引进GE Signa 1．5T磁共振、数字乳腺，Agfa数字X线摄影、计算机X线摄影及GE CT等数字化医学设备。GE PACS是英文系统，所以前期医院在未解决信息一致性时只通过PACS对检查影像进行保存，通过PACS系统中简单的信息管理工作，并没有真正意义上的worklist。2个月后，我院采用国际上先进的解决方法即通过医学数字成像及通讯(digital imaging and communication in medicine，DICOM)标准的工作列表(worklist)的方法实现信息的一致性。在RIS系统中将患者中文信息转换为英文信息，保存并为worklist提供患者的英文信息。结果 我院在集成PACS和RIS的2年多时间以来，通过worklist来保证RIS与影像设备患者检查信息的一致性，取得了非常好的效果。在所有诊断工作站上，诊断医生通过中文RIS系统，对病人的信息进行编辑、修改、产生。结论 通过worklist实现PACS、RIS、影像设备之间患者检查信息的一致性是可行的。     

Increased productivity of a digital imaging system: one hospital's experience.

During peak hours of operation, it was not uncommon for the radiology department at St. Luke's Episcopal Hospital in Houston, Texas, to have a backlog of six to ten patients. While some of this was due to competing schedules from the emergency department (ED) and inpatients, the major problem was an inefficient workflow, especially for emergency department patients. Our staff in the radiology department worked with the hospital management to include plans for a new radiology room in an ED renovation project. In designing the new radiology room the most important issues under consideration were the physical location of the room and the type of radiography system to be installed. With plans to implement PACS, we evaluated computed radiography and digital radiography options. At St. Luke's, we had had our first experience with digital radiography after the purchase of a dedicated digital chest system. As a beta test site for the manufacturer, we had an opportunity to test--what was at the time--a new digital radiography system. The powerful impact of digital radiography became most evident by the decreased patient backlog. Even without PACS, workflow became dramatically more efficient. Images now are available for review within seconds after exposure, since there are no films to process. This has reduced our average exam time from ten minutes to one and a half minutes, not including patient transport time. The efficiency demonstrated with the digital chest system provided evidence that digital systems could handle significantly more patients than computed radiography or screen-film systems, without a compromise in image quality. Therefore, we decided to put a digital radiography system in the new ED radiology room. We estimate that the new unit will pay for itself in less than three years.     

The integration of medical images with the electronic patient record and their web-based distribution

Medical images are currently created digitally and stored in the radiology department's picture archiving and communication system. Reports are usually stored in the electronic patient record of other information systems, such as the radiology information system (RIS) and the hospital information system (HIS). But high-quality services can only be provided if electronic patient record data is integrated with digital images in picture archiving and communication systems. Clinicians should be able to access both systems' data in an integrated and consistent way as part of their regular working environment, whether HIS or RIS. Also, this system should allow for teleconferencing with other users, eg, for consultation with a specialist in the radiology department. This article describes a web-based solution that integrates the digital images of picture archiving and communication systems with electronic patient record/HIS/RIS data and has built-in teleconferencing functionality. This integration has been successfully tested using three different commercial RIS and HIS products.     

IT-Systeme in der Radiologie und IT-Systeme für den Radiologen

Radiology plays an important role in introduction and use of information technology (IT) systems in the daily clinical routine. The radiology information system (RIS) and picture archiving and communication system (PACS) are the main systems used in a digital radiology department. In this article the basic principles and functions of these systems and trends in development are described.     

Digital imaging overview

Digital imaging consists of digital acquisition modalities, image, and information management systems. All modalities are available to be purchased as digital acquisition devices. Image management has been the domain for PACSs. PACSs are complex systems designed to transmit, store, and display medical images. They use and rely on many types of different information and display technologies. The initial focus for PACSs has been on solving the engineering issues associated with the transfer of large image data sets and the suitability of softcopy displays for diagnosis particular to the human visual system. For operating within a centralized radiology department, these are largely solved. However, for enterprise wide dissemination and distribution, there are still challenges in the form of expedient transfer syntaxes and image quality, but these are also being effectively addressed. Information management is the domain of the RIS. One of the goals of radiology management should encompass the development of a robust practice environment that emphasizes workflow enhancements with seamless integration of decision support tools. The concept of "person-machine" systems emphasizes taking full advantage of both human and machine capabilities with a capacity to grow and change function. As the computer capabilities increase, more jobs can be relinquished to the machine. The physician can then focus on tasks that require more complex judgment and comprehension. The goal of this human-machine hybrid is to have more power than either of its components alone. This multifaceted role will most likely be embedded in the background having agents query and retrieve context specific information to be presented to the user. As augmenters of human talent, computers can turn data into information and information into knowledge. Medical imaging is a beneficiary of the information technology developments driven by the consumer and business sectors. Although these applications of information technologies are not a solution to every problem, it certainly can bring the radiology department much closer to the desired ideal operational model. Even though there are many challenges to overcome, the benefits derived from a successful RIS/PACS implementation can be instrumental toward achieving a level of excellence in clinical service, teaching, and research that is unrivaled. Strategies for change management and quality improvement should begin by considering the entire chain of events from image acquisition through display to communication of a report.     

Effect of digital radiography on emergency department radiographic examinations

The purpose of this paper is to determine the time-savings realized as a result of conversion from film-based radiography to digital radiography (DR) in emergency department patients receiving multiple radiographic examinations. We retrospectively reviewed the computer records of 69 patients from the preconversion group (January 2004) and 62 patients from the postconversion group (January 2005), calculated the mean examination time per image from each group, and used a one-tailed t test to compare the two means. The preconversion (a mix of screen-film and computed radiography) group had a mean examination time of 3.27±1.50 min per image. The postconversion (DR) group had a mean examination time of 2.51±1.16 min. The p value between the two means is 0.000822 with a standard error of 0.330 min. DR reduces radiographic examination time by 23% when compared to conventional screen-film radiography.     

A tale of two CRs: hospital conducts side-by-side test

While we elected to install a digital radiography system in the busiest exam room in emergency room (ER) suite at our 535-bed hospital, we selected computed radiography as the primary platform for digital capture throughout the facility because of its flexibility, productivity and cost-effectiveness. We now use CR systems to handle six exam rooms and portable exams conducted by the radiology department, as well as imaging studies conducted in two ER exam rooms. Before committing to a CR vendor, we conducted an eight-week, side-by-side pilot study with two vendors' systems. One CR system was located in the emergency room and the other unit was located in the main radiology department. Our staff received education and training from both vendors. I led an evaluation team that included representatives from the radiology group, the information services (IS) department, biomedical engineering, staff physicians, ER physicians, pulmonologists and orthopedic specialists. Our team met to design the trial and develop a list of factors that technologists would use to evaluate the two systems. The team met after installation and again after the trial was complete to provide verbal input on each vendor for each category and to review feedback from the technologists' survey. Categories included image quality, interactions with each vendor's sales and service staff, workflow, time studies, durability of cassettes and plates, entry of John Doe patients for ER, and other factors. After the trial, we chose a system by unanimous vote. We learned a lot about CR technology throughout this process. Overall we are extremely satisfied with the platform we selected and with this method of evaluating the two systems prior to making this important decision.     

A time-motion study of digital radiography at implementation

With increasing budgetary restraints on the health system, it is apparent that the main contribution that radiology departments can make to significant cost reduction in hospitals is to decrease the length of time between requesting an X-ray examination and receiving the report (and images). Digital radiography (DR) was introduced into the Radiology Department at the Royal Adelaide Hospital as a pilot project to research the cost-benefits and efficiency of the system, and to determine future directions for planning a digital department. The business plan developed prior to implementation of this pilot project predicted a saving of one bed-day per inpatient when a fully digital department with a picture archiving and communication system (PACS) is installed. This initial study comparing DR and conventional radiography (convR) provides baseline data and shows encouraging results for more rapid transmission of reports to clinicians.     

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。     

Radiology report turnaround: expectations and solutions

The ultimate work product of a radiology department is a finalized radiology report. Radiology stakeholders are now demanding faster report turnaround times (RTAT) and anything that delays delivery of the finalized report will undermine the value of a radiology department. Traditional reporting methods are inherently inefficient and the desire to deliver fast RTAT will always be challenged. It is only through the adoption of an integrated radiology information system (RIS)/picture archiving and communication system (PACS) and voice recognition (VR) system that RTAT can consistently meet stakeholder expectations. VR systems also offer the opportunity to create standardized, higher quality reports.     

Development of an electronic radiologist's office in a private institute.

A computer system that improves the quality, user-friendliness, accessibility, and management of radiology data (images, reports, databases, knowledge) was implemented at a private institute. A picture archiving and communication system (PACS) was integrated with the radiology information system (RIS). Two servers and 12 personal computers form the integrated system. The first server is dedicated to management and archiving of Digital Imaging and Communications in Medicine (DICOM) images. The second server is dedicated to management of the RIS and archiving of patient data (Structured Query Language database), reports (hypertext markup language [HTML]), and images in the Joint Photographic Experts Group (JPEG) format (mini-PACS). There are three main client-server networks: a common network of imaging modalities (magnetic resonance imaging, computed tomography, ultrasonography, digital radiography) and two fast Ethernet networks (the PACS network and the RIS network). The RIS-PACS is linked remotely with other workstations and servers via Integrated Services Digital Network (ISDN). Images and reports can be distributed to referring physicians in the form of multimedia HTML and JPEG documents, which can also be used for quick and easy archiving, distribution, and reviewing within the institute. However, referring physicians have been reluctant to use electronic reports and images.     

Integrating your radiology information system in a complex computing environment

Radiology departments are a major source of important information regarding patient care. Such information is valuable in its own right but also provides significant added value when correlated with other information, including other clinical diagnoses, therapies, utilization, costs of care and outcomes. In the past, hospitals/imaging centers have typically sought the "best" RIS to meet the needs of the department and its user constituencies (physicians, nurses, medical records, etc.). Function and feature drove the RIS selection process. "Best of breed" was the rallying cry. Having multiple systems and vendors requires information systems and departmental staff to maintain expertise and support in each system and to interact with each vendor. The best-of-breed approach has a number of hidden costs. Before buying, ask "Is the best-of-breed RIS so much better than a more integrated solution that the support and integration efforts are worth it?" This is a complex question involving true needs, perceived needs, wants (justifiable or not), ego, politics, institutional future plans and more. Effective integration in a complex computing environment involves both technical processes and people processes. A cooperative, team-oriented process with the appropriate allocation of staff functions based on expertise and experience is needed. In general, the radiology department is best able to manage operations of the RIS. The information systems department should retain responsibility for housing the RIS computer and performing routine backup procedures as well as monitoring RIS performance. Both organizations can contribute to a highly successful integrated system operation based on their respective knowledge and experience. The IHE (Integrating the Healthcare Enterprise) is a joint initiative of the RSNA and HIMSS (Healthcare Information Systems Society) to stimulate the integration of information and imaging systems. The initiative will promote enterprise-wide sharing of data via established standards. The organizations, at their annual national meetings, will provide a visible forum and showcase of integration capabilities (most recently at HIMSS 2000).     

Digital image archive: using statistical-caching techniques.

To achieve full implementation of the digital radiology department or of picture archive and communication systems, an efficient digital image archive must be constructed. This paper discusses the use of statistical-caching techniques within an image archive. In addition, the results of computer modeling will be used to demonstrate the advantages of this approach.     

A new approach to the film library: time-unit filing

The installation of a new radiology information system (RIS) at Children's Hospital Medical Center of Akron in Akron, Ohio, took the radiology department into a new world of technology, but raised issues we never anticipated. The major problem the new RIS forced the department to overcome was how to eliminate the film file's reliance on a proprietary radiology numbering system. Previously, the department had used its own numbering system--a proprietary x-ray number--to file film jackets and had used the hospital-issued medical record number to access patient and payer information from the hospital information system. It became clear that we should use a single number--the medical record number--to access all data, but we wondered how that would affect our film file room. An RIS consultant suggested that we consider filing films by last date of service, a system called "time-unit filing." Time-unit filing means keeping the most recent two-weeks worth of films in the main file room. They are organized by gender in blue or pink jackets and marked alphabetically by the patient's last name in a way that makes mis-files easy to see. If a patient's film jacket is activated again, it is refiled in the current two-week time unit. Inactive jackets remain in their two-week time unit indefinitely. Time-unit filing has had many benefits for the radiology department at Children's Hospital Medical Center of Akron: fewer mis-files, less time needed for filing and searching, and successful implementation of the new RIS.     

Demystifying radiology information systems

Selecting the right radiology information system (RIS) can be a difficult and tedious task for radiology managers. Sometimes the information systems department ends up selecting the RIS. As a radiology manager, you can help yourself and your department greatly by becoming more educated concerning the technology and terminology of radiology information systems. You can then participate in one of the most important decisions that will ever be made regarding your department. There is much confusion about the meanings of the terms interfaced and integrated. Two applications are generally considered integrated if they freely access and update each other's databases. Two applications are generally considered interfaced if they pass data to each other but don't directly access nor update the other's databases. Two more terms are centralized and decentralized. Centralized is the concept of "putting all of your eggs in one basket." Decentralization means you spread your resources out. The main difference between centralized and decentralized is that all components of a centralized system share the same fate (good or bad), while decentralized components operate independently and aren't affected directly by failures in another system. Another significant term relevant to RIS systems is HL7, which is a standardized data format that allows one application to pass data to another application in a format that the receiving application understands. RIS vendors generally fall in three categories: single-source vendors, multiproduct vendors and single-product vendors. Single-product vendors include best-of-breed vendors. No one approach is necessarily better than the others; which you choose will depend on your needs. When considering the purchase of an RIS system, there are important questions to ask yourself, the vendor and the vendors' customers as you gather information and prepare to make a decision.     

A comparison of low contrast performance for amorphous Silicon/caesium iodide direct radiography with a computed radiography: A contrast detail phantom study

A range of digital image acquisition devices exists in diagnostic radiology. This study compares contrast performance of two such systems: an amorphous Silicon/caesium iodide (a-Si:CsI) based flat panel (DR) digital chest radiography system and a computed radiography (CR) system. Images of a contrast detail resolution phantom were acquired at a range of radiation doses. Three observers assessed all hardcopy images using a four-alternative forced choice observer perception technique. Contrast detail performance was calculated and low contrast performance quantified.The DR system demonstrated significantly better low contrast performance and potential dose savings of up to 75% compared to the CR system. Threshold levels of contrast detail resolution were defined and levels of under- and over-exposure, compared to the threshold level, were highlighted. Both systems were noise limited at lower exposures and latitude limited at higher exposures. The results demonstrate that the DR system should perform better than the CR system under typical clinical conditions relevant to chest radiography particularly for the detection of low contrast details such as lung metastases or pneumothoraces.     

小型医学影像存储与传输系统的临床应用

目的 探索小型医学图像存档与通讯系统(minimizing picture archiving and communication system，mini—PACS)在实际工作中的应用，逐步实现科室内的无胶片化管理。方法 建立基于PC机的局域网，连接CT、MR、数字胃肠机、DSA、激光相机等医学影像设备，整合数字图像网络(digital imaging network，DIN)和医学图像诊断系统(medical diagnostic imaging system，MDIS)，组成放射科信息管理系统(radiology information system，RIS)。RIS系统通过其中1台安装双网卡的PC工作站与医院信息系统(hospital information system，HIS)相连。结果 系统在2年多的时间内得到连续使用，放射科信息管理系统得以实现和完善。在现有的数字化影像设备上实现了符合医学数字图像传输标准3．0(digital imaging communication in medicine，DICOM3．0)格式的图像采集、储存、传输、打印、浏览功能。图像和诊断报告信息通过Microsoft Access数据库管理，不同设备上保存的在线图像为3～6个月，所有图像用CD—R光盘刻录，作为离线永久保存，已有32700多份诊断报告存入数据库；HIS终端可有限制地从该系统获得图像和诊断信息。结论 mini—PACS系统投入和运行成本低、维护简单、性能可靠，可基本实现PACS的重要功能，在中、小医院具有良好的应用前景。