1. PACS—How to Choose One PACS – What to Look For and What to Avoid From an Experienced Perspective PACS Communication:RIS, HIS, Internet and Doctors Integrating a PACS: Interfacing Computers, Doctors and IT Personnel

2. The Way It Used To Be... TEACHING FILES... RETRIEVE OLD STUDIES... FILE FILM ANNOTATE FILM RADIOLOGIST READ STUDY Camera Vendor #1 Camera Vendor #2 Camera Vendor #3 PROCESSING ACQUISITION REDO FILM... FILM CAPTURE

3. PACS Way... TEACHING FILE... RETRIEVE OLD STUDIES... FILE FILM ANNOTATE FILM RADIOLOGIST READ STUDY ACQUISITION PROCESSING FILM CAPTURE REDO FILM Camera Vendor #1 Camera Vendor #2 Camera Vendor #3 Cable TV Windows NT Server Viewing Room Web Disk Storage RIS / HIS / RTAS Backup RTAS

4. A PACS Replaces... »Film »Image formatter and Camera »Processor »Viewboxes »File Room & Personnel »Film jackets »Repeat films »Laser printers »Lost film = lost billings

5. Why PACS? Lower costs Faster access to studies Read studies from home or beach (or SNM meeting...) Efficient interpretation No repeat studies Instant access to older studies Old study & new study dialed to same gray level W W W access by referring physician Cheap plain paper copies of studies with reports to referring physicians

6. PACS Efficiencies ¤No wrong patient id, misspelled names, or other header data ¤Technologist time No waiting for on-call MD No processor time Combine images from different gamma cameras (and different times) ¤Multiple camera vendors; one set of analysis & display software to learn ¤Instant study availability ¤Dynamic display ¤Gray scale variation

7. Distributed MiniPACS Separate, stand alone, self contained PACS for each Radiology Subspecialty, with Communication to other MiniPACS

8. No Radiology Departmentwide PACS Has Adequate Nuclear Medicine Module Unique Software for Each Subspecialty Backup and Redundancy –Archive –Workstations –Network Network Overload MiniPACS

9. Caveat Emptor One man’s “dicom compatible” is the next man’s headache. Be sure your PACS can translate native vendor formats

10. A PACS Is For The Nuclear Medicine Physician, Not the Programmer 5 Minute Training Intuitive Operations PACS for Doctors (i.e. Dummies) Backup and Redundancy– System NEVER Goes Down

11. Photographic vs. Digital Costs Annual Exam Volume: Nuclear Medicine 13,368 CT 22,050 MRI 7,775 Ultrasound 22,951 66,144 43.6% of total departmental exam volume

12. Photographic Costs Film & File Room: Film (NM (?), CT, MRI, US) $ 410,988 Maintenance Processors,Multiloaders,Alternators 42,006 Film jackets, Folders, & Supplies 11,964 Storage off-site 32,669 File Room Personnel / Benefits 286,233 File Room space -Personnel overhead 101,227 -Depreciation 29,936 $ 915,023

13. Photographic Costs Equipment Depreciation: Film processors $ 20,000 Laser Printers 50,000 ______________ Total: $ 70,000

14. Technologist time: Process time 90 seconds Loading/unloading cassette 60 seconds Annotation, flashing & preparation for filing 120 seconds Total: 4.5minutes/study Salary/benefits @ $23.52/hr Cost per study $1.76 Total: $116,413 Total: $116,413 Photographic Costs

15. Digital costs 1 2 Workstations, 5 year depreciation $ 200,000 4 MiniPACs servers, with backup, 5 year depreciation 60,000 High speed network, 5yr depreciation 30,000 System supplies 10,000 Space depreciation and Maintenance 30,000 System manager and benefits 70,000 Service contracts 130,000 Total: $530,000/yr

16. Annual Savings Photographic costs $ 1,101,436 Digital costs 530,000 SAVINGS = $571,436

17. NUCLEAR MEDICINE $4.13 Total photographic cost/study = $4.13

18. NUCLEAR MEDICINE Digital costs Equipment 2 Workstations, 5 year depreciation $14,000/yr 1 Server, 5 year depreciation 7,800/yr Maintenance 9,810/yr Total:$31,610/yr Cost per study = $3.16

19. Enormous Gain in Nuclear Medicine Physician Efficiency Gains in REFERRING PHYSICIAN Efficiency: No waiting to retrieve new and old study No waiting for Nuclear Medicine Physician to review emergency study

32. Mt. Auburn Hospital OFFICE BIDMC East Clinical Center BIDMC West Nuclear Medicine INTERNET BIDMC East Nuclear Medicine PACS SERVER NT

33. Cameras Nuclear Medicine Nuclear MedicineNetwork Network GEStarCam TrionixBIAD TechnicareMobile ADACPEGASYS ElscintSP6 ElscintHELIX BIDMC East Nuclear Medicine ADACPegasysADACPegasys BIDMC East Clinical Center BIDMC West Nuclear Medicine MT. AUBURN Camera OhioNuclear Strichman Siemens Siemens DH SPECT DH SPECT Siemens SH SH Siemens SH SPECT SH SPECT ADACPegasys

34. Remote Access for Physicians Remote Access for Physicians Nuclear Medicine Nuclear MedicineNetwork CableModem Telephone Modem Cell Modem Internet

35. Image Center Workstations Image Center Workstations Nuclear Medicine Nuclear MedicineNetwork Network BIDMC East Nuclear Medicine Projection Screen Work Station Optical Backup 1.3GBRTAS RTAS WorkStation

40. Standard off-the-shelf Software & Hardware Low cost Multiple vendors Upgradeable Easy maintainability and serviceability Links to other systems Creation of new functions

41. BACKUP What’s got to be there when everything is broke...

42. What could happen... 1)Hospital fire fries all disks 2)Server is down 3)Hospital Ethernet is down 4)ALL workstations are down

43. - 1) Data backup 2) Database backup 3) Hardware backup

44. Data backup 1) Two disks - not mirrored 2) Daily automatic (night) backup -WORM disk -not on Server 3) Weekly download to tape -taken off-site

45. Database backup 1) Nightly backup - to workstation 2) Recovery program -to reconstruct database by reading header data on all files

46. Hardware Backup Use standard PC hardware All Workstations and Server are PC-based and interchangeable Network backup with floppy disks Modem backup for telenuclear medicine access for W W W-Internet failure Floppy transfer if network is down

47. How does BACKUP work? Automatically

48. 14 YEAR’S EXPERIENCE What did happen... 1) Power Supply 2) Disk Controller 3) Disk Errors 4) Disk Crash 5) Work Station Down 6) Gamma Camera Gateway to Server Down 7) Delete *.* 8) Four hours total system downtime. Citywide power failure.

50. The All-Digital Department Moves to the Web The All-Digital Department Moves to the Web - http://ej.rsna.org/EJ_0_96/0006-96/home.htm Cable Modem–assisted Tele–Nuclear Medicine Cable Modem–assisted Tele–Nuclear Medicine - http://ej.rsna.org/EJ_0_96/001996.fin/cable_modem.html Cost Savings in a Digital Radiology Department Cost Savings in a Digital Radiology Department - http://ej.rsna.org/EJ_0_96/005197.fin/Pacs97.html Backup and Redundancy: 10-Year Experience with a Division-wide PACS - Backup and Redundancy: 10-Year Experience with a Division-wide PACS - http://ej.rsna.org/ej2/0052-97.fin/pacsfail.html Publications on the Web

51. *Gerald M. Kolodny, M.D. J. Anthony Parker, M.D., Ph.D. Kevin J. Donohoe, M.D. Thomas C. Hill, M.D. Dace Jansons, M.S., C.N.M.T. Larry Barbaras, B.S. Division of Nuclear Medicine Beth Israel Deaconess Medical Center Boston, MA * stockholder, Sudbury Systems, Inc.