1. PACS -- How to Choose One PACS Communication: RIS, HIS, Internet, and Doctors J. Anthony Parker, MD PhD Beth Israel Deaconess Medical Center Boston, MA Society of Nuclear Medicine St Louis, MO Monday, June 5, 2000, 3:00-3:30 Caveat Lector

2. Beth Israel Deaconess Medical Center Department of Nuclear Medicine 1982 All digital 1987 Filmless 1995 Web-based

3. PACS Communication Database 101 1 Communication with HIS / RIS / workstation Communication with referring physician 2 Call 3 1. http://www.med.harvard.edu/JPNM/Lectures/Database101/Database101.html. 2. Barbaras l, Parker JA, Donohoe KJ, Kolodny GM: The All-Digital Department Moves to the Web. RSNA ej 1996. 3. Parker JA, Barbaras L, Donohoe KJ, Biedron WE, Kolodny GM: Cable Modem- assisted Tele-Nuclear Medicine. RSNA ej 1997.

4. Database: Tables Simple two dimensional Hold all the data Rows called “records” Columns called “fields” Organize data / application Examples: order, invoice, product A record is often represented by a form RIS examples: patient, study, dataset

5. Table Example: ADT MRNLastFirstMiddleSex 1274829AdelsteinS.JamesM 1756983HolmanB.LeonardM 6432235ParkerJ.AnthonyM 7824824ParkerJ.ScottM 7832134ParkerM.JaneF 7354851TrevesS.TedM

6. Table Example: Study Table MRNStudy NoTypeReport 1274829960345Bonehttp:// 144.134.206.52/R960345.html 1756983960346Brainhttp:// 144.134.206.52/R960346.html 6432235960347Lung http:// 144.134.206.52/R960347.html 1756983960348Bone http:// 144.134.206.52/R960348.html 1756983960349Lung http:// 144.134.206.52/R960349.html 1274829960350Heart http:// 144.134.206.52/R960350.html

7. Table Example: Dataset Table Study NoDataset NoNameDataset 960345125785Anthttp://144.134.206.52/Im960345.tiff 960345125786Post http://144.134.206.52/Im960346.tiff 960346125787Flow http://144.134.206.52/Im960347.tiff 960346125788Dyn http://144.134.206.52/Im960348.tiff 960346125789Stat http://144.134.206.52/Im960349.tiff 960346125790Delay http://144.134.206.52/Im960350.tiff

8. Index: Rapid Table Access MRNLast NameFirst NameMiddle NameSex 1756893AdelsteinS.JamesM 3234252HolmanB.LeonardM 6432235ParkerJ.AnthonyM 7832134ParkerJ.ScottM 7834453ParkerM.JaneF 3259204TrevesS.TedM MRN Index

9. Database: Relations Connect two tables One field from each table e.g. ADT.MRN = Study.MRN Record(s) with the same field value are associated Relations provide application complexity

10. Relational Database MRNNameSexDOB... MRN Study #DateType... 1526872 1994-6184 Study #...Dose #IsotopeForm Isotope... Tc-99m Xe-133 Tc-99m Xe-133 Patients Studies Inventory Dose

11. Database Concepts Tables are simple Table design provides application structure Indexes allow rapid access to tables Relations provide richness to application

12. Communication How to Choose a Database You don’t care

13. HIS: Hospital Information System ADT ChemistryBilling RIS NMIS Interface Engine Protocols: SQL HL7 Distributed database

14. Let’s have a little talk about tweetle beetles... Suess: Fox in Sox. 1965

15. Jargonology PACS - Picture Archiving and Communication System HIS - Hospital Information System ADT - Admission Discharge Transfer RIS - Radiology Information System NMIS - Nuclear Medicine Information System HL7 - Health Level 7 SQL - “Structured Query Language”? DICOM - Radiology communications protocol ACR/NEMA 3 for European sensibilities

16. Database Access Old paradigm Middleware - SQL Some cross platform New paradigm The web - Java, JavaScript Total cross platform

17. Web Server CGIBrowser Table HTML

18. PACS / RIS / Workstation PACS Image Server HIS / RIS / NMIS Database Workstation User Interface

19. Communication Between Systems: A Case Study Workstations only connect to Radiology maxiPACS Radiology maxiPACS includes some RIS work flow functions Order entry (HL7) -> image data (DICOM) -> report (HL7) HIS NMISRIS miniPACSmaxiPACS ADT Reports Order entry Report Images Workstation

20. Communication: The Web The Web provides a very easy method for linking the Nuclear Medicine Information System, PACS, and workstations. This paradigm extends easily to larger departments or to an entire health care enterprise. Use of public domain communication protocols and data formats means that communications can be implemented using mass market systems.

21. Communication How to Choose a Protocol No brainer: Internet World wide web (http:, https:)

22. DICOM PennState College of Medicine, Department of Radiology http://www.xray.hmc.psu.edu/dicom/basicinfo.html

23. Communication How to Choose a Data Format Radiology niche format (Interfile, DICOM) Often within modality Rarely between modalities Almost never outside Radiology General format (jpeg, gif, tiff) Whenever possible

24. Film Disadvantages - overwhelming No cine, windowing No SPECT visualization Single original Loossable Expensive - infrastructure, expertise Advantage - communication View boxes widely available Good quality static picture

25. Multimedia Report Demographics are already captured in RIS Typist enters text using a word processor Demonstration(?) images, cines Selected at report time Stored in PACS URL stored in RIS Report can be e-mailed (MIME format) Report can be accessed using WWW

29. Multimedia Reporting

30. Communication with Physician How to Choose Method(s) Traditional report Mail, fax, e-mail Include a half tone image World wide web (http:, https:) Workstation functions (Java)

31. Security Yes

32. Cable Modem Fast 1.5 Mbits/second download Always available No dialing

33. Cable Modem Tele-Nuclear Medicine

34. Web-based Nuclear Medicine Integrate NMIS and miniPACS Integrate with HIS / RIS and maxiPACS Provide multimedia reports Implement high speed tele nuclear medicine

35. Communication How to Choose a PACS maxiPACS Single vendor Better integration (?) miniPACS Special needs of modality Better bandwidth utilization Redundancy

36. Take Home Points HIS / RIS is just a distributed database Communications: Internet and web General data format when possible Multimedia reporting Web based call