Information Management in Radiology Filmless Radiology Information Management in Radiology

Filmless Radiology Filmless radiology refers to a hospital or network-wide environment in which film has either completely or mostly been replaced by an electronic system that acquires, archives, and communicates and displays images.

Filmless Radiology Two major benefits: Improves accessibility, integration, and efficiency of images incorporated into the patient's electronic medical record and; The creation of new techniques to take advantage of the recent developments in image acquisition, display, and image processing.

Realized Clinical Advantages Better image management with fewer lost and unread studies Use of computer enhancement to produce consistently higher quality images Ability to provide real-time image interpretation Greater image accessibility

PACS Picture Archival Communication System (PACS) a computer system that is used to capture, store, distribute, and then display medical images. PACS technology can be utilized to achieve near filmless operation.

Subsystems of PACS Archival Storage Network Display Workstation CR Short Term Storage Long Term Storage MR CT Archival Storage US DF PET W/S W/S Network Display Workstation Image Acquisition

Image Acquisition and PACS Image acquisition devices must be able to send images to the PACS rapidly to minimize radiologist and clinical waiting times. For routine images- preferably less than 30 seconds.

PACS Interfaces Three types of interfaces or gateways (communication highways) are required for the successful operation of a large scale PACS: PACS interface: permits transfer of medical images to and from the acquisition devices (CR, CT, etc.) and PACS; (DICOM) HIS/RIS to PACS interface: transfer of patient info to and from PACS; and HIS/RIS to modality interface: permits direct communication between a medical imaging device and the hospital or radiology information system (HL7 communication)

Interfaces The RIS directs information flow of exams from the ordering process, scheduling, and image acquisition through interpretation, communication of results, and billing. RIS can also provide management information such as, exam mixes, volume, and turnaround time. The PACS serves to receive and store images from the modalities and to distribute them to radiologists for primary interpretation and throughout the healthcare enterprise for clinical review.

Radiology’s Communication

PACS Interfaces Reliability of the interfaces is the most important requirement These “gateways” should be fully operational more than 99.5% of the time The modalities must rapidly transfer patient images and accurate patient and study data to PACS, at least 2 megabits per second. Modality interface must comply with DICOM standard

PACS Networks “Highways” to carry images to the PACS from acquisition modalities and from the PACS to workstations, the HIS/RIS gateway, and the image archive. Central architecture Short term storage available at all workstations Potential for system wide failure Distributed architecture Images stored in multiple servers Must know which images go to which servers for display

Centralized Server PACS Long term storage ODJ 5 Home Teleradiology W/S Digitizer PC O C S/HIS W/S Slide maker Web server W/S PC ... Short term storage ISU 256 GBytes PACS/ RIS interface PC W/S ..... PC 137 W/S Dicom Gateway OR PACS Angio MR CT CR Fluoro 3 3 3 7 4 ....... W/S W/S W/S US Gateway Film Printer 30 US PACS

Distributed Server PACS CR CR CR MR MR MR LAN LAN CR Server MR Server Display W/S Display W/S Backbone Network Display W/S Display W/S CT Server DF/Angio Server LAN LAN CT CT CT DF DF Angio

Parallel DB Servers / Long Term Archives / RIS Brokers Hybrid PACS Parallel DB Servers / Long Term Archives / RIS Brokers Web Server MTA 1 MTA 2 MTA 3 MTA 4 AP1 AP2 AP3 AP4 6 CR 4 US 3 MR 3 CT 2 CR 1 CT 3 Fluoro 2 CR 1 US 1 CT NM TFS Server 57 Display Workstations

PACS PACS viewing software can be used to dissect, analyze, magnify, or reformat image data in an infinite number of ways. Virtual private networks (VPN) can transmit whole exams across the globe in seconds for remote consultation. Archives can keep decades of studies online in a cost effective manner and in a more organized and accessible manner than the traditional file room.

PACS Networks PACS network must be able to support dozens or more simultaneous users without a significant degradation of throughput; and Provide a high level of security for authorized users.

MCV PACS Started mid-2001 Hybrid PACS solution

Medical College of Virginia Gateway Complex AD Williams West Hospital Ambulatory Care Center Main Hospital North Hospital Sports Medicine Clinic 3 miles 10 miles 10 miles Stony Point Hospital Chester Sports Medicine

Input Modalities- 2005 5 CT, 4 MRI, 11 CR 6 US, 3 NM, 1 PET 4 Angio, 4 Fluoro 4 C-Arms, 2 Digitizers

In MCV Archive (7/12/05) 803,901 studies on-line 26,560,718 images 195,259 patients

Images/Studies Online 2001 2002 2003 2004 2005 Multi-detector CT (MDCT)

---------------------------- FIREWALL --------------------------- MCV BACKBONE VCU BACKBONE MCV CLINICAL PACS RIS DVD Long Term Archive DVD Jukebox Database Server 1 Off-site DLT Tape Jukebox Database Server 2 Midterm Archive RAID 5: 50 TB Stentor Webserver PC DICOM Router 1 DICOM Router 2 DICOM Router 3 DICOM Router 4 30 Diagnostic W/S PC PC 6 CR 5 US 3 MRI 3 CT 2 CR 1 CT 1 MRI 1 PET 3 Fluoro 1 CT 2 CR 1 US 3 NM 4 Angio 1 Digitizer Tele radiology .... 27 Clinical W/S VPN Software 11/6/2018

PACS Archival Images must be stored (archived) for late viewing Short term storage: available for fast retrieval of newly acquired studies; retention for at least 2- 3 weeks and CR images retrieved within 2 seconds. (RAID- redundant array of inexpensive disks, images stored on hard disk and readily available) Long term storage: required for legal archive, backup, and disaster recovery; retention for 5- 6 years and CR images retrieved within 1 minute. (Storage ranges from tape and optical jukeboxes to storage-area networks)

PACS Image Display Display surface of 14 x 17 and preferably 2.5 K by 2 K resolution One monitor Two monitors Four monitors preferred for increased productivity cost of high resolution and bright monitors a limiting factor

PACS Major Organizational Effects Within Radiology: Improved handling of clinical information, resulting in time savings in the performance and reporting of examinations Net reductions in staffing, through the elimination of film-handling tasks and fewer lost films and reports. Outside Radiology Faster and more accurate diagnoses resulting in reduced time to initiate clinical action Potential reduction in average length of patient stay Potential improvements in overall health outcomes