An Overview of Workflow with RIS/PACS Dr Mark Macentee Mr Ali B Alhailiy

Digital Radiology • The application of modern information technology to the practice of radiology • Depends on automated systems for acquiring, transmitting, storing, and displaying digital images and associated data

Picture Archiving and Communication System (PACS) • A system capable of acquiring, transmitting, storing, retrieving, and displaying digital images and relevant patient data from various imaging sources, and capable of communicating the information over a network • Depends on interfaces to other medical information systems, such as the Radiology Information System (RIS)

Digital Imaging and Communications in Medicine (DICOM) An international standard (ISO) describing how radiology images are identified and formatted and how imaging devices communicate with each other • Jointly developed by the American College of Radiology and the National Electronic Manufacturers Association • Based on the ISO Open Standards Intercommunications (OSI) model • http://www.dclunie.com/

Hospital Information System (HIS) A system used to store and retrieve patient information. • An integrated computer system that may include or be linked to a radiology information system (RIS)

Four Major PACS Components 1- Acquisition 2- Network CT ,MRI,X RAY RIS 4- Display 3- Archive LCD IMAGE DATABASE

Examples of errors within and between PACS components 3• Archive errors –– Storage failure – Sequestered exams 4• Display errors – Associated data not displayed – Artificial shutters 1• Acquisition errors – Improper technique selection – Wrong exam performed – Image deleted 2• Network errors – Image lost – Image corrupted – Unable to transmit

Acquisition: Improper Technique Selection • Digital detectors are more tolerant of over-exposure than conventional detectors • Excess digital signal is scaled to provide consistent appearance • Consequence: is unnecessary radiation exposure to patient

Acquisition: Wrong exam performed • Radiographer may image thorax using digital examination intended for abdomen • Digital signal is rendered inappropriately for review Consequence: may be repeated examination and unnecessary radiation exposure to patient

Acquisition: Image deleted • Radiographer may delete image at acquisition station without transmitting to PACS • It may not be possible to restore deleted image • Consequence: may be repeated examination and unnecessary radiation exposure to patient

Network: Image corrupted • Interruption in network service may degrade image • It may not be possible to retransmit image from acquisition station • Consequence: may be repeated examination and unnecessary radiation exposure to patient

Network: unable to transmit • Interruption in network services prevents transmission of images from acquisition station • Local storage capacity of acquisition station is limited • If acquisition continues, images can be lost, causing repeated examinations and unnecessary radiation exposure to patients

Archive: storage failure • Storage failure can prevent images from being archived • If images have already been deleted from acquisition station, may require repeated examinations and unnecessary radiation exposure to patients

Archive: images sequestered • When demographic and examination information on images does not match information from RIS, images may be hidden from view •radiographer may repeat examination with unnecessary radiation exposure to patients

Display: associated data not displayed • Data accompanying the image may not be displayed for the radiologist • If missing data includes information on the radiographic technique or patient exposure, the radiologist cannot oversee radiographer practice • Without radiologist oversight, radiographers may perform examinations with unnecessary radiation exposure to patients

Sources of Errors in PACS • Mistakes in configuration of PACS • Improper calibration of PACS devices • Discrepancies between PACS and hospital processes • Inherent limitations of human operators • Inadequate training and documentation of PACS and hospital processes

• Electronic devices and media are im-permanent records: the consequence of loss is greater than one film or one film jacket. • A single bad electronic image can be proliferated: a single bad film image can be controlled. • Bad electronic images can disappear without a trace: bad films disappear, but leave a signature. How many

The best maintenance is preventive maintenance. • Calibrations need to be performed on-schedule. • Operators need to clean, inspect, and document. Start-of-shift routines or checklists are helpful. • Schedule PM to occur at convenience of clinical operation. • Software upgrades are major service events that demand reverification

Conclusions • Unfortunately, errors will always occur in PACS. • Some of these errors cause unnecessary radiation dose to patients • QC is the key to detecting errors. • Training is key to averting errors. • Reliability engineering is key to continuity of clinical operations. • Disaster recovery is key to restoring normal clinical • Optimisation includes all of the above.