Picture Archiving and Communication Systems (PACS) – A New Paradigm in Healthcare
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Picture Archiving and Communication Systems (PACS) revolutionize healthcare by enabling efficient storage, retrieval, and distribution of medical images. Initially driven by U.S. federal interests, PACS addresses the limitations of film-based systems and improves the operational efficiency of radiology departments. With advancements in technology, PACS is essential for continuity of patient care and integration of patient data across healthcare systems.
Picture Archiving and Communication Systems (PACS) – A New Paradigm in Healthcare
- 1. Picture Archiving and Communication Systems (PACS) – A New Paradigm in Healthcare
- 2. Review Article Information Technology (IT) has driven healthcare delivery to new frontiers. Although radiologists were exposed to digitization way back in early eighties with the invention of Computerized Tomography by Hounsfield, it took quite a while to really reapply the benefits of digitization. In fact digitization in radiology was way ahead of the electronic IT boom but took a long time to be translated into a useful tool to facilitate smooth flow. Roots of digital imaging can be traced to United States federal interests. The federal government in USA under the auspices of the Departments of Defense (DoD) and Veterans' Affairs drove the movement of PACS into clinical care, according to Dr Greg T Mogel, an assistant professor of research radiology at the University of Southern California. This DoD work was done domestically to provide continuity of care for a highly mobile military-dependent population. Internationally, it came in response to the increasing rate of small-scale deployments of forces, as in Haiti and Somalia and the Gulf war. The recent growth in imaging technology, stressed the capacity of film-based systems to meet the increasing needs of radiology departments. Electronic PACS have been developed in an attempt to provide economical storage, rapid retrieval of images, access to images acquired with multiple modalities, and simultaneous access at multiple sites. Input to a PACS may come from digital or analog sources (when the latter have been digitized). A PACS consists primarily of an image acquisition device (an electronic gateway to the system), data management system (a specialized computer system that controls the flow of information on the network), image storage devices as servers (both short and long- term archives), transmission network (which serves local or wide areas), display stations (which include a computer, text monitor, image monitors, and a user interface), and devices to produce hard-copy images if required, (currently, a multiformat or laser camera). The goals of PACS are to improve operational efficiency while maintaining or improving diagnostic ability. What is PACS anyway? The Picture Archiving and Communication Systems have two very critical functions embedded in the system which are archiving, and, communication. It uses networks and computers which store, retrieve, present, and distribute images in a medical environment. This storage helps in safeguarding images and ensures availability for review in future. Traditional analog department is transformed into a highly functional, efficient digital environment. No more lost images, no more degradation of images with time and almost immediate access for viewing even at remote sites. BASIC REQUIREMENTS TO IMPLEMENT A PACSACROSS AN ORGANIZATION Any Secondary or Tertiary Care Hospital invariably has Radio diagnostic facilities. The additional 181 Apollo Medicine, Vol. 7, No. 3, September 2010 PICTURE ARCHIVING AND COMMUNICATION SYSTEMS (PACS) – ANEW PARADIGM IN HEALTHCARE Dinesh Kapoor Senior Consultant, Department of Radiodiagnosis, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India. E-mail:[email protected] Digitization and transfer of images in Radiodiagnosis and Imaging dates back to to early 70s with the advent of Computerized Tomography Scanning, and, subsequently sending these images to cameras and printers hooked on to the machines through a local "network". Rapid advancements in Information Technology (IT) as well as in the imaging technology have facilitated the healthcare organizations across the world to manage patients' images, records and other data more efficiently. Today, capturing images, archiving and retrieval have already reached great heights, and, further refinements are in progress. The infrastructural requirements for such a venture have to be very finely and judiciously planned well in advance with a view to go filmless as the ultimate objective. Involvement of all concerned and connected agencies is a must e.g. IT, Radiologists, Clinicians and the Vendors. Key words: PACS, Digital Imaging Communication (DICOM), Filmless, LocalArea Network (LAN), Radiology department.
- 3. Apollo Medicine, Vol. 7, No. 3, September 2010 182 Review Article requirements for setting up PACS would be: (i) Equipments must be DICOM compliant. (ii) Some of non-compliant equipments could/may still be used with addition of DICOM software on CDs. (iii) DICOM is the industry standard messaging format for digital imaging-it was established by NEMA (National Electrical Manufacturers Association) and is routinely reviewed and updated. (iv) DICOM files can be recognized by the extension “.dcm”. (v) Connecting the PACS to RIS, HIS, EHR, and/or EMR can be accomplished through HL7 interfacing. • A PACS server will receive studies from equipments, store them, allow queries or retrieval, archive, and, allow automated routing • DICOM workstations will be required for use by the Radiologists for viewing, processing, analyzing, and reporting the studies • A good quality network to connect equipments, PACS server and DICOM workstations. Multiple vendors may be involved but they must have the capability of seamless interfacing to avoid any cracks. • Storage and backup infrastructure for reliable storage of the studies carried out. • Disaster recovery server preferably at a remote location with adequate redundancy. A qualified vendor support on site well before the PACS system live date must be insisted upon. And also plan on reduced elective patient load during initial system live period. A training team must be identified and trained expertly prior to general staff training. Super users/ trainers should be given reduced clinical responsibilities to allow them adequate time to learn and master the new systems. Training sessions should be well structured and available to all staff and potential users. If there will be remote users, training needs to be planned and performed for them as well. Unless the PACS is being installed in a brand-new facility, there is going to be a repository of old images. Physicians will want to see these images for comparison studies. The decision then becomes how to manage the repository images. The most common situation is to have a library full of film. Some vendors provide film digitizers to make a digital image of the film, which then gets stored in the PACS. Typical system workflow The equipments in the department viz CT, MRI, Conventional Radiology, Mammography, Fluoroscopy, Ultrasound Nuclear Medicine, DSA, and Cath Labs are used to acquire images. Images are sent to PACS via modalities from the RIS system which connects all the radiology equipment. • Images received are processed using raw data information to create image data-base. • Images are stored in archive device(s). These must be of a capacity to be able to store images over a very long period of time preferably upto 5yrs or so, as images and medical records must be stored legally for that duration. • Images are routed to requested devices to include historical info like clinical details and patient demographics, if requested. • Time limits apply compression and move images between different local CACHE (memory), short term storage, and long term storage. • Modalities and conversion systems must configure PACS as a destination using the correct AE title (Application Entity), IP address (Internet Protocol), and TCP Port (Transmission Control Protocol). In a non-technical sense, you can think of an AE title as a building, the IP address as the address of a specific business in the building, and the TCP ports are individual offices within that business. • Eventually images are viewed at the viewing workstations or at the remote client Desktops. The viewing workstation is where users can query for, select, and call up images for display, mark-up, interpretation, reference, post processing and measurements Etc. It is recommended that the diagnostic workstations are equipped with diagnostic grade display systems e.g. typically a mammogram would best be viewed at 5mega pixels to avoid any misses. A very critical aspect to consider is, redundancy. At least two or three copies of the images must be stored in compartments or remote servers. Redundancy is a must for digital imaging as a system down effectively equals care delivery disruption. All systems related to digital imaging should be configured with redundancy in mind for archive integrity as well. Once the systems are in place and “Go
- 4. Review Article 183 Apollo Medicine, Vol. 7, No. 3, September 2010 live” gets closer, testing should be well underway for any interfacing between systems… required messaging between systems should be proven operational before live date as otherwise it turns into a very painful experience. PACS technology has been changing quite rapidly. Initially it was newer and more sophisticated equipment, like good quality CT, MRI, PET/CT etc. These have already allowed clinicians to diagnose with much better accuracy. In future we anticipate that with more development in algorithms and computing power, computer assisted diagnosis based storage and backup infrastructure for reliably storing the studies will further make life easy for all clinicians. Traditionally, film served many purposes in the organization of the conventional radiology department. The "filmless" environment is now made possible by PACS, has replaced traditional delivery mechanisms with electronic ones which include features like auto routing, perfecting, and manual-retrieval. The image records could be made available on CDs/DVDs. The selection of the CD writer device must also be carefully evaluated and designed so as to be able to take on the workload. Different sizes and configurations are available. Time taken to burn CDs must be estimated and accordingly clients must be given the collection times for reports. There are a few people, or groups of them, who play key roles in achieving successful PACS facility installation - the radiology manager, the IT manager, the PACS administrator and the Radiologists. They must be involved in the selection and implementation process for the PACS as early as possible and their inputs given due credence. Circum-venting any of these persons could create possibilities of resistance, dissatisfaction and failure. Each party may have their own priorities, such as: Will the PACS save or cost money? Will it add to my workload? Will it help improve work quality and efficiency? While it may not be possible to satisfy everyone completely, the effort spent to involve these key players upfront in the decision-making process can increase the likelihood of success. It is observed that more and more physicians and even patients have started preferring the PACS systems to hard copies. Turnaround time for modalities connected with PACS is much faster in comparison to traditional films. Further there is no easy way to keep hard copies of 64-slice CT, PET/CT, 4D/5D etc and keeping them digitally remains the only viable option. The future is the use and integration of CPOE (Computerized Physician Order Entry) to further enhance healthcare delivery systems. The response for PACS in India? Quite good! In fact, the market is getting very exciting. Most of the top league hospitals are already using PACS while most other progressive hospitals are exploring PACS. Earlier signi- ficant high cost of ownership, due to high license fee and hardware & storage costs were deterrents. However the
- 5. Apollo Medicine, Vol. 7, No. 3, September 2010 184 Review Article spiraling prices of hardware & storage, combined with reasonably priced solutions from some of the vendors has removed that barrier. Today, hospitals of any size can acquire highest quality PACS server and specialist workstation at a price affordable to them. In conclusion, PACS is the way to go considering trends in healthcare progress in our scenario. Various IT applications that a hospital uses can be categorized as PAS (Patient Administration System), CAS (Clinical Administration System), EMR (Electronic Medial Records) and ERP (Enterprise Resource Planning). In order to get complete view of a patient's EMR, integration of complete radiological studies is needed, and, this is maintained in PACS. This makes PACS an essential part of continuity of patient care and significantly contributes towards the best practices in patient management. BIBLIOGRAPHY 1. Lee F Rogers: PACS Radiology in the digital world; AJR Sep 2001. 2. Paul J Chang: Challenges and opportunities for Radiology in the next millennium; Radiographics 2001, July-August 1013-1014. 3. Imaging Business Journal PACS in India.
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