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Implementation of a web-based PACS: the users’ point of view

Hans Schneider
Senior Physician
Department of Diagnostic and Interventional Radiology
Sozialstiftung Bamberg

At the beginning of 2000 a new health information system/­radiological ­information system (HIS/RIS) was installed at Bamberg Hospital, Germany, to which the future web-based picture ­archiving and communication system (PACS) was to be integrated. The radiology workflow at the time was suitable for an RIS-­centric design because the worklist and the digital reporting system were integrated in that system. Planning began early 2003. Some radiologists who had had experiences with different PACS suggested ideas for PACS design which were suitable for the required workflow. After the decision to use MedServ Neumann and Partner as a ­medical consultant to manage the ­technical and legal requirements, a PACS workgroup was established. This group, consisting of clinical ­doctors, radiologists and IT specialists, would make the final decision on a suitable system. As radiologists, we saw the importance of involving clinicians, so that they could manage their daily workload as well as familiarise themselves with the new system.

At that time the following modalities were installed in the radiology department: one MRI 1-Tesla; a digital substraction angiography unit; two fluoroscopy units; one ultrasound; three ­conventional X-ray units and a multislice computed ­tomography scanner (16-slice MSCT); two older fluoro‑scopy units (one in the urology department of urology and another one at a second site [the former Nervenklinik Bamberg], which treated neurological and psychiatric patients). An older CT scan, a fluoroscopy unit and an X-ray unit were also to be added. Conventional units (daylight systems) would be converted to a computed radiography (CR) system. The decision to use the Fujifilm fully computed radiography (FCR) system was made in the spring of 2003. In the ­radiology department, the two fluoroscopy units and the angiography system, as well as the ­urology systems, were too old to be changed to a primary digital system, so it was decided to use a ­secondary digitalisation unit by Merge Healthcare. The ultrasound was also dated, so it was decided to postpone digitalisation until the arrival of a new unit. MRI and MSCT (Philips Medical Systems) were already digital. At the second hospital site, after implementation of the same FCR system, we cancelled the fluoro‑scopy unit; the CT connection (Picker) did not cause any problem. Due to the ­specialised data required for psychiatric patients, we planned separate data storage for these.

Radiology workflow
We requested a workstation for each of the 10 physicians in the radiology department. These workstations would be connected to the already installed RIS system to avoid additional changes in the well-established workflow. Within the ­radiology department, our aim was to get a PACS with 3D power or a 3D program on every workstation to relieve the CT workstation. A newly installed demonstration unit with two beams gave us a better chance of ­displaying the work of the radiology department. For plain films sent by external doctors, a scanner ­station was installed. A burning ­station for CDs and a dry printer for the r­emaining ­hospitals and doctors who still demand plain films outside of our hospital was planned. Two ­workstations, a demonstration unit with one beam, a scan/burning­ unit and a dry printer were to be installed at the second hospital.

Data storage
For conventional units with X-ray and MRI, we already knew the number of procedures required and could estimate the expected data volume. Our problem was the data storage needed for the new MSCT. Until recently, there were no legal guidelines as to which parts of an MSCT investigation had to be archived. We decided to archive all the 1.5 or 0.75 mm slices – with about 600–800 for a “routine” scan, ­meaning that reconstruction is possible for every ­investigation, even after a few years. The ­problem then was net traffic, archiving storage and retrieving­ pictures.

We appointed six PACS manufactors to ­evaluate their solutions. Hospital visits were made by the PACS workgroup in the summer of 2003 at four different hospitals in Germany and other European countries.In the end, Fujifilm Medical Systems’ Synapse PACS was chosen. The selection of Synapse was made by clinicians, radiologists and the IT group. As a tool for 3D analysis, Voxar 3D(®) (Barco) was integrated to ­radiology ­workstations.

In autumn 2003, Fujifilm Europe GmbH and their local installation manager started to ­cooperate with the manufacturers of the ­different modalities required for the workflow, to combine them with Synapse. A fully installed test server was used to verify whether the now combined modalities were working. The CR systems, MRI and MSCT were first implemented with the RIS by HL7 and DICOM Standard to Synapse, followed by the older units (DSA [digital substraction angiography] and fluoroscopy), using MERGE. In January 2004, the first workstations were installed and training started for radiologists. Until that point, every picture was printed as hard copy. In March 2004, demonstration started together with the web delivery system and ­training of doctors. On 4 May 2004, paper printing was stopped. By this time all doctors had been ­training for a month. From the beginning of the implementation of the HIS/RIS in 2000, there were at least two computers on each ward, as well as in the ICU and the operating ­theatres. Through the use of the web-based Synapse system, all image data are now available on every PC ­connected to the intranet system. Monitor quality has been rated as sufficient.

Advantages of the web-based Synapse system
During the installation of the system (less than six months) there was no disturbance of the workflow in the radiology department. The test server used for planning installations was copied to the real server. Radiologists became used to the system very quickly, without changes in the former RIS-centric workflow. Using already installed PCs in the periphery led to a very fast rollout of the system. Synapse’s logical compression algorithms resulted in lower intranet traffic; thus, retrieval is not necessary, as large data volumes for MSCT (more than 1,500 pictures) are not a problem to handle simultaneously in daily work.

Self-explanatory PACS tools are the same in the radiology department and in peripheral PCs, with some special tools available for daily use in the radiology department (shortcuts and tools on the mouse). This has lead to a hospital-wide ­acceptance of the system by doctors and the IT unit.

Synapse offers easy-to-use administration tools to define users, their roles and folders. For example, the demo folders are updated automatically. We also integrated external doctors into the system (with restricted access), so that they could look at their work.

The ­possibility to combine Synapse with other tools – in our case Voxar 3D – is a great advantage to multiply multiplanar reformation (MPR), maximum intensity projection (MIP) and 3D work. The ­system’s flexibility to cope with ­changing modalities and data handling is also very advantageous. A new digital X-ray unit and a new ultrasound modality were integrated without any problem.

Patient data storage had to be changed after the neurology department was moved to the main hospital, and patient data storage moved to one store. Peripheral net solution was changed from terminal PCs to a Citrix(®) farm ­solution ­without any problem of data distribution.

A workflow of RIS-based reporting and ­documentation system was rapidly adapted to the PACS in the department. From the RIS worklist it is possible to handle the reporting­ system and picture display at the press of a button. A PACS-centric workflow would also be possible.

Long-term archiving 
This was made possible with a DVD player, with which the only ­problem encountered in three years of use was caused by hardware failure. The newer systems should be based on a big redundant array of independent disks unit or storage area network unit to minimise mechanical problems. Workstations should be installed in sufficient numbers for all the doctors in the radiology department. An additional 3D program, Voxar 3D, helps to do work outside the dedicated 3D workstation on the modalities in a fast and highly effective way.

Patient data archiving 
Make an early decision about the archiving of patient data. After a large department was moved to the main hospital, the formerly separated cases of the psychiatric and ­neurological patients had to be combined with other patient ­history. In our experience, the volume of CT investigation and picture counts doubled compared with estimates.

Monitor quality 
This is also important outside the radiology department, and some monitors in the surgery, ambulance and paediatric units had to be upgraded to a higher-quality monitor solution.

IT support  
This is essential in a digitalised hopital­ environment. With the installation of HIS/RIS/PACS units, a digital reporting system in several departments and big-net solutions, there is a need for 24-hour service from the IT department, especially in the ­radiology department, where a member of staff who is ­familiar with all the workstations, additional tools and modalities should always be present.