KEYWORDS: Ultrasonography, Picture Archiving and Communication System, Doppler effect, Radiology, Diagnostics, Data storage, Surgery, 3D image processing, Color imaging, Databases
The purpose of this study was to determine if the size of ultrasound examinations was increasing over time.
The primary reasons for this are believed to be an increased number of images per study, the incorporation of "cine
loops", and increased use of color flow Doppler. The result of this study, if it supports the hypothesis that ultrasound
study size is increasing, would be directly applicable to planning for future expansion of storage in the Ultrasound
PACS. Data were obtained from the ultrasound PACS server for number of studies, number of images, and total
stored volume for sampled months (January and July of 2003 - 2006). The investigators believed that these months
would provide a reasonable sample of study size as examination types did not vary significantly from month to month
(based on Departmental statistics). The Radiology Department's information system (RIS) was used to determine total
yearly ultrasound examination volume to determine the trend over time. Because no protected health information (PHI)
was to be used in this study, the investigators believed that no IRB approval was necessary. The number of studies done per month was more variable than the investigators had believed. One month in
particular (July, 2003) had an anomalously large number of studies. However, despite this, computations of the number
of images per study, the total data volume per study, and the average amount of data per image did show an increasing
trend as expected. Also, the total volume of data stored showed an increasing trend over the study time period. The
investigators' hypothesis that examination size is increasing has been demonstrated to be true for the months sampled. From Departmental data, the investigators know that the most recent ultrasound yearly volume
increased approximately ten percent over the previous year, and that trend was also seen for the study period (from 7-10
percent per year increase in volume). With the information that the examination size is also increasing, the Department
can make better plans for future expansion of the Ultrasound PACS storage system. Ultrasound examination size is increasing, largely because of the increased use of cine loops. A change to
using more of these to replace single static images will further increase examination size.
In the process of installing picture archiving and communications (PACS) and speech recognition equipment, upgrading it, and working with previously stored digital image information, the authors encountered a number of problems. Examination of these difficulties illustrated the complex nature of our existing systems and how difficult it is, in many cases, to predict the behavior of these systems. This was found to be true even for our relatively small number of interconnected systems. The purpose of this paper is to illustrate some of the principles of understanding complex system interaction through examples from our experience. The work for this paper grew out of a number of studies we had carried out on our PACS over several years. The complex nature of our systems was evaluated through comparison of our operations with known examples of systems in other industries. Three scenarios: a network failure, a system software upgrade, and attempting to read media from an old archive showed that the major systems used in the radiology departments of many healthcare facilities (HIS, RIS, PACS, and speed recognition) are likely to interact in complex and often unpredictable ways. These interactions may be very difficult or impossible to predict, so that some plans should be made to overcome the negative aspects of the problems that result. Failures and problems, often unpredictable ones, are a likely side effect of having multiple information handling and processing systems interconnected and interoperating. Planning to avoid, or at least not be so vulnerable, to such difficulties is an important aspect of systems planning.
KEYWORDS: Picture Archiving and Communication System, Radiology, Speech recognition, Software development, Time metrology, Information fusion, Imaging systems, System integration, Medical imaging, Surgery
The purpose of this study was to determine if the interval between an examination being ordered by an Emergency Department physician and his or her review of the report and images could be shortened by notifying the physician that the results were available. Though some time shortening was shown, it was not clearly attributable to the notification process.
KEYWORDS: Picture Archiving and Communication System, Radiology, Chromium, Radiography, Emergency medicine, Surgery, Information assurance, Computing systems, Medical imaging, Nickel
A study of timings of different events from the scheduling of an Emergency Department (ED) examination to the final reporting of it and review by the ED physician showed some expected and unexpected findings. Both computed radiography (CR) on film and CR using PACS were studied. The move of daytime reading of ED radiographs out of the Radiology reading area in the ED to a reading room in Radiology lengthened the time from when the request was sent to the time when the images were reviewed by the ED physician (1.02 hours to 1.29 hours). Despite anecdotal reports of increased reading time at workstations, the radiologists' use of PACS for reading ED radiographs resulted in a slight improvement in the time between the examination completion and report dictation (0.43 hours to 0.3 hours). Recently, we have found that there may be a workload effect on this time and this is presently being analyzed. The time from the sending of the request for an examination to the first review of the images by the ED physician was shortened with implementation of a PACS workstation in the clinical area of the ED (1.35 hours to 0.92 hours). A surprising finding was the impact the change to PACS had on the time between sending the request and the technologist's completion of the requested examination. The time increased with PACS from 0.45 hours for film-based CR to 0.8 hours for PACS. Several studies are ongoing to determine the causes of this increase.
KEYWORDS: Picture Archiving and Communication System, Radiology, Image processing, Surgery, Diagnostics, Ultrasonography, Chromium, Printing, Radiography, Medical research
The purpose of this paper is to examine the effects of PACS installation on the tasks related to the performance and interpretation of diagnostic radiological examinations.
KEYWORDS: Picture Archiving and Communication System, Radiology, Chromium, Chest, Analog electronics, Data conversion, Telecommunications, Image processing, Medical imaging, Image quality
To evaluate the changes in workflow, in the radiology department, after switching from a film-based image management system to a picture archival and communication system.
Steven Horii, George Grevera, Eric Feingold, Harold Kundel, Reuben Mezrich, Calvin Nodine, Curtis Langlotz, Regina Redfern, Jill Muck, Megan Phelan, Steven Scoleri
The purpose of this work was to develop a set of controls for image navigation and manipulation for use at a workstation. The intended focus was to provide a set of controls that would be most useful for the task of reading plain radiographs, such as those from chest, abdominal, and musculoskeletal imaging. We thought that most workstation controls were better suited to the interpretation of cross sectional imaging rather than plain radiography, and from current reports on user ergonomics and our own experience, developed a prototype control set. A goal of this design was to create controls that could be operated without the need to display menus on the workstation or select items from them. The control set was also designed to be operable without having to do visual searches for the controls or observe the controls while they were being used.
KEYWORDS: Radiology, Picture Archiving and Communication System, Image processing, Telecommunications, Chromium, Medical imaging, Imaging systems, System integration, Image quality
To evaluate a conventional radiology image management system, by investigating information accuracy, and information delivery. To discuss the customization of a picture archival and communication system (PACS), integrated radiology information system (RIS) and hospital information system (HIS) to a high volume emergency department (ED). Materials and Methods: Two data collection periods were completed. After the first data collection period, a change in work rules was implemented to improve the quality of data in the image headers. Data from the RIS, the ED information system, and the HIS as well as observed time motion data were collected for patients admitted to the ED. Data accuracy, patient waiting times, and radiology exam information delivery were compared. Results: The percentage of examinations scheduled in the RIS by the technologists increased from 0% (0 of 213) during the first period to 14% (44 of 317) during the second (p less than 0.001). The percentage of images missing identification numbers decreased from 36% (98 of 272) during the first data collection period to 10% (56 of 562) during the second period (p less than 0.001). Conclusions: Radiologic services in a high-volume ED, requiring rapid service, present important challenges to a PACS system. Strategies can be implemented to improve accuracy and completeness of the data in PACS image headers in such an environment.
KEYWORDS: Picture Archiving and Communication System, Radiology, Chromium, Analog electronics, Digital imaging, Chest, Diagnostics, Video, Telecommunications
Investigate the availability and use of radiographic reports both with and without a PACS workstation and investigate physician's opinions on using a workstation. The availability and use of radiographic reports and related patient care were evaluate in a randomized prospective study. Data from a 20 week period of collection, when images were displayed on multiviewers was compared to a 16 week period of data collection, when images were available on an image workstation in the clinical area. Patient care was evaluated by comparing clinical actions. A survey was distributed to the clinical staff to clinical area. Patient care was evaluated by comparing clinical actions. A survey was distributed to the clinical staff to determine their opinion of the image workstation. During periods without the workstation the clinical staff obtained reports o n 90 percent of the exams. During the PACS periods reports were obtained on 51 percent of exams. Sixty four percent of the surveyed clinicians reported a low to moderate level of confidence in interpreting images on the workstation. The percentage of image based clinical actions taken without radiology input increased from 12 percent during periods without the workstation to 74 percent during PACS. A PACS workstation in the clinical area decreases consultation if not supported with timely radiographic reports and may not benefit patient care.
KEYWORDS: Picture Archiving and Communication System, Radiology, Medical imaging, Manufacturing, Control systems, System integration, Human-machine interfaces, Diagnostics, Computing systems, Image processing
The technology for building workstations suitable for the display of most medical images has existed for almost a decade. Yet the diagnostic interpretation process has not shifted form film to such workstations in early as large numbers as had been predicted. While, in a large part, this is due to the high costs for acquisition of picture archiving and communications system equipment, there is also the aspect of physician acceptance. Since the workstation serves as the primary system-to-person interface, an examination of the way in which workstations are designed and the way in which radiologists actually work yields some insight into the relative lack of penetration of workstations into the diagnostic image interpretation task.
KEYWORDS: Picture Archiving and Communication System, Radiology, Chest, Chest imaging, Medical imaging, Analog electronics, Chromium, Phase modulation, Video surveillance, Epitaxial lateral overgrowth
In order to determine the effect of an image workstation, viewing patterns and related clinical actions were evaluated in a randomized prospective study. During 16 weeks of Computed Radiography data collection, an image workstation was conveniently available to the Medical Intensive Care Unit clinicians. The workstation was not available for clinical use during 16 weeks of Analog Film data collection. Viewing patterns were evaluated by comparing viewing times. Patient care was evaluated by comparing the time of performing image based clinical actions. The percentage of routine exams viewed before AM Radiology Conference increased from 0% during the Analog Periods to 27% during the CR PACS Periods. Clinicians selected images taken during the first few days of the patient's admission for viewing before conference. Images taken later in admission were viewed during or after conference. On days when radiology conference was not held, images were viewed significantly earlier when the workstation was available. Clinical actions based on images viewed on the workstation were performed significantly earlier. When an image workstation was available routine images were viewed sooner and image based actions occurred earlier.
KEYWORDS: Radiology, Picture Archiving and Communication System, Phase modulation, Surgery, Computed tomography, Magnetic resonance imaging, Neuroimaging, Brain, Spine, Video
Two hundred examinations were tracked through the neuroradiology reading room. The median time from completing the exam to starting the interpretation was 1.6 hours for 76% and 18 hours for 24% of the cases. The delay occurred because exams done after 4:00 PM were held for the next day along with exams for which relevant prior studies were unavailable. The median times required for previewing, interpreting and consulting on a case were 7, 8 and 5 minutes respectively.
KEYWORDS: Picture Archiving and Communication System, Radiology, Chromium, Diagnostics, Chest, Databases, Data analysis, Analytical research, Chronology, Data modeling
Our purpose was to determine the economic effects associated with the introduction of PACS and computed radiology (CR) in a medical intensive care unit (MICU). Clinical and financial data were collected over a period of 6 months, both before and after the introduction of PACS/CR in our medical intensive care unit. Administrative claims data resulting from the MICU stay of each patient enrolled in our study were transferred online to our research database from the administrative databases of our hospital and its affiliated clinical practices. These data included all charge entries, sociodemographic data, admissions/discharge/transfer chronologies, ICD9 diagnostic and procedure codes, and diagnostic related groups. APACHE III scores and other case mix adjusters were computed from the diagnostic codes, and from the contemporaneous medical record. Departmental charge to cost ratios and the Medicare Resource-Based Relative Value Scale fee schedule were used to estimate costs from hospital and professional charges. Data were analyzed using both the patient and the exam as the unit of analysis. Univariate analyses by patient show that patients enrolled during the PACS periods were similar to those enrolled during the Film periods in age, sex, APACHE III score, and other measures of case mix. No significant differences in unadjusted median length of stay between the two Film and two PACS periods were detected. Likewise, no significant differences in unadjusted total hospital and professional costs were found between the Film and PACS periods. In our univariate analyses by exam, we focused on the subgroup of exams that had triggered primary clinical actions in any period. Those action-triggering exams were divided into two groups according to whether the referring clinician elected to obtain imaging results from the workstation or from the usual channels. Patients whose imaging results were obtain from the workstation had significantly lower professional costs in the 7 days following the action-triggering exam compared with patients whose exam information was obtained through the usual channels. No significant differences in patient age or APACHE score were noted between these two groups. Our preliminary results show possible evidence of a reduction in unadjusted cost of care for the subgroup of patients whose action-triggering exams were first encountered on the PACS workstation. Whether these results represent clinicians' differential workstation utilization patterns or true effects of PACS/CR will be determined by further data analysis, including case mix adjustment, subgroup analysis, and multivariate modeling.
KEYWORDS: Chromium, Control systems, Radiography, Chest, Picture Archiving and Communication System, Zoom lenses, Diagnostics, Radiology, Medical imaging, Sun
In previous studies of workstation usage by physicians in the Medical Intensive Care Unit (MICU) of the University of Pennsylvania Medical Center, we have compared which image manipulation functions were used when viewing digitized film and phosphor plate (CR) images. We had found some differences in the use of such features, particularly a decrease in the use of brightness and contrast adjustment, for CR images. We had predicted this because of the improved uniformity of CR images compared to conventional film [Horii 95]. We were interested in how radiologists viewing similar CR images would differ (if at all) from their MICU physician colleagues. We found that the radiologists used the brightness and contrast adjustments to a greater degree than the MICU physicians when viewing CR images from MICU patients. Use of other image manipulation functions by the radiologists was considerably lower; in this first series of readings, zoom, invert grayscale, and high-resolution display controls were not used at all.
Harold Kundel, Sridhar Seshadri, Curtis Langlotz, Paul Lanken, Steven Horii, Marcia Polansky, Sheel Kishore, Eric Finegold, Inna Brikman, Mary Bozzo, Regina Redfern
KEYWORDS: Radiology, Chest imaging, Picture Archiving and Communication System, Radiography, Image transmission, Chromium, Medical imaging, Digital imaging, Image processing
The purpose of this study was to compare the efficiency of image delivery, the effectiveness of image information transfer, and the timeliness of clinical actions in a medical intensive care unit (MICU) using either conventional screen-film imaging (SF-HC), computed radiography (CR-HC) or a CR based PACS. When the CR based PACS was in use, images could be viewed in the MICU on digital workstation (CR-WS) or in the radiology department as laser printed hard copy (CR-HC). Data were collected by daily interviews with the house-staff, by monitoring computer log-ons and other time stamped activities, and by observing film viewing times in the radiology department with surveillance cameras. The time at which image information was made available to the MICU physicians was decreased during the CR-PACS period as compared with either the SF-HC periods or the CR-HC periods but the image information was not accessed more quickly by the clinical staff. However, the time required to perform image related clinical actions for pulmonary and pleural problems was decreased when images were viewed on the workstation.
Image sources for the medical intensive care unit workstation used to view portable chest radiographs include both digitized screen-film images and phosphor plate images. This study compares usage of image manipulation functions when physicians view the images from different sources on the workstation. The authors hypothesize that the improved image-to- image uniformity afforded by phosphor plate radiography reduces the use of some of these functions; in particular, the controls for image brightness and contrast. The automated workstation logs and analysis of the results from digitized film-based and phosphor plate-based study periods show that this hypothesis is supported. Overall, use of all image manipulation functions decreased, but use of brightness/contrast showed the largest decrease, from 24.5% for digitized film to 7.6% for phosphor plate imaging. The overall workstation usage increased for the phosphor plate period, supporting the idea that this decrease in function usage was not the result of overall decrease in workstation use. This paper further describes the comparison of the workstation usage during these two study periods.
KEYWORDS: Picture Archiving and Communication System, Chromium, Radiology, Chest, Data modeling, Imaging systems, Optical discs, Instrument modeling, Systems modeling, Surgery
Our purpose is to determine the incremental costs (or savings) due to the introduction of picture archiving and communication systems (PACS) and computed radiology (CR) in a medical intensive care unit (MICU). Our economic analysis consists of three measurement methods. The first method is an assessment of the direct costs to the radiology department, implemented in a spreadsheet model. The second method consists of a series of brief observational studies to measure potential changes in personnel costs that might not be reflected in administrative claims. The third method (results not reported here) is a multivariate modeling technique which estimates the independent effect of PACS/CR on the cost of care (estimated from administrative claims data), while controlling for clinical case- mix variables. Our direct cost model shows no cost savings to the radiology department after the introduction of PACS in the medical intensive care unit. Savings in film supplies and film library personnel are offset by increases in capital equipment costs and PACS operation personnel. The results of observational studies to date demonstrate significant savings in clinician film-search time, but no significant change in technologist time or lost films. Our model suggests that direct radiology costs will increase after the limited introduction of PACS/CR in the MICU. Our observational studies show a small but significant effect on clinician film search time by the introduction of PACS/CR in the MICU, but no significant effect on other variables. The projected costs of a hospital-wide PACS are currently under study.
Harold Kundel, Sridhar Seshadri, Peter Shile, Marcia Polansky, Curtis Langlotz, Paul Lanken, Steven Horii, Robert Grossman, Janine Purcell, Sheel Kishore, Inna Brikman, Mary Bozzo, Regina Redfern
KEYWORDS: Picture Archiving and Communication System, Lithium, Telecommunications, Radiology, Radiography, Data communications, Chromium, Chest imaging, System integration, Chest
Preliminary data is presented from a prospective study of a Picture Archiving and Communication System (PACS) in a Medical Intensive Care Unit (MICU). These data compare the efficiency of image information communication and utilization when the MICU operates in a conventional manner using standard x-ray film as an image acquisition, storage and display medium and a digital manner when images are acquired by Computed Radiography (CR), transmitted and displayed digitally. The CR images were made available for viewing more quickly than conventional film images due to the increased automation provided by the management system of the PACS. Despite the improvement of the availability of images, the time required for the MICU physicians to utilize the image information did not change.
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