M. Elon Gale, MD (left) and Daniel Gale, MD

The plan seemed prudent enough. Boston VA Hospital would spend six months collecting images in its newly arrived picture archiving and communications system (PACS) and, during that time, gain familiarity with the operation of the equipment before rolling it out, one area at a time. Implementing in phases, it was thought, would be the least disruptive-and least intimidating-way to convert from a film-based to a filmless radiology environment.

But events did not unfold according to that plan. Indeed, within 48 hours of initial roll-out, the plan was jettisoned. So, instead of a gradual acclimatization, the radiology department ended up converting to PACS all at once.

“The way it was supposed to play out, we were going to start by switching the ICU and one ward over to filmless,” recalls M. Elon Gale, MD, then a staff radiologist but now chief of Radiology Service. “With part of our operations in PACS and the rest not, we found it impossible to know whether images had been read if they were of patients transferred between the ICU and the various sections of the hospital where everything was still film-based. So we decided to abandon our planned phase-in and just switch everything over to PACS in one fell swoop.”

The decision to immediately go with full-blown PACS stunned many staffers. Nonetheless, the choice worked well for the Boston VA.

Particularly remarkable was the fact that the suggestion to damn the torpedoes and proceed full-speed ahead came not from some young, hot-blooded radiologist who was born with a high-tech spoon in his mouth, but, rather, from one of the department’s more senior radiologists who, at the time at least, was not particularly fluent with computers.

“She said let’s just do it and move on, so we did and haven’t looked back since,” says Gale.


The year that all this transpired was 1996. However, the effort to bring PACS to Boston VA had been in the works since 1992-a time when very few institutions anywhere in the United States were giving much thought to such technology. To be sure, some observers express surprise that a VA hospital could have been so far ahead of the curve, given the propensity of government-operated, bureaucratically managed enterprises to move at a slower pace than their private-sector counterparts.

“There’s a misconception about VA hospitals that paints us as being late adopters,” Gale protests. “That is simply not true. VA hospitals in major metropolitan areas-and these are hospitals that typically have affiliations with major universities-have been at the forefront of many technologic innovations. It is not at all uncommon for them to be as much on the cutting edge of technology as anybody else. In fact, I think it is fair to say that the VA hospitals have been an earlier adopter of new technology than has the private sector.”

Few VA hospitals, it seems, have been earlier to adopt innovation than Boston VA.

Test First,?Implement Later

The transition from a film to filmless environment typically proves more traumatic an endeavor than most administrators and radiologists expect, warns M. Elon Gale, MD, chief of radiology service at VA Boston Healthcare System in Boston.

“A hospital that’s not part of our VA system but that I’m nevertheless familiar with is in the process of converting to PACS and wants to have it up three months from now,” Gale says. “They have a plan in place to accomplish that very thing. But what they have not considered is what happens three months and one day from now. Because, on that day after going live, they will have a chest x-ray done electronically, but everything else will still be on film. Since they’ve got the equivalent of one foot in the boat and one on the dock, the amount of time it’s therefore going to take a radiologist to look at any study will easily be double or even triple the amount of time it took before.

“Also, this hospital’s referring physicians have not yet been trained to work with the radiology department’s upcoming filmless environment. This is something that should have occurred months earlier so the referring physicians would be fully up to speed and comfortable by the time of the PACS goes lives. And a mechanism has yet to be put in place to accommodate referring physicians who are accustomed to having hard-copy films sent to them, because when PACS comes up there will no longer be hard-copy films to send to them.

“The lesson this hospital is going to learn the hard way is that the implications of being filmless extend far beyond the walls of the radiology department, and this too catches many administrators and radiologists by surprise.”

Gale’s advice to enterprises setting up a PACS: test it for six months before going live with it.

“During those six months, collect data so that you will have historical content that can be used for quality management testing of your modalities to make sure everything is technically functioning correctly, and more importantly to provide a database of historical images on the PACS for comparison when live reading begins,” he says. n

–Rich Smith

“We have an electronic patient record system that is light-years ahead of what is available in the private world-and this is something we started developing 20 years ago,” says Gale. “Moreover, my department has been doing computer-based entry of radiology requisitions for a decade-in the private sector, that kind of capability is still unavailable to most enterprises. We were the second hospital in the entire national VA system to acquire an MRI unit, and we were among the very first VAs to employ CT.”

Even so, it was not until Boston VA adopted PACS that its operations were truly revolutionized, Gale concedes.

“PACS made the biggest difference of anything we have added thus far,” he says. “I think an argument can be made that, without PACS, we would have been in serious trouble a few years ago after Boston VA merged with two other Massachusetts VA hospitals and an assortment of outpatient clinics to form what today is known as VA Boston Healthcare System. The merger and the fact that we are providing coverage to a small, separate independent VA hospital that was not part of the merger caused a sharp increase in our imaging volume-we went from about 80,000 examinations per year to more than 130,000 per year. PACS made it possible for us to absorb that greater workload.”

The system is now set up so that PACS funnels images from the modalities in place at each of those VA Boston Healthcare facilities to the radiologists for interpretation. The majority of those radiologists are based at the Boston campus where the radiology department is headquartered. The other radiologists spend most of their time at VA Boston Healthcare’s main inpatient hospital, located in West Roxbury. A few of the remaining radiologists are dispatched several times each month to oversee fluoroscopy studies at the VA hospital in the city of Bedford.

“Before PACS, all of these sites taken as a whole employed about 25 radiologists; now, the number is around 15,” says Gale. “In part, we had 25 because our operating budgets were more generous in those days and we could afford to staff like that. But, mainly, we had 25 because we needed 25.? Now we are able to accomplish an equivalent workload thanks to PACS and its potent economies of scale.”


Boston VA’s march to filmless dates back to the mid-1980s.

“We operated a very large outpatient clinic in downtown Boston back then,” says Gale, “and we needed to be able to provide urgent-care interpretations for that site on a regular basis. But the radiology department was located across town from that site. The challenge was to figure out some way of quickly getting those images from the clinic? to our department headquarters.”

At the time, images were sent over by courier. This proved to be inefficient and costly, so the department searched for alternatives.

Daniel Gale, MD, (foreground) and M. Elon Gale, MD, review images at four-monitor station

“The first thing we attempted was a very primitive teleradiology application,” says Gale. “It opened our eyes to the possibilities of the filmless environment, but we realized that this was not the technology to make it happen.”

Then, in 1992, the hospital’s administrator discovered a small surplus of funds in the capital equipment budget. He dropped by the office of the then-chief of radiology and, without telling him of the surplus, asked the radiology chief what he would invest in if some extra money were to come his way.

“The VA hospital in Baltimore had just at that time gone live with its own PACS system, and our radiology chief was aware of it,” Gale remembers. “He told the administrator that electronic imaging was the wave of the future, and that PACS was what he would invest in today had he the money to do so.”

The administrator liked what he heard. Later, it was decided that the radiology department would receive some of those surplus funds for the purpose of acquiring a PACS. As soon as the radiology chief received word of that decision, he and Gale began crafting a request for proposals from PACS vendors far and wide.

“We specified in our RFP that we would be deploying PACS only at Boston VA, since we were not in those days a merged enterprise,” says Gale.

Some of what Boston VA announced it wanted included a PACS that came with 2K display monitors, not the 1K and 1.5K monitors that were industry standard then.

“We also required that each reading station have four screens instead of just two,” Gale adds. “We wanted four-screen workstations because we knew from our nosing around that these make it much, much easier for radiologists to do their work in an electronic environment. We were aware that they let you have more views and allow you to work more along the lines of how a radiologist thinks, thereby contributing to getting the interpretation completed correctly in a shorter time than would be the case using a two-screen configuration.

“Four-screen workstations with 2K monitors were going to be expensive, so we specified that we wanted only four of them. When we actually took possession of them, they worked so well that we subsequently ordered more. Today, we have 14 of them.”

Boston VA also specified in its RFP that the PACS it purchased be capable of retaining images in a readily accessible short-term storage system for six months and then for five years after that in a long-term storage system. Additionally, the hospital wanted the PACS’s networking and interfaces to be DICOM-based throughout, rather than based on the HL-7 protocol.

“We insisted on this because our hospital information system was DICOM-based and so were our modalities,” Gale explains. “Plus, in 1992, when we sent out our RFP, the DICOM standard was not standard, and HL-7 was not yet fully refined.”

Boston VA decided to purchase its PACS from a company in Lexington, Mass., by the name of AVP, which later became eMed Technologies.

“There were other companies in the running for our business, but we went with eMed because it was best able to satisfy the requirements we outlined in our RFP,” says Gale. “And eMed’s approach to creating the ideal PACS for us was quite impressive. They sent up a couple of their senior engineers to do nothing but watch our radiologists manually read films for a period of about two weeks. The engineers sat in chairs directly behind us, notebooks open and pens in hand. Every time we did something, the engineers would ask us to explain why it was that we did it that particular way and not some other. They were extremely inquisitive and, as a result gained a very deep understanding of our work flow.

“We really liked this approach. Because, one of the things about the competing PACS products we looked at-and this holds true in many instances even today-was that it seemed as if they were designed by engineers who could only guess at how radiologists work. And since they weren’t really sure about that, they ended up putting into their systems everything plus the kitchen sink. Consequently, features, functions and controls ended up in the wrong places. In other words, the products weren’t designed for efficiency.”


Gale notes that, after implementing PACS, the already high quality of patient care at Boston VA improved. He credits this to the gained ability to better subspecialize the radiology service.

“It used to be that we had radiology generalists reading whatever studies came in,” he says. “But PACS makes it possible to automatically route each study by type to the radiologist who is the specialist in that particular area.”

Wider, faster access to images and speedier turnaround time on interpretations also resulted from PACS, both of which likewise contributed to improved quality of care, Gale offers.

“Each time it receives an image, our PACS sends a copy to our hospital information system, which has an image component to it. So any image on the PACS is viewable through our HIS from any of the 2,500 HIS-connected computers deployed throughout the hospital.

Boston VA has periodically requested enhancements to its PACS. One of the most useful has been a checking feature to ensure that no image would go unread.

“If a study is done and the radiologist has marked the image as read, the system will automatically retrieve that image and unmark it if PACS subsequently receives an additional image that is part of that same examination,” says Gale. “Let me explain. If the technologist doing a chest x-ray takes the frontal view first and processes it before taking the lateral view, that frontal view will percolate through our PACS and show up on a workstation about a minute later for reading. This created the possibility that we could be reading a PA chest without realizing that a lateral view had also been requested and was momentarily going to be arriving. Now that we have the checking feature, this kind of workflow disruption can’t happen.”

Although Boston VA has enhanced its PACS with this and other desirable features, the technology underlying the entire system is the same today as it was when the hospital first acquired it. This, however, seems not to be a problem.

“Even though we have what is officially considered a legacy system, we don’t think of it as such,” Gale assures. “Legacy seems nowadays like a pejorative, a term that connotes the system is old and therefore doesn’t work well. The fact is our system works better than most systems out there today. If you asked any one of our radiologists whether they would prefer using our system or one they’ve seen elsewhere, it’s a no-brainer-they’ll all pick ours.

“The product that eMed offers is basically a front-end and back-end. It has a server and a workstation client. But the server has been rock-solid, requiring no significant modifications over the years. Also, eMed had an early implementation of DICOM that was very robust and it has stayed that way.

“When we experienced that big increase in examination volume as a result of the merger, we did find it necessary to upgrade to a faster computer, but it essentially uses the same code as before. So, having a legacy system has not held us back at all. In fact, it is keeping us on the cutting edge.”

Rich Smith is a contributing writer for Decisions in Axis Imaging News.