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Picture archiving and communications systems (PACS) can trim film from operations, potentially resulting in significant cost savings. However, if film is purged, images still have to be viewable on something—and that something is a video display monitor, a rather expensive item when deployed by the score or by the hundreds or even by the thousands across an enterprise. Up to 40% or more of the cost of a PACS implementation is tied up in monitors alone.
Because monitor costs are so significant, serious thought must be given to their acquisition in order to ensure that neither too many nor too few are brought aboard. Determining appropriate numbers of monitors is a process that takes into account, among other matters, questions of who will use what type of screens set up in which precise locations—questions seldom easily resolved.
An enlightening illustration of these issues comes from San Diego, where Scripps Health has been implementing PACS in each of its hospitals (there are five) and freestanding major clinics. Spearheading the effort in one of those is Nikunj K. Patel, MD, lead radiologist for advanced technology selection, department of radiology, the Scripps Clinic Medical Group, a multi-specialty medical practice attached to Scripps Clinic.
“Each of our hospitals has its own on-site PACS hardware and software,” says Patel, noting that the full Scripps Health organization (not all of which is yet PACS-equipped) generates about 80,000 to 100,000 imaging studies a month. “The individual PACS sites have their own server, with duplication of storage in a central enterprise-based server and in a data recovery center located outside the state. Each site’s PACS is capable of storing 12 to 18 months of images; older than that and they’re routed to the enterprise-wide server, which has 15 terabytes of storage. As the enterprise-wide server fills up, another server in parallel can be brought in to augment the first. This arrangement offers scalability sufficient that we won’t ever have to worry about running out of storage capacity. Most important, this isn’t archiving in the traditional sense because this setup allows us to have all studies online all the time.”
As of the end of the first quarter of 2005, there were 15 radiologist workstations deployed at the Scripps Clinic Medical Group’s sites, and approximately 70 more workstations will be deployed within the next year at the other Scripps Health entities. The deployment strategy advocated by Patel seeks to place in a central reading room one workstation for each radiologist typically present during peak times.
Says Patel, “If we have a site that has five radiologists, it will have at least as many workstations, plus one or two extra as backup in the event any of the five primary workstations goes down. That way, we can ensure little or no disruption in workflow when problems occur.”
(Those extra workstations do not sit idle until then. They are frequently used by clinical residents for training purposes, by physicians who want to review cases in person with a radiologist, and by radiology technologists who have been asked to reformat images for special purposes.)
The basically one-to-one ratio of workstations to radiologists is seen at Scripps as “allowing us to maximize the potential of PACS, which is to say an environment where you move images rather than people,” Patel observes.
Each workstation is equipped with three display monitors. The first is a color 23-inch screen delivering 2-megapixel resolution and used mainly to view administrative data—patient information, prior reports, and the like. In addition, the color screen can be used to view color-encoded PACS-based images, such as ultrasound, 3D reconstruction of angiograms, and PET fusion studies. The second and third monitors are designated to handle PACS images—they are true 12-bit grayscale screens of either 3- or 5-megapixel resolution, depending on usage location (digital radiography modalities feed into the 5-megapixel version, while CT, MR, and ultrasound feed into the other).
“Our deployment of workstations was dependent on workstation costs,” says Patel. “So, with that in mind, I obtained only the minimum number of 5-megapixel monitors we would need. This left me with sufficient capital to be able to afford the greatest number of 3-megapixel monitors.”
He reports that, for the price of two 5-megapixel stations, he was able to purchase as many as three 3-megapixel workstations.
“If we had bought an equal number of 3- and 5-megapixel monitors, we would have ended up displaying on the 5-megapixel screens many images that could just as effectively be displayed on the 3-megapixel screens,” Patel reveals. “However, displaying on a 5-megapixel screen images that do not require 5-megapixel capability amounts to a waste of money. For example, with ultrasound—you need only a 3-megapixel monitor for that type of image; putting that same ultrasound image up on a 5-megapixel monitor isn’t going to improve your ability to diagnose abnormalities. It’s like having a car with an engine powerful enough to let you accelerate from 0 to 60 mph in 2 seconds, but you drive it only on traffic-congested city streets—the acceleration power is of no real use to you in that situation.”
WORKSTATION IN EVERY OFFICE
All of the workstations Scripps bought have been installed in communal rooms designed for reading film, not soft copy. Consequently, those rooms lacked lighting appropriate to the new technology. Also, they were not furnished for the kind of comfort needed by radiologists who will be seated in front of the consoles for long hours each day. The remedy was to retrofit. A big job, as R.L. (Skip) Kennedy, MSc, can attest.
“We had to learn the hard way about the challenges involved in retrofitting, so now we’re going back to take a second look around and put to use the knowledge we gained, with the idea that we’ll improve lighting and ergonomics in the earliest batch of rooms we worked on and get them totally, 100% right,” says Kennedy, assistant director for radiology informatics in the North Valley service area of Kaiser Permanente, Sacramento, Calif.
Retrofitting became an issue for Kaiser Permanente because its monitor deployment strategy revolved around placement of workstations in each radiologist’s private office.
“In hindsight, we probably shouldn’t have attempted to retrofit those small offices,” says Kennedy. “We should have instead wiped the slate clean and built brand-new offices designed specifically to accommodate a PACS workstation. The changes that need to be made to transform a physician’s existing private office into a productivity-oriented, one-man radiology reading room are not anything of a cosmetic nature. They are substantive and completely critical to radiologist function.”
Kennedy gives as the reason Kaiser Permanente opted for retrofitting a desire to avoid the mess of a major construction job.
“We realize now that the construction mess would have been relatively brief with the end result being that it would have put us 2 years farther along than we are now,” he says.
Even more fundamental is the question of why Kaiser Permanente elected to install workstations in individual offices in the first place.
“Because it made economic sense,” Kennedy replies. “In the old days, a single workstation cost $125,000, so to get your ROI out of it, you had to install it in a central room and give your radiologists an assigned share of time on it. Now, with the cost of the radiologist going up and the price of the workstation going down, the economics favor decentralized deployment.
“Originally, our plan was to have PACS vendor-integrated workstations. We figured these would have to be deployed centrally, that putting them in every radiologist office would be impractical, again because of the cost of the monitors—expected to be $75,000 to $80,000 each. Then we discovered that we could bring the price of each workstation down to about $17,000 if we were to buy just the software from our PACS vendor and separately obtain the monitors and CPUs from a different source, and then integrate them ourselves in-house. Suddenly, we were talking about savings so deep that we could afford to put a workstation in every radiologist’s office.”
For Kaiser Permanente, deployment in that manner has proven very advantageous.
“With our radiologists each able to read from the convenience of their own private office, we were able to gain from them a lot more efficiency,” Kennedy reveals. “In my estimation, decentralized workstation deployment is a better model than the centralized approach. This allows the radiologist to read whenever he’s got free minutes, such as in the time between meetings. He’s not confined to reading in a designated block of time since the workstation is available whenever he is. As a result, the radiologist can get more reading done without facing a longer day.”
Kennedy estimates that the value inherent to radiologist extra efficiency can easily offset the cost of a workstation.
“Radiologist time is the most valuable resource in this entire equation—it just happens not to be a capital budget item you can point to,” he says. “Nevertheless, getting 15% to 20% more efficiency out of the radiologists represents significant dollars, enough to pay for the monitors and enough, actually, to pay for the PACS project itself.”
LCD MUCH PREFERRED
Kaiser Permanente’s Northern California region takes in 17 hospitals and 28 separate medical buildings. Radiology services offered include interventional radiology, mammography, general diagnostic, MRI, CT, and ultrasound. Collectively, Northern California generates 3.3 million radiology images a year, of which 1.7 million are currently stored in PACS.
Northern California set out on its journey to a filmless and paperless environment about 4 years ago. It expects to achieve near-total filmlessness by the second quarter of 2006; total filmlessness when mammography goes completely digital about 4 years after that.
Separate but identical PACS are located in each of the 17 hospitals; they exchange images using a file-sharing network that somewhat resembles the one devised by Kazaa (and the old Napster) for peer-to-peer swaps among music lovers. Each site has storage capacity totaling 4.6 terabytes—an amount sufficient to handle about 2 years’ worth of studies. Longer-term storage is provided by a Southern California-based deep archive that employs a powderhorn-type tape library. As to infrastructure, the basic local pipeline is 100 baseT, full-duplex, with a limited amount of 1-gigabit backbone.
North Valley’s initial installation budget for PACS was $1.8 million, about 40% of that to cover the cost of monitors, according to Kennedy.
“Right now, we have about 220 PACS workstations installed, with 175 more to come,” he says. “They are all of one type—a three-monitor setup, with the two main screens each measuring 23 inches diagonally.”
These PACS workstations are supplemented by 120 clinical image distribution workstations (when deployment of these is completed, there will be 580 in service).
“Our clinical image distribution workstations come with a 21-inch monitor that satisfies the Kaiser Permanente-specified diagnostic quality requirement for images,” Kennedy says. “These are deployed entirely outside the radiology departments—mainly the ICUs, ORs, orthopedics, pulmonary, and emergency departments. Only the PACS workstations are inside radiology.”
Many of the clinical image distribution workstations have been allotted to the medical office buildings (MOBs), not just the hospitals. That is because the MOBs not only house physician offices; they also are home to outpatient clinics and ambulatory surgery centers.
“In the referring physician offices, access to PACS images is mainly through our standard desktop PCs and distributed through IT,” Kennedy clarifies.
The PACS workstations (as well as the clinical reference versions) are fitted with LCD-type display screens.
“Initially, we had a large number of legacy systems that used CRT monitors,” says Kennedy. “We took all of those out and replaced them with LCDs.”
Kaiser Permanente did not necessarily have to ditch the CRTs owing to any technologic problem; those monitors would have worked just fine on the new system. However, the CRTs had to go because of their girth and their heat output.
Says Kennedy, “There was no way we could have put a workstation in every radiologist’s office if we had stuck with our CRTs. There wasn’t space for them in most of the rooms, and there wasn’t enough cooling to prevent the rooms from becoming uncomfortably hot after the tubes had been running a while. Smaller, quieter, and cooler in a private office environment is critically important.”
The compact footprint of the LCDs created an added benefit for the organization—it freed up real estate elsewhere that can be put to good use.
“In the film environment, we always had to allocate space for a radiologist office and a reading room,” Kennedy says. “Now, we’re able to make the reading room and the radiologist office one and the same. As a result, we’ve recaptured significant amounts of space in our hospitals that we can use for other purposes, such as extra offices to allow us to properly accommodate a larger number of radiologists.”
The LCD monitors, by the way, are among radiologists hands-down more popular than the CRTs because of their superior image quality.
“Now I’m stuck with storage rooms full of CRTs,” Kennedy points out. “I can’t even give them away.”
Maintaining Monitor QAPACS monitor acquisition and deployment plans need to take much into account. On the list of considerations should be the matter of quality assurance, for, after they are installed and in operation, monitors must be periodically checked for proper calibration. The process of inspecting, correcting, and verifying calibration consumes about 15 minutes per monitor—the associated cost of which depends in part on the pay grade of the technician assigned to the task, says John Weiser, PhD, DABR, medical physicist and chief scientist at Xtria Healthcare, Digital Imaging Solutions, Frederick, Md, a professional consulting and managed services firm for digital imaging environments. According to Weiser, QA can be provided in-house or through outside sources:
“What I see most often in hospitals around the country is QA assigned to a radiology support person. But, with monitors now being deployed far outside the radiology department, biomed is also a good choice since they’re intimately familiar with those other areas of the hospital.” Also affecting the per-monitor cost of QA are workflow processes. At Weiser’s company, a workflow aid now under development seeks to take a QA database and synchronize it with a handheld PDA that accompanies the technician on his rounds. The database, accessible through the PDA, would supply invaluable information about the workstations and monitors, their locations in the enterprise, date of last testing, the results of that most recent test, and more. “The concept here is that, as you perform your QA tasks, you’d be able to enter the new information about the workstations and monitors in that PDA,” he explains. “When you return to your office, you could then upload the PDA data into the database to bring everything up to date. This would relieve you of certain of the documentation chores associated with the QA process.” (The synchronized database system he describes would also have the ability to arrange QA inspections in the most efficient order so that the person assigned to perform the calibrations will not be zig-zagging about campus.) STILL NEED CHECKINGOne might expect that, given the internal self-monitoring and automatic white-level readjustment capabilities of most of today’s high-level medical-grade diagnostic monitors, QA would be unnecessary. “It’s true that they don’t require as much manual intervention as lower-level monitors; even so, it’s still a good idea to check them and validate their calibration every 6 months,” says Weiser. On some monitors, initial calibration is built into the computer’s graphics display card. “That means if you remove the monitor and redeploy it elsewhere—thereby separating it from the display card—you have to recalibrate it before it can be used again,” says Weiser. “Other monitors have their own internal electronics that store the calibration. With this latter type, the calibration automatically goes wherever the monitor goes. As a result, you don’t have to be quite so particular about the display card you use.” A relatively new tool for making the QA process more cost-efficient is remote monitoring software. The user sits at a central management console and obtains, over the network, information about the status of any of the monitors. “It lets you remotely see current status—what the actual white level is, how many hours of backlight time the monitor has had, and how many hours have lapsed since last calibration validation,” he explains. That feature is available only on higher-end monitors. If down-market models are used, remote monitoring may be possible—just not as robustly. “Some remote-monitoring software products are designed to work with the lower-end monitor types and provide basic historical information, such as the last time anyone went in to validate the calibration,” says Weiser. “Some of these software products are designed only to work with that vendor’s brand of monitors, while others are nonproprietary. “Generally, remote monitoring is an application best suited for larger facilities where you might have 20, 30, 40, or more workstations. In those environments, this is a tool that can save a lot of man-hours in what otherwise would be a very labor-intensive operation.” |
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—R. Smith |
Rich Smith is a contributing writer for Decisions in Axis Imaging News.
