d04b.jpg (14386 bytes)As a private, not-for-profit hospital, St. John Medical Center (Tulsa, Okla.) faced several major challenges in providing medical imaging services for a facility with 125,000 exams a year and an average inpatient population of about 400 inpatient beds (with a capacity of 700 beds).

We wanted to digitally route images to our special care units, such as the ICCU, MICU and PICU, etc. We wanted a digital imaging network that would efficiently store and transmit images throughout the hospital and to remote sites and to make the images available to our users wherever they may be. And, we wanted to achieve this functionality as part of establishing the most cost-effective path to a PACS (picture archiving and communications system).

We learned quickly that installing a DICOM (digital imaging and communications in medicine) upgrade to an existing modality might not give us what we wanted. We also realized the capital investment required by a turnkey PACS was out of our reach.

As a result, three years ago we began to create our own solution – one step at a time. We developed a five-year plan and we are currently one year ahead of schedule.

Flexible routing, worklist management
Because many DICOM upgrades did not support DICOM print or worklist management, our initial plan was unworkable until we substituted Kodak PACS Link Medical Image Managers for some of these upgrades.

d04a.jpg (10731 bytes)These medical image managers are about half the price of a DICOM upgrade and offer much greater flexibility. In addition to fully featured DICOM printing, each manager supports routing images to multiple locations, such as archives and workstations and receives patient demographic information automatically from our radiology information system. We began sending images to several local viewing stations and to our laser imagers for output, and the process worked flawlessly.

Since these medical image managers interface to our hospital and radiology information systems, technologists no longer have to re-key patient information and other data. A technologist downloads patient information (name, ID number, birth date, referring physician) from the radiology information system (RIS) using a touch screen. Errors in patient information that can delay proper processing and billing are therefore eliminated.

Based on these outstanding results, we installed eight medical image managers: one system for each of our five digital R/F suites; two systems in nuclear medicine; and one “print only” system in the CT suite.

Real savings
Because fully featured medical image managers have the ability to translate digital or video signals to DICOM formats for transmission and printing, we have been able to save more than $200,000 compared with the cost of installing DICOM upgrades to existing modalities.

Images from all modalities are transmitted to a centralized printing area that includes three Kodak Ektascan 2180 laser printers. These printers are network routable, so if a printer is down, we can access an alternate printer. Because the medical image managers can address any of the networked printers, this configuration supplies redundant printing.

These managers play an important role in the development of a scaleable enterprise-wide digital imaging solution because of their ability to simultaneously transmit images to multiple locations – such as archives, workstations and printers – at a much lower cost than purchasing DICOM upgrades for legacy systems.

Two years ago, we added another critical element to our PACS – two 286-gigabyte RAID systems for short-term storage of images. Referring physicians can view all images produced during the preceding 40 days at 26 dedicated review workstations, from any one of the 2,000 PCs on the hospital intranet, or from anywhere in the world via the Internet.

St. John Medical Center
Radiology Department

Image acquisition via 32 individual acquisition devices
from 10 separate manufacturers:
Acuson, ADAC, Applicare, Fischer, GE, Kodak,
Lumisys, OEC, Philips and Siemens

d04c.gif (21024 bytes)

Chart courtesy of Eastman Kodak Co.

Although we continue to print to film for long-term reference, this process will be gradually replaced thanks to a long-term, 8.8 terabyte digital archive we recently purchased from Cemax-Icon. Using lossless compression, we expect the long-term archive to store approximately a four-year volume of images. After 40 days of inactivity, the image is dropped from the RAIDs and remains on the long-term archive. We write images to two separate tape cartridges so that one can be removed for off-site storage. Now that we have converted to digital storage, we plan to gradually phase out our film library.

Soft-copy only reading
The final stage of our plan, interpretation from soft-copy display, is underway. We are currently routing nuclear medicine and ultrasound images to a diagnostic workstation, which is located in the central reading area that serves these two modalities. When radiologists are completely comfortable with soft-copy reading, we will phase out automatic production of film images. Nuclear medicine and ultrasound images will be the first to convert completely to soft-copy reading, and we will gradually add other modalities.

We will continue to print selected images on an “as needed” basis. Some patients, for example, carry film copies of their imaging exams to specialists or to out-of-state physicians. We also will maintain our existing film library until it is no longer needed.

Web-based image access
A Web server that makes medical images available to authorized staff members completes our enterprise-wide digital imaging system. There are more than 2,000 PCs on campus that can view images supplied by our intranet and Web server. Medical staff members also can securely access images via the Internet from anywhere in the world.

In conclusion, we have created a PACS by combining best-of-breed components from leading vendors. Kodak PACS Link Systems have proved a vital element in our strategy. (The medical image management capabilities found on our standalone PACS Link systems are now available in PACS Link-configured Kodak DryView and Ektascan laser imagers.)

Three years into system implementation, we can see the light at the end of the tunnel. We believe our PACS will equip us to provide better service to referring physicians and patients, with greater efficiencies for the hospital and its staff. end.gif (810 bytes)

Phil Ames, CNMT, is the administrative director of radiology at St. John Medical Center in Tulsa, Okla. The center is part of the St. John Health System. Layne King, CNMT, is a systems analyst at St. John Medical Center and acts as project manager for the hospital’s enterprise-wide digital imaging solution.