With radiology PACS now standard in most medical facilities, it is small wonder that cardiologists and interventional radiologists want the same easy access to digitally stored images. And with the number of cardiology procedures growing each year, the demand for workflow efficiencies makes cardiology PACS even more inevitable.

In a perfect world, hospitals that want to add a cardiology PACS would just integrate it with their existing radiology PACS. While PACS vendors seem to be moving in that direction, at this point, most facilities are keeping the two systems separate or only partially integrating them. The reason lies in two primary differences.

The first is that cardiology and most interventional radiology images are dynamic and require more bandwidth and storage space than their static, single-frame, radiology cousins. Until recently, technology was not widely available to support the volume of data moving across a network that dynamic images demand. Today, with most hospital facilities at one gigabyte or more in bandwidth and with digital storage costs coming down, this is no longer a barrier.

The second and more important difference lies with the differing needs of the PACS users themselves.

In this article, we will look at two facilities that are leading the way in cardiology PACS and hear what their administrators have to say about integrating with radiology PACS.


If anyone should know about cardiology PACS, it is Ed Majors, executive director of imaging and PACS for Florida Hospital in Orlando. Part of Adventist Health System, Florida Hospital is a group of seven hospital-based facilities and multiple outpatient centers. With 130 cardiologists and cardiovascular surgeons and 1,000 cardiac nurses and technicians, they perform 15,000 advanced cardiac procedures annually, including 2,300 open-heart surgeries, 9,500 heart catheterizations, 1,900 electrophysiology studies (EPS) and atrial fibrillation ablations, and 1,100 pacemaker and defibrillator implants.

Florida Hospital was an early adopter of cardiology PACS. Implemented 6 years ago, its first system was used for catheterization laboratory imaging and was totally separate with its own archive, storage, and management system.

In early 2005, it retired its original catheterization laboratory PACS and began implementing a new cardiology PACS, going live with interfacing and integration in October of last year. In addition to migrating the imaging from the old cardiology PACS, the new system brought in echocardiogram images, which were previously stored on video tape, and interventional radiology.

The new PACS is dedicated for cardiology and IR, but shares a central core for image storage and archiving with the hospital’s radiology PACS. “Expanding existing storage hardware for economies of scale is the wise thing to do,” says Majors. “In this day and age, there’s no reason why you shouldn’t be using a common archive for both cardiology and radiology.”

There are three tiers of archiving: spinning disk for quick access to images, a large online tape library, and another copy on tape, which is stored at an off-site facility if needed for disaster recovery.

Majors cautions that generous bandwidth and storage are critical for cardiology PACS. “Newer cath lab and IR systems using digital flat plate detectors drive image acquisition per frame to 2000 x 2000. Depending on the device that’s generating data, you can end up with very large datasets if you’re pumping through multiple series of 60, 80, or 100 frames of 2000 x 2000 data,” he says.

Although sharing storage with radiology is fairly easy, Majors says, the differences in cardiology versus radiology workflow demand that they have a separate front-end system with dedicated workstations using cardiac software for display and reading of both echo and cath images.

“In today’s world, you need totally different tool sets at the display level to both present and manipulate images from a cardiology and echo perspective versus what we use in radiology,” he says. “In radiology, you’re mostly viewing static images one at a time, except for fluoroscopy, for which we don’t save those image sets in cine (movie) mode. But in cardiac cath and echo, dynamic images are their whole world. The physicians need totally different tool sets to be able to read those modalities.”

Majors believes a front-end interface that combines all the necessary tool sets for radiology and cardiology is both possible and likely in the future. “Several vendors are working on it,” he says. “Eventually, we’ll see one piece of hardware, one log-in, and the appropriate tool sets, but for now most of us have two separate systems.”

Majors says one of the great advantages of expanding the cardiology PACS is in making echocardiogram image data more available to clinicians to facilitate timely interpretations. “A cardiac physician does not have to be on-site when an echo tech performs an echocardiogram, but when we were storing the studies on videotape, somebody had to physically move the tape to the physicians for it to be read. And since cardiologists don’t sit in one facility all day reading–they’re seeing patients, operating a practice down the street, coming and going from the hospital–sometimes there can be a day of delay or more before the physician reviews the tape. Our business case with echo was to improve read times and patient care.”

So far it seems to be working. “We’re early into it,” Majors says, “but we’re already seeing improvements. It’s all about access.”


Asante Health System in Medford, Ore, is another early adopter of cardiology PACS. Rogue Valley Medical Center (RVMC) is a member of Asante Health System and was recently named as a Solucient 100 Top Cardiovascular Hospital. RVMC has received the designation five times and is the only hospital in the West to do so. Its new cardiac center opened in August 2005 and features a cardiac monitoring system, telemetry, continuous oxygen saturation monitors, and six mobile units to monitor patients’ vital signs. RVMC performed 3,000 cardiac catheterizations–including its 50,000th–5,200 echocardiograms, and 800 coronary stent procedures.

David Kinyon, imaging informatics manager for Asante, says RVMC started  years ago with a thick-client cardiology PACS from which images could be viewed only from the system’s few workstations.

In March 2004, it installed a new cardiology PACS that allows authorized users with Internet access and a secure connection to the hospital to see images from a physician’s office or from home with a standard Web browser.

Kinyon says the cardiology PACS market has changed significantly in the last few years, with vendors now offering more complete solutions. “We were trying to avoid having six third-party vendors,” he says. “We were looking for a comprehensive cardiac package. The one we chose has Web capabilities, hemodynamics, digital echo, nuclear medicine, ECG, and more.”

Because there was an existing digital archive from the old cardiology PACS, Kinyon had to do a manual migration. A conversion station was set up, and cases were loaded in one at a time. It took 5 months to load 3 years’ worth of cases into the new system. While the process sounds laborious, Kinyon says the manual approach was significantly less expensive than the vendor-offered solution and they finished the migration several months ahead of schedule.

Bandwidth also was an issue for the new PACS. “Dynamic images are much bigger,” Kinyon says. “A chest x-ray is only 10MB, but what if you’re doing a cine of the chest at 30 frames per second for 20 seconds or longer? On an interventional case, you can have more than 50 runs.”

Many of the remote sites on the Asante system had only 100MB backbones, and some of the cardiology studies moving through the new system exceed 1 and 2 GB in total size. The problem was solved by upgrading to gigabit bandwidth in all areas where full fidelity catheterization laboratory images are viewed.

The new cardiology PACS handles images from four catheterization laboratories, a brand new endoluminal suite in the OR, and five echocardiogram carts that run almost continuously. The system does reporting and hemodynamics, builds coronary trees, and generates full reports without transcription.

Kinyon says that currently about half of the physicians use the PACS exclusively without a transcriptionist to report cases. The system uses a form of structured reporting with drop-down menus to build a case transcription that includes procedure start time, equipment and supplies used, key personnel, etc, while the patient is still in the laboratory.

“There were growing pains,” Kinyon says, “We had to educate and train diverse groups of people involved: technologists, nurses, nurses, recovery staff, echo techs, cardiologists and interventional radiologists, echo techs, and nurses–but it has been very successful.”

PACS for IR Still a Struggle

Ed Majors says there are still some issues with the way some-although not all-PACS vendors handle interventional radiology (IR).

Unlike cardiac catheterization, IR does a mask run, then a run with contrast, then images are subtracted for the final set.

“Some vendors are good at doing that automatic subtraction on their system,” he says. “However, if they don’t hand over the finished dataset in a DICOM format to the PACS vendors for display and viewing, then it’s a struggle for the IR physicians to read on PACS.

“Some vendors can give you the mask run, the vascular run, and then there’s a lot of work-arounds you can go through, but the tool set that’s predominantly missing in some PACS solutions is the ability to accept that data, do pixel adjustment and alignment, and then the subtraction,” Majors says.

He says that getting interventional radiology right on a PACS can be a struggle and people need to be aware of it. “Don’t look only at the display the physician’s going to use and the tools sets available to them,” he says. “Ask yourself how will the physician look at subtracted images and how does your vendor hand off those datasets to a PACS display and storage system?”

T. Greenleaf

The new cardiology PACS is getting more and more remote use by physicians. “With digital imaging, there’s a tipping point, and I think we’re there now. We’re getting more and more requests from physicians for remote digital access,” he says.

Remote access is proving popular because RVMC serves a large geographic area that includes southern, coastal, and eastern Oregon and northern California. RVMC even installed a cardiac review station at a hospital 70 miles away on the other side of the Cascades mountain range. “They can do a case, load it up to the system, and before the patient gets to our hospital for heart surgery, it will already be in the system, so the interventional cardiologist can review the case and prepare a plan of care before the patient arrives,” Kinyon says.

RVMC is highly unusual in the fact that it acquired its cardiology PACS before its radiology PACS. “For radiology, we’re currently using a teleradiology system that is basically a cut-down PACS with a 4-week archive,” Kinyon says. RVMC is now in the process of upgrading to a full enterprise PACS for radiology.

And will they integrate it with the cardiology PACS?

“We are absolutely going to integrate the two,” Kinyon says, though the exact nature of the integration between the two PACS has not been decided. “We aren’t sure yet if we’ll have shared or separate storage,” he says. “We have purchased a large medical archive that will eventually store all the studies, but at this point, the hemodynamics will stay on the cardiology PACS system. There isn’t a pathway at this point to bring that data across.”

Other integration issues include how cardiology cases will look on the radiology workstations and how to get physicians away from having multiple front-ends that they must interact with.

A major point of the integration is to give the referring physicians more access to cardiology studies and to reduce the number of places they have to look to get data. “One of the largest complaints we have from physicians is too many passwords,” Kinyon says. “This should help with that, and the integration will allow other referring physicians to easily view the cardiac cath and echo cases.”

Kinyon says one of the keys for successful integration of cardiac and radiology PACS is to make sure the information retains its fidelity so the images are as good on the secondary system as on the primary system. “For true integration, if you bring up a cardiology image, it should come up as easily as a chest image,” he says. “You shouldn’t have to go through a separate sequence of events. It should be standardized and intuitive.”

Tamara Greenleaf is a contributing writer for Decisions in Axis Imaging News.