One benefit of the web-based PACS was that it enabled the organization to choose the more cost-effective tablets instead of equipping all examining rooms with PCs and monitors. Key team members were, from left, Amy Bailey, assistant IS director; Molly Dempsey, MD, radiology chair; and Tina Reese, radiology administrative director.

When it is finally time to let go of inefficient technology and move up to state-of-the-art capability, the process of upgrading can be almost as painstaking as the initial implementation. Many decisions must be made, and sometimes the most difficult one is whether to remain with the current vendor or switch to a new one. This is a particular challenge when it comes to picture archiving and communications systems (PACS).

Take the case of Texas Scottish Rite Hospital for Children (TSRHC) in Dallas. Founded by the Texas Scottish Rite Masons and supported by donations made by individuals, foundations, and corporations, the 100-bed hospital provides care without charge to any patient or family. There is no billing department. Eight out of 10 children receive treatment for orthopedic conditions, such as scoliosis and spina bifida, as well as neurodevelopmental disorders, dyslexia and other learning problems, and cerebral palsy.

The facility serves approximately 250 children per day on an outpatient basis in seven clinics, all located within the facility’s main building. TSRHC’s inpatients stay on one floor for postoperative care, with an average length of stay of 3 to 5 days. There is no emergency department or intensive care unit, as the majority of the volume is outpatient traffic.

With an annual volume of approximately 34,000 examinations, TSRHC’s radiology department includes one CT scanner, one MRI, two ultrasound machines, and two CR rooms, as well as three fluoroscopy roomstwo of which are dedicated to imaging for scoliosis. The scoliosis rooms include digital fluoroscopy capture capabilities, as well as diagnostic capabilities. The hospital also has three C-arms.

TSRHC installed its PACS in 1999 in a major move to go filmless and enhance the care of its pediatric orthopedic patients through the more efficient delivery of images to radiologists, clinicians, and referring physicians. Image accessibility was needed beyond radiology in locations such as the operating room, seven clinics inside the facility, and 43 examination rooms.

PACS EXPANSION

The initial PACS included four diagnostic dual monitor workstations in the reading room and one clinical single monitor workstation in the radiology file room to accommodate the clerical and technologist staff.

To expand image access within the facility without benefit of web technology would have meant purchasing 10 workstations for the seven clinics, one clinical station for the research area, and one clinical workstation in the fellows/conference area at a price of approximately $50,000 per workstation. TSRHC also would have been limited to that vendor’s proprietary workstations in order to be compatible with the existing PACS.

TSRHC weighed increased accessibility to images with the affordability of additional technology and resources in its eventual decision to add web-based capabilities to its existing PACS. The hospital also considered outfitting its 43 examination rooms with PCs and viewing monitors at a cost of approximately $126,000, but determined that that option could be cumbersome.

TSRHC chose to bring on a web overlay from its original vendor that would ease access for referring physicians by lending the ability to access images via a standard PC, but ruled that the cost of equipping all examination rooms with PCs and monitors was prohibitive. However, the institution ran into immediate problems when it was discovered that the web product did not have the necessary orthopedic measurement tools, and that the measurements that could be made using the web product could not be saved to the PACS.

The measurement tools that were available on the web product were not persistent: once physicians closed out of a study on the web browser, their measurements were gone, explains Molly Dempsey, MD, TSRHC chair of radiology. Additionally, Cobb angles could be created only on a dedicated PACS workstation as opposed to the web product.

SWITCHING PACS

The goal of having the same user interface throughout the entire hospitalwhether in a doctor’s office, reading room or clinicwas a primary motivating factor for TSRHC to explore the possibility of taking on a new PACS from a different vendor.

“The problem is, when you’re using a web product, it doesn’t have the same functionality [as the client-server PACS] and the user interface is different,” Dempsey says, “so users are using two different interfaces, depending if [physicians] are in their office or the clinic.”

Tina Reese, TSRHC’s administrative director and former PACS administrator, recalls that the web product “went from working fine to having issues” when upgrades were installed. Some images would not display at all, while others took too long to access. Eventually, the hospital removed the upgrade, because doctors became dissatisfied and would not use it anymore. A subsequent web product the vendor introduced did have the Cobb angle capability, but it would not display the digital scoliosis images.

“If it were just radiology we had to satisfy, we probably would have stayed with [the initial PACS],” Reese adds.

As TSRHC investigated other vendors’ PACS offerings, it found a product that would enable referring physicians to save the Cobb angles marked on the images to the archive. The technology also would help the hospital to accomplish its goal to jettison its tape archive and move to a hard drive-based storage area network, or SAN.

WORK FLOW IMPACT

While work flow within the radiology department has not changed dramatically with the switch to the newer PACS technology, there has been a major impact on prefetching capabilities, allowing physicians to automatically retrieve numerous prior images to chart changes in a child’s condition, whether it be spina bifida, cerebral palsy, or scoliosis.

The new web-based PACS also allowed for the purchase of 19 wireless tablets at approximately $3,000 each, complete with softwarefor its attending physicians, fellows, nurse practitioners, and residents in the seven clinics, for a total cost that was considerably less than the $126,000 it would have taken to outfit all 43 examination rooms with PCs and monitors.

To date, Dempsey says the tablets have “worked wonderfully,” allowing provider untethered access to images to show the patients in any clinic location. “Because of patient confidentiality, you would not want to bring a parent into the main work area where other patients’ medical records and images could be inadvertently viewed. Patient privacy is important and must be ensured.”

“The tablets are particularly useful in a pediatric setting,” Dempsey adds. “Because our patients are children with high activity level and natural curiosity, we thought it more prudent not to station the computer equipment in the indivdual exam rooms.”

According to Amy Bailey, assistant information systems director, Information Systems, TSRHC, it was the web-based PACS that enabled the institution to “dip its feet into a wireless implementation.” “When we first looked at tablets, they were not quite up to running client-server applications, but they are perfect for the web-based implementation on the clinic side,” she said. “Their displays are nondiagnostic quality, but work well for in-room family consultation.”

When TSRHC made its transition to the second PACS, the facility took the opportunity to design a new PACS reading room to centralize PACS and film reading in the same location. The room hosts five radiologist workstations, as well as one 3D workstation for MRI and CT images. It also can project PACS images onto a larger screen for group consultation within the reading room.

The key was designing the room to prevent the film lightbox from reflecting onto and interfering with viewing on PACS monitors. Dempsey describes the room as a “four-pod” configuration, so when a light is on, it “shines to the back of the room and not onto someone else’s screen.” At the same time, the design allows for interaction between the radiologists.

The vendors who supplied both PACS conducted training for radiologists and in-house staff initially. Training for the current PACS was not as extensive as with the initial system, because radiologists already were quite familiar with the technology. The second vendor spent 1 day on-site with the radiologists and then 3 days with other hospital in-house staff with TSRHC’s PACS administrator in attendance, so she could take over training duties for subsequent sessions. TSRHC’s administrative director and PACS administrator received additional off-site administrative training from the second vendor.

TSRHC currently has 23 full-time physicians, including four radiologists, 16 part-time positions, and 76 consulting staff, as well as 20 fellows and residents , including six pediatric orthopedic fellows per year, all of whom participated in the PACS training.

DATA MIGRATION HEADACHE

Easily the biggest headache associated with moving from one platform to another in PACS is data migration.

TSRHC had been through the process once before with a prior vendor’s system application overhaul and the memories were not pleasant. The initial migration of approximately 0.5 terabytes of data from one tape library to a new tape library took about a year to complete. The second time around, TSRHC currently is migrating 3.5 terabytes of data to a hard drive archive, rather than dealing with tape.

“Tapes go bad and tapes get stuck; it is a very painful process,” Reese says. “So, we knew going into the new PACS and the new storage systemthe SANthat we wanted it on [hard drive] type of media. If we ever changed to something else, it would be an easy transfer.”

IS was pleased that a SAN storage solution was proposed because the hospital network was already on a SAN, a centralized pool of storage that can be stocked with spinning magnetic disks that are similar to the hard disk drives on a PC. “We had already implemented a SAN, so it went very smoothly,” Bailey explains. “It is more expensive because SAN requires the implementation and installation of a framework. You have to spend a lot to get it going, but it becomes a more cost-effective solution over time.”

Bailey reports that IS elected, for simplicity’s sake, to maintain the modalities, review stations, and key workstations in the clinics on its original PACS network, a virtual LAN (VLAN) with a gigabit Ethernet backbone and 100-base-T to the desktops, almost identical to the original network. “When one workstation goes down, it’s a much harder problem to solve when it’s on the hospital network,” she explains. “We’ve got 1,000 nodes on the network. If we are trouble-shooting a problem on the VLAN with just 50 nodes, we are dealing with a lot less variables.”

TSRHC started this past May to migrate its amassed 3.5 terabytes of data from the previous PACS to the new hard drive archive. Again, the facility expects the process to take about a year, concluding some time in the second quarter of 2005. Since TSRHC started the migration last May, all newly imaged patient data have been sent directly to the new hard drive archive, which also means that radiologists have to deal with two image storage systems.

When a child has an imaging study scheduled at the facility, it triggers a pre-fetch of the most recent six examinations. Dempsey says the images are “pulled” from the previous PACS to the new PACS before the study is presented for reading.

The IS department at TSRHC had already implemented a storage area network solution for general hospital purposes.

The majority of the process occurs at night, as preorders are placed the evening before the child is scheduled to arrive for the examination. If studies are ordered on the fly by the clinician, she adds, the same process of “triggering” occurs. The on-the-fly request may be slowed, if the images have not been migrated and are still stored on the older tape archive and have to be transferred to the new PACS.

“Once we get everything migrated over, [images] will always be available; every image will be at our fingertips anytime,” Dempsey says. “When I go to a patient’s master jacket, I don’t just get to see 10 prior images. I’ll get to see anything that was ever done, which is beautiful for pediatrics and 18 years of images.”

TSRHC has also added a backup hard drive storage system for disaster recovery, which will be located in another building on campus.

When the old PACS is no longer needed, Reese anticipates that the hospital will use its trade-in value to the vendor for new technology. In addition, TSRHC’s service contract for the first PACS does not expire until May 2005, so the hospital has an added incentive to keep the system in place.

Reese estimates that TSRHC has invested some $1 million on its current PACS.

BEST-LAID PLANS

Despite best intentions in planning the PACS, some issues could be addressed only after the system went live. For instance, the facility’s two ultrasound devices were located in two different rooms. One system would print an image and send it to the PACS, but the images would never arrive. After some additional sleuthing and vendor assistance, sonographers now know the steps to transfer images to the PACS correctly.

Technologists and radiologists also have had to standardize vocabulary to make sure the same term was used for each procedure to make hanging protocols consistent. For example, an image had to be labeled as “right” or “left” and not abbreviated as “RT” or “LT.”

“Could we have figured that out ahead of time? Probably not,” confesses Dempsey. “Until you get the technology there, you can’t foresee every issue. It is hard to second-guess every possible problem.”

On the migration of data to the new archive, the vendor began transferring TSRHC’s oldest images from 1999 instead of its most recent 2004 images to the new SAN first. Why that choice was made Dempsey is not quite sure, but it was reversed in just a couple of days.

“Migration is harder than you think, but if you think through all the possible issues, you’ll catch most of them,” Dempsey says.

DICOM COMPATIBILITY

When it came to integrating the institution’s various modalities into the PACS, its previous experience was of little help to TSRHC. Modality integration into the PACS became “quite a feat,” says Reese, especially when the facility found that some of its imaging systems were not necessarily DICOM-compliant or compatible.

“You run into…private tags on certain machines read by another vendor,” Reese notes. “As much as everything can be DICOM, it doesn’t mean [different machines] can talk to each other. There is some tweaking that needs to be done.”

TSRHC, for example, used medical image manager (MIM) technology to capture and digitize video fluoroscopy images to make them DICOM-capable for transmission to and on the PACS. Reese said the limitation of the MIM technology is that it cannot enhance an image, but only copy and digitize the quality the video provides.

The facility also had to configure its DICOM-challenged, single-detector CT to prevent the scanner from identifying patients with a string of zeroes in front of each patient name.

“We had to put in a merge box to strip the zeroes,” Reese says. “It is an accepted piece of equipment, but there are certain things you come across that you don’t think about when you’re evaluating your equipment. Perhaps the most difficult one is how to make [the images] DICOM before you send them into the PACS.” The radiology department ran non-DICOM CT images through a 3D workstation, which converted the images to DICOM-compatible information for transfer to the PACS.

FUTURE PLANS

Completing its data migration to the new PACS is TSRHC’s top priority. The hospital also expects to finish the transition of its operating room to a filmless environment before the end of the year, where surgeons will view images on two 40-inch LCD screens fitted with video cards so that images can be seen in portrait mode. “You can look at AP and

lateral views simultaneously while you are operating,” Dempsey says.

TSRHC has not abandoned film altogether. Approximately 10% of TSRHC’s images continue to be printed on conventional film today. For example, scoliosis images acquired in the operating room are 14- by 28-inch images taken on conventional film and then digitized for the PACS. The facility still prints some images from clinic for viewing in the surgical suites pending the completion of the OR implementation, anticipated to be November 15.

The hospital currently is evaluating the performance of available computed radiography systems from two vendors, that can generate images of the spine and lower extremities at 14-in by 51-inch in the department or 14-in by 34-in in the OR. “We are still using conventional film for the 14 by 28 images we do,” says Reese. “Once we find that solution, we can get rid of film totally.”

With its anticipated purchase of a new DICOM-compliant C-arm, TSRHC will perform real-time fluoroscopy in all operating rooms and have those images transferred directly into the PACS, eliminating the need for film.

Dempsey says the facility also would need to acquire the technology to send images to other institutions via CD, a goal that could be accomplished with an investment of approximately $40,000.

Dempsey advises to expect it will take some time to fine tune the system and to be patient, but persistent, with the vendor during the process of installation and implementation. “Final payment should not be made until the hospital and providers are fully satisfied,” she notes. “A point person on the vendor’s staff should be identified to receive, coordinate, and address the final glitches. Likewise, there should be an internal team to monitor progress of the installation to its satisfactory completion.

Wayne Forrest is a contributing writer for Decisions in Axis Imaging News.