No specialty in medicine has benefited more from the rise of high technology than radiology. Space-age electronics and detector materials, along with fast, powerful computer systems, are now embedded in every kind of imaging device. The emergence of computed radiography and computer-based direct digital capture radiography have completed our ability to acquire all types of radiological images in digital form, underscoring the prospect of the all-digital department of radiology. Stunning advances in applications for all modalities have, over the past decade, increased the breath and depth of our diagnostic and interventional capabilities. As a consequence, the volume of radiology procedures delivered each year in the United States is growing much faster than the overall growth of health care.

Against this optimistic picture of radiology as a vibrant, growing specialty are set important coemergent trends in health care that are changing the expectations of radiology’s patients and other stakeholders. In formulating our strategic thinking and planning, it is important to understand these new stakeholder expectations and not simply to be mesmerized by our ever-increasing arsenal of new technology.

More than ever, patients want timely, easy access to services. They expect their physicians to receive radiological reports quickly, and they expect their reports and images to be readily and reliably available during the process of their care. Contemporary patients are more sophisticated and more involved in their own medical decision making and will not tolerate delayed or lost reports and films.

Referring physicians want timely access to services for their patients. Increasingly, referring physicians expect to be able to use computer information systems to order radiological studies and to receive reports and images directly on their desktops. Referring physicians have been frustrated for decades by the inefficiency and poor reliability of our film handling and delivery systems for hard-copy reports. Referring physicians are under tremendous cost and time pressures to deliver their services more efficiently; they expect their radiologist colleagues to help them achieve their goals.

Hospitals are also under immense cost pressures, partly from the Balanced Budget Act of 1997,1 which markedly reduced reimbursements from Medicare. Hospitals are highly driven by incentives to lower average lengths of stay, both as a cost-reduction measure and to increase their capacity to admit more patients. Hospitals are looking for a positive financial return on investment from the direct support of their departments of radiology, but they are also looking for help from those departments in reducing the length of the care-process cycle and eliminating unnecessary inpatient days.

Radiologists are also key stakeholders in departments of radiology. Radiologists are interested in better practice-support infrastructure and the implementation of systems that make it easier to get work done. Radiologists have been just as frustrated as their patients and clinical colleagues, over the years, about the unreliability and inefficiency of hard-copy film management systems. They recognize that their economic futures depend on working smarter (with better infrastructure).

In analyzing stakeholder expectations, four dominant themes emerge: convenience, reliability, cost, and time. Departments of radiology that understand these imperatives and develop strategies for meeting stakeholder expectations will have tremendous advantages in the marketplace, compared with departments that fail to do so. At the Massachusetts General Hospital (MGH), Boston, we believe that the strategic integration of front-end digital imaging systems with hospital and departmental information systems, especially picture archiving and communication systems (PACS), is the key to achieving these objectives of reduced cycle times and costs with improved convenience and reliability.

Convenience and Reliability

To address these issues at MGH, we have defined a concept that we refer to as the electronic round trip. In the electronic round trip, a referring physician can enter an order for a radiological procedure on his or her desktop computer. The request is transmitted through the hospital information system to the radiology information system (RIS), where the procedure is scheduled. The patient and study information then flow to the correct imaging device. The images are obtained and transmitted to the PACS, where a radiologist at the PACS workstation, using a voice-recognition dictation system, renders the report. The report is returned to the RIS, and both the report and the images are then made available, over the hospital network, to the referring physician at his or her desktop computer. The electronic round trip guarantees the integrity of patient data; it also reduces the total cycle time from request to report delivery by disintermediating all of the repeated data-entry steps of the traditional process and by eliminating all of the handling steps necessary for the use of hard-copy film and conventional report dictation. In this construct, images and reports are reliably and conveniently made available throughout both the department and the enterprise on a continuous basis, without limiting the number of caregivers who can have access to the information. Front-to-back electronic connectivity eliminates transcription errors, improving data integrity and reliability of retrieval. All stakeholders benefit.

In order to achieve this level of care-process integration, departments of radiology will need to go beyond their original vision for PACS. As originally conceived over 25 years ago, PACS were intended for the electronic management of images within departments of radiology. The dream of the all-digital department was focused internally. Indeed, most commercially available PACS have been designed for the management of images at the department level, not at the enterprise level or beyond.

At MGH, we recognized this problem early in our experience with PACS. We realized that we needed a Web-based solution that would allow us to communicate with physicians beyond the borders of the department. We implemented an Web image distribution system from AMICAS, Inc, Newton, Mass, for that purpose in 1996. All images generated in the department are now routed to the departmental PACS and also to the AMICAS system, where the images are made available, through the hospital network, to every physician’s desktop. Subsequently, the AMICAS system was integrated into the MGH electronic medical record results reporting system; radiological images and reports are available, with one keystroke, from the same screen as laboratory values, operative notes, discharge summaries, and similar information.

Recently, MGH has made virtual private networks (VPNs) available to physicians for remote access. Members of the MGH department of radiology and all referring physicians have access, via VPN, to images resident on an AMICAS server. This is enormously convenient because it allows attending physicians to consult with house staff concerning imaging findings without having to travel to the hospital. It even allows physicians to keep track of their patients, including their radiological studies, while traveling outside of the Boston area.

PACS Costs

Cost issues have taken a very interesting turn in the past 5 years. When we first proposed PACS in a serious way to the MGH administration in the mid 1990s, one of our strong selling points was the ability to reduce the costs associated with hard-copy film (including the purchasing, processing, and handling costs of film). At the time, our total film budget was on the order of $2 million per year, with another $2 million spent on processing and handling. We employed six full-time equivalent (FTE) workers to clean and repair our several dozen film processors. Our film-library was staffed by 48 FTEs, and virtually all receptionists and secretaries were also involved, to some degree, in handling the tide of hard-copy film folders flowing through the department.

We were able to demonstrate to the MGH hospital administration a positive return on investment for the purchase of a PACS based on a significant reduction in the need to print film. The ability to reduce film printing was entirely predicated, however, on the ability to deliver images to physicians’ desktops electronically. Installation of a PACS without enterprise-wide distribution capability does not result in film cost savings because hard copies are still needed outside the department of radiology. Fortunately, MGH had made a major investment in physician workstations and general networking capability in the mid 1990s. Therefore, at the time of our PACS proposal, every physician’s office was equipped with a desktop-computer workstation capable of running AMICAS (with connectivity to the hospital network).

By having the AMICAS solution to the enterprise image distribution problem in place , we were able to work with the respective clinical departments at MGH to fine-tune the image-distribution equation to suit their needs. For example, in the department of orthopedics, a desktop workstation (with a flat-panel display) running AMICAS was placed in each examining room. Orthopedic surgeons could rapidly and easily bring up the images just acquired in the radiology department, and could even discuss them with their patients at the workstation, as appropriate.

In some areas of the hospital, higher-level workstations were installed. These included larger-screen workstations in the intensive care units, where teams of physicians would be viewing images together. Subsequently, we have worked with departments to wire their conference rooms for liquid-crystal display projection systems. This has proved enormously popular. The projected images are large enough for group viewing, and displaying them using the AMICAS system provides features such as windowing and leveling that were not typically available for the projection of hard-copy images in the conference-room setting.

With the AMICAS solution in place, the department of radiology at MGH was able to reduce film costs for CT and MRI by approximately 85% to 90%, achieving its initial financial goals. In the 5 years since AMICAS implementation, changes in procedural volume and in the nature of CT and MRI studies have made the cost equation even more favorable for PACS. For example, in CT, the multislice era has radically changed the average number of images per study. In the year 2001, we estimate that the average CT examination of the head (including CT angiography) contains 500 images. The average for fiscal year (FY) 1996 was 80 images. For body imaging, the numbers for comparison are 300 in FY 2001 and 160 in FY 1996. In an even more dramatic change, some whole-body CT angiograms contain well over 1,000 images per case.

The net impact is that the average number of sheets of film that would be required per CT examination at MGH increased from 6 in FY 1996 to 15 in FY 2001. At the same time, the total number of CT scans increased from 38,000 to 89,000. The net impact on cost is a startling increase from $500,000 in FY 1996 to a theoretical $2.7 million in FY 2001, if we were still printing every image on every case (with an estimated cost of $2 per sheet for film and film processing). A similar calculation for MRI takes the total cost from $200,000 in FY 1996 to $1.2 million in FY 2001 for 35,000 examinations. Taken together, these two modalities alone would have resulted in an increase in film costs of $3 million, had enterprise-wide image distribution not been available. It could be argued that institutions without PACS, and those with PACS but without enterprise-wide image distribution, might simply print selected images on each case. While this is true, there is an enormous time expense involved because radiologists must select the images that will go into summary data sets.

Just how dramatic these factors are in a given institution also depends on whether the institution has converted from single-slice to multislice CT, and to what extent an institution has adopted CT angiography, MR angiography, and functional MRI methods. Institutions that have made these technological conversions cannot afford to have PACS without enterprise-wide image distribution. As multislice systems continue along their development pathway, with eight-slice and 16-slice devices on the horizon, the need to work in an all-digital environment at the enterprise level will become even greater.

The Time Imperative

The time imperative for radiology practice is easy to understand once we recognize that our final work product is information, not the image. In radiology, we do not really create value in the care process until a report is delivered to the caregiver responsible for the patient. This should push us to think in terms of a real-time, online practice. We must simply shorten cycle times from the point of procedure request to the time of report delivery in order to create value and meet the expectations held by patients, referring physicians, and hospitals.

Electronic image management takes distance out of the time equation for the delivery of images and reports outside of the department. This is, again, predicated on having an enterprise-wide distribution method, such as an AMICAS system, in place. Even within the department of radiology, the queuing of cases for radiologists to interpret is made far more efficient and faster with PACS. Prior studies are always available for comparison, and new studies are automatically added to the work list without the need to wait for a film librarian to batch process 10 or 20 examinations, including searching for prior studies.

The addition of voice recognition reduces the transcription loop that, even in the most efficient departments, is still on the order of hours (and, in many academic departments, days) in length. A major commitment by the radiologist is required if the use of voice recognition is to reduce the actual time spent dictating. When the total time spent on the task is measured, however, voice-recognition systems have the advantage of not requiring the radiologist to revisit the report later, when case details may be remembered less well.

The time that radiologists and clinicians alike spent hunting for films in the past is now spent on productive activities. Radiologists and clinicians can consult by phone while each is looking at the same images. This is an enormous time savings for busy clinicians who might otherwise have to come to the radiology department in the middle of a busy clinic schedule.

In retrospect, the smartest thing we did was to implement both a departmental and enterprise solution independent of one another. AMICAS clearly has stayed ahead of the curve technologically to the point that it now would meet all of our needs both inside and outside the department. We now have a fully redundant departmental PACS. The Agfa and AMICAS PACS both receive and archive 100% of the department/s studies.

One of the goals of departments of radiology should be to match the stunning modality-by-modality advances seen at the front end of the radiological process with equally beneficial advances in the information and image handling infrastructure underlying radiology practice. Patients unquestionably benefit from breakthrough imaging methods that provide more accurate, earlier diagnosis and better monitoring of therapy. If it lacked the integration of PACS and enterprise wide-image distribution, however, radiology would be left with a 21st-century product and a 19th-century distribution system.

James H Thrall, MD, is the Juan M. Taveras professor of radiology, Harvard Medical School, Boston, and radiologist in chief, Massachusetts General Hospital, Boston.


  1. Pub L No. 105-33.