PACS is not just about image archiving anymore. The latest PACS trends are providing radiologists with more automatic image processing, integrated enterprise workflow, and the ability to seamlessly share images with anyone, anywhere in the world.

PACS is not just a simple, digital radiology image storage system anymore. PACS is the cost of doing business in radiology today, and vendors continue to develop their products so that radiologists can lower that cost by improving workflow and enhancing image processing.

Every vendor has its special PACS bells and whistles, but there are some particular new trends and features that many vendors are working on for today’s PACS—and tomorrow’s.

RIS/PACS Integration

Years ago when PACS first started to become common in radiology practices, you bought your PACS and then you bought—or created in-house—a separate radiology information system (RIS) product to manage scheduling, billing, patient info, etc.

As PACS vendors began to create separate RIS products, they saw how the two programs could complement each other. Rather than re-create the wheel from scratch, some PACS companies bought stand-alone RIS companies, hoping to marry the two products into one seamless package. The first generation of these RIS/PACS products were often poor matches, forcing the two DICOM and HL7 cousins to play nice when they really had little programming in common.

However, the latest generations of RIS/PACS products truly are made for one another, and for those companies that want to invest in a new integrated system, there are distinct enterprisewide advantages.

Tyler Harris, RT, director of implementation for Novarad Corp, American Fork, Utah, said, “The trend is moving more to a complete package that is totally self-contained from the time the patient walks in the door to the moment they leave, including all the billing interfaces, reporting, etc. It’s a PACS that will make a radiologist autonomous from anywhere in the world, and enable referring physicians to see images and reports from anywhere in the world.”

Joe Maune, director of product line management at Carestream Health, Rochester, NY, adds, “You get to drive a very nice Lean manufacturing approach to radiology. So, as you extend the imaging set into the information set, when you link these two workflows together, you remove a lot of extra work from the system.”

Maune points to billing as an example of improved workflow and management. “In the past, billing has always been an afterthought. Now, at the time of ordering, you can check insurance eligibility and make sure that you have appropriateness. So, you’re starting to move some of the things that used to catch radiology off-guard at the end, like having the wrong ICD-9 code or CPT code, or making sure it’s the right insurance company. So, [PACS] companies are starting to look at those things holistically to make sure that these types of things are being done right up front instead of at the end.”

Another advantage to an integrated RIS/PACS is that the RIS information can provide information to the PACS, which enables more automated features for the radiologist’s diagnosing and reporting tasks.

Automation, Automation, Automation

Hanging protocols that cater to the viewing preference of a particular radiologist have been a staple of any modern PACS, but they are becoming even more powerful when integrated with RIS systems.

One advantage of an integrated RIS/PACS is that the RIS can provide information to the PACS, enabling more automated features for the radiologist?s diagnosing and reporting tasks.

An integrated system that knows the patient’s history, reason for the exam, and the exam ordered can now automatically anticipate specific views based on the exam ordered and other RIS information.

When a radiologist views a CT exam, for example, a great deal of effort typically goes into manipulating the data set before being able to make the diagnosis. But PACS vendors are trying to reduce those steps—and time—with automatic segmentation, automatic registration, and volume matching of prior exams.

Maune uses Carestream’s cardiology package as an example. He said, “We know that this patient wants to look at this organ, so we’re going to hang up the short axis, the long axis, and the four-chamber view, and we’ll do a volume 3D rendering of the heart for that reason.”

The result is that the latest PACS systems are decreasing manual image manipulation and allowing radiologists to more quickly start their evaluations.

Reports and dictation are also being streamlined with more RIS/PACS integration. Today, a radiologist no longer has to dictate relevant but redundant information, such as the patient’s name, reason for exam, date of exam, and exam ordered. Automated reports automatically include that information, leaving the radiologist to simply dictate their findings.

In addition, many PACS programs even have automated normal reports, where, with a few clicks of a mouse, a template report tells referring physicians that all is well with the particular anatomy being viewed.

Later this year, Carestream’s next update takes voice dictation a step further with a feature that allows a physician to dictate an exam and then say, “Next patient.” The next exam in the worklist then appears without the physician even having to click a mouse.

A mouse click or two will not save a great amount of time by itself, but when that feature is added to all the other new automated time-saving features, it could mean one more CT exam being read during the course of the day or more. With ever-decreasing reimbursements, operators say that it is volume that must make up for declining revenue, and PACS vendors are responding.

It’s All About the Web

The beauty of PACS is that, unlike film, radiology images are accessible to physicians anywhere at any time. That’s the theory, but in reality, one hospital’s PACS system is not compatible with another imaging center’s, not to mention HIPAA privacy laws.

Today, PACS manufacturers are increasingly creating Web-based viewing solutions that make exams and reports more accessible to different workstations, a home computer, or a PDA.

Additionally, PACS companies are creating various methods for accomplishing better interoperability among different PACS. Some systems now use an off-site intermediary server, where radiologists can push or pull exams from separate and disparate systems into their own systems.

One way or another, it is all about the Web. “Everybody’s going to need to go Web based,” Harris said. “The radiologists can get the images anywhere, even on Palm Pilots or Blackberries. They can look at films and get reports. Also, all PACS are definitely going to get more wireless, even in the hospitals.”

As part of this Web trend, PACS designers are providing role-based access, where the end user and administrator can control access into their system by assigning limited roles to each user. Consequently, a referring physician is able to log in and see reports or even pending patient reports from his patients only, while a radiologist can use the same PACS system from home or another imaging center and have access to all patients.

There are also more trends in automatic reporting, where, for example, when the report is finished, an e-mail or page is automatically sent to the referring physician with a Web link to the final report, which may be viewed on a laptop or even a handheld device.

It is only recently that off-site reading was made more practical with improved data compression and image streaming. Modern PACS systems that use image streaming allow partial data sets of, for example, the heart, to be streamed over the Internet to the radiologist’s home, rather than the entire data set. As the radiologist navigates around an image of the upper quadrant, only that image data flows over the net instead of the entire heart. The result is faster viewing while conserving bandwidth.

Teleradiology, of course, is all Web related, and PACS companies are also making it easier for hospitals and imaging centers to take advantage of the various teleradiology services. Merge Healthcare, Milwaukee, recently introduced TeleRead, a software package that allows studies to be placed in a dedicated teleradiology worklist that can then be manually or automatically transmitted to an offshore reading center. Thus, when an imaging center shuts down for the night, a complete package of medical images, prior reports, prior image studies, scanned documents, and all relevant patient demographics can be sent to overnight services.

The Future: More Integration, Automation, Voice, and CAD

If a radiology center is not able to take advantage of the latest and greatest today, it can expect more and better of the same trends in the future.

The latest PACS systems are decreasing manual image manipulation and allowing radiologists to more quickly start their evaluations.

RIS and PACS will become even more integrated, and while some operators may still love their separate systems, it will be difficult to turn down the seamless features of an increasingly integrated RIS/PACS.

“I think you’re going to go to a one-stop shop for radiology as opposed to best-in-breed for the different components,” Maune said. “We’re seeing that shift now, where a lot of folks have had an older RIS system, typically, and they’re either looking for a new PACS or to refresh their PACS, and I’d say about 75% are probably going to go for one vendor.”

In addition, Maune sees Carestream and other PACS vendors improving wide-scale PACS capabilities that reach across different PACS systems, regardless of the individual site’s vendor.

Another trend will be new mammography feature sets, with vendors taking advantage of recent digital mammography storage and reading technology.

Computer-aided detection (CAD) features for mammography and CAD for other types of lesions will continue to improve, along with more automatic segmentation and registration.

Maune said, “We’re doing segmentation of lesions and tracking lesions over time and pulling that information out and putting it into the final report. That frees physicians from all that “manual” work—or what will be looked at in the future as previously manual work. So a lot of effort is going into these enhanced productivity tools for the radiologist.”

Mouse clicks and keyboards will also become less utilized in favor of voice commands or perhaps even an eye-tracking helmet that moves the mouse and navigates according to the radiologist’s gaze.

In terms of voice-recognition technology alone, PACS companies (with their voice software partners) are moving toward natural language processing. It won’t be too long before radiologists will be able to dictate a report without having to verbally include the punctuation.

Furthermore, natural language processing will become more powerful, allowing radiologists, for example, to modify “normal” templates with their voice. Thus, with a few words, a radiologist can order the PACS to remove a template paragraph and replace it with a specific dictated abnormal evaluation and diagnosis. Or the voice software may even recognize key words as the radiologist dictates, such as “hemo,” and then automatically pull up a liver template and insert the dictated diagnosis into the template’s appropriate section.

However, for Maune, the main PACS trend for today and the future is sophisticated image processing and improved automation.

He said, “When you think about it, when a radiologist pops up a CT, they have to do a lot of manipulation of that data set and all those images to get to the point where they start to make the diagnosis. We’re trying to get to the point where we can provide that clinically relevant information as quickly as possible and remove their time spent on navigation and manipulation to the point where they can quickly make their diagnosis.”

Tor Valenza is a staff writer for Medical Imaging. For more information, contact .