Tom Agar

Picture archiving and communications system (PACS) projects are becoming increasingly visible on every hospital’s radar screen. Some are software-based systems that employ best-of-breed, nonproprietary hardware-archival storage and retrieval systems, as well as commercial computer workstations compatible with the Digital Imaging and Communications in Medicine (DICOM) standard.

Homegrown PACS, however, are the exception, rather than the rule. For the most part, institutions of all sizes are more comfortable purchasing PACS from experienced information-technology vendors that can offer a turnkey solution designed to grow with an institution’s imaging and patient record-keeping needs. Security outweighs cost savings with many CFOs and COOs when it comes to new technology purchases.

Unfortunately, many institutions are creating future problems for their enterprises and their referring physicians by establishing islands of information around various imaging modalities. The assumption is that because the hardware is DICOM-compatible, institutions will be able to link these discrete PACS, at some future date, into a single database. DICOM-compatibility, however, has its limitations when it comes to the way that each system is designed to operate; a user may be able to live with those limitations, but the solution could be less than ideal.

As a result, an institution may wind up with separate radiology, echocardiology and catheterization-laboratory image-management systems that require separate databases, archives, and review stations that cannot easily interface with each other. The bottom line is that the enterprise may find itself with three different islands of patient information. Those islands may have an overall cost that is significantly higher than what the institution might have spent to acquire a single system designed to accommodate all of those imaging modalities.

Information-technology departments are coming to understand the value of having a single source: a single, core infrastructure that provides ubiquitous service across the enterprise. By being able to put all of their information in a single archive, and by having a single vendor supply PACS needs across different modalities and departments, institutions can achieve not only financial and clinical advantages, but space advantages as well.

The strategy favoring an enterprise-wide PACS is not unrelated to the need to create an electronic medical record (EMR). By creating an EMR for every patient, hospitals will make it possible for physicians to have easy access to all relevant clinical information pertaining to their patients from a single database. Agfa’s strategic vision targets EMRs that will lead to faster diagnoses. This vision encompasses not just radiology and cardiology images, but also other “ologies” like opthamology and pathology for example. This is where we think health care is going.

Introducing impax® for cardiology

Robert Donahue

While radiology, because of its procedural volume at most hospitals, sometimes presents the logical launching site for PACS, it need not always be the starting point, particularly in institutions with strong cardiology departments, or where the radiology hast not yet made the decision to go filmless. For that reason, Agfa Corporation has introduced IMPAX for Cardiology, a digital image and information management system for cardiologists that can stand alone or be integrated into Agfa’s existing enterprise-wide IMPAX for Radiology system.

IMPAX for Cardiology was previewed in 2000 at the American College of Cardiology annual meeting, and it underwent successful evaluations at Brigham and Women’s Hospital, Boston (a world-famous tertiary care center and one of five major teaching affiliates of Harvard Medical School). The evaluations at the 702-bed hospital, which is rated each year by US News & World Report as one of “America’s Best Hospitals,”1 were under the direction of radiologist Ramin Khorasani, MD, and cardiologist Jeffrey J. Popma, MD.

Later, IMPAX for Cardiology underwent evaluation at Queen Elizabeth II Hospital in Halifax, Nova Scotia, an institution where the staff includes radiologists trained in cardiology. Such cardiac radiologists are trained to not only read and diagnose radiology studies, but have an additional specialty in cardiology. This cross-cultural specialty is prevalent in many Canadian provincial hospitals, as well as in many socialized societies. Western Baptist Hospital in Paducah, Ky, and the VA North Chicago in Chicago, Ill, will be the next installations for IMPAX for cardiology.

Although there are can be significant cultural differences and turf issues between radiologists and cardiologists, Agfa does not try to resolve those differences with its PACS technology. Rather, we concentrate on providing an institution with the ability to become filmless and to have an information and image management system that spans departments and/or multiple facilities. Hospitals can start in radiology and move into cardiology or vice versa, or they can implement both modalities at the same time. Agfa’s aim is to provide every hospital with the ability to make its entire enterprise filmless by providing an infrastructure that can accommodate multiple departments. By eliminating the need to acquire separate digital systems for each department, Agfa is able to reduce a facility’s total cost of ownership.

The initial tests at Brigham and Women’s Hospital were confined to catheterization laboratory cine studies. The hospital has been participating in the evaluation of a cardiac workstation for echocardiography and nuclear cardiology images, which is projected to be available by the end of this year. This evaluation is being done under the direction of Khorasani, Scott D. Solomon, MD, director of noninvasive cardiology, and Ted Treves, MD, director of nuclear medicine.

The latest release of IMPAX for Cardiology-which consists of an integrated digital server, single-monitor workstations, and archive and report generation software for the catheterization laboratory and echocardiology-is scheduled to be shown at the Radiological Society of North America’s conference in Chicago in November, 2001, with worldwide marketing to commence by the year’s end.

Whereas cardiologists previously have needed to use special cine-film projectors to view individual catheterization-laboratory studies, the Agfa PACS provides diagnostic review stations with flat-panel or high-brightness monitors on which preangioplasty and postangioplasty images can be displayed side by side.

Because Brigham and Women’s Hospital’s cardiology PACS is interfaced with its Agfa radiology PACS, which went online in September, 1998, the system enables the reviewing of images at the multimodality workstations from the radiology and cardiology departments. Thus, four multimodality images can be displayed simultaneously in either the cardiology department or the radiology department. Such a display might include an MRI study of the left ventricle, a two-chamber echocardiology sequence, a chest radiograph, and a cardiac catheterization-laboratory sequence.

Because the display needs of invasive and noninvasive cardiologists are different, the Agfa software provides users with a tool box that enables them to navigate through the images in the way they want.In fact each user can have their own custom designed user interface based on the studies they review and the features they require.

The amount of storage available in the archive depends on how much a customer wants or can afford. The Brigham and Women’s Hospital PACS, for example, currently archives approximately 350,000 inpatient and outpatient radiological procedures annually. These require several terabytes of online storage every month or two.

Many cardiology departments have indicated that they want 6 to 12 months’ worth of images stored online. Older images can then, as an option, be sent to an offsite deep-storage archive. A typical cardiac catheterization or angiography study requires about 250 MB (at 2:1 lossless compression) of storage. Echocardiology studies can require anywhere from 25MB to 300MB of storage, depending on the type of study. Echo studies are typically compressed at 20:1 lossy compression. For distribution on the Web, catheterization laboratory and echocardiology studies are MPEG compressed using user selectable lossy compression to reduce the size of a study significantly (so that it can be sent to a physician’s office computer, for example).

The Cardiology Connection

Brigham and Women’s Hospital signed on for the cardiology enhancement of its Agfa radiology PACS because it is committed to deploying an enterprise-wide, multidisciplinary information management network that will enable all its departments-as well as Partners HealthCare hospitals (which include Massachusetts General Hospital, Boston) and some 5,000 contract and referring physicians-to exchange information with one another. Further, it has a huge cardiology presence that is larger than the presence of its radiology group.

Brigham and Women’s Hospital’s five catheterization laboratories perform more than 6,500 studies annually, including right heart studies, intra-aortic balloon pump placements, and transplant biopsies. It also performs 2,000 interventions, 1,300 electrophysiology studies, and 500 pacemaker and internal automatic cardiac defibrillator placements. In addition, it provides some 13,000 echocardiograms, as well as hundreds of gated gamma-camera studies, motion studies of the heart walls, and perfusion studies of the myocardium.

As an add-on for the institution’s enterprise radiology PACS, IMPAX for Cardiology is essentially an upgrade to the existing PACS system with added diagnostic review stations and additional archival storage. Eleven workstations were installed to allow cardiologists to view catheterization-laboratory studies, and additional single monitor diagnostic review stations are planned to accommodate echocardiology and nuclear medicine studies.

Agfa’s PACS technology is completely scalable; systems can be installed in hospitals of any size. Several institutions started out with a freestanding cardiology PACS because there was no radiology PACS to which it could be added. Once the core infrastructure is in place, whether in cardiology or radiology, other imaging modalities can be added later. An institution need not have catheterization laboratories doing 5,000 or 6,000 studies a year to deploy IMPAX for Cardiology. It can start with one or two laboratories doing 400 to 600 studies a year and expand the technology as needed.

Having created a multidisciplinary PACS for radiology and cardiology, Agfa is now working to create IMPAX Solutions for other fields, including both ophthalmology and orthopedics. Another modality that Agfa is exploring and hopes to include in future IMPAX systems is that of fluoroscopic peripheral vascular studies. Agfa recently acquired a minority interest in Medivision Medical Imaging Ltd, an ophthalmology specialist, and is currently working with two other institutions involved in Partners HealthCare, the Joslin Diabetes Center, Boston, (one of the nation’s foremost diabetes treatment centers) and the Massachusetts Eye and Ear Infirmary, Boston. Agfa hopes to be able, eventually, to incorporate ophthalmological images as part of a hospital’s EMR.

Tom Agar is the senior marketing manager, cardiology segment, the Americas, IMPAX Solutions, Agfa Corporation, Ridgefield Park, NJ.

Robert Donahue is North American sales manager, IMPAX for Cardiology Agfa Corporation, Ridgefield Park, NJ. Agfa, the Agfa-Rhombus and IMPAX are trademarks of Agfa Corporation or its affiliates.


  1. Health: Best Hospitals 2001. Available at: http://www. Accessed October 16, 2001.