(Left to right) Matt Van Vranken, COO, Ramin Khorasani, MD, director of information management for radiology, and Maria Damiano, director of operations for multidisciplinary PACS.

Brigham and Women’s Hospital, Boston, a world-famous tertiary care center that has, for the past decade, been ranked among the nation’s top hospitals, has a long history of medical milestones. In 1847, one of its predecessors, the Boston Lying-In Hospital (later merged with the Free Hospital for Women, Boston), administered the first anesthesia in a US maternity ward. In 1954, physicians at Robert Breck Brigham Hospital, Boston, performed the first successful kidney transplant.

Today, as a cornerstone of Partners HealthCare System, an integrated health care delivery organization that serves some 5,000 referring physicians in the Boston area, Brigham and Women’s Hospital continues to make medical history.

Its latest breakthrough is the integration of all the imaging done at the 702-bed teaching hospital and two affiliates-the Dana-Farber Cancer Institute, Boston, and the Faulkner Hospital, Jamaica Plain, Mass-into a single, multidisciplinary picture archiving and communications system (PACS).

This enterprise-wide PACS enables imaging specialists to do their primary interpretation work within their own departments and to store the images and reports in a central, multidisciplinary archive where the information can be accessed by partner institutions, as well as by primary care physicians, using a custom-designed web browser and desktop computers running Windows? NT software.

The installation of an enterprise-wide PACS is a strategy supported by Brigham and Women’s Hospital COO Matt Van? Vranken and the chair of the radiology department, Steven E. Seltzer, MD. Their vision of the PACS was that it should not belong exclusively to the radiology department, but should be funded by the institution and be regarded as a hospital asset. Further, to maximize the return on that investment, they determined that the PACS should be deployed to all departments within the hospital that do imaging.

The charter to implement this vision was given to Ramin Khorasani, MD, director of information management for the radiology department. As medical director for multidisciplinary PACS, he has worked closely over the past 4 years with the hardware and software supplier, Agfa Corp; with the chairs of the involved departments; and with Brigham and Women’s Hospital CIO Susan Schade and Maria Damiano, director of operations for multidisciplinary PACS, to roll out the system throughout the hospital. He is now extending it to the Dana-Farber Cancer Institute and Faulkner Hospital as well.

“One of the things that we believe,” Khorasani says, “is that a radiology PACS, by itself, will not provide an adequate return on investment. It will not cover its costs as a stand-alone system, so you have to leverage one department’s PACS into other departments. If you are to have a return on investment in the enterprise, you also have to be able to deploy those images throughout the enterprise, which requires an investment in personal computers. You have to have networks so that you can get your images to the people who use them, and so that you can turn off the use of film.”

To distribute images throughout? Brigham and Women’s Hospital and other member institutions (as well as to primary care providers) and to provide access to electronic medical records, Partners HealthCare System has created a web-based information systems (IS) infrastructure that currently involves some 40,000 personal computers. Deployed at a cost of $71 million over a 3-year period, the IS has a current operating budget of about $30 million per year for maintenance and upgrading, plus an annual budget of another $10 million for new capital equipment. The IS network has a staffing level of 180 full-time equivalents. In addition to providing access to what Van Vranken refers to as the longitudinal medical record, which might be looked on as the ultimate enterprise-wide patient record-keeping system, another major IS application is email.

“The PACS must be coupled very tightly to the enterprise IS,” Khorasani says, “so that it can become part of the electronic medical record and so that users can take advantage of its electronic ordering, scheduling, and reporting features.”

Agfa’s IMPAX Solutions system was initially deployed in the radiology department beginning in September 1998. In late 2000, it was upgraded to Release 4; Brigham and Women’s Hospital was the first hospital to get that advanced version. The radiology department is currently performing some 400,000 studies per year, and there are more than a million studies available in the online archive. Brigham and Women’s Hospital currently has no plans to send any of the older images to deep storage off-site. It just continues to expand the archive with additional blocks of memory as need.

The next step in making the PACS multidisciplinary was to leverage it to the cardiology department, first integrating five cardiac catheterization laboratories and later adding echocardiography and nuclear medicine studies. Brigham and Women’s Hospital does some 7,500 catheterization-laboratory procedures and 13,000 echocardiography examinations annually. Faulkner Hospital also has a catheterization laboratory, but since it does not have the ability to perform interventions, images made there are sent electronically to Brigham and Women’s Hospital, generally arriving at about the same time as the patient arrives by ambulance.

Also on PACS are the vascular ultrasound studies done within the division of medicine and fetal ultrasound studies performed in the department of obstetrics and gynecology. Currently, the PACS is being deployed to the department of gastroenterology for endoscopy. Early in 2002, the department of anesthesia will be added to the system.

“We are almost entirely on PACS now,” Khorasani says. “We have been able to accomplish this because we have several relationships with vendors who wanted to do special things with Brigham and Women’s Hospital, and that has really enabled us to complete the enterprise-wide system. For example, in gastroenterology, we are working directly with a vendor to get endoscopy images into the PACS; we are working with another to get full integration of ultrasound for the radiology, vascular medicine, and obstetrics/gynecology departments, which have been using that vendor’s software. I expect that a decision will be made, early next year, to shift this application directly to IMPAX.”

Khorasani continues, “We also are working with multiacquisition vendors to connect computed radiography and direct radiography suites directly into PACS. We currently are taking films from a few old? radiographic rooms and digitizing them. Everything else, except mammography, is digital. We are keeping an eye on that area, waiting for it to become less expensive.”

To accommodate all of its enterprise-wide imaging needs, Khorasani says, Brigham and Women’s Hospital adds 1.5 to 2 terabytes of archive storage every month. It has been acquiring the additional storage capacity from Agfa, and expects to make a decision by mid 2002 on what archival medium to use in the future. “We will do that in conjunction with, and in collaboration with, Agfa,” he says.

Brigham and Women’s Hospital’s enterprise PACS is a $5 million investment. Currently, it is linked to about 100 acquisition modalities, and it has approximately 80 Agfa diagnostic workstations. Some 65 of those single-monitor and dual-monitor workstations are in the radiology department. There currently are 15 single-monitor workstations in the cardiology department. These single-monitor workstations can display up to four images simultaneously. A user might, for example, select an MRI of the left ventricle, a chest radiograph, an echocardiogram, and a catheterization-laboratory sequence.

Although its imaging systems have been upgraded over the last several years and are now 98% to 99% digital, Brigham and Women’s Hospital is still printing a considerable amount of film. “We have shut off all inpatient films, but have not been able to stop making outpatient films because of the large number of primary care physicians who are not on our IS and, thus, do not have electronic access,” Khorasani says. “Our plan, this coming year, is to close off all outpatient film and to roll out our intelligent order-entry application aggressively. In this way, we can actually help physicians make better use of computer technology, not just send them fancy images electronically. “

The online order-entry module enables physicians to order imaging examinations and other tests electronically, without having to make a telephone call that might necessitate leaving a voice mail message and prevent immediate scheduling of the test. One feature of the order-entry system is its ability to alert a physician to the fact that the test that he or she wants to order has recently been done and is in the archive. This prevents inappropriate testing and overutilization.

Another order-entry feature of the Partners system is designed to eliminate medication errors. It uses an algorithm to help prevent drug errors and warn users of possible drug interactions. Still another intelligent computer order-entry application, which Khorasani had a hand in developing, helps clinicians make better decisions based on the past experience of other physicians. It flags requests for imaging examinations that have been shown, over time, to have only limited value in helping physicians make an accurate diagnosis.

Brigham and Women’s Hospital PACS also employs a quality-control filter. Described by Khorasani as a work-flow engine, it enables technologists (who formerly inspected films visually to determine whether the patient’s name was indicated correctly on them) to verify electronically whether the images are from the designated patient. This software application, called Relay, enables the technologist to check and correct the Digital Imaging and Communications in Medicine header before the image is committed to the archive. If an incorrect header were to be used, an image could become irretrievable.

While Brigham and Women’s Hospital’s enterprise PACS has solved the problem of image storage and instantaneous retrieval, prompt dissemination of diagnostic reports remains on ongoing challenge. In those areas of the radiology department where transcriptionists are still being used to prepare reports, turnaround time can still be as long as 2 days.

Khorasani is well aware of the problem, and it is being addressed in several ways. “There are multiple tools available to generate real time reports,” he says. “We are moving to end user voice recognition systems in some areas, such as radiology, but we haven’t rolled that out in a big way yet.”? Also being pilot tested is a system in which the physician speaks into a microphone and a voice-recognition engine is used to produce produce a typed report, which is immediately read and corrected by a transcriptionist.

“We are also looking at structured reporting and the use of templates,” Khorasani says. Structured reporting is currently being used by radiology department ultrasonographers to provide immediate reports, as well as by mammography readers.

Richard B. Elsberry is a contributing writer for Decisions in Axis Imaging News.