PACS

In today’s modern hospital, timely access to information is no longer a luxury; it is an absolute necessity. Clinicians expect almost immediate and universal access to information that is critical to successfully diagnosing illnesses and injuries. There are few areas where this can be seen more clearly than in the field of radiology. Delivery of diagnostic, quality patient images is no longer measured in hours, but in minutes—and often seconds. And clinicians expect access to images in multiple locations from different types of devices both inside and outside the facility where the examination was conducted. The fact that this level of access is accepted as standard today is largely due to the evolution of picture archiving and communication systems (PACS), and clinical engineers play an important role as such systems continue to blur the line between devices and information.

From Analog to Digital

Traditional x-ray radiology relied on standard film developing technologies to produce images that a clinician could use. A physician examining a piece of x-ray film on a light box has become almost iconic, but the chemical process used for developing film is messy, noxious, and expensive. In addition, storing physical film not only requires sufficient space, but also cannot prevent the film’s inevitable deterioration. Twenty years or so ago, access to patient film and other associated clinical data could be as limited as a one-of-a-kind historical manuscript stored in a library archive, requiring elaborate filing systems that slowed a clinician’s access to stored patient images.

By the early 1990s, digital technology had become economical and reliable enough to allow the digitization of radiological images, and new imaging devices—often called modalities—came along that were inherently digital, such as CT scanners and MRI machines. It was not long before hospitals began to realize the many advantages of digital images: they are easy to store, retrieve, and distribute, and they can be attached to other electronic patient data. Then came ever more powerful processors, cheaper and more reliable storage media, and faster networks, along with the emergence of data standards such as DICOM and HL7. The result is the modern, sophisticated PACS found in most hospitals today that can collect and process digital images from sources as varied as ultrasound, MRI, PET scans, CT scans, endoscopy, mammography, direct radiography, and computed radiography.

New Knowledge, New Challenges

In fact, digital technologies have brought such rapid change to radiology, that clinical/biomedical engineers often find themselves caught between having to be experts on information technology (IT) as well as equipment.

Sean Keeley is a senior clinical engineering technician who for the last 4 years has also served as the PACS administrator at Harbor Hospital, a 193-bed facility in Baltimore. Wearing both hats has given him a deep appreciation for both areas of expertise.

“I’m a clinical engineer by training, so I know what a difficult job it can be, and that many in the hospital have such little understanding of what the position involves,” he says. “But the same can be said for PACS administrators. When I became the PACS admin here at Harbor, the amount of information that I had to process was just incredible.”

One of the biggest challenges for Keeley is endemic to all hospitals—the fact that different clinical areas have their own ways of doing things. Unfortunately, the PACS has to consistently absorb, store, and facilitate access to images regardless of department or modality. “Workflow can definitely be a confusing area,” he says. “Each department and system may have a different workflow. For example, our radiology PACS receives orders and patient information from the RIS [radiology information system], while the cardiology PACS receives it from the HIS [hospital information system]. That’s the beginning of your workflow.”

Keeley also points out that the imaging process varies as well. “For x-ray we use something called CR (computed radiography)—it’s basically a digital plate reader that allows us to convert older analog x-ray machines to digital. The plate has an imaging chip in it that is read, after which the CR will send it to PACS. That’s a different workflow.”

He also cites the separate workstation that nuclear medicine uses for the quality assurance process before submitting images to the PACS. “Other departments might do some image reconstruction, where radiologists can modify images on a tech workstation, or have a separate station where it’s read, before sending it to PACS,” he says. “So some departments use PACS only for archival, whereas others need constant access to PACS for workflow, and have all the tools for those images.”

The bottom line, according to Keeley, is that workflow definitely matters. “If a biomed doesn’t understand the unique aspects of each workflow, he won’t know where to look when problems come up.”

And they will.

Keeley rattles just a few off the top of his head. “Scheduled studies aren’t receiving images, no worklist from the RIS, no network connectivity, studies aren’t QA’d correctly,” he says. “If there’s an issue with sending images, it’s either the modality, the network, or the PACS itself. You start with the modality and move forward.”

Open Communication Is Vital

Daniel Cawthon is the manager of imaging support services for Memorial Hermann Healthcare System, Houston, where he oversees 18 engineers at 11 different hospitals. He currently sits on two different biomedical advisory boards and co-chaired AAMI’s subcommittee for imaging from 2007 to 2008. While PACS problems may be inevitable, how they are dealt with may vary, he says.

“When something does go wrong, that’s the big chasm,” Cawthon says. “The end user needs to contact somebody—but who? Biomed? IT? My answer is both. They should contact the IT department and say that there’s been a failed transmission. On their next breath they should call imaging support services to ensure that the hardware is working properly—that the wire between the modality and the wall is plugged in. Could be that there’s a problem on the PACS end, which is where IT comes into play.”

Regardless of where the problem exists, Cawthon says that communication is key. “Maybe the modality needs to be rebooted,” he says. “If that works, we’ll contact IT to let them know it’s been resolved at the device end. Or if they solve the problem, they’ll let CE know. It’s really a three-way street between the end user, clinical engineering, and IT.”

Troubleshooting is not the only place where open communication and teamwork is essential, according to Cawthon. There needs to be constant discussion between biomeds and IT when it comes to modifications and upgrades as well.

“I have a very good relationship with the IT group,” he says. “We meet on a monthly basis, and they can forecast their vision for next month. We have a format that we talk about business in general, or they may have a project that may involve medical devices. That’s where we do some discussions.”

Cawthon says that these discussions benefit both teams when it comes time to execute the project. “With most enterprise solutions there are upgrades that come down the line, sentinel points that have to be bridged, and modifications to the network,” he says. “The most recent one here was titled a CCG [centricity clinical gateway] upgrade, which is the PACS broker—a tie-in to the ADT [admissions discharge transfer]. The PACS broker pulls demographics from the ADT. So we worked very, very closely with the IT department through the CCG project. My guys were on the floor with their hands on the equipment, the IT guys were in the background monitoring the project. When we made adjustments, they could see it on the worklist to the modality and what was going on. If there was an issue—and there were several modalities that didn’t migrate properly—we were right on top of it between the two departments.”

Teamwork to Resolve Conflicts

Unfortunately, an increasing amount of crossover between equipment and software within the PACS context can sometimes result in conflicting goals between IT and the clinical/biomedical engineering department.

“I think our major roadblock is with the IT department pushing patch management to modalities,” Cawthon says. “We work in a Microsoft age where the OS [operating system] is considered IT’s responsibility. So when Microsoft sends out patches, they are pushed to the imaging devices that work on a Microsoft platform. Many of them work on a Microsoft shell, not a full-blown operating system like XP Professional. So some of these patches may not affect the operation of the equipment, but they can hinder its functionality.”

To further complicate matters, regulatory requirements that apply to devices may or may not be considered in the IT world. “Now, according to 510(k) compliance, patches that affect medical device functionality should come through the manufacturer for approval,” Cawthon says. “This is kind of a touchy subject with the IT group, who is responsible for the integrity and vulnerability of the PACS network. In their defense, I understand why they have to do patch management, and most IT teams have a risk assessment that they go through to determine if they should implement a given patch.”

Working closely with IT when it comes to PACS is also essential for Tom Martin, CRES, a senior field service specialist with St Joseph Healthcare, Lexington, Ky.

“Cooperation between our departments (biomed/CE, IT, and PACS administrators) is a must,” Martin says. “If any department fails to do their part, the system breaks down and issues will remain. To keep confusion to a minimum, we need our roles defined, and I feel our facility has done a very good job on this.”

Adding new systems is one area where Martin cites successful teamwork. “We normally assign the IP address and DICOM parameters to the acquisition modality being installed,” he says. “The IT department makes sure the network connection between our modality and the PACS servers is working. The PACS administrators make sure the DICOM association is good between our modality and PACS. We then test by sending a test patient study to the servers and check by seeing if the study is viewable on the PACS workstations.”

Like Cawthon, Martin regularly communicates with other departments to ensure proper maintenance and appropriate upgrades run smoothly. “We work together to maintain and service any problems that may come up,” Martin says. “If a project is being planned, it is best for the hospital planning committee to involve all affected departments. We usually meet beforehand and have management expectations defined regarding the timing of various parts of the project and our individual roles in bringing the project to completion.”

Ongoing Training Essential

While communication and teamwork are clearly essential for successful PACS management, it all begins with knowledge. Opportunities for training and learning for clinical engineering may vary from facility to facility, but it is important for the biomedical professional to be proactive to take advantage of the learning that is available.

“Biomeds definitely need to get up to speed on their computer skills,” Keeley says. “Network training is key, and a basic PACS course would also be helpful.” Keeley has taken PACS courses through the Medical Technology Management Institute, and says that OTech also provides good training. “I’ve also learned a lot through the IS team here—we have a good team, and they’ve been very helpful,” he says. Of course, experience is often the best teacher. “Every day I learn something new.”

Martin encourages using vendors as a resource for training, and echoes the need for basic networking knowledge. “It’s required for biomed,” he says.

Cawthon agrees that networking knowledge is critical when it comes to PACS. “When my guys go off for training on the equipment itself, training on network essentials is part of that,” he says. While not required, he knows some biomeds who have gone so far as to read the DICOM/NEMA standards. “There are 13 chapters. It is something to read when you have one of those sleepless nights—it’s very detailed on the structure of the DICOM format. But it’s very useful to know.”

As PACS continues to close the gap between the realms of devices and software, biomedical professionals can bring a lot to the table.

“CE is a broad discipline,” Cawthon says. “Not only are we responsible for the safety of equipment and patient safety, but also how the equipment operates and how it communicates—and not only in a PACS environment.” Cawthon believes such broad expertise can be helpful to other professionals because it fosters a unique thought process. “It’s a level of understanding that comes from being in front of doctors, in front of patients, in the line of fire.”

While IT professionals may tend to bring a range of laser-focused skills to problem solving, biomeds can see the big picture, according to Cawthon. And there’s no bigger picture than PACS.

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Kent Lupino is a contributing writer for 24×7. For more information, contact .