Why PACS in Modern Medicine?

2nd European Tutorial of Radiology

LVIV/Ukraina January 2011

Frans Dhaenens MD

Remember: PACS

• PACS –(P)icture

(A)rchiving(C)ommunication

(S)ystem

AGFA PACS/RIS.

МРТ

КТ

УЗ

Ангио

Яд.мед.

Рентген Дигитайзер

Сервер управления потоками

Сервер Базы ДанныхPACSАрхив 1 год

Архивный сервер

Архив на 10 лет

Диагностическиестанции

Web cервер

Рабочие станцииклиницистов Web

Серверкоммуникации

Сервер RIS

Cтанции RIS

PACS

RIS

Cтанции RIS

Some other abbreviations

• RIS : Radiological Information System

• HIS : Hospital Information System

• EPR: Electronic Patient Record = EHR = Electronic Health Record

HIS

RIS PACS

EPR

History of PACS(1980) and Tele-radiology (1960)

• PACS= Picture Archiving & Communication System started in 1980, hospital & radiology based, today part of the Hospital Information System (HIS), images and data stored in the Electronic Patient Record (EPR).

• Tele-radiology part of Tele-medicine = much older (1960), “feeling” of low quality & remote connections.

• Every PACS has “tele-radiology” capabilities through its Wide Area Network connections and DICOM web-viewers: enables home-radiology, mammography screening programs.

What is PACS ?? History

• PACS = Picture Archiving and Communication System• DICOM =Digital Imaging and Communication in Medicine

PACS connects CT, MRI, US, DR,..

PACSIn the

Radiology Department

Radiologist

Specialist

Hospital

PACS = flexibility & creativity

A short history of PACS: standards & control

CONTROLCONTROL

PACS 1982PACS 1982 PACS 2012PACS 2012

Standards & Standards & SecuritySecurity

Modality->Departmental->Hospital->Multi-site->GRID-PACSModality->Departmental->Hospital->Multi-site->GRID-PACS

NEMA/DICOM cardio, dental, RT, visual-lightNEMA/DICOM cardio, dental, RT, visual-light

HL7 + IHEHL7 + IHE

MPI + XDSMPI + XDS

RIS = Radiological Information SystemRIS = Radiological Information System

HIS = Hospital I.S.HIS = Hospital I.S.

EPR = Electr. Pat. Rec.EPR = Electr. Pat. Rec.

“CODE”

VirtualityVirtuality

Technical evolution of all PACS functions

1980 2012

PICTURES

Archiving

Communication

Systems

2D

tapes

ATM, video

Hardware + show an image

Represent 5D datasets

Internet archives

Internet/web/

Wifi

Functionality+ knowledge

Drivers for the PACS evolution

• Modality Technology and IT: e.g. MDCT• Subspecialization in Radiology : neuroradiology• Economical: cost, speed, access,..• Up scaling = mergers, cooperation between

hospitals

• Clinical and Research needs: Personalized Medicine, Molecular Imaging, clinical trials

• Patient: mobility and consumerism

Mayo: Image Information Overload of MDCT, PACS visualization

– 2002: 16,000 CT images per day per radiologist, approx. 2 seconds per image

– Projected 2006: 80,000 CT images per day about 0.45 seconds per image

– At 1 image per second would take >22 hours to review all of the CT images

01000020000300004000050000600007000080000

1994

2002

2006

… Triggered a Variety of Visualization Applications…

Now you have all the images... So what?

Radiology: the Analog Workflow

Experience

SpecialtiesSpecialties

KnowledgeKnowledge

PatientPatient

Process Turnaround TimeProcess Turnaround Time

IMAGES

Information

Report

DATA

ModalityModality

IMAGESIMAGES

DATADATA

InformationInformation

Hospital/ World

Radiology: the Digital Workflow

Experience

SpecialtiesSpecialties

KnowledgeKnowledge

PatientPatient

Process Turnaround TimeProcess Turnaround Time

IMAGES

Information

Report

DATA

ModalityModality

IMAGESIMAGES

DATADATA

InformationInformation

Hospital/ World

PACSPACS

RISRIS

HISHIS

EPR EPR

-50%

Databases + WEBDatabases + WEB

Business Intelligence Server Kit

From Modalities to Multi-Site PACS

PACSDepartmental

“enterprise”

Radiologist

Specialist

Clinical Workstation EPR

HIS/RIS

Hospital 1

Hospital 2

Hospital 3

Multi-site PACS

Teleradiology

$$

Starting a PACS: several steps

1. In the radiology department: integration of the modalities on a workstation = modality PACS

2. Add the clinics : clinical workstation

3. Add all departments in the hospital: film and paperless = enterprise PACS

4. Later: several hospitals together = MULTI-SITE PACS

Step 1 = Radiology RIS +PACS

Step 2 = Clinical PACS + WS

Doctor-Patient: Technology Mismatch

Step 3 = Enterprise-PACS filmless and paperless part of EPR

HÔPITAL EUROPÉEN GEORGES POMPIDOU - PARISHÔPITAL EUROPÉEN GEORGES POMPIDOU - PARIS

R E S E A U I M A G E

10/100 Mbits ATM

10/100 Mbits

RIS

RADOS

INTERPRETATION DIAGNOSTIC

4XVIDEO

Bloc Opératoire

see more do more

URGENCES

1er ETAGE2ème ETAGEMédecine Nucléaire

3ème ETAGEPTI - PTNI

6ème - 7ème ETAGE

ACQUISITION - TRAITEMENTACQUISITION - TRAITEMENT REPROGRAPHIE VISUALISATION

SALLES CONFERENCE

VISUALISATION

10XPC DICOM

IMPAX CS500

100 à 300clients WEB

25IMPAX

DS 3000

LUMYSIS75

TS 5

ADC

ID

VIPS

VIPS

ADC

VIPS

VIPS

ADC

ID

TS 5LUMYSIS

ADW

LUMYSISTS 5

NM

NM

NM

NM

NM

NM

GESTION et COMMUNICATION

A 5200E 4500

SERVEUR DATA BASE

DLT 9710ARCHIVE SERVEUR 1 + WORFLOW

MANAGER 1

E 450

ARCHIVE SERVEUR 2 + WORFLOWMANAGER 2E 450

E 250

E 250

E 250

HP LH4

WEB 1000 SERVER

WORKFLOW MANAGER 3

WORKFLOW MANAGER 4

WORKFLOW MANAGER 5

PACSBROKER

HP LH4

INTEGRATION

DRYSTAR 3000

DRYSTAR 2000

Hardware can be fairly complex

Hospital –Doctors Office: HIS-PACS communication

• Different types of data, including images.

• Generic mechanisms for security and access control.

Does hospital-wide PACS work ?

• Thousands of proven and working cases.

• In all sizes.(from 10.000 to >10million ex/year)

• PACS is serious, not a toy !! Be aware of ”out of the box PACS”, plug-in and cheap PACS.

• Proven benefits: diagnostic, clinical and economical = faster diagnosis.

• Protection of future PACS developments: Multi-Site PACS and GRID PACS

Benefit of PACS: faster diagnosis

Mean transit time 1998.

90 90

0

10

20

30

40

50

60

70

80

90

R - EX EX - R R - D Total patient Total exam

waiting Before activity waiting After Total

Mean transit time with soft copy reading. (Test Impax)

32 36

0102030405060708090

R - EX EX - R R Total patient Total exam

waiting Before activity waiting After Total

Benefit of PACS: faster diagnosis

How to buy a PACS?

• Cheap and Toy-like ??

• Serious with perspective on growth and expansion (in capacity and capabilities) .

• Need for experienced partner for long-term cooperation. You buy experience.

• Home-made is no longer an option: slow and vulnerable…

PACS Toys for real doctors?

PACS dangers: chaos in the archives

PACS dangers: OVERLOAD system too small

Business Intelligence Server Kit

From Modalities to Multi-PACS

PACSDepartmental

“enterprise”

Radiologist

Specialist

Clinical Workstation EPR

HIS/RIS

Hospital 1

Hospital 2

Hospital 3

Multi-site PACS

Teleradiology

$$

Reasons for MULTI-SITE PACS

• Organ-based sub-specialties in radiology requires:– Integration of multi-modality

images in 1 place= PACS-workstation.

– Cover more territory: expert covers large geographic area

– Better communication between specialists; (EBM)

• Hospitals cooperate/merge.• Patient movement between

hospitals• Government benefit (U.K.)

Agfa experience with PACS

• Agfa has thousands of PACS installations in all kind of clinics and hospitals in all countries.

• Since 90-ties

• In all sizes: from 10.000 exams/yr to 10 million exams/yr.

• In all kind of environments: military, mountains, ships,…

• Some examples….

Adventist Health System, Florida

• All sites have PACS infrastructure• 17 total sites (so far)

– Plus FRI Clinics – referring into Florida Hospital• Imaging Center Solution w/ Promedicus• IMPAX MPI managing cross-reference of Patient IDs

• Multiple HIS/RIS– Multiple RIS transitioned into a single Cerner RIS across health

system

• ~2 mil exams per year

Toronto East Network Canada

• 16 Hospital Corporations• 26 Clinical Sites• 3 Local Health Information Networks

– LHINS 7,8 and 9

• 1.9 Million exams annually • Multi-vendor

– PACS: Agfa, GE, Siemens, Philips– HIS/RIS: McKesson, Meditech, Cerner, Medisolution

United Kingdom: all hospitals digital

• England is divided in 5 clusters:– London– Southern– North West & West Midlands– North Eastern– Eastern

• Cost between 10-20 b£

Agfa PACS in 2 clusters

• 2 clusters• 30 trusts• 75 hospitals• Servicing a population

of 17 million• Image Data Volume

– 10.000.000 exams/year– 300 Terabyte/year

• Hub and Spoke model

Tele-radiology based on PACS

• Every PACS can do Teleradiology

• Uses the Local Area Network (LAN) and Wide Area Network (WAN) for point to point Communication (via VPN)

• of (Anonymous) images =internet and reports + data = e-mail.

• Security levels : Information is sent via e-mail

Classics in telemedicine

64 % -> 18 % NEWS: AGFA rewarded NEWS: AGFA rewarded HIS for 100 million EuroHIS for 100 million Euro

Overview of a large Tele-radiology site in Germany

Villingen-Schwenningen

Tuttlingen

Rottweil

Singen

Konstanz

Donaueschingen

VPN

VPN

VPN

VPNVPN

Internet

Workflow Kliniken Villingen-Schwenningen: satellite asks help

DICOMPseudonymisation

Firewall+VPN

DICOMC-STORE

DICOMC-STORE

Automatic pseudonymisatio

nWorkstation

Modality

HTTPe-mail notificatio

n

DICOMC-STORE

I

nte

rnet

AGFA Teleradiology

client

AGFA SA Workstation

DICOMC-FIND/MOVE

AGFA WEB1000

server

HTTP

Remote

opinion

Satellite Site

Central Site

IPSec

SAT-ID + SAT-PIDSAT-ID + SAT-ACC#Anonymous patient

Firewall+VPN

SAT-PIDSAT-ACC#SAT-Patient nameSAT-Patient address

SMTP

@

URL acces

s

Central repository of

pseudonymised studies

Reports & Communication = e-mail satellite central

Message received

Workflow Kliniken Villingen-Schwenningen: central radiology answers

Firewall+VPN

Workstation

HTTP

I

nte

rnet

AGFA Teleradiology

client

AGFA teleradiology

server

HTTP

Satellite Site

Central Site

IPSec

Firewall+VPN

SMTP

@

Mail server

SMTP

Report

ReportTemplate

Images

HTTP

Report

Report storage

on filesystem

Report

How far can PACS go ??

• Images can be stored outside the hospitals: in data-centers or in internet grids.

• PACS can be come virtual: patient and doctor can be everywhere but connected by internet.

• Radiologist will have access to all radiology knowledge available in the world.

“Virtual” GRID-PACS: the future coming now

• GRID = network of databases (anonymous images, knowledge, experts) and application software (CAD), hosted in many universities and private companies, in NON-DICOM format. Mostly related to cancer and mammography.

• Virtual PACS: User PACS interface = DICOM and transparant

• Examples:– ACRIN: Am College of Radiology Imaging Network = digital mammo– Nat. Cancer Institute: lung cancer with MDCT = Lung Imaging

Database Consortium >1000 peer-reviewed and documented lung cancers, approved by FDA, Agfa, Siemens, GE, Philips =members

– UK and USA: Mammo-Grid = CAD and second reading.

Virtual GRID-PACS: Purposes = CAD & second-opinion & knowledge for lung-nodules

Virtual GRID-PACS: how it looks

You sit here

Cancer databas

e

Cancer database

No Blind Communication

Patient is here

Secure transmission of massive datasets: MDCT, cardio, angio

Cine Images Transmission of Encrypted Cine Images

PACS the basis for the future of “Diagnostic Imaging”

• PACS becomes the network for dissemination of Imaging and Knowledge in a world of “personalized medicine”. (Molecular Imaging).

• Think in terms of patient, cost, time, speed and access to an accurate diagnosis.

New technology, new habitsNew technology, new habits