John R. Romlein

Evaluation of the medical diagnostic imaging support system based on 2 years of clinical experience.

The Medical Diagnostic Imaging Support (MDIS) system at Madigan Army Medical Center (MAMC) has been operational in a phased approach since March 1992. Since then, nearly all image acquisition has been digital with progressively increasing primary softcopy diagnosis used. More than 375,000 computed radiography (CR) images as well as other modality images have been archived. Considerable experience in installation and implementation phasing has been gained. The location and ergonomic aspects of equipment placement were refined with time. The original clinical scenario was insufficiently detailed and additions were made to facilitate smoother and more complete transition toward a filmless environment. The MDIS system effectiveness and performance have been good in terms of operational workload throughput, background operations, and reliability. The important areas regarding reliability are image acquisition, output, display, database operations, storage, and the local area network. Fail-safe strategies have been continually improved to maintain continuous clinical image availability during the times when the MDIS system or components malfunction. Many invaluable lessons have been learned for effective quality assurance in a hospital-wide picture archiving and communication system. These issues include training, operational quality control, practical aspects of CR image quality, and increased timeliness in the generation and distribution of radiographic reports. Clinical acceptability has been a continuous process as each phase has been implemented. Clinical physicians quickly used the workstations soon after the start of MDIS at MAMC. The major advantage for clinicians has been the amount of time saved when retrieving multimodality images for review. On the other hand, the radiologists have been slower in their acceptance of the workstation for routine use. Radiologists need the completed software and hardware implementation to achieve the throughput necessary for a high-volume practice setting in making primary softcopy diagnoses.

Lessons learned and two years clinical experience in implementing the Medical Diagnostic Imaging Support (MDIS) System at Madigan Army Medical Center

The Medical Diagnostic Imaging Support System at Madigan Army Medical Center has been operational in a phase approach since March 1992. Since then, nearly all image acquisition has been digital with progressively increasing primary soft copy diagnosis utilized. Nearly four terabytes of data will have been archived in compressed form by the two year anniversary including more than 300,000 Computed Radiography images.

Optimization and quality control of computed radiography

Computed radiography (CR) is a relatively new technique for projection radiography. Few hospitals have CR devices in routine service and only a handful have more than one CR unit. As such, the clinical knowledge base does not yet exist to establish quality control (QC) procedures for CR devices. Without assurance that CR systems are operating within nominal limits, efforts to optimize CR performance are limited in value. A complete CR system includes detector plates that vary in response, cassettes, an electro-optical system for developing the image, computer algorithms for processing the raw image, and a hard copy output device. All of these subsystems are subject to variations in performance that can degrade image quality. Using CR manufacturer documentation, we have defined acceptance protocols for two different Fuji CR devices, the FCR 7000 and the AC1+, and have applied these tests to ten individual machines. We have begun to establish baseline performance measures and to determine measurement frequencies. CR QC is only one component of the overall quality control for totally digital radiology departments.

PACS: acceptance test, quality control, warranty, and maintenance continuum

As PACS gain greater acceptance and use in medical facilities the question of life cycle management must be addressed in terms that relate to the common business practices for medical information system and medical devices. The issues in life cycle management of such a system are relatively new to the industry. Increased use of PACS within the medical community requires that standardized life cycle management practices by developed and implemented. This paper develops a new of life cycle issues as cyclic and related events that are not only manageable, but also predictable in terms, of, frequency, duration data content, data exchange, potential outcomes, staffing requirement, documentation, and staff interaction. This view is presented as a continuum that begins at the acceptance testing of a PACS and continues throughout its life cycle. The continuum incorporates the required relationship between quality control testing and maintenance actions during warranty period and the maintenance years. Interrelated cyclic events are described that bind these processes together and provide a basis for long-term proactive management of PACS in a medical environment.

Planning factors for developing an enterprise-wide picture archiving and communication system maintenance program.

Picture archiving and communication system (PACS) maintenance on an individual site basis has historically been a complex and costly challenge. With the advent of enterprise-wide PACS projects such as the Virtual Radiology Environment (VRE) project, the challenge of a maintenance program with even more complexities has presented itself. The approach of the project management team for the VRE project is not one of reactive maintenance, but one of highly proactive planning and negotiations, in hopes of capitalizing on the economies of scale of an enterprise-wide PACS maintenance program. A proactive maintenance program is one aspect of life-cycle management. As with any capital acquisition, life-cycle management may be used to manage the specific project aspects related to PACS. The purpose of an enterprise-wide warranty and maintenance life-cycle management approach is to maintain PACS at its maximum operational efficiency and utilization levels through a flexible, shared, yet symbiotic relationship between local, regional, and vendor resources. These goals include providing maximum operational performance levels on a local, regional, and enterprise basis, while maintaining acceptable costs and resource utilization levels. This goal must be achieved without negatively impacting point of care activities, regardless of changes to the clinical business environment.

Security model for picture archiving and communication systems

The modern information revolution has facilitated a metamorphosis of health care delivery wrought with the challenges of securing patient sensitive data. To accommodate this reality, Congress passed the Health Insurance Portability and Accountability Act (HIPAA). While final guidance has not fully been resolved at this time, it is up to the health care community to develop and implement conprehensive security strategies founded on procedural, hardware and software solutions in preparation for future controls. The Virtual Radiology Environment (VRE) Project, a landmark US Army picture archiving and communications system (PACS) implemented across 10 geographically dispersed medical facilities, has addressed that challenge by planning for the secure transmission of medical images and reports over their local (LAN) and wide area network (WAN) infrastructure. Their model, which is transferable to general PACS implementations, encompasses a strategy of application risk and dataflow identification, data auditing, security policy definition, and procedural controls. When combined with hardware and software solutions that are both nonperformance limiting and scalable, the comprehensive approach will not only sufficiently address the current security requirements, but also accommodate the natural evolution of the enterprise security model.

Task allocation chart: quality control of a picture archive and communication system (PACS)

With radiology departments moving into a digital environment, Quality Control (QC) has shifted from film processor monitoring, and film-screen contact tests to computed radiography (CR) calibrations, soft copy display evaluations, and thread test of the imaging chain and the supporting data flow. An analog QC plan encompasses each piece of equipment and everyone in radiology, from the radiologists providing image quality feedback and the technologists performing film processor checks, to the biomedical maintenance technicians calibrating exposure rooms, everyone has input to a good analog QC plan. The digital radiology environment is no different; it requires user and maintainer involvement at all levels. This paper will explain the Task Allocation Chart and how it fits into the QC, warranty, and maintenance continuum that must be in place for an effective installation, implementation, and operation of a PACS.

The philosophy of benchmark testing a standards-based picture archiving and communications system

The Department of Defense issued its requirements for a Digital Imaging Network-Picture Archiving and Communications System (DIN-PACS) in a Request for Proposals (RFP) to industry in January 1997, with subsequent contracts being awarded in November 1997 to the Agfa Division of Bayer and IBM Global Government Industry. The Governments technical evaluation process consisted of evaluating a written technical proposal as well as conducting a benchmark test of each proposed system at the vendors test facility. The purpose of benchmark testing was to evaluate the performance of the fully integrated system in a simulated operational environment. The benchmark test procedures and test equipment were developed through a joint effort between the Government, academic institutions, and private consultants. Herein the authors discuss the resources required and the methods used to benchmark test a standards-based PACS.

Clinical services assessment and reengineering: Lessons learned

Healthcare enterprises often “acquire and install” picture archiving and communications systems (PACS) without examining many of the care delivery processes and information flows that will be affected. Many times these unexamined factors can delay or be the cause of failure of the PACS project. This article presents issues that were worked through as part of a PACS clinical services assessment and reengineering analysis for several US military medical treatment facilities.

Significance of the Fuji-computed radiography algorithms on hardcopy images.

The appearance and diagnostic quality of images from Fuji-based computed radiography equipment is dependent upon a series of steps involving both procedural criteria and machine parameters. These steps can be divided into the three general categories of image acquisition, image digitization, and image display. The implementation of an effective quality control program for computed radiography requires an understanding of the interdependence of these three stages of image production, and the development of methods to assess both operator and machine deviations from required performance. Our experience thus far with the implementation of CR in a large scale PACS at 3 medical centers underscores the need for dedicated applications training support, and for a systematic approach to parameter adjustment.