Michael A. Cawthon

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 Nearly four terabytes of data will have been archived in compressed form by the two year anniversary including more than 300,000 Computed Radiography images.

The impact of a picture archiving and communication system on nuclear medicine examination interpretation

Radiographic correlation is essential for many of the examinations performed in nuclear medicine. The purpose of this study was to evaluate the impact of a picture archiving and communications system (PACS) on the function and efficiency of a nuclear medicine department at a tertiary care institution. We evaluated 250 consecutive noncardiac nuclear medicine imaging examinations and asked the interpreting physician the following questions: (1) Was PACS used in the interpretation of the study? (2) Did the use of PACS expedite examination completion or aid in study interpretation? And (3) Did the use of PACS permit a definitive diagnosis to be made? PACS was accessed for correlative radiographic images in 155 of the 250 (62%) nuclear medicine examinations. Images available on PACS for review aided in study interpretation in 74% (115 of 155) of cases The use of PACS was thought to expedite examination completion in 55% (86 of 155) of cases. The system was accessed but not operational in only 1% of cases (2 of 155). PACS provides reliable, rapid access to multimodality correlative radiographic images that aid in the interpretation of nuclear medicine examinations. Such systems also increase the efficiency of a nuclear medicine service by allowing timely and conclusive interpretations to be made.

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.

PACS: implementation in the U.S. Department of Defense

The Department of Defense has been a leader in Radiology re- engineering for the past decade. Efforts have included the development of two landmark PACS specifications (MDIS and DIN- PACS), respective vendor selection and implementation programs. A Tri-Service (Army, Navy and Air Force) Radiology re-engineering program was initiated which identified transitioning to digital imaging, PACS and teleradiology as key enabling technologies in a changing business scenario. Subsequently, the systematic adjustment of procurement process for radiological imaging equipment included a focus on specifying PACS-capable-digital imaging modalities and mini- PACS as stepping stones to make the hospitals and health clinics PACS-ready. The success of the PACS and teleradiology program in the DOD is evidenced by the near filmless operation of most Army and Air Force Medical Centers, several community hospitals and several operational teleradiology constellations. Additionally, the MDIS PACSystem has become the commercial PACS product for General Electric Medical Systems. The DOD continues to forge ahead in the PACS arena by implementing advanced configurations and operational concepts such as the VRE (Virtual Radiology Environment), the negotiation of Regional Archiving and Regional PACS Maintenance Programs. Newer regulations (HIPAA, the FDA approval of digital mammography) have been promulgated impacting the culture and conduct of our business. Incorporating their requirements at the very outset will enable us to streamline the delivery of radiology. The DOD community has embraced the information age at multiple levels. The Healthcare portion of this community with these initiatives is integrating itself into DODs future. The future holds great possibilities, promises and challenges for the DOD PACS programs.

New facility picture archiving and communication system implementation strategy.

Strategies for deployment of picture archiving and communications systems (PACS) in new hospitals often involve the establishment of initial PACS operations. Such a strategy is flawed in the sense that the clinical and radiological users must adapt to PACS operations, while being faced with several other new facility learning curves. This increases the complexity and risk of the radiological services. A strategy of implementing PACS operations in the old facility and performing a zero-downtime transition into the new facility offers several advantages to this method. The successful undertaking of such a project will support not only the physical movement of the existing PACS, but the accomplishment of other re-engineering goals associated with the new hospital. This report will describe the strategy used in two successful transitions of PACS into newly constructed hospitals.

Parlaying digital imaging and communications in medicine and open architecture to our advantage: The new Department of Defense picture archiving and communications system

The Department of Defense (DoD) undertook a major systems specification, acquisition, and implementation project of multivendor picture archiving and communications system (PACS) and teleradiology systems during 1997 with deployment of the first systems in 1998. These systems differ from their DoD predecessor system in being multivendor in origin, specifying adherence to the developing Digital Imaging and Communications in Medicine (DICOM) 3.0 standard and all of its service classes, emphasizing open architecture, using personal computer (PC) and web-based image viewing access, having radiologic telepresence over large geographic areas as a primary focus of implementation, and requiring bidirectional interfacing with the DoD hospital information system (HIS). The benefits and advantages to the military healthcare system accrue through the enabling of a seamless implementation of a virtual radiology operational environment throughout this vast healthcare organization providing efficient general and subspecialty radiologic interpretive and consultative services for our medical beneficiaries to any healthcare provider, anywhere and at any time of the night or day.The Department of Defense (DoD) undertook a major systems specification, acquisition, and implementation project of multivendor picture archiving and communications system (PACS) and teleradiology systems during 1997 with deployment of the first systems in 1998. These systems differ from their DoD predecessor system in being multivendor in origin, specifying adherence to the developing Digital Imaging and Communications in Medicine (DICOM) 3.0 standard and all of its service classes, emphasizing open architecture, using personal computer (PC) and web-based image viewing access, having radiologic telepresence over large geographic areas as a primary focus of implementation, and requiring bidirectional interfacing with the DoD hospital information system (HIS). The benefits and advantages to the military healthcare system accrue through the enabling of a seamless implementation of a virtual radiology operational environment throughout this vast healthcare organization providing efficient general and subspecialty radiologic interpretive and consultative services for our medical beneficiaries to any healthcare provider, anywhere and at any time of the night or day.

Clinical Experience with Teleradiology in the U.S. Military

The U.S. military through the Medical Diagnostic Imaging Support (MDIS) system is installing teleradiology at multiple medical treatment facilities throughout the US and abroad. The goals are to improve patient care, maximize limited resources, and realize cost savings. This presentation reviews early experience with clinical use of the MDIS teleradiology configuration. Emphasis is on lessons learned in the areas of image quality, speed of image transmission, communication between sites, and the advantages of the MDIS two-way teleradiology configuration. The data is accumulated from the combined experience of the authors at multiple different sites within the continental US, Hawaii, and Korea.

PACS: moving a live PACS with zero downtime

As PACS implementations increase during the new millennium, the need to plan and execute the movement of a live PACS from an existing facility into a replacement hospital increases. Such an undertaking should support not only the physical movement of the existing PACS but also the continuous support of clinical radiology operations throughout the transition period. This paper will describe two successful transitions of live PACS into newly constructed replacement hospitals. In 1994 the Brooke Army Medical Center transitioned into a newly constructed 450-bed facility in San Antonio Texas. In 1999 a similar movement of the Elmendorf Air Force Medical Center was successful accomplished in Anchorage Alaska. Both moves provided continuous operations of the Radiology Department and full clinical services in the old facilities in a near filmless mode while fully supporting the simultaneous installation and testing of new PACS components and PACS-to- modality interfaces in the new facilities. The process also included the migration of the image archives and acceptance testing of the final installation. While the exact migration process must differ, depending on the PACS architecture and the facility transition plans, these two examples provide a general framework for the issues and strategies for such a move.

Strategy of DIN-PACS benchmark testing

The Digital Imaging Network -- Picture Archive and Communication System (DIN-PACS) procurement is the Department of Defenses (DoD) effort to bring military medical treatment facilities into the twenty-first century with nearly filmless digital radiology departments. The DIN-PACS procurement is unique from most of the previous PACS acquisitions in that the Request for Proposals (RFP) required extensive benchmark testing prior to contract award. The strategy for benchmark testing was a reflection of the DoDs previous PACS and teleradiology experiences. The DIN-PACS Technical Evaluation Panel (TEP) consisted of DoD and civilian radiology professionals with unique clinical and technical PACS expertise. The TEP considered nine items, key functional requirements to the DIN-PACS acquisition: (1) DICOM Conformance, (2) System Storage and Archive, (3) Workstation Performance, (4) Network Performance, (5) Radiology Information System (RIS) functionality, (6) Hospital Information System (HIS)/RIS Interface, (7) Teleradiology, (8) Quality Control, and (9) System Reliability. The development of a benchmark test to properly evaluate these key requirements would require the TEP to make technical, operational, and functional decisions that had not been part of a previous PACS acquisition. Developing test procedures and scenarios that simulated inputs from radiology modalities and outputs to soft copy workstations, film processors, and film printers would be a major undertaking. The goals of the TEP were to fairly assess each vendors proposed system and to provide an accurate evaluation of each systems capabilities to the source selection authority, so the DoD could purchase a PACS that met the requirements in the RFP.

Personnel training during large scale PACS implementation

The introduction of a new technology, such as PACS, on a large scale into a clinical environment requires a comprehensively designed training plan to achieve success in implementation of the system and minimal impact on the clinical operations of the facility. A tremendous range of experience and computer literacy will be found in the personnel who require training in some aspect of operation of the PACS. This presentation will describe the development and implementation of such a comprehensive plan.