From the June 2006 Issue

On the Road to RHIOs

Passing the "Yo' Mama" Test

A Season of Change

Implementing EHRs Requires a Shift in Thinking

In Praise of Unitasking

A Season of Change

 By Mike McBride, Associate Editor

For nearly a century, there was little change in the complex processes and procedures to develop, handle, transport and store hard-copy X-ray films. Automation and manufacturing advances increased the speed of the film processing. However, at its core, it remained a chemical process. Even in the past decade, the stations at which hard-copy films could be viewed also went relatively unchanged—basically, a simple light box with no zoom or rotation capabilities.

Then, seemingly overnight, PACS arrived to supplant that technology, displacing tried and true methods with digital systems to examine and archive medical images. The new technology revolutionized the capture, movement, storage and display of medical images, and though old methods can die hard, innovative institutions, such as Oregon Health & Science University (OHSU) in Portland, Ore., found themselves, out of necessity, in a race to increase functionality.

Out With the Old, In With the New
OHSU’s approach to PACS somewhat mirrors the rise of their institution over the past 200 years. What began in 1867 as a medical education department at Willamette University in Salem, Ore., today sits on 263 acres atop Portland’s Marquam Hill. The OHSU campus encompasses two hospitals, OHSU Hospital and Doernbecher Children’s Hospital, with 447 beds and 31 buildings including clinics, administration, research labs and classrooms. Dental clinics, an eye institute and a child development and rehabilitation center are part of the institution, as well as a school of science and engineering, a primate research center, the Neurological Sciences Institute, and the Vaccine and Gene Therapy Institute. In 2005, OHSU provided more than 175,000 ambulatory services, with more than 39,000 ED visits, 24,900 hospital discharges, and 730,000 medical and dental outpatient visits.

OHSU purchased Agfa’s IMPAX PACS in 1998, to address a growing need for a centralized repository of radiological images that could effectively service the entire organization, though, initially, only the radiology and pediatrics departments used it. Film cost was the primary motivation for switching to a PACS system, says Jon Hanada, systems manager, diagnostic imaging. “As soon as we converted, though, we knew it was more than just film cost we would be saving, it was time. Time to get the images from the modality to the radiologists, and still get the same studies, the same images to the clinicians.”

OHSU’s radiology department is quite decentralized, says Erwin Schwarz, director of diagnostic imaging services. It is spread out between eight different locations at five different buildings, with pediatric services offered in all five. As OHSU grew, moving images among the various branches of the institution became problematic. According to Schwarz, “PACS was able to facilitate the transfer of images across the enterprise better than the traditional method of film.”

From 1998 to 2000, OHSU converted their children’s hospital from film to digital. They also scanned decades of prior film studies and slowly reduced their image library staff. Though their ROI initially was small, as a portion of OHSU’s entire operating budget, the full benefit was not yet realized. “The total volume of the children’s hospital is less than 10 percent of the institution,” says Schwarz, “so the full payback didn’t happen until we implemented the system enterprisewide.” After that, OHSU’s expenditures dropped from more than $500,000 dollars per year they were spending on film and image library FTEs to less than $25,000 on just film.

Digital Automation
Today, IMPAX is fully integrated into OHSU’s clinical and radiological systems, and the institution’s image library is a fully automated database. X-ray techs digitally capture a CR study, for example, examine it for anomalies, and, if necessary, rotate or brighten the images. Then the study is sent to the PACS with a header containing the patient’s name, medical record number and study I.D. This information is drawn from the RIS in HL7 format and converted into DICOM data that can be understood by the PACS.

When the study arrives at the IMPAX gateway (a server that identifies the study’s “type” by its DICOM header), another server, the broker, verifies that the study belongs to the correct patient and communicates that to the gateway. Then, based on routing rules defined by radiology, the gateway forwards the study to its next destination. If that destination is the Web, which is outside of the PACS, the Web server converts the data into formats that can be viewed by the clinicians at their locations.

Differing Workflows and Version 6
OHSU’s IMPAX PACS is an enterprisewide system in use by surgeons and radiologists, as well as clinicians to view images at the POC. More than 3,000 PCs are on the system, according to Schwarz, and they are primarily used by non-radiologists. “Anybody who needs to look at an image for healthcare delivery can use the PACS, whether it’s a nurse practitioner, an emergency room physician, a physician’s assistant or a surgeon,” he says.

Agfa’s IMPAX version 6 upgrade, which OHSU plans to have installed by the end of 2006, integrates those departments currently outside of the PACS. For example, version 6 is Web-capable. Clinicians will be able to use their login to access lower resolution images from any location on the Web, while primary interpreters and surgeons, whose work require high-resolution images, will continue to integrate with the PACS by traditional “thick-client” means.

The new version also enables OHSU to tailor the PACS display to each individual clinician’s workflow and needs. Based on the clinician’s login, IMPAX version 6 presents the images in a manner pre-established by OHSU. It also examines the characteristics of the endpoint display and tailors the images accordingly. For example, in the surgical suite, where 3MP monitors may be in use, version 6 sends the maximum amount of information, so that the images will be of the highest viewable quality. Agfa calls this technology “Websurge.” Were the same images requested from a clinician’s office for display on a 1MP monitor, version 6 would scale the image resolution accordingly. Websurge is designed to increase the speed at which images can be displayed on lesser monitors, and generally increase the efficiency of the IMPAX PACS.

Future Growth
IMPAX version 6 is more than a simple upgrade; it is an entirely new version of the PACS. According to Hanada, for those OHSU departments with no existing PACS, the installation will be fairly straightforward. However, installing it in departments that currently use earlier versions of IMPAX will require more effort, since the previous versions are not as fully integrated.

Agfa continues to refine IMPAX Version 6 by adding more of the functionality being requested by departments such as cardiology and echocardiography. OHSU’s general diagnostic radiology customers, e.g., X-ray, CT, MRI and nuclear medicine, will immediately be able to take full advantage of version 6’s single-view, Websurge technology. Once fully integrated, all of OHSU’s departments will have an adaptable, Web-deployable PACS.

Since OHSU’s initial PACS installation, three classes of medical students have graduated having not touched film. They completed their radiological studies entirely on the PACS system, indicative of its widespread acceptance. Still, according to Hanada, seasons of change can present challenges. “It’s not really the technology that’s a challenge,” he says. “It’s convincing people that the different way of doing this is not necessarily wrong—it’s probably better. You can hold onto pieces of your old procedure, but the old procedure may have outlasted itself.”

When it comes to long-standing educational institutions, enterprisewide changes can have far-reaching implications. The doctors and clinicians who graduate from OHSU classrooms enter the medical community armed with state-of-the-art PACS skills that should serve them well in whatever hospital or clinical setting they choose.

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