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Acquainted with some of the compelling advantages written in Part I, Part II focuses on unraveling the daunting task of Pre-PACS preparation, a complexity one might deduce to be the only disadvantage PACS has, if any at all.

In part I, of ‘Going Filmless,’ the decision for a clinical practice, whether searching for efficient data management, or pledging and striving for errorless and advantageous operation, or desiring to provide state of the art imaging solutions for accessibility interdepartmentally, or for that matter, practically anywhere in the world, to invest, procure, and deploy a PACS (Picture Archiving and Communication System) is a “no brainer”, and perhaps, more appropriately, is made, rather than asking the question, “can we?” answering, “how can we not?’”

It is just plain irrational, especially for a new imaging department, or a new hospital, not to install such a system given all the advantages PACS has to offer. DICOM (Digital Imaging and Communications in Medicine), the brains behind PACS, was even given high admiration by some suggesting that “if you could give a Nobel Prize for DICOM, that would be a good thing,” according to an Imaging Economics interview with Dr. Mezrich, professor of radiology and chairman of the radiology department at the University of Maryland School of Medicine, Baltimore.

The careful workflow analysis, seamless integration with other IT (Information Technology) systems and imaging modalities, assurance of DICOM and HL7 (health level 7 – a standard for data information systems) compliance, digitization of analogue film, if necessary, and quality of the network infrastructure are not merely important considerations, but necessities.

Workflow and workload patterns are assessed by documenting how many annual imaging exams are performed on all the various modalities including ultrasound, magnetic resonance, PET, computed tomography, endoscopy, mammograms, DR/CR etc., the average and maximum number of images per exam for each, and generating an overestimated prediction for growth of workflow or an unexpected demand, i.e. an introduction of an image storage hungry CT scanner. Considering other activities, such as staff round presentations, lecture sessions, or even team meetings, requiring the use of PACS, would be noteworthy. Contemplation in other areas, such as the number of non-reported imaging studies, could also be an important workflow factor.

Seamless integration between IT systems and the various imaging modalities present in a clinical practice is vital for successful functionality. Old imaging machines must be upgraded to DICOM standards and data information systems, such as radiological information systems (RIS), hospital information systems (HIS), or in some health care institutions, the electronic patient/medical record (EPR) must be upgraded to HL7 standards. To achieve compliance status, an inventory of the equipment and IT systems with their respective DICOM or HL7 description levels are necessary before a PACS project can be properly designed and priced.

Ignoring the compliance and adherence of DICOM standards leads to one of the most challenging historical impediments for PACS, and still is today--the interoperability between equipment from different manufacturers and their use of private DICOM attributes. Loss of functionality occurs because certain DICOM fields, storing pertinent information, are simply not present, cannot be linked within the network, cannot be shared with other apparatus, and ultimately, cannot be viewed on a workstation.

Chances are good that plain radiography, utilizing conventional analogue film, and rendering the images digitally, at some point, will be required as these types of imaging exams take place in most radiology departments (about 60% of the time). The transference from analogue to digital form is necessary if utilization within PACS is desired. Since digitization is a costly and labor-intensive process, some institutions choose not to digitize at all, but rather make past hard-copy imaging available on request from an off-site storage facility.

Network infrastructure, a crucial link between all components of a PACS system, and its performance, determines how well the PACS will handle and support the demands of workflow and workload of the institution. Cable type, bandwidth, how the bandwidth is shared, and communication protocols all affect the rapidity and response time of a rendered image at a workstation monitor. The PACS system, however, is only as fast as the slowest constituent, lest one forgets to consider all components of a PACS system, including hardware and software quality.

References:

The Royal College of Radiologists : Guide to information technology in radiology. BFCR (in preparation),  London, Royal College of Radiologists, 2007.

Boochever SS: HIS/RIS/PACS integration: getting to the gold standard.  Radiol Manage  2004; 26:16-24.

Andriole KP: Productivity and cost assessment of computed radiography, digital radiography, and screen-film for outpatient chest examinations.  J Digit Imaging  2002; 15:161-169.

Graschew G, Roelofs TA, Rakowsky S, Schlag PM, Heinzireiter P, Kranzlmuller D, Volkert J: New trends in the virtualization of hospitals – tools for global e-Health.  Stud Health Technol Inform  2006; 121:168-175.

Reiner BI, Siegel EL, Hooper FJ, Pomerantz S, Dahike A, Rallis D: Radiologists' productivity in the interpretation of CT scans: a comparison of PACS with conventional film.  Am J Roentgenol  2001; 176:861-864.

Pilling J: Problems facing the radiologist tendering for a hospital wide PACS system.  Eur J Radiol  1999; 32:101-105.

http://www.imagingeconomics.com/issues/articles/2005-05_01.asp

http://www.medicexchange.com/PACS/going-filmless-intro-to-pacs-part-i.html