Cover Story

Future is Here

No more is PACS a simple, digital radiology image storage system. PACS is empowering radiologists with précised integrated enterprise workflow, automatic image processing and the capability to share images with anyone, anywhere in the world, finds out Nancy Singh

The medical imaging field is evolving rapidly. In the latter half of the decade, we have witnessed a noticeable switch from hospitals and radiography departments using bulky film to more digital means. Nowhere else is this thing more evident than the manner in which computed radiography has been the crucial link between traditional film radiography and digital radiography.

The Century Gone By

In the last 25 years, the technological developments in medical imaging have affected and mostly redefined almost all fields of medicine. The involvement of computers in modern medicine has completely changed the role of the radiologist. Technically speaking, in the late 1960s, digital imaging commenced in nuclear medicine. Then, the 1970s observed the materialisation of Computed Axial Tomography. But, since the discovery of X-rays, there has been hardly any advance in medical imaging that actually changed the diagnosis and management of patients better. Ultrasound transformed as a useful tool during the 1980s due to the computers. The same decade also saw the inclusion of digital imaging to vascular radiology. Magnetic resonance imaging just came as a new technology revolutionising imaging in neuro-radiology and orthopaedics. Progress in image acquisition and display dominated the 1990s. Plain radiography (CR) entered the digital age in this decade.

PACS: The Revolutionary Technology

The world of 3-D imaging and non-invasive vascular imaging are today a reality in MRI, CT and ultrasound, primarily because of faster computing speed. Until recently, the digital imaging studies have been archived and viewed on a radiographic film. Transfer of image was also limited to the digitisation of filmed images and their transfer by proprietary systems. The volume of data that gets lost due to this kind of conversion to and from analog film and the inbuilt limitations of film-display and storage resulted in the development of PACS or Picture Archiving and Communications Systems). "For the past 100 years, film has been almost 'the' exclusive medium for capturing, storing, and displaying radiographic images but it is a fixed medium with usually only one set of images available. PACS technology allows for a near filmless process, with all of the flexibility of digital systems. It also eliminates all costs associated with hard film and releases valuable space currently used for storage," shares Suhas Pokale, Country General Manager, Fujifilm, India. PACS system allows the imaging studies to be viewed, manipulated and archived in their digital form.

The DICOM Standards

In the beginning of 1990s, American College of Radiology formulated and worked hard to establish a specific standard for systems in imaging. As a consequence, DICOM or Digital Imaging Communications in Medicine became accepted as the standard format for image acquisition, display and archiving. With the establishment of these standards, digital imaging was no longer vendor specific. Images now could be viewed, manipulated, stored and transmitted in the same language. With the high-resolution display devices, the images could be viewed in their digital form at a computer workstation.

A Filmless World

Today, PACS technology allows for a near filmless process, with all of the flexibility of digital systems. It also eliminates all costs associated with hard film and releases valuable space currently used for storage. For patients as well as the radiographer, even the amount of exposure to radiation gets reduced because fewer images need to be repeated using this technology. What's more, patients do not have to wait for long for results which also ensures speedier move to the next point of treatment or discharge. Privacy is guaranteed as access to patient's digital images is rights-based i.e. what they will be able to view, shall depend on their role and involvement in patient's care. For example, a consultant will be able to look at a patient's digital images because they are a clinical care provider, whereas a receptionist may not be able to view clinical information.

The images are stored in highly secure database systems. Since the images are digital in nature, they are more reliable. Unlike film, there are no black spots on images due to bad light. "Our PACS allows for flexible viewing with the ability to manipulate images on screen enabling better analysis. Moreover, instant access to historic images and patient records facilitates comparison of images (old and new) and thus the measuring of the effectiveness of treatment or the development of patient's condition," shares Kenichi Tanaka, Managing Director, Fujifilm India.

The group has already implemented PACS in 10 hospitals in the country which include Sri Sathya Sai Institute of Higher Medical Sciences (SSSIHMS), Bangaluru, Sagar Hospitals, Bangaluru, SSSIHMS, Puttaparthi, Institute of Liver & Biliary Sciences (ILBS), Delhi; Primus Super Speciality Hospital, Delhi; Rajiv Gandhi Cancer Institute & Research Center, Delhi; and Pushpanjali Crosslay Hospital, Ghaziabad.

The Digital Magic

As a consequence of electronic requesting, radiographers have all the necessary information available to them in digitalised format. Today, investigation is appropriate to the request and safer for the patient - misinterpretation of what is handwritten has become a thing of the past. Information only needs to be entered into the system once. This reduces some of the administrative tasks currently undertaken by radiographers, thereby freeing up time to focus on caring for the patient. The ability to manipulate images once they are taken means that radiographers can zoom in on areas of interest to ensure adequate information has been captured, which can then be passed on to the relevant clinician.

Says Prakash S Kamat, Managing Director, SoftLink, "In the last couple of years, a number of significant changes have occurred in image capturing, archiving and data retrieval. Integration with information systems and networked approach have dramatically changed disease management, with the help of implementing C-PACS, a cardiology imaging network solution, by upgrading traditional standalone workstation." The cardiologist can view the digital images on a cardiology workstation, which is composed of a display monitor and a central processing unit that is networked into PACS. The image server is connected directly to the cathlab and/ or ECHO machine for receiving DICOM patient images, which are stored on the server with an on-line storage of about six months and can go up to a few years.

Trends

PACS today is just not about image archiving anymore. The newest PACS are providing radiologists with more précised integrated enterprise workflow, automatic image processing and the capability to impeccably share images with anyone, anywhere in the world. In the present times, PACS is not anymore a simple, digital radiology image storage system. "PACS has become the cost of doing business in radiology today, and vendors continuously improve their products through better workflow and enhanced image processing. Each vendor aggressively promotes their 'special' PACS with add on features," shares Dr JV Divatia, President, Indian Radiological and Imaging Association.

The RIS/ PACS Marriage

Integration of Radiology Information Systems (RIS) with PACS is a defining trend in the imaging market. A recent Frost & Sullivan study indicates that the market was worth $125 million in 2006 and this is expected to increase to $181 million by 2013. Years ago when PACS was starting to become common in radiology practices in the west, the users bought their PACS and then either bought-or created in-house-a separate RIS product to manage the added info like billing, scheduling, patient info, etc. As the vendors started to develop separate RIS products, they noticed as to how the two programmes can complement each other. Hence, instead of building it all up from scratch, the some smarter companies bought stand-alone RIS companies, with an aim to marry the two products into a single flawless package.

Though initially the first by-products of this marriage were quite poor matches, compelling the HL7 and DICOM cousins to play nice to each other, when they hardly had little programming in common. However, the next or latest versions of RIS-PACS are really made for each another, and for the most Indian healthcare organisations that are likely to invest in the latest integrated system, there are definitely distinct enterprisewide advantages. "The future lies in IT," says Sunder Natrajan, CEO, Ashva Technologies. "Hospitals prefer to go paperless and filmless. Data archiving is picking up gradually in India. Digital records score over manual records. Data is readily available at the modality end. It can be easily retrieved. Initially, many hospitals were hesitant in taking PACS because of high prices," admits Natrajan." However, the trend is now changing. The prices are coming down and more hospitals and diagnostic centres are moving towards digital records. "Adopting IT has intangible benefits. It increases the productivity and has an impact on the workflow," he adds. PACS companies have started to look at all the things holistically to ensure that things like billing, registration, patient info and stuff are done upfront instead at the end. Another distinct advantage to an integrated RIS/ PACS is that RIS information can make available information to the PACS, which in turn enables more automated features for the radiologist's diagnosing and reporting tasks.

Life in Automatic Highway

Typical advantage of RIS/ PACS is that the RIS can provide information to the PACS, facilitating more automated features for the radiologist. An integrated system which already knows certain information like patient's history, reason for the examination, and the tests ordered, these systems can now automatically predict or rather anticipate specific views to the radiologist. For instance, when a radiologist who is trying to examine a CT scan has to put in a lot of efforts in manipulating the data set before being able to make the correct diagnosis. So today, as a solution vendors are now trying to reduce the number of steps and hence reduce the time taken by introducing things like automatic registration and segmentation or volume matching of prior examinations. Says Vinod Kalra, Project Manager, SAP, Artemis Health Institute, Gurgaon, "The integration of PACS with other system seamlessly ensures that the entire patient medical records and financial transactions are available online on real-time basis."

Hence, the end result is such that these intelligent machines of today are lessening the manipulation of image manually and giving more time to the expert for faster evaluations. In addition, there are many PACS programmes in the west where they even have 'automated normal reports.' Just through a few clicks, a template report notifies the referring physicians that the results are normal.

This Decade Goes to the Web

The best part about PACS is the fact that, unlike films, the images can be viewed by physicians anywhere in the world at any given point of time. Well that is how it seems to work on face value, but a closer look in reality shows that one hospital's PACS system is not really compatible with another imaging centre. As a result, the PACS manufacturers are nowadays creating web-based viewing solutions by the help of which reports and images can be accessed through varied workstations, your home PC or a PDA. Also, the manufacturers are creating different methods to facilitate better interoperability amongst different PACS. There are a few PACS systems that have started using an off-site intermediary server, by the help of which, the radiologists can obtain reports from separate and disparate systems into their own systems. Whatever the method, the core part of everything is the web. "Technology permits radiologists to have a look at images anywhere, even on their Blackberries," says Thulasiraj Ravilla, Director - IT & Systems, Aravind Eye Care Systems.

As part of this ongoing trend, PACS designers are offering 'role-based access', whereby the user and the administrator have control over the access into their system by assigning limited roles to each user. Therefore, the referring physician manages to log in and review reports or even pending patient reports from his/ her patients only, whereas the radiologist can use the same PACS system from home or any other imaging centre and have access to all patients. There is also an increasing trend in automatic reporting, wherein, for instance, when the report is done, an e-mail or document is automatically sent to the referring physician with a web link to the final report, which can either be viewed from a laptop or a handheld device. It is quite recent that off-site reading has been designed in a more practical fashion by improved data compression and streamlining of images.

Contemporary PACS systems that stream images allocate partial data sets of, for instance, the heart, to be streamed on the internet at the radiologist's home, rather than the entire data set. If the radiologist is navigating around an image of the upper quadrant, only that image data flows over the net instead of the entire heart. The end result - faster viewing utilising lesser bandwidth.

Teleradiology, certainly, is all web based, and companies are indeed making it easy for the hospitals and imaging centers to take advantage of the various teleradiology services. "We conduct almost 600 consultations everyday through our highly integrated tele-ophthalmology network," shares Ravilla. There are software packages available in the market that facilitates studies to be placed in a dedicated teleradiology worklist, which in turn, can be manually or automatically transmitted to an offshore reading centre.

Hence, when the imaging centre is not operating in the night, the complete package of images, scanned documents, prior image studies and reports, and all the data that is relevant in terms of patient demographics can be sent to overnight services. Primarily, the main PACS trend for today and the coming future is more sophisticated image processing with improved automation. Digital imaging, PACS and internet-based image review is the wave of the future in medical imaging.

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