Web-based PACS Packs Interest

It doesn't seem right to call PACS old because the technology is still in its youth. But the PACS of today is definitely a more mature sibling of the PACS of a decade ago.

Today, hospitals want their digital images to travel outside the confines of radiology and reach the entire radius of their healthcare enterprise: fast, on demand from anywhere, all the while maintaining excellent image quality. Vendors are doing just that by serving up PACS (picture archiving and communications systems) dependent on a Web-based architecture. The systems are more organized and efficient in design, relying on sophisticated storage techniques, advanced software and increased bandwidth.

It may be more appropriate these days that PACS are maturing, and the World Wide Web is now its companion down this long and winding road of information technology.


It was only natural that Boston Children's Hospital would implement a PACS that allowed doctors to read images online, seeing that the 350-bed pediatric facility had already been using the Internet to access clinical information for more than five years.

"We adopted Web technology inside the hospital to develop a Web-based Results Reporting application [to access the electronic medical record] that contained many pieces of electronic medical information that could be viewed using networked PCs," says Ted Treves, M.D., vice chairman of Radiology Information Systems. The only images that could be accessed during that time were nuclear medicine, since the department had a mini-PACS of its own, explains Treves.

By the time the hospital installed Fujifilm's Synapse PACS in 2003, the physicians were more than ready for its arrival. "The results reporting application was built purposely so that when PACS arrived, we would have enterprise access to all diagnostic images," explains Treves.

Synapse uses a compression scheme that stores three versions of an image - making it less network intensive and saves storage expenditure - thus satisfying both the imaging experts within the department and at the same time providing enterprise image access to all Children's Hospital clinicians.

Film has not been eliminated, rather it is gradually being reduced, says Treves. "We recognize that some [clinicians] cannot get the job done without printing film. The key is not just to cut the film, but also to have broader and timely access to the images when and where needed. With our PACS we no longer lose film, so we feel good that images are available all the time. And the more people who have access to the PACS, the more they are secure that they don't need to ask for the film," says Treves.


It is not a one-way street hospitals travel down when making the Web a part of daily workflow. Web-based models are flexible so healthcare facilities can start with enterprise distribution or teleradiology, and then build upon that investment to move to full PACS. University of Chicago Health Systems (UCH) first used Amicas Inc.'s enterprise wide distribution system for referring physicians and clinics because their initial PACS focus was enterprise clinicians, not primary interpretation by radiologists.

"Two and a half years ago, there was a push to get our clinics - such as hematology, oncology, rheumatology, ER, thoracic surgery - filmless," says Sanju Abraham, director of Radiology Informatics at UCH. What was their objective? "To not print films in these areas, giving clinicians access to the images immediately and making the most out of UCH's archive investment," says Abraham.

While the Web granted clinicians immediate access to the images, film use did not stop altogether. The operating room (OR) still uses film, says Abraham. It's not a software challenge impeding the OR's filmless transition, rather challenges are posed in configuring a filmless OR. "There are 25 ORs and each one presents a unique challenge. There are going to be two, dual-head monitor configurations on carts tethered to the wall with a network cable. Where do you position them? Where do you keep them in such a way that it is not going to be in the way?" poses Abraham.

In June, the 603-bed system then decided to employ Amicas' Vision Series PACS for primary interpretations by their radiologists and deployed diagnostic workstations. Backed by years of on-line priors, helpful training, a physician champion and workstation-replaced-alternators, radiologists had little reason not to use it.

"The first thing we accomplished was Web distribution of images before it was brought to radiology," says Abraham. "What we have accomplished with that is immediate access to the images by ER and clinicians. It's given them tools they would not have had with film and when you combine that with the fact that they can do it within minutes of the exam being completed, that's a pretty amazing thing."


In order to get the electronic images to referring physicians, Long Beach Memorial Medical Center and Miller Children's Hospital, part of a five-hospital chain in Southern California, installed Kodak Healthcare's DirectView Web Distribution system to its existing PACS in April.

"Before the Web, our system was not a complete PACS because there was no long-term storage. We were still printing film and the hardcopies were stored in four different locations," says PACS Administrator Eric Aune.

"When I started working, I was told the first six months would be 90 percent PACS, and then it will drop to 50. Well that did not work; about 75 percent or more of my time is PACS. I currently make daily rounds to reconcile multiple datasets. As of now, the images come from the modality and go to an archive server, which handles long-term storage. That device then sends the image to a Web server, for the distribution system, or to the workroom server, for our main PACS," explains Aune.

The next step in Long Beach's sequence of events is upgrading the system with Kodak's DirectView PACS 5, developed by the company's Health Imaging Group. In May 2002, Kodak and Israel-based Algotec signed an agreement under which Algotec would provide supplemental software for the development of Kodak's PACS products. System 5 is the most recent proof of the companies' collaboration. In December, Kodak purchased Algotec.


"People can spend a lot of money on a PACS and never get the film savings and efficiency that they desire," says John Bauman, radiology director for Carolinas HealthCare System (CHS), an integrated health system in Charlotte, N.C. "We spent a lot of money on a PACS, but film was still being used and we were not meeting the needs of our referring physicians at all," explains Bauman.

Printing film and spending money on PACS is an expensive concept for any healthcare provider to swallow, especially CHS which covers four large institutions in Charlotte totaling 1,300 beds and producing 500,000 images annually, in addition to supporting multiple out patient imaging centers and rural facilities.

"The trouble with our system before was that there was no archive and we were still at a very manual process from a workflow perspective. Our archive was hardcopy and referring physicians accessed these images from a hard-copy format. If a patient came into MRI, we could network over the image to the reading area for quick viewing and quick reading. But for the file, we would have the film printed and store it for multiple years," explains Bauman.

CHS turned to the Web two years ago to solve its costly problems and installed iSite Enterprise developed by Silicon Valley upstart Stentor Inc.,

followed by the company's iVault Archive. Stentor's iSyntax technology allows images to be sent in pieces and not as a large 100-megabyte file that jams the network. This allows diagnostic quality images to be transmitted and read anywhere throughout the enterprise.

The benefits have been many, says Bauman. "It even allows a hospital to begin to create an electronic medical record for the images and it's a hook to our referring physicians to use us over and over again and not send anything outside unless they create a fragmented imaging record. Today in a film environment, it does not matter where a patient gets the image taken because he or she can bring it with him or her to the hospital. By the time it's in an electronic folder, that's where it starts to change things."


Baylor Healthcare System (BHCS), a 14-hospital chain in Texas, purchased high-end workstations for radiologists to utilize GE Medical Systems' Centricity PACS at three sites: Baylor University Medical Center Dallas (900 beds), Baylor Garland (220) and Baylor Grapevine (197).

Administrators and directors from all Baylor sites then decided that the most cost-effective alternative in providing enterprise access to referring physicians - and meeting rigid security standards - would be to purchase their own server in agreement with GE to utilize their Centricity Web software.

"Now, any Baylor referring physician from any location with Internet access and proper privileges can access PACS at any Baylor site which has GE Centricity PACS through Centricity Web," says Kelly Murphy, PACS administrator at Garland.

"There are two different applications: the workstation application, which is not Web [based], but has its own server and archive, and then there is the Web server that delivers to places such as nursing units, physician offices, and mobile Web stations in surgery," explains Murphy.

The Web in PACS implies that the host is relatively modest in price; hospitals can buy multiple PCs rather than a $40,000 workstation. "At Garland, we basically took the cost of the original six workstations and with the savings bought 19 PCs that we turned into the workstations," says Murphy.

What's in a name? Defining Web-based

In the early days, PACS proved its worth by moving electronic reports and images around the radiology department. Still, the confined data could not reach referring physicians and clinicians outside. Unsatisfied, PACS customers wanted more bang for their buck; something that was truly "enterprise."

Vendors returned with a product that cast its delivery on a URL-based mechanism to transfer images, and at the same time, developed a name that became a little tricky to define: Web-based PACS.

The fundamental design of an Internet delivered system is based on a server that provides image display and database functions to workstations using Web-based methods. Hospitalsneed a secure method of transportation, an intranet or VPN (virtual private network) and users need a DSL connection, 512 RAM, 700 of gigabytes for speed, and a monitor of 17-inches or larger. The result, any PC can run a browser and turn into a workstation!

There's more.

"When you look under the hood of the PACS, there are a lot of pieces that work together in a collaborative fashion to pull off PACS functionality, such as workflow engines, multiple databases, multiple operating systems, workstations for visualization, archive components and multiple tiers of archives," says Brad Levin, director of strategic marketing for Amicas.

Some systems solidify these components using a Web-centric architecture while others may offer a Web component that provides enterprise images. Does Web-based depend on the technology used to get the images across hospital borders, or rather on the mere fact that images are sent over the Internet remotely?

The difference may be confusing and the semantics a little too technical, but in the end, physicians want confidence in their systems. That comes with excellent image quality, speed in which the images are transmitted, a reliable network and of course, an ample return on investment.