PACS Across the Enterprise

The benefits of integrated RIS/PACS in radiology are absolutely clear: improved workflow, faster report turnaround time and enhanced patient care. Enterprise care, however, is equally important, and digital image management solutions such as the Siemens RIS/PACS and related solutions can deliver powerful benefits to clinicians across the enterprise.

Take for example Children’s Hospital of Alabama in Birmingham. PACS is an enterprise project at Children’s. Clinicians across the Children’s Health System use Siemens Web-based Viewer image and report distribution and web-based 3D to access radiology images and reports and improve clinical processes. The approach delivers advantages across the enterprise. Consider:

• The ICU has eliminated the historical challenge of the sneaker net where a resident trails a tech to deliver urgent films. Siemens Web-based Viewer facilitates immediate image review and feedback, which, in turn, expedites patient care.
• Enterprise-wide, web-based 3D provides neurosurgeons and other clinicians additional information in difficult cases such as skull fractures.
• Siemens PACS has helped to deliver tremendous improvements in patient throughput and quality of care in the ER, says Director of Emergency Medicine Peter Glaeser, MD. For example, specialists can review images from home to provide immediate input.
• The ability to review and manipulate digital images prior to orthopedic surgery helps surgeons place pins, screws and bolts more accurately during procedures to treat complex deformities of the spine, hips or knees.
• Enterprise PACS is a complex undertaking; success hinges on careful planning and communication and collaboration among all stakeholders. But, as Children’s Hospital demonstrates, the enterprise approach reaps significant dividends.

The integrated ICU

Imaging needs and applications differ across the enterprise. Optimizing digital image management requires configuring solutions to each department’s needs. Children’s Hospital developed systems and processes to ensure maximum gains with the Siemens PACS and Web-based Viewer deployments.

The ICU traded conventional viewboxes for the Web-based Viewer thin-client viewing systems about four years ago. Today, intensivists can view images on every computer in the unit or at a Plasma screen viewing station. In addition, mobile physicians can access reports on handhelds via Palm-compatible software.

The differences between conventional film-based care and RIS/PACS-enabled digital processes are significant, says Intensivist Margaret Winkler, MD. Radiologists and intensivists still meet for morning rounds, but the process of reviewing digital images is less cumbersome and much faster, says Winkler. Specialists gather around the large central ICU viewing station to review and discuss images every morning. During the day, the process of reviewing random urgent x-ray and CT studies is more efficient and facilitates better patient care. Residents no longer chase after techs to ensure that radiologists review stat studies. Instead, radiologists review ICU studies immediately without the physical intervention of a resident. In addition, radiologists call intensivists with urgent results like a pneumothorax. “If I miss something, the radiologist catches it and immediately brings it to our attention,” explains Winkler. Finally, she and other intensivists can review images with on-call subspecialists who use Web-based Viewer to view studies from home. The approach eliminates the ambiguities and delays associated with film. That is, intensivists don’t need to describe a small subdural hematoma by phone; nor do subspecialists need to drive in at night to review films.

In addition, electronic imaging empowers ICU staff, Winkler says. For example, nurses can place a feeding tube, order the x-ray, review the image and let an intensivist know that the tube is in place so the department can start feeds. Extra staff training focused on image interpretation provided staff the skills needed to adopt this approach.

The web-driven operation

Neurosurgeons at Children’s rely on a configuration similar to that in the ICU. Most view images in their office via Web-based Viewer, but the department conference room is outfitted with a 60-inch, flat-screen plasma display system. In addition, each of the hospital’s OR suites contains a pair of 23-inch monitors on ceiling arms, and clinics feature monitors where physicians can share images with patients and parents.

Web-based viewing is ideal and facilitates rapid access to images and reports, says Pediatric Neurosurgeon Leslie Acakpo-Satchivi, MD. Web-based 3D delivers additional clinical benefits. “Patients are 3D entities. Surgeons are accustomed to translating 2D imaging studies into three dimensions in our heads. Web-based Viewer 3D creates 3D images for us, so we can preview what we’ll see in the OR prior to surgery,” explains Acakpo-Satchivi. 3D images provide additional diagnostic information to help surgeons assess skull fractures or place hardware.

Despite its early promise, 3D remains a work in progress and surgeons expect to see additional benefits in the future. “There is a great deal of potential for 3D. We might find a way to visualize cerebral ventricles. Current 2D studies do not provide a complete view of the ventricular system. Many of our patients present with dismorphisms in the ventricles. Knowing what we would encounter ahead of time could help us better plan procedures,” sums Acakpo-Satchivi.

Orthopedic surgeons report benefits similar to other clinicians with the RIS/PACS project, and they also attribute additional clinical benefits to integrated digital surgical planning tools on Siemens MV 300. Orthopedic surgeons use the tools to review images prior to surgery. “The combination of high-resolution 64-slice CT images and 3D modeling enhances our ability to manipulate, rotate and measure images and translates into more accurate placement of pins, screws and bolts,” says Pediatric Orthopedic Surgeon John Killian, MD. In addition, surgeons can better indirectly view parts of the body, which facilitates minimally invasive surgical procedures. Finally, the availability of accurate measurements can help decrease the amount of surgical fluoroscopy.

The digital ER

The Children’s Hospital ER transition to digital image review was seamless and rapid, says Glaeser. Currently, physicians can access imaging studies at most computers in the department, including two higher resolution monitors in the trauma room and main nursing station.

“We’ve seen a definite increase in throughput,” Glaeser says. Annual ER patient visits hover in the 55,000 range, and prior to Siemens PACS it wasn’t unusual to see six to eight patients waiting for x-ray studies at any given time. Since integrated RIS/PACS was added, turnover has improved because kids don’t have to wait for images to be developed. On the clinical front, the ability to modulate the digital image improves physicians’ ability to pick up subtle abnormalities that would likely be missed in the analog environment. The integrated digital systems allow physicians to zoom in, change the contrast and use a host of other tools to improve their ability to detect significant disease or injury.

In addition, electronic tracking tells physicians when radiology orders are complete. Specialists such as neurosurgeons and orthopedic surgeons can review images anywhere via Web-based Viewer, which increases throughput and improves patient care. “We can provide immediate feedback to help the ER temporize and stabilize patients via phone,” Killian points out.

Digital processes fuel other quality improvements. For example, both ER physicians and radiologists read ER patient studies. Prior to Siemens RIS/PACS, the hospital relied on paper-based processes to catch discrepancies between the ER and radiology interpretations. That is, physicians communicated their findings by placing a sticker with the initial interpretation on the film. One problem? Some 10 percent of the films were lost between the ER and radiology. With the new system, the ER physician attaches a preliminary digital report to images. If a radiologist disagrees with the interpretation, the discrepancy is reported to a nurse for immediate follow-up.

Enterprise advice

An enterprise RIS/PACS project can transform patient care and re-engineer workflow to create a solid foundation for 21st century healthcare. Successful projects require a careful, coordinated approach.

Insiders at Children’s Hospital offer some advice for working out the wrinkles.

• Involve enterprise end-users in the project from the beginning, says Pete van Pelt, senior vice president of operations. PACS does benefit enterprise users, and they can help craft plans to optimize the investment across the enterprise, particularly when they are involved from the outset of the project.
• Consider the single-vendor approach. “We have very little downtime,” reports van Pelt. In addition, Siemens offers complementary solutions such as web-based 3D that allow the hospital to capitalize on additional benefits.
• It’s critical to have a back up plan, says Winkler. Children’s Hospital duplicated its radiology viewing station, Siemens MagicView 300, and also stores images locally in the ICU to ensure continuity of care and immediate, constant availability of images and reports.
• Prepare for digital success. At Children’s Hospital, specialists no longer want to wait for films of transferred patients. “They want to order repeat scans, which we can’t do because of costs and additional radiation exposure,” notes Glaeser. Currently, the ER and IT are collaborating to develop systems and processes to digitize films of transferred patients.
• Children’s Hospital employs two PACS administrators familiar with both radiology and IT. On the enterprise end, the PACS administrators provide just-in-time training and education and assist with porting images to other sites.
• Invest in staff training; a knowledgeable, empowered staff is the best ticket to optimizing the investment across the enterprise.

Enterprise impacts

PACS is no longer a radiology-only project. It is an enterprise undertaking with enterprise benefits. As specialists from intensivists to surgeons and ER physicians tap into digital image management processes, patient care is expedited and improved. Forward-thinking groups like Children’s Hospital that assess and address the variety of PACS needs across the enterprise can better design systems and processes to meet these needs and realize maximum gains.