Spiral CT and PACSHow to Arrange a Marriage

Gary J. Wendt, MD, MBAGary J. Wendt, MD, MBAVice Chair of InformaticsVice Chair of Informatics

University of Wisconsin - MadisonUniversity of Wisconsin - Madison

Department of RadiologyDepartment of Radiology

orWhat is PGP and IHE?

IHE and PGP

Integrating the Healthcare EnterpriseIntegrating the Healthcare Enterprise

Presentation of Grouped ProceduresPresentation of Grouped Procedures

What is the Clinical Problem?

Multislice CT and high speed MR generate HUGE Multislice CT and high speed MR generate HUGE quantities of images quicklyquantities of images quickly 3000+ Images3000+ Images Too large for virtual memory in a 32 bit operating Too large for virtual memory in a 32 bit operating

systemsystem Multiple orders and / or requested procedures Multiple orders and / or requested procedures

done in one acquisitiondone in one acquisition Entire exam may not read by one radiologistEntire exam may not read by one radiologist Clinicians often not interested in entire examClinicians often not interested in entire exam Cant track status of each requested procedureCant track status of each requested procedure

What is PGP?

IHE definition: Presentation of Grouped Procedures (PGP) provides a mechanism for facilitating viewing images and reporting on individual requested procedures that have been fulfilled by a single acquisition Single CT may consist of CT Head, Chest, Single CT may consist of CT Head, Chest,

Abdomen, PelvisAbdomen, Pelvis This is done as one exam acquisition and This is done as one exam acquisition and

generates one datasetgenerates one dataset

University of Wisconsin Hospital and Clinics – UW Health

800 Physicians800 Physicians 30 Radiologists30 Radiologists 463 bed main hospital463 bed main hospital 60 clinics60 clinics

6 large clinics with digital modalities6 large clinics with digital modalities Over 250,000 exams per yearOver 250,000 exams per year HIS / RIS with Web based EMR and integrated HIS / RIS with Web based EMR and integrated

DICOM Modality WorklistDICOM Modality Worklist

University of Wisconsin Hospital and Clinics – UW Health

UW PACS History Incremental approach to PACS Incremental approach to PACS

implementationimplementation US mini-PACSUS mini-PACS 99 – CR softcopy reading from 2 remote clinics99 – CR softcopy reading from 2 remote clinics 98-99 – initial evaluation of web interface to 98-99 – initial evaluation of web interface to

digital modalitiesdigital modalities

UW PACS History 99 - 2 new large clinics filmless (except mammo)99 - 2 new large clinics filmless (except mammo) 99 - 00 - PACS RFP99 - 00 - PACS RFP 5/00 - Selected PACS Vendor5/00 - Selected PACS Vendor

2 softcopy workstations for CT/MR2 softcopy workstations for CT/MR

11/00 – Install PACS archives and servers11/00 – Install PACS archives and servers 2000 – Spiral CT2000 – Spiral CT 3/01 – 12 Additional diagnostic workstations installed3/01 – 12 Additional diagnostic workstations installed 2001 – Multislice CT2001 – Multislice CT 11/02 – 55 Diagnostic workstations11/02 – 55 Diagnostic workstations

Over 150 clinical review workstationsOver 150 clinical review workstations

11/02 – 1 Spiral and 7 Multislice CT11/02 – 1 Spiral and 7 Multislice CT

Workflow at the University of Wisconsin - Madison

CTGE Lightspeed

MRGE Signa

CR – FujiDR - GE

US

NM

Mammo VLVisible Light

XA/RF

HIS/RISSiemens

Modality Worklist MPPS

PACSRadiology

and ClinicalALI / McKesson

PACSArchive307 TB

ADIC Scalar 1000

PACSOffsite Archive

307 TBADIC Scalar 1000

PACSOffice andTeaching

UltraVisual

Thick ClientDiagnostic

Workstations

Web ReviewWorkstations

Thin ClientJAVA

Workstations

GSPS

PGP

Image Data (SC)

Dictation &Electronic Signature

Report Data

HL7 – ADT, orders, reports

Web Based EMRWISCR-IT

PGP Details

IHE Template definesIHE Template defines OrderOrder Requested ProcedureRequested Procedure Scheduled ProcedureScheduled Procedure AcquisitionAcquisition StoreStore ReportReport

This is not a one to one relationThis is not a one to one relation

Several Possible Combinations

Non grouped caseNon grouped case Grouped acquisitionGrouped acquisition Grouped acquisition with physical splitGrouped acquisition with physical split Grouped acquisition with logical splitGrouped acquisition with logical split

Non-grouped Case

Common in older devicesCommon in older devices Similar to a film based environmentSimilar to a film based environment Don’t get benefits of newer devicesDon’t get benefits of newer devices

Store

Non-Grouped Case

Request Acquire Report Review Bill

Order

RequestedProcedure 1

RequestedProcedure 2

Report1

Report2

PPS1

Schedule

ScheduledProc. Step 1

ScheduledProc. Step 2

Acq

1

PPS2

Acq

2

Data1

Data2

Grouped Acquisition

The real problem childThe real problem child 1000+ image series1000+ image series 3000+ image exams3000+ image exams

Impossible to deal with in a film environmentImpossible to deal with in a film environment Difficult to deal with in a radiology departmentDifficult to deal with in a radiology department Potentially devastating to electronic enterprise Potentially devastating to electronic enterprise

distributiondistribution

Store

Acquisition Group Case

Request Acquire Report Review Bill

Order

RequestedProcedure 1

RequestedProcedure 2

Report1

Report2

PPS1

Schedule

ScheduledProc. Step 1

ScheduledProc. Step 2

Acq

1

Data1

Grouped Acquisition With Physical Split

Potential solutionPotential solution No easy option to modify split if the initial No easy option to modify split if the initial

split is wrongsplit is wrong Duplicates many images – 120 – 140%Duplicates many images – 120 – 140%

100% - need to store entire original in case the 100% - need to store entire original in case the splits were wrongsplits were wrong

20-40% for overlap20-40% for overlap Not easy to review entire examNot easy to review entire exam

Store

Acquisition Group Case + Physical Split

Request Acquire Report Review Bill

Order

RequestedProcedure 1

RequestedProcedure 2

Report1

Report2

PPS1

Schedule

ScheduledProc. Step 1

ScheduledProc. Step 2

Acq

0PPS2

Data1

Data2

Grouped Acquisition With Logical Split

The best solutionThe best solution No duplication of imagesNo duplication of images Easy to modify virtual splitEasy to modify virtual split

New GSPSNew GSPS Potential to re-combine multiple virtual Potential to re-combine multiple virtual

splitssplits

Store

Acquisition Group Case + Logical Split

Request Acquire Report Review Bill

Order

RequestedProcedure 1

RequestedProcedure 2

Report1

Report2

PPS1

Schedule

ScheduledProc. Step 1

ScheduledProc. Step 2

Acq

0PPS2

View

1V

iew2

Data 0

PPS0

What will PGP do for me?

Multiple orders and /or requested procedures done Multiple orders and /or requested procedures done in one acquisitionin one acquisition

Entire exam may not be read by one radiologistEntire exam may not be read by one radiologist Clinicians often not interested in entire examClinicians often not interested in entire exam Enable tracking status of each requested procedureEnable tracking status of each requested procedure Reduce impact of huge datasets on clinical and Reduce impact of huge datasets on clinical and

system infrastructuresystem infrastructure

Multiple Orders and / or Requested Procedures Done in One Acquisition

A single exam acquisition may consist of A single exam acquisition may consist of several requested proceduresseveral requested procedures Trauma scan may have head, chest, abdomen, Trauma scan may have head, chest, abdomen,

pelvis, spinepelvis, spine Grouping / splitting portion of PGPGrouping / splitting portion of PGP

Done at modalityDone at modality Should (Must) be on worklist at time of examShould (Must) be on worklist at time of exam

Entire Exam May Not be Read by One Radiologist Common in academic and large private practices Common in academic and large private practices

where there are sub-specialistswhere there are sub-specialists Neuro, body, chest…Neuro, body, chest…

PGP virtual or physical splits could present a PGP virtual or physical splits could present a problem with too fine of a granularityproblem with too fine of a granularity Splitting abdomen and pelvis and requiring that each be Splitting abdomen and pelvis and requiring that each be

opened and read separatelyopened and read separately Virtual splits would be easiest to solve by combining Virtual splits would be easiest to solve by combining

the GSPS objects and opening multiple virtual splits as the GSPS objects and opening multiple virtual splits as one larger combined examone larger combined exam

Clinicians Often Not Interested in Entire Exam The orthopedic surgeon does not want to The orthopedic surgeon does not want to

wait for and look at the first 2000 images of wait for and look at the first 2000 images of the head, chest, abdomen… to find the 50 the head, chest, abdomen… to find the 50 images of the fractured hipimages of the fractured hip

Enable Tracking Status of Each Requested Procedure Performed procedure step (PPS) for each Performed procedure step (PPS) for each

requested procedure can now be tracked by requested procedure can now be tracked by the HIS / RIS, PACS and modalitiesthe HIS / RIS, PACS and modalities

Radiologists know what needs to be readRadiologists know what needs to be read Clinicians can track status of exams – Clinicians can track status of exams –

decreases phone / pager tagdecreases phone / pager tag

Reduce impact of huge datasets on clinical and system infrastructure Clinical impactClinical impact System impactSystem impact

NetworkNetwork Workstation hardwareWorkstation hardware

Diagnostic workstationsDiagnostic workstations Clinical review workstationsClinical review workstations Web viewerWeb viewer

Barriers to Clinical PGP Implementation PGP requires that worklist entries are PGP requires that worklist entries are

present prior to exampresent prior to exam Implementation on modalityImplementation on modality Implementation on PACSImplementation on PACS RIS supportRIS support

PGP Requires that Worklist Entries are Present Prior to Exam Problem with unidentified patients (e.g. Problem with unidentified patients (e.g.

trauma patients)trauma patients) Potential solutionsPotential solutions

Manual entering of orders on RISManual entering of orders on RIS Auto generation of predefined set of orders for Auto generation of predefined set of orders for

unidentified trauma patient – cancel orders not unidentified trauma patient – cancel orders not donedone

Generation of new orders on modality Generation of new orders on modality consoleconsole

Generation of GSPS after the study is sentGeneration of GSPS after the study is sent

Manual Entry of Orders on RIS

Time consumingTime consuming Technicians often not prepared or able to Technicians often not prepared or able to

enter ordersenter orders May delay scanMay delay scan

Auto Generation of Predefined Set of Orders for Unidentified Patient

Have RIS auto generate a “Top 10” entry of Have RIS auto generate a “Top 10” entry of orders for trauma or unidentified patientsorders for trauma or unidentified patients

Cancel orders that are not done at a later Cancel orders that are not done at a later time (or on the scanner)time (or on the scanner)

Minimal user interventionMinimal user intervention Orders ready before patient gets to scannerOrders ready before patient gets to scanner

Generation of New Orders / Scheduled Procedures on Modality Console Best solutionBest solution Radiology workflow is often driven at (or Radiology workflow is often driven at (or

by) the scannersby) the scanners Would require HIS/RIS vendors to Would require HIS/RIS vendors to

acknowledge that they are not the center of acknowledge that they are not the center of the universethe universe

Generation of GSPS After the Study is Sent to the PACS

Possible but does little to resolve workflow Possible but does little to resolve workflow issues in a trauma environmentissues in a trauma environment

Implementation on modality

Prospective – at time images are prescribed Prospective – at time images are prescribed on the topogramon the topogram

Retrospective – after axial / spiral images Retrospective – after axial / spiral images are acquiredare acquired

Separate console – potential add-on for Separate console – potential add-on for older systemsolder systems

Implementation on PACS

Get multiple “In-Box” entriesGet multiple “In-Box” entries Accession number for each performed Accession number for each performed

procedureprocedure All point to same image setAll point to same image set

RIS support

Need multiple unique orders for patientNeed multiple unique orders for patient DICOM Modality WorklistDICOM Modality Worklist

UW Proposed Solution

Integrated selection of images for PGP on Integrated selection of images for PGP on scanner consolescanner console

Multiple in-box entries on PACSMultiple in-box entries on PACS Worklist from RIS or PACSWorklist from RIS or PACS

Vendor Partners at UW

General Electric – CT and MRGeneral Electric – CT and MR ALI – PACS, DICOM WorklistALI – PACS, DICOM Worklist Siemens / SMS - RISSiemens / SMS - RIS

Implementation Plan Define user interface requirementsDefine user interface requirements

ScannerScanner PACSPACS

Vendor implementationVendor implementation Lab to lab testingLab to lab testing Preliminary install on one scanner and PACS test Preliminary install on one scanner and PACS test

serverserver Refine user interfaceRefine user interface Test RIS vs. PACS WorklistTest RIS vs. PACS Worklist Full production PACS and scanner Full production PACS and scanner

implementationimplementation

Current Status of PGP Implementation at the UW Lab to lab testing completedLab to lab testing completed Initial CT scanner installInitial CT scanner install Test PACS systemTest PACS system Refine workflow issuesRefine workflow issues

PGP on the CT Scanner

Select multiple orders on modality worklistSelect multiple orders on modality worklist Scanner generates MPPS at start and end Scanner generates MPPS at start and end

and groups scansand groups scans Retrospective generation of GSPS objects Retrospective generation of GSPS objects

to do virtual splitto do virtual split

PGP on the CT Scanner

PGP on the CT Scanner

PGP on the CT Scanner

Example of PGP In-Box

Abdomen

Chest

Full Exam

Save Presentation State on Workstation – While Reading Exam

Save Presentation State on Workstation – As Exam Close

Summary

PGP will enable filmless and paperless PACS PGP will enable filmless and paperless PACS operationoperation

Exam can be effectively read by multiple Exam can be effectively read by multiple radiologistsradiologists

Clinicians can access only the parts of the exam Clinicians can access only the parts of the exam they are interested inthey are interested in

Enable tracking status of each requested procedureEnable tracking status of each requested procedure Reduce impact of huge datasets on clinical and Reduce impact of huge datasets on clinical and

system infrastructuresystem infrastructure

Comments and Suggestions

Gary Wendt, MDGary Wendt, MD University of Wisconsin - MadisonUniversity of Wisconsin - Madison gjwendt@wisc.edugjwendt@wisc.edu www.radiology.wisc.eduwww.radiology.wisc.edu