Update on PACS, Radiology Informatics, and Workflow

Update on PACS, Update on PACS, Radiology Informatics, Radiology Informatics,

and Workflowand Workflow

Paul J. Chang, M.D., FSIIMPaul J. Chang, M.D., FSIIMProfessor & ViceProfessor & Vice--Chairman, Radiology InformaticsChairman, Radiology Informatics

Medical Director, Pathology InformaticsMedical Director, Pathology Informatics

University of Chicago School of MedicineUniversity of Chicago School of Medicine

Medical Director, Enterprise ImagingMedical Director, Enterprise Imaging

University of Chicago HospitalsUniversity of Chicago Hospitals

Speaker DisclosureSpeaker Disclosure

CoCo--founder founder –– Stentor (acquired by Philips)Stentor (acquired by Philips)Medical/Technical Advisory Boards:Medical/Technical Advisory Boards:

PhilipsPhilipsAmirsysAmirsysPoiesis InformaticsPoiesis InformaticsMEDIAN TechnologiesMEDIAN TechnologiesVisage ImagingVisage ImagingVital ImagesVital Images

Grants and contracts Grants and contracts -- NIH, NLM, DARPANIH, NLM, DARPAAir Force, SCAR/SIIMAir Force, SCAR/SIIM

ChallengesChallenges

Advances in data acquisition technology Advances in data acquisition technology Increased treatment options and complexityIncreased treatment options and complexityHealth care enterprise is becoming increasingly Health care enterprise is becoming increasingly complexcomplexSignificantly increased user expectations and Significantly increased user expectations and requirements requirements External and economic constraints significantExternal and economic constraints significant

Present and Near Future RealitiesPresent and Near Future Realities

““Do more in less time with greater Do more in less time with greater constraints in a more complex distributed constraints in a more complex distributed environmentenvironment””““Film and paper no longer workFilm and paper no longer work””Digital based informatics solutions inevitableDigital based informatics solutions inevitable

PACS InfrastructurePACS Infrastructure

NetworkNetworkArchiveArchiveModality InterfaceModality InterfaceRIS InterfaceRIS InterfaceWorkstationsWorkstationsOperational SupportOperational Support

PACS Infrastructure: TrendsPACS Infrastructure: TrendsNetworks:

More capable, ubiquitous, and integrated Increased use of wireless

Archive: Less dependence on hierarchical modelsMore capable and cost effective options(NAS, SAN)Trend towards on demand performance; less dependence on prefetch models

Better integration models (IHE, web services, CCOW, etc); less dependence on RIS-PACS broker agentsWorkstations:

Significantly more capable, affordableTrend towards web based thin clients

Modern PACS offerings are more capable and affordable; Modern PACS offerings are more capable and affordable; however, expectations and requirements have also however, expectations and requirements have also

significantly increasedsignificantly increased

““The target always movesThe target always moves…”…”

Advances in data acquisition technology create massive and complex datasets“Do more in less time with greater constraints in a more complex distributed environment”– “real time hyper-efficient radiology”Absolute requirement for truly comprehensive enterprise image distribution strategy- “radiologists aren’t the only ones who need images”Support for non-radiology image data

CardiologyVisible light (pathology, dermatology, endoscopy, ophthalmology, etc.)

Integration into electronic health record (EHR)

““The maturation of digital image The maturation of digital image managementmanagement””

Electronic image management within the radiology department is no longer a daunting task “PACS is nothing…”Today’s challenge: “fully leveraged electronic based workflow and practice management” that can support today’s more complex requirementsThe real goal: measurable improvements in efficiency, productivity, cost-effectiveness, accuracy, and patient outcome.Modern digital image management workflow must support the radiologist value innovator

Radiology Informatics and Workflow Radiology Informatics and Workflow ChallengesChallenges

Large image dataset managementLarge image dataset managementMaximizing productivity by optimizing information Maximizing productivity by optimizing information throughput in radiologythroughput in radiologyIntegration and interoperability models to support Integration and interoperability models to support advanced workflowadvanced workflowEnhanced communication and collaborationEnhanced communication and collaboration

Large Image Dataset ManagementLarge Image Dataset Management

An Informatics ChallengeAn Informatics Challenge

Use of large image datasets with advanced visualization has demonstrated great clinical utilityAdoption of digital based image management (PACS) inevitable Proportion of near-isotropic image datasets will continue to significantly increasePresents a non-trivial data management and informatics challenge

Informatics ChallengesInformatics Challenges

Archive ArchitectureArchive ArchitectureServerServer--Client Data TransmissionClient Data TransmissionVisualization ToolsVisualization ToolsWorkflow ModelsWorkflow Models

Archive Architecture: Current TrendsArchive Architecture: Current TrendsTrend towards on-demand (“spinning”) archive designs (less emphasis on hierarchical storage models)

Penalty for migration of very large datasets from slower media increasingly unacceptableUnpredictable and on-demand study retrieval requirements from enterprise users

Current and even near future storage requirements for large image datasets track reasonably well with continuously improving technical and economic efficiencies related to mass storageThese trends have significantly influenced archive persistence models for large image datasetsThe challenge is not storage, but image transmission

Archive ModelsArchive Models

SelectiveSelectiveSelective with temporary cacheSelective with temporary cacheComplete datasetComplete datasetSelective with intelligent DICOM router / cacheSelective with intelligent DICOM router / cacheComplete dataset with Complete dataset with ““pseudopseudo”” integrated workstationintegrated workstationComplete dataset with integrated workstationComplete dataset with integrated workstationComplete dataset with Complete dataset with ““serverserver--thin clientthin client”” communicationcommunication

Variations of these m odels exist

““SelectiveSelective””

Archival ModelArchival Model

Modality PACS Archive

“Traditional” PACS Workstation

3D / Advanced Visualization Workstation

“Thick Slices”

(DICOM)

“Thick Slices”

(DICOM)

(DICOM)Selected Images

Video Clips (“Key Images”)

“Thin Slices”

(DICOM)(Manual or Automatic)


Archival ModelArchival ModelAdvantages:Advantages:

Permanently storing only “thick slices” least demanding on PACS archive storage requirementsTrivial to implement

Disadvantages:Disadvantages:Not able to use interactive advanced visualization on prior or even relatively recent studies (only stored “key images” are available)Not able to take full advantage of future visualization and analysis tools on prior studiesGenerating and transmission of separate thin slices may be labor intensive and disruptive to normal workflow (especially ifrequirement for thin slices not anticipated)Modality not suited to scalable DICOM SCU to multiple destinations


Archival Model with Temporary Archival Model with Temporary CacheCache




“Thick Slices”

(DICOM)

“Thick Slices”

(DICOM)

(DICOM)Selected Images

Video Clips (“Key Images”)

Temp Cache

“Thin Slices”

(DICOM )

“Thin Slices”

(DICOM)


Archival Model with Archival Model with Temporary CacheTemporary Cache

Advantages:Advantages:Permanently storing only “thick slices” least demanding on PACS archive storage requirementsAllows use of interactive advanced visualization on all current and relatively recent prior studies (depending on size of temporary cache)Generation and transmission of thin slices can be automated

Disadvantages:Disadvantages:Not able to use interactive advanced visualization on prior studies no longer resident in the temporary cache Not able to take full advantage of future visualization and analysis tools on prior studies no longer resident in the temporary cache

““Complete DatasetComplete Dataset”” Archival ModelArchival Model




“Thick and Thin Slices”

(DICOM)

“Thick Slices”

(DICOM)

(DICOM)

Selected Images Video Clips

(“Key Images”)

“Thin Slices”(DICOM)

““Complete DatasetComplete Dataset””

Archival ModelArchival Model

Advantages:Advantages:Permanently storing both thick and thin slices allows advanced visualization on all current and prior studiesGeneration and transmission of thin slices can be automated

Disadvantages:Disadvantages:Greatly increases PACS archive permanent storage requirements PACS archives tend to have poor SCU performance, especially with respect to scalabilityStoring both thick and thin slices within PACS archive wasteful and redundant


Archival Model with Intelligent Archival Model with Intelligent DICOM Router / CacheDICOM Router / Cache

Modality

PACS Archive




(DICOM)

“Thick Slices”(DICOM)



“Thin Slices”

(DICOM)

DICOMRouter Cache

(HL7, Web Services, etc.)


Archival Model with Archival Model with Intelligent DICOM Router / CacheIntelligent DICOM Router / Cache

Advantages:Advantages:Permanently storing only “thick slices” least demanding on PACS archive storage requirementsAllows use of interactive advanced visualization on all current and relatively recent prior studies (depending on size of temporary cache)Improves efficiency and scalability of thin slice DICOM image transmission; reduces burden to modality and PACSGeneration and transmission of thin slices can be automated

Disadvantages:Disadvantages:Not able to use interactive advanced visualization on prior studies no longer resident in the temporary cache Not able to take full advantage of future visualization and analysis tools on prior studies no longer resident in the temporary cache


Archival Model with Archival Model with ““PseudoPseudo--IntegratedIntegrated””

Workstation (Workstation (““PlugPlug--inin””))



(DICOM)


(DICOM)“Traditional”

PACS Workstation

3D / Advanced Visualization

“Plug-in”

“Pseudo-Integrated Workstation”


(“Key Images”)


Archival Model with Archival Model with ““PseudoPseudo--IntegratedIntegrated””

Workstation (Workstation (““PlugPlug--inin””))

Advantages:Advantages:Permanently storing both thick and thin slices allows advanced visualization on all current and prior studiesGeneration and transmission of thin slices can be automatedAvailability of advanced visualization tools via “plug-in”convenient and less disruptive to normal workflow

Disadvantages:Disadvantages:Greatly increases PACS archive permanent storage requirements PACS archives tend to have poor SCU performance, especially with respect to scalabilityStoring both thick and thin slices within PACS archive wasteful and redundant


Archival Model with Archival Model with ““IntegratedIntegrated””

WorkstationWorkstation


“Thin Slices”

(DICOM)

“Thin Slices”

(DICOM)


Tools


Tools

“Integrated Workstation”


(“Key Images”)


Archival Model with Archival Model with ““IntegratedIntegrated””

WorkstationWorkstation

Advantages:Advantages:Permanently storing thin slices allows advanced visualization onall current and prior studiesGeneration and transmission of thin slices can be automatedEliminates inefficiency of storing redundant thick slicesGreatly reduces inefficient image data transmissionAvailability of advanced visualization tools integrated into PACS workstation convenient and less disruptive to normal workflow

Disadvantages:Disadvantages:Greatly increases PACS archive permanent storage requirements PACS archives tend to have poor SCU performance, especially with respect to scalability


Archival Model with Archival Model with ““ServerServer--Thin ClientThin Client””

CommunicationCommunication


“Thin Slices”

(DICOM)

“Just in Time” or “Streaming” Server–Client

Protocols


Tools


Tools

“Thin Client” Integrated Workstation(DICOM)


(“Key Images”)


Engine / Server

* DICOM or Shared Architecture

*


Archival Model with Archival Model with ““ServerServer--Thin ClientThin Client””

CommunicationCommunication

Advantages:Advantages:Permanently storing thin slices allows advanced visualization on all current and prior studiesGeneration and transmission of thin slices can be automatedAvailability of advanced visualization tools integrated into PACS workstation convenient and less disruptive to normal workflowServer-thin client communication greatly reduces hardware and network requirements for PACS workstationsServer-thin client model can greatly improve client performance Allows for full featured advanced visualization tools for web viewers

Disadvantages:Disadvantages:Greatly increases PACS archive permanent storage requirements

ServerServer--Client Data TransmissionClient Data Transmission

Transmission of “thin slice” datasets from PACS archive server to PACS workstation client via DICOM can be very time consuming and require significant network and client resourcesTrend towards server-thin client architecture:

3D / Advanced Visualization engine located server-sideEngine usually has direct and efficient assess to PACS archiveServer communicates to thin-client server via very efficient “just in time” or streaming mechanismsCan allow for very high client performanceMuch lower network and workstation resource requirementsCan provide advanced visualization functionality to web clients

Visualization ToolsVisualization Tools

Tools must be seamlessly integrated into “routine” workflow (“just like window/level, zoom/pan, etc.”)Advanced presentation and navigational tools must be available for current and prior studies simultaneously Requirement for user intensive editing and “setup” (ROI definition, segmentation, thresholding, etc.) must be significantly reduced (automated protocols should be clinically oriented and context-specific)Advanced visualization tools must be available to enterprise users (non-radiologists) via web clients

Workflow ModelsWorkflow Models

Must be seamlessly integrated into overall departmental workflow (not “out of band”)Integrated functionality a must for both radiology workstations and enterprise web clients (“master worklist’)Integration with computerized order entry (CPOE) and protocol tools – will greatly reduce user editing / setup requirement

Maximizing Productivity by Maximizing Productivity by Optimizing Information Optimizing Information

Throughput in RadiologyThroughput in Radiology

Why Increase Productivity and Why Increase Productivity and Efficiency in Radiology?Efficiency in Radiology?

Decreased delay in diagnosisDecreased delay in diagnosisDecreased patient length of stayDecreased patient length of stayReduce backlog of elective outpatient studiesReduce backlog of elective outpatient studiesMaximize revenue generation Maximize revenue generation Improve patient satisfactionImprove patient satisfaction

Barriers to Efficiency in RadiologyBarriers to Efficiency in Radiology

Workflow based on film and paper information Workflow based on film and paper information deliverydeliveryExcessive time spent on Excessive time spent on ““peripheralperipheral”” taskstasksInflexible Inflexible ““serializedserialized”” workflow modelworkflow modelFilm and paper are used as information Film and paper are used as information ““batonsbatons””passed between technologist and radiologistpassed between technologist and radiologistDoes not scale to large and distributed practicesDoes not scale to large and distributed practicesShortsighted perspective re: enabling Shortsighted perspective re: enabling ““lubricationlubrication””FTEFTE

An Approach to Improve Efficiency in An Approach to Improve Efficiency in RadiologyRadiology

Improved Improved patientpatient throughput is not sufficient; improved throughput is not sufficient; improved informationinformation throughput is the real goalthroughput is the real goalMust eliminate or minimize Must eliminate or minimize ““peripheralperipheral”” taskstasksInformatics goal: to sever the Informatics goal: to sever the ““hardhard--linkagelinkage”” between between technologist workflow and radiologist workflowtechnologist workflow and radiologist workflowMust change from serialized workflow model to Must change from serialized workflow model to asynchronous asynchronous ““parallelparallel”” modelmodel

RequirementsRequirements

Must get rid of film and paperMust get rid of film and paperElectronic based informatics systems are Electronic based informatics systems are requiredrequiredTighter integration of electronic information Tighter integration of electronic information systems requiredsystems requiredMust reMust re--engineer all workflow processes to engineer all workflow processes to maximally leverage electronic infrastructuremaximally leverage electronic infrastructure

PACS is just the first stepPACS is just the first step……

Getting rid of film (and filming) is an important first Getting rid of film (and filming) is an important first stepstepHowever, one must also get rid of However, one must also get rid of paper paper (the (the ““otherother”” information baton)information baton)This can be very challenging: the paper requisition This can be very challenging: the paper requisition serves many workflow functionsserves many workflow functions

Informs the radiologist that a study needs to be Informs the radiologist that a study needs to be interpretedinterpretedContains clinical information / context Contains clinical information / context Frequently serves as the interface to the dictation systemFrequently serves as the interface to the dictation system

ReRe--Engineering Technologist Engineering Technologist Workflow to Increase EfficiencyWorkflow to Increase Efficiency

Technologist Workflow:Technologist Workflow: Performed Procedure with Context SpecificationPerformed Procedure with Context Specification

Automated Exception HandlerAutomated Exception Handler

ReRe--Engineering Radiologist Engineering Radiologist Workflow to Improve EfficiencyWorkflow to Improve Efficiency

Integrated Dictation / Speech RecognitionIntegrated Dictation / Speech Recognition

““Find PhysicianFind Physician””

Clinical DashboardClinical Dashboard

22.5 hrs24.3 hrs

17.7 hrs*

24% reduction

*p < .001

Improved Report Turnaround Time Improved Report Turnaround Time with Dashboardwith Dashboard

PACS Admin User InterfacePACS Admin User Interface

The Radiology Dashboard :The Radiology Dashboard : Delinquent Undictated CasesDelinquent Undictated Cases

Improved False Dictation Turnaround Improved False Dictation Turnaround with Dashboardwith Dashboard

Division Pre Post

Abdominal 10 0

MSK 26 0

Neuro 13 0

Chest 0 0

Total 49 / 33,077 0* / 36,958(0.15%) (0%)

*p < .001

Prevalence of “C-Status” Dictations (>72h)

Supporting Clinician WorkflowSupporting Clinician Workflow

Advanced ClinicianAdvanced Clinician

WorkflowWorkflow

Optimized image presentation, worklistsOptimized image presentation, worklistsPhysician Order Entry and SchedulingPhysician Order Entry and Scheduling(with Decision Support)(with Decision Support)MultimediaMultimedia--enhanced web reportsenhanced web reportsAsynchronous and synchronous Asynchronous and synchronous collaboration toolscollaboration toolsContext sharing with EMRContext sharing with EMR

Prioritized Report ListPrioritized Report List

With permission from Amirsys, Inc

Results at UPMCResults at UPMC

1.3 million studies / year1.3 million studies / yearCT in Abdominal Imaging:CT in Abdominal Imaging:

Study throughput increased by 54% when PACS Study throughput increased by 54% when PACS institutedinstitutedThroughput Throughput doubleddoubled when enterprise image distribution when enterprise image distribution deployed and paper requisitions eliminated.deployed and paper requisitions eliminated.

$5.8 million saved per year in film and distribution $5.8 million saved per year in film and distribution costscosts

What is Needed?What is Needed?

Better coordination with other services Better coordination with other services (nursing, transport)(nursing, transport)Intelligent ordering and schedulingIntelligent ordering and schedulingElectronic study protocol selection with Electronic study protocol selection with access to RIS and CISaccess to RIS and CISElectronic positive patient ID (PPI) with Electronic positive patient ID (PPI) with integration with modality worklist and RISintegration with modality worklist and RISIntegration of modalities with RIS/PACSIntegration of modalities with RIS/PACS

Integration and Interoperability Integration and Interoperability ModelsModels

The Holy Grail:The Holy Grail:

The Multimedia Enabled The Multimedia Enabled Electronic Medical RecordElectronic Medical Record

(with Synchronous and (with Synchronous and Asynchronous Collaboration)Asynchronous Collaboration)

The PACS The PACS ––

RIS Workflow Integration RIS Workflow Integration Model is not sufficient!Model is not sufficient!

RadiologyRadiology--centric, imagecentric, image--centric perspectivecentric perspectiveIHE is an improvement butIHE is an improvement but……Truly valuable workflow enhancement can only be Truly valuable workflow enhancement can only be achieved if a true enterprise perspective is used with achieved if a true enterprise perspective is used with respect to integrationrespect to integrationRequires a more flexible integration workflow modelRequires a more flexible integration workflow model

Advanced Integration ApproachesAdvanced Integration Approaches

IHE (DICOM, HL7)IHE (DICOM, HL7)Distributed Object toolsDistributed Object tools

CORBA CORBA JAVAJAVAActiveXActiveX

Web Services, Web Services, Service Oriented Architecture (SOA)Service Oriented Architecture (SOA)

Typical LegacyTypical Legacy--based IT Environment:based IT Environment: ““Using humans to integrate workflowUsing humans to integrate workflow””

Patient EHR RIS PACSPath

Integration using aIntegration using a ““Single Vendor SolutionSingle Vendor Solution””

Single Vendor Application “Suite”

Path ModuleRIS ModuleEHR Module PACS Module

Using “Edge”

Protocols (DICOM & HL7) to Orchestrate Integrated Workflow:

IHE PACS –

RIS Integration Workflow Model

RIS PACS

Scheduled PrefetchReport PrefetchDemographic / ADT UpdateStudy ValidationDictated Status Worklist Update

Modality

Modality WorklistModality Performed Procedure

Dictation Reporting

Storage Commit

Performed Procedure

Performed Procedure

Dictated Status Update

Storage Commit

DICOM

HL7

HL7DICOM

DICOM

Limitations of Current IHE Limitations of Current IHE ““Edge ProtocolEdge Protocol””

ApproachesApproaches

OK for relatively few actorsOK for relatively few actorsPointPoint--toto--point messaging approach challenging to scale point messaging approach challenging to scale and manage beyond 2and manage beyond 2--4 actors4 actors““Everyone has to be on the same pageEveryone has to be on the same page””““Cookie cutter vs OptimizationCookie cutter vs Optimization””Needs more flexible and powerful workflow / business Needs more flexible and powerful workflow / business logic logic orchestrationorchestration

Limitations of Vendor Integration Limitations of Vendor Integration Offerings:Offerings:

Inability to provide optimized / customized solutions for specific workflow domains(“one size fits all”)Delay in responding to changing priorities and user functional specifications

Proposed solution: a more flexible, capable, and scalable Proposed solution: a more flexible, capable, and scalable architecture coupled with a more agile software development architecture coupled with a more agile software development

methodologymethodology

Enterprise Integration Model:Enterprise Integration Model: Towards a Service Oriented ArchitectureTowards a Service Oriented Architecture

Pathology HIS PACSRIS

Middle (“Business Logic”) Layer(Agents, ORBs, Web Services, etc.)

Service Oriented Architecture (SOA)Service Oriented Architecture (SOA)

Component based architecture that supports Component based architecture that supports ““compositecomposite””applications by orchestrating loosely coupled applications by orchestrating loosely coupled ““servicesservices””Transition from Transition from ““hard linkedhard linked”” data and presentation state to data and presentation state to ““loosely coupledloosely coupled”” services:services:

Universally exposableUniversally exposableUniversally selfUniversally self--describingdescribingUniversally consumableUniversally consumable

Services are Services are ““orchestratedorchestrated”” to create optimized to create optimized ““compositecomposite””user user ““experienceexperience””

Challenges to Integration:Challenges to Integration:Architecture specification very challenging Architecture specification very challenging (What is the (What is the ““business model?business model?””))Common semantic and vocabulary models immature:Common semantic and vocabulary models immature:

SNOWMED, RadLex, ICD, UMLS, HLSNOWMED, RadLex, ICD, UMLS, HL--7 extensions, etc.7 extensions, etc.Probably not yet ready for prime timeProbably not yet ready for prime timeOntologies are still not ready for Ontologies are still not ready for ““prime timeprime time””

Master person identification and authenticationMaster person identification and authentication((““single logonsingle logon””))SecuritySecurityRequires exposure to vendor database schema and interfacesRequires exposure to vendor database schema and interfacesPotential threat to current vendor marketing approachPotential threat to current vendor marketing approachVery difficult to accomplishVery difficult to accomplish

Relative Relative ““ValueValue””

Proposition of Proposition of Software vs. Domain KnowledgeSoftware vs. Domain Knowledge

Time

“Val

ue”

Domain (Workflow) Knowledge

Software Development

Summary: Summary: Modern Digital Management Requirements:Modern Digital Management Requirements:

Significant improvements have been made with respect to PACS technologyHowever, expectations and requirements have increasedPACS infrastructure must now be able to address the complex workflow demands of the modern health care delivery systemThis will require significantly more powerful integration models and an enterprise perspective

It is no longer just about film savings; PACS must also result in

significant improvements in FTE productivity, efficiency, and quality of service

throughout the enterprise

It is no longer just about images; PACS solutions must “complete”

the informatics cycle

by providing up to “near real-time”

image study interpretation and

consultation in order to deliver true value. This requires getting rid of paper as well…

It is no longer just about radiology; the future is not about a

$40K PACS workstation that just displays radiology images;

the “holy grail”

is the multimedia enabled electronic medical record with both synchronous and asynchronous

collaboration functionality

It is not just about hardware and software; we must be willing to “re-engineer”

ourselves in order to

fully leverage these digital practice management systems. Technology is “easy,”

changing human behavior and legacy

workflow is much, much harder.

Update on PACS, Radiology Informatics, and Workflow

Health & Medicine

Transcript of Update on PACS, Radiology Informatics, and Workflow