Why PACS is Modern Medicine?

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Why PACS is Modern Medicine?

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  • Update diagram - high-level overview
  • Update diagram - high-level overview
  • Update diagram - high-level overview
  • Why PACS is Modern Medicine?

    1. 1. Why PACS in Modern Medicine? 2 nd European Tutorial of Radiology LVIV/Ukraina January 2011 Frans Dhaenens MD
    2. 2. Remember: PACS <ul><li>PACS – </li></ul><ul><ul><ul><li>(P)icture </li></ul></ul></ul><ul><ul><ul><li>(A)rchiving </li></ul></ul></ul><ul><ul><ul><li>(C)ommunication </li></ul></ul></ul><ul><ul><ul><li>(S)ystem </li></ul></ul></ul>
    3. 3. AGFA PACS/RIS . МРТ КТ УЗ Ангио Яд.мед. Рентген Дигитайзер Сервер управления потоками Сервер Базы Данных PACS Архив 1 год Архивный сервер Архив на 10 лет Диагностические станции Web c ервер Рабочие станции клиницистов Web Сервер коммуникации Сервер RIS C танции RIS PACS RIS C танции RIS
    4. 4. Some other abbreviations <ul><li>RIS : Radiological Information System </li></ul><ul><li>HIS : Hospital Information System </li></ul><ul><li>EPR: Electronic Patient Record = EHR = Electronic Health Record </li></ul>HIS RIS PACS EPR
    5. 5. History of PACS(1980) and Tele-radiology (1960) <ul><li>PACS= Picture Archiving & Communication System started in 1980 , hospital & radiology based, today part of the Hospital Information System (HIS), images and data stored in the Electronic Patient Record (EPR). </li></ul><ul><li>Tele-radiology part of Tele-medicine = much older (1960), “feeling” of low quality & remote connections. </li></ul><ul><li>Every PACS has “tele-radiology” capabilities through its Wide Area Network connections and DICOM web-viewers: enables home-radiology, mammography screening programs. </li></ul>
    6. 6. Historical roots of PACS: The appearance of DIGITAL Modalities CT, MRI, US in 70ties, 80ties Digital Modalities
    7. 7. What is PACS ?? History <ul><li>PACS = P icture A rchiving and C ommunication S ystem </li></ul><ul><li>DICOM = D igital I maging and Co mmunication in M edicine </li></ul>
    8. 8. PACS connects CT, MRI, US, DR,.. PACS In the Radiology Department Radiologist Specialist Hospital
    9. 9. PACS = flexibility & creativity
    10. 10. A short history of PACS: standards & control CONTROL PACS 1982 PACS 2012 Standards & Security Modality->Departmental->Hospital->Multi-site->GRID-PACS NEMA/DICOM cardio, dental, RT, visual-light HL7 + IHE MPI + XDS RIS = Radiological Information System HIS = Hospital I.S. EPR = Electr. Pat. Rec. “ CODE” Virtuality
    11. 11. Technical evolution of all PACS functions 1980 2012 P ICTURES A rchiving C ommunication S ystems 2D tapes ATM, video Hardware + show an image Represent 5D datasets Internet archives Internet/web/ Wifi Functionality+ knowledge
    12. 12. Drivers for the PACS evolution <ul><li>Modality Technology and IT : e.g. MDCT </li></ul><ul><li>Subspecialization in Radiology : neuroradiology </li></ul><ul><li>Economical : cost, speed, access,.. </li></ul><ul><li>Up scaling = mergers, cooperation between hospitals </li></ul><ul><li>Clinical and Research needs : Personalized Medicine, Molecular Imaging, clinical trials </li></ul><ul><li>Patient : mobility and consumerism </li></ul>
    13. 13. Mayo: Image Information Overload of MDCT, PACS visualization <ul><ul><li>2002: 16,000 CT images per day per radiologist, approx. 2 seconds per image </li></ul></ul><ul><ul><li>Projected 2006: 80,000 CT images per day about 0.45 seconds per image </li></ul></ul><ul><ul><li>At 1 image per second would take >22 hours to review all of the CT images </li></ul></ul>
    14. 15. … Triggered a Variety of Visualization Applications… Now you have all the images... So what?
    15. 16. Role of Diagnostic Imaging in Future Healthcare Patient-Disease “ Personalized Medicine”
    16. 17. Radiology: the Analog Workflow Experience Specialties Knowledge Patient Process Turnaround Time IMAGES Information Report DATA Modality IMAGES DATA Information Hospital/ World
    17. 18. Radiology: the Digital Workflow Experience Specialties Knowledge Patient Process Turnaround Time IMAGES Information Report DATA Modality IMAGES DATA Information Hospital/ World PACS RIS HIS EPR -50% Databases + WEB
    18. 19. Evolution of PACS <ul><li>From Modality PACS to Enterprise PACS = hospital-wide PACS with use of HIS in clinical workstations. </li></ul><ul><li>PACS is the Imaging Component of the Electronic Patient Record = a HIS “slave”. </li></ul><ul><li>PACS covers all kinds of imaging , c o l o r, charts, drawings and reports of different specialties. Cardio-PACS, dental PACS, Radiotherapy, DICOM standard </li></ul><ul><li>Enterprise-PACS is wider than radiology: part of the clinical workstation , reports via RIS to the HIS. </li></ul><ul><li>Historical path was growth path, today starting with state of the art concepts. </li></ul>
    19. 20. From Modalities to Multi-Site PACS Business Intelligence Server Kit PACS Departmental “ enterprise” Radiologist Specialist Clinical Workstation EPR HIS/RIS Hospital 1 Hospital 2 Hospital 3 Multi-site PACS Teleradiology $$
    20. 21. Starting a PACS: several steps <ul><li>In the radiology department : integration of the modalities on a workstation = modality PACS </li></ul><ul><li>Add the clinics : clinical workstation </li></ul><ul><li>Add all departments in the hospital: film and paperless = enterprise PACS </li></ul><ul><li>Later: several hospitals together = MULTI-SITE PACS </li></ul>
    21. 22. Step 1 = Radiology RIS +PACS
    22. 23. Step 2 = Clinical PACS + WS
    23. 24. Doctor-Patient: Technology Mismatch
    24. 25. Step 3 = Enterprise-PACS filmless and paperless part of EPR
    25. 26. HÔPITAL EUROPÉEN GEORGES POMPIDOU - PARIS R E S E A U I M A G E 10/100 Mbits ATM 1 0 / 1 0 0 M b i t s INTERPRETATION DIAGNOSTIC 4X VIDEO Bloc Opératoire  see more  do more  URGENCES 1er ETAGE 2ème ETAGE Médecine Nucléaire 3ème ETAGE PTI - PTNI 6ème - 7ème ETAGE ACQUISITION - TRAITEMENT ACQUISITION - TRAITEMENT REPROGRAPHIE VISUALISATION SALLES CONFERENCE VISUALISATION 10X PC DICOM IMPAX CS500 100 à 300 clients WEB 25 IMPAX DS 3000 LUMYSIS 75 TS 5 ADC ID VIPS VIPS ADC VIPS VIPS ADC ID TS 5 LUMYSIS ADW LUMYSIS TS 5 NM NM NM NM NM NM GESTION et COMMUNICATION A 5200 E 4500 SERVEUR DATA BASE DLT 9710 ARCHIVE SERVEUR 1 + WORFLOW MANAGER 1 E 450 ARCHIVE SERVEUR 2 + WORFLOW MANAGER 2 E 450 E 250 E 250 E 250 HP LH4 WEB 1000 SERVER WORKFLOW MANAGER 3 WORKFLOW MANAGER 4 WORKFLOW MANAGER 5 PACS BROKER HP LH4 INTEGRATION DRYSTAR 3000 DRYSTAR 2000 R I S R A D O S
    26. 27. Hardware can be fairly complex
    27. 28. Hospital –Doctors Office: HIS-PACS communication <ul><li>Different types of data, including images. </li></ul><ul><li>Generic mechanisms for security and access control. </li></ul>
    28. 29. Does hospital-wide PACS work ? <ul><li>Thousands of proven and working cases. </li></ul><ul><li>In all sizes .(from 10.000 to >10million ex/year) </li></ul><ul><li>PACS is serious , not a toy !! Be aware of ”out of the box PACS”, plug-in and cheap PACS. </li></ul><ul><li>Proven benefits : diagnostic, clinical and economical = faster diagnosis. </li></ul><ul><li>Protection of future PACS developments : Multi-Site PACS and GRID PACS </li></ul>
    29. 30. Leuven University Hospitals ± 500.000 exams a year + 250.000 reports a year are dictated or typed directly into the computer by the radiologists !
    30. 31. PACS rollout - month 10 Q4 2001 Radiology Department essentially filmless Q1 2001 First workstations in Radiology Department 2001 2002 2003 January 2001 Preparation of PACS project
    31. 32. month 26 Q4 2001 Radiology Department essentially filmless Q1 2001 First workstations in Radiology Department January 2002 Pediatrics & ICU filmless July 2002 No CR film printing October 2002 No MR/CT film printing March 2003 Orthopedics filmless 2001 2002 2003 January 2001 Preparation of PACS project
    32. 33. Benefit of PACS: faster diagnosis
    33. 34. Benefit of PACS: faster diagnosis
    34. 35. How to buy a PACS? <ul><li>Cheap and Toy-like ?? </li></ul><ul><li>Serious with perspective on growth and expansion (in capacity and capabilities) . </li></ul><ul><li>Need for experienced partner for long-term cooperation. You buy experience . </li></ul><ul><li>Home-made is no longer an option: slow and vulnerable… </li></ul>
    35. 36. PACS Toys for real doctors?
    36. 37. PACS dangers: chaos in the archives
    37. 38. PACS dangers: OVERLOAD system too small
    38. 39. From Modalities to Multi-PACS Business Intelligence Server Kit PACS Departmental “ enterprise” Radiologist Specialist Clinical Workstation EPR HIS/RIS Hospital 1 Hospital 2 Hospital 3 Multi-site PACS Teleradiology $$
    39. 40. Reasons for MULTI-SITE PACS <ul><li>Organ-based sub-specialties in radiology requires : </li></ul><ul><ul><li>Integration of multi-modality images in 1 place= PACS-workstation. </li></ul></ul><ul><ul><li>Cover more territory : expert covers large geographic area </li></ul></ul><ul><ul><li>Better communication between specialists ; (EBM) </li></ul></ul><ul><li>Hospitals cooperate/merge . </li></ul><ul><li>Patient movement between hospitals </li></ul><ul><li>Government benefit (U.K.) </li></ul>
    40. 41. Multi-site PACS: critical factors <ul><li>Transparency +access of PACS: patient identification (ID) must be “uniform” to find all information in all places. </li></ul><ul><li>Solution: Master Patient Index = MPI and Global Patient Identification . </li></ul><ul><li>Configuration concept : CENTRALIZED or HUB + SPOKE </li></ul><ul><li>Multi-vendor PACS: open connectivity </li></ul><ul><li>Reaching a “maturity-level” in the functionality= efficiency. </li></ul>
    41. 42. How Master Patient Index (MPI) is working Querable DICOM patient ID NON-Querable DICOM patient ID Global Patient Information MPI Initiate HIS Patient information RIS Multi-site MPI=Master Patient Index Patient Information Domain LOCAL LOCAL DICOM Header
    42. 43. PACS MPI Integration Example GPI = G15975 Kate Lamb PID = C678 Mrs. K. Jones PID = D753 GPI = G15975 Catherine Lamb PID = A123 Katharine Jones PID = B455 GPI = G15975 GPI = G15975 Katherine L. Jones MPI# G15975
    43. 44. Levels of Maturity of Multi-Site PACS Level 1 Share Resources Level 2 Share Data Level 3 Share Workflow Patient Identity Management Consent Management Increase in Maturity Security Management
    44. 45. Deployment Models – Centralized vs. Hub & Spoke
    45. 46. Agfa experience with PACS <ul><li>Agfa has thousands of PACS installations in all kind of clinics and hospitals in all countries. </li></ul><ul><li>Since 90-ties </li></ul><ul><li>In all sizes: from 10.000 exams/yr to 10 million exams/yr. </li></ul><ul><li>In all kind of environments: military, mountains, ships,… </li></ul><ul><li>Some examples…. </li></ul>
    46. 47. Adventist Health System, Florida <ul><li>All sites have PACS infrastructure </li></ul><ul><li>17 total sites (so far) </li></ul><ul><ul><li>Plus FRI Clinics – referring into Florida Hospital </li></ul></ul><ul><ul><ul><li>Imaging Center Solution w/ Promedicus </li></ul></ul></ul><ul><ul><ul><li>IMPAX MPI managing cross-reference of Patient IDs </li></ul></ul></ul><ul><li>Multiple HIS/RIS </li></ul><ul><ul><li>Multiple RIS transitioned into a single Cerner RIS across health system </li></ul></ul><ul><li>~2 mil exams per year </li></ul>
    47. 49. Toronto East Network Canada <ul><li>16 Hospital Corporations </li></ul><ul><li>26 Clinical Sites </li></ul><ul><li>3 Local Health Information Networks </li></ul><ul><ul><li>LHINS 7,8 and 9 </li></ul></ul><ul><li>1.9 Million exams annually </li></ul><ul><li>Multi-vendor </li></ul><ul><ul><li>PACS: Agfa, GE, Siemens, Philips </li></ul></ul><ul><ul><li>HIS/RIS: McKesson, Meditech, Cerner, Medisolution </li></ul></ul>
    48. 51. United Kingdom: all hospitals digital <ul><li>England is divided in 5 clusters: </li></ul><ul><ul><li>London </li></ul></ul><ul><ul><li>Southern </li></ul></ul><ul><ul><li>North West & West Midlands </li></ul></ul><ul><ul><li>North Eastern </li></ul></ul><ul><ul><li>Eastern </li></ul></ul><ul><li>Cost between 10-20 b£ </li></ul>
    49. 52. Agfa PACS in 2 clusters <ul><li>2 clusters </li></ul><ul><li>30 trusts </li></ul><ul><li>75 hospitals </li></ul><ul><li>Servicing a population of 17 million </li></ul><ul><li>Image Data Volume </li></ul><ul><ul><li>10.000.000 exams/year </li></ul></ul><ul><ul><li>300 Terabyte/year </li></ul></ul><ul><li>Hub and Spoke model </li></ul>
    50. 53. Tele-radiology based on PACS <ul><li>Every PACS can do Teleradiology </li></ul><ul><li>Uses the Local Area Network ( LAN ) and Wide Area Network (WAN ) for point to point Communication (via VPN) </li></ul><ul><li>of (Anonymous) images =internet and reports + data = e-mail. </li></ul><ul><li>Security levels : Information is sent via e-mail </li></ul>
    51. 54. Classics in telemedicine
    52. 55. 64 % -> 18 % NEWS: AGFA rewarded HIS for 100 million Euro
    53. 56. Overview of a large Tele-radiology site in Germany
    54. 57. Workflow Kliniken Villingen-Schwenningen: satellite asks help DICOM Pseudonymisation Firewall +VPN DICOM C-STORE DICOM C-STORE Automatic pseudonymisation Workstation Modality HTTP e-mail notification DICOM C-STORE Internet AGFA Teleradiology client AGFA SA Workstation DICOM C-FIND/MOVE AGFA WEB1000 server HTTP Remote opinion Satellite Site Central Site IPSec SAT-ID + SAT-PID SAT-ID + SAT-ACC# Anonymous patient Firewall +VPN SAT-PID SAT-ACC# SAT-Patient name SAT-Patient address SMTP URL access Central repository of pseudonymised studies @
    55. 58. Reports & Communication = e-mail satellite  central
    56. 59. Message received
    57. 60. Workflow Kliniken Villingen-Schwenningen: central radiology answers Firewall +VPN Workstation HTTP Internet AGFA Teleradiology client AGFA teleradiology server HTTP Satellite Site Central Site IPSec Firewall +VPN SMTP Mail server SMTP Report Report Template Images HTTP Report Report storage on filesystem Report @
    58. 61. Back-up from second Central site <ul><li>Referral to other central site in case of lack of resources or expertise. </li></ul><ul><li>DICOM/MIME is the standard </li></ul><ul><li>Images are converted to mime attachments and sent via e-mail </li></ul><ul><li>Mime attachments are encrypted using GPG </li></ul><ul><li>Public key has to be made available to participating sites. </li></ul>DICOM Pseudonymisation Firewall +VPN DICOM C-STORE DICOM C-STORE Workstation Modality HTTP e-mail notification DICOM C-STORE Internet AGFA SA Workstation DICOM C-FIND/MOVE Satellite Central Site A IPSec SAT-ID + SAT-PID SAT-ID + SAT-ACC# Anonymous patient Firewall +VPN SAT-PID SAT-ACC# SAT-Patient name SAT-Patient address Workstation DICOM C-STORE Central Site B Firewall +VPN DICOM C-STORE HTTP AGFA Teleradiology server Local C-STORE to DICOM/MIME gateway Encrypted e-mail DICOM C-STORE IPSec Remote DICOM/MIME to C-STORE gateway DICOM C-FIND/MOVE Encrypted e-mail SMTP SMTP Automatic pseudonymisation
    59. 62. How far can PACS go ?? <ul><li>Images can be stored outside the hospitals : in data-centers or in internet grids. </li></ul><ul><li>PACS can be come virtual : patient and doctor can be everywhere but connected by internet. </li></ul><ul><li>Radiologist will have access to all radiology knowledge available in the world. </li></ul>
    60. 63. “ Virtual” GRID-PACS: the future coming now <ul><li>GRID = network of databases (anonymous images, knowledge, experts) and application software (CAD), hosted in many universities and private companies, in NON-DICOM format. Mostly related to cancer and mammography. </li></ul><ul><li>Virtual PACS : User PACS interface = DICOM and transparant </li></ul><ul><li>Examples: </li></ul><ul><ul><li>ACRIN: Am College of Radiology Imaging Network = digital mammo </li></ul></ul><ul><ul><li>Nat. Cancer Institute : lung cancer with MDCT = Lung Imaging Database Consortium >1000 peer-reviewed and documented lung cancers, approved by FDA, Agfa, Siemens, GE, Philips =members </li></ul></ul><ul><ul><li>UK and USA: Mammo-Grid = CAD and second reading. </li></ul></ul>
    61. 64. Virtual GRID-PACS: Purposes = CAD & second-opinion & knowledge for lung-nodules
    62. 65. Virtual GRID-PACS: how it looks You sit here Cancer database Cancer database
    63. 66. Virtual GRID-PACS: how it works
    64. 67. No Blind Communication Patient is here
    65. 68. Secure transmission of massive datasets: MDCT, cardio, angio Cine Images Transmission of Encrypted Cine Images
    66. 69. Grid–PACS= retrieval time in seconds: 4 Gb in 300 secs
    67. 70. PACS the basis for the future of “Diagnostic Imaging” <ul><li>PACS becomes the network for dissemination of Imaging and Knowledge in a world of “personalized medicine”. (Molecular Imaging). </li></ul><ul><li>Think in terms of patient, cost, time, speed and access to an accurate diagnosis. </li></ul>
    68. 71. New technology, new habits

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