Managing Extra-Radiology Data within a PACS-like Framework

Saskia Van Den Dool

Saskia Van Den Dool, Wordwide Marketing Manager, Healthcare Information Solutions, Carestream

Dr. Marco Foracchia, Medical IT Systems Manager, Santa Maria Nuova Hospital, Reggio Emilia, Italy, gave an online presentation as part of HIMSS Europe’s participation at ECR 2015 earlier in March. The presentation focused on residual radiology IT needs and how facilities should go about managing this low quantity, yet highly-specialized data.

Most of the residual data is media in the form of images, video, traces, etc. These media are emerging now because of three reasons:

  1. Clinical pathways providing access to all evidence for all professionals involved
  2. Regulatory legislation requires all data to be readily available in case of patient request
  3. Research requires evidence-based medicine

The clinical pathway is key and includes the following:

  • Referral from periphery to competency center
  • Collective evaluation of all available evidence
  • Comparison of evidence from previous events/different patients

Dr. Foracchia and his organization partnered with Carestream to sponsor and perform a one-year survey of all potential data (media) sources in the hospital—managed, improperly managed, and currently managed.

The remainder of his presentation at ECR went through this study and explained the findings. Dr. Foracchia touched on how radiology may be the solution to managing this residual data since radiologists have been managing data (images) for the last 20 years. The positives and negatives of having radiology lead this change were both be presented, and will leave it up to you, the viewer, to decide on what the right decision is for your organisation.

Dr. Foracchia ended by saying that Reggio Emilia is currently going through a number of projects that will force the organization to address its present and future challenges. This includes gradually extending the number of data sources connected to the central vendor neutral archive, immediately connecting all DICOM sources, and gradually connecting all other non-DICOM sources. The plan is to connect all DICOM sources by end of 2015, and connect all non-DICOM sources by the end of 2016.

The entire presentation has been embedded below for viewing.

Global Worklist and the Connected PACS

Cheshire & Merseyside PACS sites

Dark blue crosses are Carestream sites, and light blue other PACS sites.

I will be taking part in two presentations at the European Society of Radiology’s ECR 2015 Congress, and each one will be related to the use of our Carestream Multisite Virtual PACS.

The first is a poster titled, “Establishing a regional on-call radiology service using a shared virtual PACS,” and was completed with co-workers K. Slaven, S. Dyce, and L. Anslow

Out-of-hours radiology has been delivered by radiology residents working on-call rotations in individual hospitals. As the intensity of work has increased, out-of-hours work has seriously impacted time spent during the day in the department. The need for compensatory rest has led to significant loss of training in what is already a relatively short training scheme.

Cheshire and Merseyside is a small but complex health economy in the North West of England. The system has the following facilities:

  • Seven acute hospitals
  • One tertiary cardiac hospital
  • One neurosciences centre
  • One tertiary paediatric centre
  • One cancer centre
  • One specialist obstetrics/gynaecology hospital

Six acute sites have resident radiology specialist registrars in rotations between four and nine in size.

None of the rotations were compliant with the European working time directive (EWTD). Four of the sites were on shared RIS/PACS, and the other two had PACS from different vendors.

The move to a shared global worklist (Vue Connect) and shared RIS has meant that the acquisition of images and reporting can be accomplished on separate sites. This also means that one resident can be on-call for more than one site at a time.

By combining the registrar workforce, we have been able to achieve compliance with the EWTD and significantly reduce the number of nights worked, hence allowing for a significant increase in training hours within the base  departments.

We are about to incorporate the last two acute sites. We have placed a Carestream agent on the last two sites, which allows image sharing seamlessly across all the sites including systems from other vendors. We plan to move to PACS-based reporting soon, so the residents will have a single workflow for their out-of-hours work, and to avoid having to work in three different PACS and three different RIS.

Our PACS has some unique features that makes this possible, and will be presented in the second presentation:

“Development of a shared multi-site virtual PACS”PACS - Cheshire & Mersyside

The co-authors for this presentation are S. Dyce, N. Pfirsch and S. Lomax.

As mentioned previously, Cheshire and Merseyside is a complex health economy. The previous system procured during the National PACS programme in England had PACS supplied by a single vendor in our region. However, image sharing was never a part of the programme and images had to be transferred by CD, DICOM push and latterly by a bespoke email-like system—the Image Exchange Portal.

There was a huge movement of patients from one acute site to another, or to specialist centres. Frequently, previous imaging was not available in a timely fashion, studies were reported in isolation, or even repeated when they could not be accessed. Regional multidisciplinary meetings were a massive effort to ensure all imaging was available for discussion, and image transfer was a huge overhead for all of our departments.

The goal was for all 10 trusts to have left the national PACS programme by June 2013 and this was achieved.

During procurement, we looked for a system that would behave as a single virtual PACS with seamless display of all current and prior studies. There was also a requirement to be able to view and report images from any site, and a requirement to support images from the two hospitals that had PACS from other vendors. A single mega PACS was a possible solution, but individual institutions wished to keep ownership of the images.

We selected our vendors based on these requirements:

  • Single master identifier – the NHS number
  • Acquisition and reporting are kept separated
  • Single instance of a study so annotations and reformats are applied to a single study
  • Seamless display of priors; the reporter could be unaware of the location of prior studies, but they appeared in local PACS

Carestream was chosen as a vendor that could support this workflow and deliver it in the six-month fixed timetable. The system was delivered before the cut-off date, and over 100TB of data was migrated into the system.

All of the above objectives were achieved, as well as the following:

  • Seamless multidisciplinary meetings with display of priors
  • Major reduction in overhead of image transfer
  • Specialist reporting e.g. paediatric, neuro is supported
  • Centralised on call centre for radiology residents
  • Significant Cost Reduction

The live presentation for “Development of a shared multisite virtual PACS,” will be given at ECR 2015 in SS 1805, on Sunday morning from 1030-1200.

Dr. Peter Rowlands, NHSDr Peter Rowlands, consultant radiologist at Royal Liverpool & Broadgreen University Hospitals NHS Trust (RLBUHT).



X-ray Pulse Duration and Anatomical Noise Studies at ECR 2015

In March, I will be presenting two papers at the European Society of Radiology’s 2015 European Congress of Radiology. Both papers are in collaboration with Dr. Narinder Paul, Division Chief of Cardiothoracic Radiology and his group at the University Health Network in Toronto, Canada. It is a pleasure to be able to report our team’s studies that take a look at lung nodules, and examine them in two ways:

  1. Measuring the influence of X-ray pulse duration on the module during digital radiography (DR) in a dynamic anthropomorphic chest phantom
  2. Observing anatomical noise and its impact on lung nodule conspicuity by comparing DR, dual-energy X-ray, and digital angular tomosynthesis (3D imaging)

The purpose behind the first paper was to observe the impact of cardiac motion on lung nodule margin. Lung nodule margin is an important component to the evaluation of interval change on surveillance imaging.  Patients that are breathless or anxious may have increased cardiac motion which may impact nodule definition.  As a result, we investigated whether shortening the X-ray pulse duration reduces the impact of cardiac motion on the sharpness of nodule margins for digital radiography.

The method and materials we used to collect our data included an anthropomorphic phantom that was modified to simulate breathing and cardiac motion. Two spherical nodules were placed in the left lung and images were acquired under a range of pulses while adjusting the mA to keep constant mAs. The cardiac rate was set to consistent rates and the exam was repeated 10 times for each ms setting. Ultimately, an algorithm was developed to locate the nodules and derive an average radial profile to yield a sharpness metric generated from the slope of the profile.

From this study, we discovered that pulse duration can impact lung nodule sharpness due to cardiac motion. As a result, care should be taken when assigning protocols for nodule screening.

reduced background anatomical noise in an X-ray

Illustration of tissue discrimination in x-ray medical imaging resulting in reduced background anatomical noise and improved feature conspicuity. DR – Digital radiography, DE – Dual-energy x-ray image.

The second paper that I will be presenting live at ECR, we will be focusing on background anatomical noise as it is a leading cause of reduced object conspicuity in digital radiographic (DR) imaging. Dual-energy (DE) imaging reduces the influence of anatomical noise via tissue discrimination, while digital tomosynthesis (DT) reduces anatomical noise via depth discrimination.

Our methods to the study involved an anthropomorphic chest phantom with a spherical nodule that was imaged with DR, DE, and DT with the same in-room system. DE images were acquired with fixed and differential filtration and DT images were acquired at three dose levels, while a chest DR provided a performance reference.

The study provided a method for comparing performance across X-ray modalities and some insight in terms of optimal acquisition setting for improved image quality and reduced x-ray dose.

The rest of the results for the study, “Anatomical noise and impact on lung nodule conspicuity: comparing digital radiography, dual-energy X-ray, and digital angular tomosynthesis,” will be shared on Sunday, March 8, as part of the Novel Digital Imaging Techniques session, scheduled between 10:30 – 12:00 at ECR 2015.

You can visit Carestream at ECR 2015 in Booth 210, in Expo B.

Sam Richard, PhD, CarestreamSam Richard, PhD, Senior Research Scientist, Carestream