RT 101: Lesson 3.

1 Picture Archiving and Communication System

Fundamentals
Workflow in Radiology
Workflow What is PACS?

 It simply means how a process is done, step by  An Image Management system that
step. acquires, stores, forwards, manipulates and
 In radiology, the term workflow has always displays images.
been used to describe how an examination is  Digital medical images are stored on a
completed, from order entry to transcribed medium that allows quick access until the
report. examination results are reviewed by a
 The movement of patients, images, and radiologist or other physician.
information throughout the imaging department  A picture archiving and communication
and healthcare enterprise (Siegel and Reiner).
system PACS, when fully implemented,
allows not only the acquisition but also the
interpretation and storage of each medical
image in digital form without resorting the
film (hard copy). The projected efficiencies
of time and cost are enormous.
* PACS improves image interpretation, processing,
viewing, storage and recall.
Hard copy vs. Soft copy
 Until the mid 1990s, essentially all medical
images were “hard copy” that is, the image
Sequence of activity for screen-film radiography.
were presented to the radiologist on film.
The image was interpreted from the film,
which was positioned on a lighted viewbox.
 Now essentially all digital images are
interpreted from presentation on a digital
display device. Soft copy viewing is
performed on a cathode ray tube (CRT) or
Liquid Crystal Device (LCD).
Note: LCDs are superior to CRT displays

Combining digital images with Picture Archiving and

Communication System (PACS) network eliminates
even more steps in medical imaging workflow and
enhances efficiency.
 Digital imaging and communications in
medicine (DICOM)
4 Principle Components of PACS
 is a universally accepted standard for
1. The image acquisition system exchanging medical images among the
2. The display system modality, viewing stations, and the archive.
3. The network
4. The storage system
IMAGE ACQUISITION
 Imaging devices that acquire images from
the patient such as CT scan, MRI,
Ultrasound, Xray machines and etc.
Machines are handled with dedicated
computers too for viewing the raw images.
DISPLAY SYSTEM
 Computer used to view a digital image.

NETWORK Image Acquisition

 This requires that each workstation must  Ultrasound, computed tomography (CT),
interact with each other imaging system magnetic resonance imaging (MRI), and
and central computer. Network is nuclear medicine have been digital for
described the manner in which computer many years and have been taking advantage
can be connected to interact with one of PACS far longer than general
another. radiography has.

STORAGE SYSTEM
 The amount of storage necessary depends
on the modality or modalities served by
the PACS and on the workload.
PACS Fundamentals
The picture archiving and communication
system (PACS) is becoming more commonplace
in today's hospitals because hospital administrators
have come to see the necessity of having such a
system to serve physicians and patients even
though it is expensive.
Display Workstations Display Workstations
 Any computer that a health care worker  The display workstation is the most
uses to view a digital image. interactive part of a PACS, consisting of a
 It is the most interactive part of a PACS, and monitor and a computer with a mouse and
these workstations are used inside and keyboard.
outside of radiology.  Conventional film/screen radiography uses
 Receives images from the archive or from large multiviewer lightboxes to display the
the various radiology modalities and images.
presents them for viewing.
 Has PACS application software that allows
the user to perform minor image
manipulation techniques to optimize the
image being viewed

 The monitor is one of the most important

elements of a PACS display station.
 The liquid crystal display (LCD) is the most
popular type of monitor used in a radiology
department

Archive Servers
 File room of the PACS.
 It is composed of a database server or image
manager, short-term and long-term storage,
and a computer that controls the PACS
workflow, known as a “workflow
manager”.
 The central part of the PACS and houses all Radiologist Reading Stations
of the historic data along with the current  Used by a radiologist when making a
data being generated. primary diagnosis.
 In many institutions, the archive serves as  Has the highest quality hardware, including
the central hub that receives all images the best monitor.
before they are released to the radiologists  There is generally access to a nearby RIS,
for interpretation. with a dictation system near or even
connected to the PACS station
Physician Review Stations Image Manager
 Step-down model of the radiologist reading  The image manager contains the master
station. database of everything that is in the archive.
 Many vendors use the same level of  It controls the receipt, retrieval, and
software but may eliminate some of the distribution of the images it stores and also
more advanced functions. controls all the DICOM processes running
within the archive.
 The image manager is also the PACS
component that interfaces with the
radiology information system (RIS) and the
hospital information system (HIS).
Image Storage
 The image storage or archive server
consists of the physical storage device of
the archive system.

File Room/Image Management Stations

 May be used to look up examinations for a
physician or to print copies of images for
the patient to take to an outside physician.
 The CD of images can be viewed on any PC
and generally comes with easy-to-use
Short-Term Storage
software burned onto it with the images.
 The short-term tier is commonly a RAID.
 A RAID is composed of several magnetic
disks or hard drives that are linked together
in an array

 The size of the RAID ranges from several

hundred gigabytes to several terabytes.
 As the individual disk sizes continue to
Picture Archiving and Communication System
increase, so does the potential size of the
Archiving and Peripherals
RAID.
Archiving Components
 The term archive can be defined as a place
where records or documents are preserved
 In a PACS, the electronic archive serves as
the new file room
and warehouse for
all DICOM
imaging
modalities
Long-Term Storage Cloud Storage
 Because RAID is becoming more cost  Many healthcare organizations are opting to
effective, many hospitals use RAID storage purchase “cloud” storage from various
for both their short-term and their long-term vendors for image storage across the
archive. organization.
 Other long-term storage products that are  The PACS software will be maintained at
still widely used are optical disk, tape, and the hospital/clinic level, but all image
magnetic disk. storage is managed by an offsite company
that maintains archive servers and ensures
the security of the stored digital information
Imagers
 Imagers, also known as film printers,
receive an image from a workstation and
print the image based on printer LUTs and
preset print layouts.
 Both of these parameters vary for each
modality that produces digital images
 There are two major types of imagers: wet
Archive Considerations (chemical) laser imagers and dry laser
 PACS archives are chosen for many imagers
reasons, including system need, system  Wet Imagers
cost, and system compatibility. o Use chemicals to process the film
 Many hospitals do not have the capital that has been exposed to the laser.
funds or the personnel to implement and o The laser beam produces an
operate the complex archive that is needed intensity of light that is proportional
for a PACS to the signal being received to
regulate the optical density recorded
on the film.
o Because wet imagers require
chemicals, they must be placed in a
well ventilated area with proper
drainage and plumbing.
o Wet imagers also take up much
more space than the dry imagers,
Application Service Provider (ASP) and the cost of chemicals, disposal,
 An ASP is a company that provides and
outsourcing of archiving and management maintenance
functions for a pay-per-use or pay-per- make them a
month charge. less popular
 ASPs give smaller institutions access to the choice than
level of hardware and software they could dry imagers.
not otherwise afford.  Dry imagers
 Moreover, they assume responsibility for o Use heat to process the latent image
the day-to-day management of the archive that is etched into the silver
system emulsion by the laser.
 Disaster recovery involves making copies o Dry laser film also has silver within
of each tape or disk and sending them to its emulsion, but instead of silver
another building or offsite location or, by halide crystals, the dry film has
using the ASP model, shipping them to an silver behenate.
outside company for storage on a pay-per-
use policy
 o The film is exposed with a laser in a Teaching Purposes
fashion similar to the wet imager.  Most hospitals train students at their
o The silver salts are then exposed to institution.
heat and turn to metallic silver to
create the image on the film. Compact Disk/Digital Versatile Disk Burners
 Most hospitals try to reduce the amount of
printing done in the
department.
 One alternative to printing
hard copies is to burn
images to an optical disk.
 All PACS vendors offer the ability to burn
images to a CD or DVD for the purpose of
o Dry imagers have been found to sharing the images outside of the PACS.
have slightly worse quality than wet  When a disk is burned with the patient's
imagers, but the dry imagers take up images, a DICOM viewer is also burned
less space and require no special onto the disk.
locations.
o The dry imager film quality tends to Common Uses of Burners
degrade over time, and it is more  CDs and DVDs can be used in most of the
sensitive to heat and humidity than same applications as the printed film, with
conventional film, especially if the the exceptions that CDs and DVDs cannot
film is stored in a warm be used as a fail-safe mechanism nor can
environment. they be used by those departments that are
o The major advantage to the dry in difficult locations.
imager is that it requires only an  Many referring physicians prefer having the
outlet and a network connection to images on disk rather than film because it
connect to the departmental takes up less space, it can be added directly
modalities. to the patient's office chart, and the images
can be manipulated.
Common Uses of Imagers
Backup Ensuring Quality in Picture Archiving and
 The ability to print just in case the PACS Communication Systems
goes down is one of the most often heard
explanations Quality Assurance
 Quality assurance (QA) can be
Difficult PACS Location defined as a plan for the
 There are a few departments that are systematic observation and
difficult to convert to PACS initially, such assessment of the different aspects of a
as surgery, orthopedics, and sometimes the project, service, or facility to make certain
emergency room. that standards of quality are being met.
 QA activities are focused around people
Outside Physicians
and service
 Some referring physicians prefer to see
their patient's images while reviewing the Quality Control
radiologist's report.  Quality control (QC) can be defined as a
comprehensive set of activities designed to
Legal Cases monitor and
 For legal cases, films can be printed to be maintain
viewed in court. systems that
produce a
product.
  QC measures are instituted to ensure that o Perform the function, and note the
radiologic procedures are performed safely, processing speed. To maintain
are appropriate for the patient, are consistency, use the same tool each
performed efficiently, and produce a high- time the test is performed.
quality image.
Printer Image Quality
 Monitor each film printed to ensure that it
is free from artifacts and that it matches
monitor or desired quality.
 Print a test pattern from the PACS. Some
printers have a built-in test pattern that can
be printed by depressing a button on the
 Image Transfer Speed
printer.
o Determine a study to be used as the
 Observe the printed test pattern for artifacts
test.
and changes in density, contrast, and
o The same study should be used each
resolution.
time to ensure there are no
 Measure the steps on the test pattern using
variables.
a densitometer, and document your
o The technologist can also use test
findings. Create a characteristic curve to
patterns that have been saved on the
compare previous measurements.
archive.
 Make sure that the preventative
o Retrieve the study from the
maintenance schedule is completed in a
workstation. Note the amount of
timely manner, and maintain
time it took the entire study to arrive
documentation of the completion and
at the workstation.
findings.
o To test the transfer speed from the
modalities, have each modality send
its QC images to the archive, and
note the amount of time the transfer
takes. Make sure that the modality
sends the exact
same image
set each time
Speed
the test is
 Workstation Processing Speed
conducted.
o Determine a study to be used as the
test. The same study must be used
each time to ensure there are no
Data Quality Control
variables.
 Three important security issues regarding
o Choose a study with several images
PACS, particularly when information is
and a patient that has several
sent between distant sites are :
studies.
 Privacy also called confidentiality , refers
o Open the initial test study, and note
to preventing persons other than the
the loading speed. Page through the
intended recipient from reading the
images, and note the loading speed
transmitted information.
of each image.
 Encryption maintains the privacy of a
o Choose an image-processing
message by translating the information into
function appropriate for the test
code that only the intended recipient can
images that you have chosen, such
convert to the original form.
as edge enhancement, stitching, or a
three-dimensional (3D) processing
function.
  Integrity means that the received
information has not been altered, either  Also in the log, note the reason, how long,
deliberately or accidentally. what had to be done to fix the problem, and
 Reliability ensures that the acquired studies who fixed the problem.
can be interpreted all the time.  If the same problem continues to occur, this
log can be used to prove either that a piece
Advantages and Disadvantages of PACS of equipment needs to be replaced or that
additional service is needed
Advantages:
1. Prompt access to images , within the
medical center and especially at remote
locations
2. Ability for more than one clinician to
simultaneously view same images
3. Ability to enhance image ( pre and post
processing) System Training
4. Reduced personnel  The vendor applications training is
5. Reduced film cost supposed to train several super users and
6. Reduced film processing help set up the system to site specifications.
7. Computer-aided detection/ diagnosis  The super users and the PACS administrator
need to set up an ongoing training program.
Disadvantages:
 Each time that a new version of the software
1. Initial and recurring equipment cost
is installed, the training protocol needs to be
2. Massive data storage
revised; retraining of existing personnel
3. Expensive technical personnel support
may be necessary.
system
 Each department also has a list of skills that
4. Maintaining access to previously archived
are tested and retrained each year.
after converting to a new archival
technology.
5. Security and reliability

Security and Reliability:

The main goal of security are to deny
unauthorized person access to confidential
information and to protect software and data from
accidental or deliberate modification or loss.

PACS Continuous Quality Improvement

Recognition of Nondiagnostic Images
 The radiologist may note the areas and
reasons for the poor-quality image.
 If the poor-quality image was caused by
equipment malfunction, the appropriate QC
test should be carried out, and the
appropriate service protocol followed.
 If the poor-quality image was operator
error, additional training or counseling by
the supervisor may be required.
System Up-Time
 A log should be kept to note any time that
the system is down.