Costs and benefits of picture archiving and communication systems

Pilot deployment of a cloud-based universal medical image repository in a large public health system: A protocol study

This paper outlines the protocol for the deployment of a cloud-based universal medical image repository system. The proposal aims not only at the deployment but also at the automatic expansion of the platform, incorporating Artificial Intelligence (AI) for the analysis of medical image examinations. The methodology encompasses efficient data management through a universal database, along with the deployment of various AI models designed to assist in diagnostic decision-making. By presenting this protocol, the goal is to overcome technical challenges and issues that impact all phases of the workflow, from data management to the deployment of AI models in the healthcare sector. These challenges include ethical considerations, compliance with legal regulations, establishing user trust, and ensuring data security. The system has been deployed, with a tested and validated proof of concept, possessing the capability to receive thousands of images daily and to sustain the ongoing deployment of new AI models to expedite the analysis process in medical image exams.

MRI scarcity in low- and middle-income countries

Since the introduction of MRI as a sustainable diagnostic modality, global accessibility to its services has revealed a wide discrepancy between populations-leaving most of the population in LMICs without access to this important imaging modality. Several factors lead to the scarcity of MRI in LMICs; for example, inadequate infrastructure and the absence of a dedicated workforce are key factors in the scarcity observed. RAD-AID has contributed to the advancement of radiology globally by collaborating with our partners to make radiology more accessible for medically underserved communities. However, progress is slow and further investment is needed to ensure improved global access to MRI.

Health information technology interventions and engagement in HIV care and achievement of viral suppression in publicly funded settings in the US: A cost-effectiveness analysis

BACKGROUND

The US National HIV/AIDS Strategy (NHAS) emphasizes the use of technology to facilitate coordination of comprehensive care for people with HIV. We examined cost-effectiveness from the health system perspective of 6 health information technology (HIT) interventions implemented during 2008 to 2012 in a Ryan White HIV/AIDS Program (RWHAP) Special Projects of National Significance (SPNS) Program demonstration project.

METHODS/FINDINGS

HIT interventions were implemented at 6 sites: Bronx, New York; Durham, North Carolina; Long Beach, California; New Orleans, Louisiana; New York, New York (2 sites); and Paterson, New Jersey. These interventions included: (1) use of HIV surveillance data to identify out-of-care individuals; (2) extension of access to electronic health records (EHRs) to support service providers; (3) use of electronic laboratory ordering and prescribing; and (4) development of a patient portal. We employed standard microcosting techniques to estimate costs (in 2018 US dollars) associated with intervention implementation. Data from a sample of electronic patient records from each demonstration site were analyzed to compare prescription of antiretroviral therapy (ART), CD4 cell counts, and suppression of viral load, before and after implementation of interventions. Markov models were used to estimate additional healthcare costs and quality-adjusted life-years saved as a result of each intervention. Overall, demonstration site interventions cost $3,913,313 (range = $287,682 to $998,201) among 3,110 individuals (range = 258 to 1,181) over 3 years. Changes in the proportion of patients prescribed ART ranged from a decrease from 87.0% to 72.7% at Site 4 to an increase from 74.6% to 94.2% at Site 6; changes in the proportion of patients with 0 to 200 CD4 cells/mm3 ranged from a decrease from 20.2% to 11.0% in Site 6 to an increase from 16.7% to 30.2% in Site 2; and changes in the proportion of patients with undetectable viral load ranged from a decrease from 84.6% to 46.0% in Site 1 to an increase from 67.0% to 69.9% in Site 5. Four of the 6 interventions-including use of HIV surveillance data to identify out-of-care individuals, use of electronic laboratory ordering and prescribing, and development of a patient portal-were not only cost-effective but also cost saving ($6.87 to $14.91 saved per dollar invested). In contrast, the 2 interventions that extended access to EHRs to support service providers were not effective and, therefore, not cost-effective. Most interventions remained either cost-saving or not cost-effective under all sensitivity analysis scenarios. The intervention that used HIV surveillance data to identify out-of-care individuals was no longer cost-saving when the effect of HIV on an individual's health status was reduced and when the natural progression of HIV was increased. The results of this study are limited in that we did not have contemporaneous controls for each intervention; thus, we are only able to assess sites against themselves at baseline and not against standard of care during the same time period.

CONCLUSIONS

These results provide additional support for the use of HIT as a tool to enhance rapid and effective treatment of HIV to achieve sustained viral suppression. HIT has the potential to increase utilization of services, improve health outcomes, and reduce subsequent transmission of HIV.

Investigating the satisfaction level of physicians in regards to implementing medical Picture Archiving and Communication System (PACS)

Background

User satisfaction with PACS is considered as one of the important criteria for assessing success in using PACS. The objective of this study was to determine the level of user satisfaction with PACS and to compare its functional features with traditional film-based systems.

Methods

This study was conducted in 2017. Residents at three large university hospitals in Kerman filled-out a self-administered questionnaire consisting of three parts: demographic information of participants, user satisfaction with PACS, comparing features of the two digital and traditional imaging systems. The validity of this questionnaire was approved by five medical informatics, radiology, and health information management specialists and its reliability was confirmed by Cronbach’s alpha (86%). Data were analyzed using descriptive statistics and the Spearman, Mann Whitney U and Kruskal-Wallis statistical tests.

Results

The mean of the participants’ ages was 31.4 (±4.4) years and 59% of the participants were females. The mean of physicians’ satisfaction with PACS’ had no significant relationship with their age (P = 0.611), experience of using PACS (P = 0.301), specialty (P = 0.093), and percent of interpretation of images with PACS (P = 0.762). It had a significant relationship with the participants’ computer skills (P = 0.022).

Conclusions

The mean of physicians’ satisfaction with PACS was at a moderate to a high level, yet there are still problems in the successful implementation of these systems and establishing interoperability between them. PACS has not fully met all the demands of physicians and has not achieved its predetermined objectives, such as all-access from different locations.

Developing intelligent medical image modality classification system using deep transfer learning and LDA

Rapid advancement in imaging technology generates an enormous amount of heterogeneous medical data for disease diagnosis and rehabilitation process. Radiologists may require related clinical cases from medical archives for analysis and disease diagnosis. It is challenging to retrieve the associated clinical cases automatically, efficiently and accurately from the substantial medical image archive due to diversity in diseases and imaging modalities. We proposed an efficient and accurate approach for medical image modality classification that can used for retrieval of clinical cases from large medical repositories. The proposed approach is developed using transfer learning concept with pre-trained ResNet50 Deep learning model for optimized features extraction followed by linear discriminant analysis classification (TLRN-LDA). Extensive experiments are performed on challenging standard benchmark ImageCLEF-2012 dataset of 31 classes. The developed approach yields improved average classification accuracy of 87.91%, which is higher up-to 10% compared to the state-of-the-art approaches on the same dataset. Moreover, hand-crafted features are extracted for comparison. Performance of TLRN-LDA system demonstrates the effectiveness over state-of-the-art systems. The developed approach may be deployed to diagnostic centers to assist the practitioners for accurate and efficient clinical case retrieval and disease diagnosis.

Augmentation of the think aloud method with users' perspectives for the selection of a picture archiving and communication system

OBJECTIVES

Users attitude toward a picture archiving and communication system (PACS) and their interaction with this system are among the most important factors that influence its acceptance. This study aimed to augment the user's interaction with the user's perspective to select a usable PACS among three systems available on the market.

METHODS

We augmented the think aloud (TA) usability evaluation method with the Post-Study System Usability Questionnaire (PSSUQ) to compare user interaction problems of three PACS user interfaces. Four radiologists and four internist physicians participated in this study. Usability characteristics including efficiency, effectiveness, learnability, error, and satisfaction were used to assess the usability of each PACS.

RESULTS

There was a significant difference in efficiency (p = 0.01), effectiveness (p = 0.005), learnability (p = 0.001), and satisfaction (p = 0.009). However, no significant difference in the number of errors (p = 0.18), mouse clicks and keystrokes (p = 0.12), and the number of usability problems (p = 0.6) were observed among the three PACS systems studied.

CONCLUSIONS

This study showed that applying the proposed approach to augment TA with the user's perspective addresses almost all of the theoretical aspects of usability and can be employed to select the most usable PACS.

Impact of duplicate CT scan rate after implementation of transfer image repository system at a level 1 trauma center

Purpose

The regionalization of trauma in the USA results in frequent transfers of patients from a primary hospital ED to a higher level trauma facility. While many hospitals have a Picture Archive Communication System (PACS) which captures digital radiological images, these are often not available to the receiving institution resulting in duplicate imaging. The state of Arkansas instituted a trauma image repository (TIR) in July 2013. We examined whether implementation of this repository would impact CT scan duplication in the trauma system.

Methods

This was a retrospective analysis of trauma patients transferred from outlying hospitals in Arkansas and Missouri to a single level 1 trauma hospital in Missouri between July 2012 and June 2015. We compared the duplicate CT rate for patients transferred from Arkansas and Missouri hospitals before and after the repository was implemented for Arkansas.

Results

Prior to implementation (July 2012–June 2013) of Arkansas TIR, duplicate CT rates were similar for patients transferred from Arkansas (11.5% ± 2.8) or Missouri (16.3% ± 7.5). Following implementation (July 2013–June 2014), the duplicate CT rate for patients transferred from Arkansas was significantly lower (Arkansas = 10.1% vs. Missouri 16.2%; CI 95%, p = 0.02), and significance continued (Arkansas = 9.0% vs. Missouri = 17.8%; CI 95%, p = 0.02) during follow-up (July 2014–June 2015).

Conclusion

Fewer patients received duplicated scans within the Arkansas as compared with the Missouri-based trauma referral systems regardless of Injury Severity Scores (ISS). Our findings suggest that TIR adoption coupled with PACS improved transferability of radiographic studies and could improve patient care while reducing costs in trauma transfers.

Evaluation of a central venous catheter tip placement for superior vena cava-subclavian central venous catheterization using a premeasured length: A retrospective study

Subclavian central venous catheterization is a common procedure for which misplacement of the central venous catheter (CVC) is a frequent complication that can potentially be fatal. The carina is located in the mid-zone of the superior vena cava (SVC) and is considered a reliable landmark for CVC placement in chest radiographs. The C-length, defined as the distance from the edge of the right transverse process of the first thoracic spine to the carina, can be measured in posteroanterior chest radiographs using a picture archiving and communication system. To evaluate the placement of the tip of the CVC in subclavian central venous catheterizations using the C-length, we reviewed the medical records and chest radiographs of 122 adult patients in whom CVC catheterization was performed (from January 2012 to December 2014) via the right subclavian vein using the C-length. The tips of all subclavian CVCs were placed in the SVC using the C-length. No subclavian CVC entered the right atrium. Tip placement was not affected by demographic characteristics such as age, sex, height, weight, and body mass index. The evidence indicates that the C-length on chest radiographs can be used to determine the available insertion length and place the right subclavian CVC tip into the SVC.

A comparative cost analysis of picture archiving and communications systems (PACS) versus conventional radiology in the private sector

Background: Radiology is rapidly advancing, with a global transition to digital imaging technology to improve productivity and enhance communication. The major challenge confronting radiology practices is to demonstrate cost savings and productivity gains when a picture archiving and communication system (PACS) is established.Aim: To undertake an incremental cost analysis of PACS compared with conventional radiology to determine productivity gains, if any, at two private hospitals in Durban.Method: An incremental cost analysis for chest radiographs, computed tomography and magnetic resonance imaging brain scans with and without contrast were performed. The overall incremental cost for PACS in comparison with a conventional radiology site was determined. The net present value was also determined to evaluate the capital budgeting requirements for both systems.Results: The incremental cost of both capital and the radiology information system for installing PACS shows an expected increase. The incremental PACS image cost shows a reduction.Conclusion: The study provides a benchmark for the cost incurred when implementing PACS. It also provides a decision framework for radiology departments that plan to introduce PACS and helps to determine the feasibility of its introduction.

Study on user interface of pathology picture archiving and communication system

OBJECTIVES

It is necessary to improve the pathology workflow. A workflow task analysis was performed using a pathology picture archiving and communication system (pathology PACS) in order to propose a user interface for the Pathology PACS considering user experience.

METHODS

An interface analysis of the Pathology PACS in Seoul National University Hospital and a task analysis of the pathology workflow were performed by observing recorded video. Based on obtained results, a user interface for the Pathology PACS was proposed.

RESULTS

Hierarchical task analysis of Pathology PACS was classified into 17 tasks including 1) pre-operation, 2) text, 3) images, 4) medical record viewer, 5) screen transition, 6) pathology identification number input, 7) admission date input, 8) diagnosis doctor, 9) diagnosis code, 10) diagnosis, 11) pathology identification number check box, 12) presence or absence of images, 13) search, 14) clear, 15) Excel save, 16) search results, and 17) re-search. And frequently used menu items were identified and schematized.

CONCLUSIONS

A user interface for the Pathology PACS considering user experience could be proposed as a preliminary step, and this study may contribute to the development of medical information systems based on user experience and usability.

Picture Archiving and Communication System (PACS): Clinician's Perspective About Filmless Imaging

Picture archiving and communication systems (PACS) are most appropriate means of acquiring, archiving, and communicating all forms of radiology imaging. The present study is to decide applicability of PACS, its exact role in patient care, and benefit as a teaching tool. To compare conventional imaging with picture archiving and communication system from user's point of view, impact of PACS on patient care and teaching. This was a single center, observational study over a period of 4 weeks from 15 January 2010 to 15 February 2010 carried out in Pravara Rural Hospital. For the present study, 100 users from various clinical disciplines were included who routinely use PACS. A pretested questionnaire related to various aspects of PACS was devised considering its advantage to clinicians, role in patient care, and as tool for teaching. Out of 100 users, 85 % users reported PACS easy to very easy for handle. Ninety-four percent users reported PACS as useful tool for the hospital. Fifty-one percent of users found image quality at image review workstation to be good to very good against 49 % found it poor to very poor. There have been several studies to demonstrate the benefits of PACS to users, but many of these have concentrated on radiology trainees, users in a particular department. Present study concentrates on the impact that PACS has made to the working of the clinicians in many different disciplines. The perceived benefits of PACS outnumbered the disadvantages and reflected the widely documented benefits of PACS in the literature.

A socio-technical assessment of the success of Picture Archiving and Communication Systems: the radiology technologist's perspective

BACKGROUND

With the increasing prevalence of Picture Archiving and Communication Systems (PACS) in healthcare institutions, there is a growing need to measure their success. However, there is a lack of published literature emphasizing the technical and social factors underlying a successful PACS.

METHODS

An updated Information Systems Success Model was utilized by radiology technologists (RTs) to evaluate the success of PACS at a large medical center in Taiwan. A survey, consisting of 109 questionnaires, was analyzed by Structural Equation Modeling.

RESULTS

Socio-technical factors (including system quality, information quality, service quality, perceived usefulness, user satisfaction, and PACS dependence) were proven to be effective measures of PACS success. Although the relationship between service quality and perceived usefulness was not significant, other proposed relationships amongst the six measurement parameters of success were all confirmed.

CONCLUSIONS

Managers have an obligation to improve the attributes of PACS. At the onset of its deployment, RTs will have formed their own subjective opinions with regards to its quality (system quality, information quality, and service quality). As these personal concepts are either refuted or reinforced based on personal experiences, RTs will become either satisfied or dissatisfied with PACS, based on their perception of its usefulness or lack of usefulness. A satisfied RT may play a pivotal role in the implementation of PACS in the future.

Impacts of e-health on the outcomes of care in low- and middle-income countries: where do we go from here?

E-health encompasses a diverse set of informatics tools that have been designed to improve public health and health care. Little information is available on the impacts of e-health programmes, particularly in low- and middle-income countries. We therefore conducted a scoping review of the published and non-published literature to identify data on the effects of e-health on health outcomes and costs. The emphasis was on the identification of unanswered questions for future research, particularly on topics relevant to low- and middle-income countries. Although e-health tools supporting clinical practice have growing penetration globally, there is more evidence of benefits for tools that support clinical decisions and laboratory information systems than for those that support picture archiving and communication systems. Community information systems for disease surveillance have been implemented successfully in several low- and middle-income countries. Although information on outcomes is generally lacking, a large project in Brazil has documented notable impacts on health-system efficiency. Meta-analyses and rigorous trials have documented the benefits of text messaging for improving outcomes such as patients' self-care. Automated telephone monitoring and self-care support calls have been shown to improve some outcomes of chronic disease management, such as glycaemia and blood pressure control, in low- and middle-income countries. Although large programmes for e-health implementation and research are being conducted in many low- and middle-income countries, more information on the impacts of e-health on outcomes and costs in these settings is still needed.

Picture Archiving and Communication System (PACS) implementation, integration & benefits in an integrated health system

The availability of the Picture Archiving and Communication System (PACS) has revolutionized the practice of radiology in the past two decades and has shown to eventually increase productivity in radiology and medicine. PACS implementation and integration may bring along numerous unexpected issues, particularly in a large-scale enterprise. To achieve a successful PACS implementation, identifying the critical success and failure factors is essential. This article provides an overview of the process of implementing and integrating PACS in a comprehensive health system comprising an academic core hospital and numerous community hospitals. Important issues are addressed, touching all stages from planning to operation and training. The impact of an enterprise-wide radiology information system and PACS at the academic medical center (four specialty hospitals), in six additional community hospitals, and in all associated outpatient clinics as well as the implications on the productivity and efficiency of the entire enterprise are presented.

Pre-Measured Length Using Landmarks on Posteroanterior Chest Radiographs for Placement of the Tip of a Central Venous Catheter in the Superior Vena Cava

Central venous catheterization (CVC) is a common procedure but catheter misplacement is a frequent complication and can be lethal. Most CVCs are inserted at a recommended mean depth of 15 cm from the skin puncture site. Chest radiographs are used to confirm the positioning of CVCs, with the carina regarded as a reliable landmark for tip placement. The C-length, defined as the distance from the edge of the right transverse process of the first thoracic spine to the carina, can be measured on posteroanterior chest radiographs. To test the accuracy of C-length based CVC placement, 637 adult patients scheduled to undergo elective major abdominal procedures and neurological surgical procedures requiring CVC were randomized to undergo either the 15-cm guided method or the C-length guided method for placement of the CVC tip into the superior vena cava (SVC). All the CVC tips in the C-length group were successfully placed in the SVC. These findings indicate that the pre-measured C-length using two landmarks can be used to determine the insertion length and to place the CVC tip successfully into the SVC.

Technical developments in radiology in Australasia dating from 1977

This article outlines the enormous technological advances that have taken place in the practice of radiology in Australasia in the 30 years since approximately 1977. These developments have led to significant improvements in image quality across all modalities, including even general radiography, which had as its genesis Roentgen's ground-breaking discovery of X-rays in 1895. However, nowhere has the development been more dramatic than in magnetic resonance imaging (MRI). This may be brought into stark reality by noting that the first MRI image of a human finger was produced in 1976 followed one year later by that of a human chest and the first MRI units were not installed in Australia and New Zealand until 1986 and 1991, respectively. The quality of these early images would be judged as laughable by today's standards where the impressive isotropic imaging that can be achieved at sub-millimetre level by both MRI and CT could not have been dreamed of 30 years ago. The review also highlights some challenges for the future of the medical physics profession.

Understanding PACS Development in Context: The Case of China

This paper describes the evolution of picture archiving and communication systems (PACS) in China and identifies several obstacles to its development, including vendors' opportunism, hospital administrators' IT ignorance, mindlessness in IT adoption, lack of system integration, and misfits between foreign PACS and local hospitals. Lessons learned from these obstacles are provided, which are of value to developing countries where PACS has just started diffusing.

Value of measuring bone density serial changes on a picture archiving and communication systems (PACS) monitor in distraction osteogenesis

Serial changes of bone density in 26 femora and 22 tibiae that underwent leg lengthening by distraction osteogenesis were investigated by measuring the pixel value shown on a picture archiving and communication systems (PACS) monitor. The pixel value of the original cortex did not change significantly until the external fixator was removed. The pixel value of the distraction sites did not change significantly for the first 5-6 weeks/cm, but rapidly increased after 7 weeks/cm in the femur and tibia, then slowly increased after 8 weeks/cm. The serial changes of the pixel value of the distracted bone showed a sigmoid curve, rather than a straight increasing line. The relative pixel values of the lengthening sites were >95% in three of the four cortices at external fixator removal. Thus, the pixel value of PACS is a rapid and easy method for the detection of bone density changes in distraction osteogenesis.

Establishing a contract for a PACS managed service

This review considers the process of contracting for a picture archiving and communication system (PACS) using the private finance initiative (PFI) managed service route. The PFI process is reviewed and the advantages and disadvantages of a managed service detailed. During contract negotiations several areas of conflict were encountered. These are discussed with an outline of how they were resolved.

CONCLUSION

A contract for a PACS has been achieved by a large acute hospital Trust using a managed service provision through PFI. In detailing the specific problems encountered in the course of negotiations, it is intended that other Trusts entering on this course will be equipped and strengthened in the finalizing of satisfactory and robust contracts.

Workflow in nuclear medicine

This paper discusses a workflow management system for nuclear medicine. It augments the more conventional PACS with automatic transfer of studies along the chain of activities making up an examination in nuclear medicine. A prototype system has been designed, built, and installed in a department of nuclear medicine, active in a network of hospitals.

Significant savings in radiologic report turnaround time after implementation of a complete picture archiving and communication system (PACS)

One of the important advantages of the picture archiving and communication system (PACS) is the time saved in comparison with the conventional system. A group of 100 radiologic studies done in a conventional radiology department is compared with another group of the same number done in a completely filmless PACS department to assess the difference in the radiologist report turnaround time. There was a statistically significant (P < .00001) decrease in the median imaging-to-dictation time (IDT) of the PACS group (3 hours and 40 minutes) in comparison with the pre-PACS group (25 hours and 19 minutes). This can be attributed to the fact that PACS eliminates all the workload associated with hard copy films, thus, improving the department's efficiency and decreasing the number of lost films.

Suitability of the general-purpose graphic printer as an image output device for digital dental x-ray images

OBJECTIVES

The purpose of this study was to evaluate the suitability of the general-purpose graphic printer as an image output device for digital dental x-ray images.

METHODS

The image quality as obtained by a thermal printer and by a dye sublimation printer was investigated. A grid pattern image was used to check parallelism and verticality of lines in each hard copy. A step-wedge image was printed with each printer, and the optical density, gradient, and root mean square granularity were compared. Depiction ability was also compared by using test images, including small signals.

RESULTS

All of the lines were parallel and vertical on hard copies of both printers. The dye sublimation printer showed better results on optical density, gradient, root mean square granularity, and depiction ability.

CONCLUSION

The dye sublimation printer produces images of the depiction ability comparable to the cathode ray tube display and seems suitable as an image output device for digital dental x-ray images.

Development of an electronic radiologist's office in a private institute

A computer system that improves the quality, user-friendliness, accessibility, and management of radiology data (images, reports, databases, knowledge) was implemented at a private institute. A picture archiving and communication system (PACS) was integrated with the radiology information system (RIS). Two servers and 12 personal computers form the integrated system. The first server is dedicated to management and archiving of Digital Imaging and Communications in Medicine (DICOM) images. The second server is dedicated to management of the RIS and archiving of patient data (Structured Query Language database), reports (hypertext markup language [HTML]), and images in the Joint Photographic Experts Group (JPEG) format (mini-PACS). There are three main client-server networks: a common network of imaging modalities (magnetic resonance imaging, computed tomography, ultrasonography, digital radiography) and two fast Ethernet networks (the PACS network and the RIS network). The RIS-PACS is linked remotely with other workstations and servers via Integrated Services Digital Network (ISDN). Images and reports can be distributed to referring physicians in the form of multimedia HTML and JPEG documents, which can also be used for quick and easy archiving, distribution, and reviewing within the institute. However, referring physicians have been reluctant to use electronic reports and images.

Evaluation of a hospital picture archiving and communication system

OBJECTIVES

To establish the net costs to the hospital and the broad range of benefits associated with a hospital-wide picture archiving and communication system (PACS) that comprised digital acquisition, storage and transmission of radiological images via a hospital-wide network to 150 workstations.

METHODS

'Before and after' comparisons and time series analyses at Hammersmith Hospital (London, UK), and comparison with five other British hospitals where PACS was not being installed. The cost analysis considered implementation costs and changes in key elements of hospital running costs, including the impact of changes in the length of inpatient stays. A range of benefit measures were investigated, including image availability, avoidance of repeat imaging, avoidance of exposure to radiation, patient turn-round speed, time from examination to image availability in intensive care, avoidance of diagnostic 'errors' by casualty doctors, the additional diagnostic value of PACS-based images and clinician satisfaction.

RESULTS

The annual equivalent capital cost of the PACS was 1.7 million Pounds (annual equivalent replacement cost: 0.8 million Pound). Overall, the PACS substantially increased running costs. No convincing evidence of a PACS-induced change in length of inpatient stay was found. PACS was associated with some improvements in the performance of the radiology department: improved image availability (97.7% versus 86.9%), lower repeat imaging rate (7.3% versus 9.9%) and 20% lower total radiation doses for examinations of the lateral lumbar spine. No improvements were identified in the quality of the radiology reporting service. Benefits outside radiology included shorter time from examination to image availability for routine uses in intensive care (19 versus 37 minutes), and a lower rate of diagnostic 'errors' in casualty (0.65% versus 1.51%). High levels of satisfaction with PACS were found amongst both providers and clinical users.

CONCLUSIONS

PACS was almost universally preferred by users and brought many operational and clinical benefits. However, these advantages came at a significant capital and net running cost.

Recommendations for responsible monitoring and regulation of clinical software systems. American Medical Informatics Association, Computer-based Patient Record Institute, Medical Library Association, Association of Academic Health Science Libraries, American Health Information Management Association, American Nurses Association

In mid-1996, the FDA called for discussions on regulation of clinical software programs as medical devices. In response, a consortium of organizations dedicated to improving health care through information technology has developed recommendations for the responsible regulation and monitoring of clinical software systems by users, vendors, and regulatory agencies. Organizations assisting in development of recommendations, or endorsing the consortium position include the American Medical Informatics Association, the Computer-based Patient Record Institute, the Medical Library Association, the Association of Academic Health Sciences Libraries, the American Health Information Management Association, the American Nurses Association, the Center for Healthcare Information Management, and the American College of Physicians. The consortium proposes four categories of clinical system risks and four classes of measured monitoring and regulatory actions that can be applied strategically based on the level of risk in a given setting. The consortium recommends local oversight of clinical software systems, and adoption by healthcare information system developers of a code of good business practices. Budgetary and other constraints limit the type and number of systems that the FDA can regulate effectively. FDA regulation should exempt most clinical software systems and focus on those systems posing highest clinical risk, with limited opportunities for competent human intervention.

Picture archiving and communication system (PACS): a progressive approach with small systems

PACS represents the natural evolution from working with digital modalities (e.g. CT, US, MRI, CR) towards a global digital environment where the film based activities are progressively replaced by their digital counterpart. The advantages of the technique and the drawbacks of the first implementations are described, as well as the recent advances in terms of technology, architecture, medical integration and cost-effectiveness. The so called 'second generation' PACS concept is presented with its features: modular architecture, progressive implementation, multi-vendor environment, integration with the Hospital Information System, standardization. This approach is particularly suited for progressive implementation in an existing hospital, in contrast to the possible top-down construction of a filmless radiology department, as a project for a totally new hospital. The implementation into the university hospital AZ-VUB is described as case study.

A methodology for the economic assessment of picture archiving and communication systems

Most economic studies of picture archiving and communication systems (PACS) to date, including our own, have focused on the perspectives of the radiology department and its direct costs. However, many researchers have suggested additional cost savings that may accrue to the medical center as a whole through increased operational capacity, fewer lost images, rapid simultaneous access to images, and other decreases in resource utilization. We describe here an economic analysis framework we have developed to estimate these potential additional savings. Our framework is comprised of two parallel measurement methods. The first method estimates the cost of care actually delivered through online capture of charge entries from the hospital's billing computer and from the clinical practices' billing database. Multiple regression analyses will be used to model cost of care, length of stay, and other estimates of resource utilization. The second method is the observational measurement of actual resource utilization, such as technologist time, frequency and duration of film searches, and equipment utilization rates. The costs associated with changes in resource use will be estimated using wage rates and other standard economic methods. Our working hypothesis is that after controlling for the underlying clinical and demographic differences among patients, patients imaged using a PACS will have shorter lengths of stay, shorter exam performance times, and decreased costs of care. We expect the results of our analysis to explain and resolve some of the conflicting views of the cost-effectiveness of PACS.

Using agent-based technology to create a cost effective, integrated, multimedia view of the electronic medical record

Image Engine is multi-user, client-server database for the storage, retrieval and sharing of a wide range of digitized biomedical images under development at the University of Pittsburgh. This paper provides an overview of the system and describes the use of agent-based technology to integrate clinical information from the Image Engine database and the MARS clinical information system at the University of Pittsburgh Medical Center. Agent-mediated links provide a mechanism for combining clinical data from multiple databases to create a unified, multimedia view of the electronic medical record.