future proof your pacs · rcr imaging informatics group 07/11/11 future proof your pacs dr neelam...

RCR Imaging Informatics Group www.pacsgroup.org.uk

07/11/11

Future Proof your PACS

Dr Neelam DugarChairman of

2013 provides most NHS Trusts with an opportunity to review their PACS implementations.

Image Display PACS

Requesting Ordercomms

Reporting RIS

1 Report- 3 IT Systems

Let us first review our NHS workflow and see what is lacking or what can be done batter.Radiology department deals with 3 distinct IT systems to produce the report, which is the end product of our department.1.Ordercomms –which gives us the electronic request2.Image Display or PACS3.Radiology Information System or RIS

Primary Report Review or Second Opinions

Radiologist Report- 2 Types

There are 2 types of reportsPrimary report & Supplementary report or 2nd opinion

import awesome

The Anglerfish Songby Hank Green

Yes it's true that I once went through lifeAs a guy who always had to rhyme life with strifeYes, I've been burned and I've been spurnedAnd through it all, yes, I have learnedThat love is not about whether you get stabbedBut how slow the knife gets turned

But my friends I've found an animalWho doesn't feel this painAnd my life is so much better Now that I can feel the same

Because you can't hate the nightIf you've lived your whole life without lightAnd you can't hate the dishIf you've only ever eaten fishAnd you can't feel aloneIf it's all you've ever known

Yeah the deep sea anglerfishHas no reason to be happyBut it has no frikkin' ideaWhat else to be

DFTBA!

neenasdesign

!!!!!!

Single Sign On

Let us look at the primary reporting workflow of radiologists. As Single Sign-on has been implemented, with a single log-in & password the radiologist is logged into 4 IT systems. Ordercomms, RIS, PACS & EPR

NHS No: 0123456789Hospital No: PAT12Surname: BLOGGS

Forename: JOEDate of Birth: 27 Mar

Sex: MaleAddress: 1, AB2 3CDClinician: Harry Potter

Location: A PlaceClinical Data: :-)

Radiology PACS

Ordercomms

RIS EPR

Single Sign On

Let us look at the reporting workflow of radiologists. As Single Sign-on has been implemented, with a single log-in & password the radiologist is logged into 4 IT systems. Ordercomms, RIS, PACS & EPR

PACS

PACSTITLE OF SUBJECT

PACS

PACS

RIS

RIS

RIS Reporting Worklist for ND

URGENT

1. Joe Bloggs-Chest CT2. Bob Wilson-CT Abdomen

NON-URGENT1. Hannah -Floris-MRI Pelvis

2. Joanne Hampson-MRI Neck

Reporting Worklist

On RIS she creates a list of exams that have been allocated to her for reporting.

TITLE OF SUBJECT

PACS- Current Chest X-Ray

Current Chest X-ray

PACS- Previous Chest X-Ray

Previous Chest X-ray

Reporting Workflow

Reporting Workflow

Ordercomms Joe BloggsChest X-ray

Clinical History: Shortness of breath

RIS Imaging History

Chest X-Ray Chest CT

MRI

DD/VR

Report: Bilateral chronic shadowing suggestive of PMF

Show EPR

Reporting Workflow:Automatic Context Synchronization Automatic display of Relevant Prior

Due to automatic context synchronization with PACS, the current chest xray for reporting appears on the middle monitor. The previous chest xray appears on the right monitor due to automatic display of relevant prior.Left monitor with RIS shows the clinical history on Ordercomms with integrated Voice Recognition or digital dictation for recording the report.

PACS


PACS

PACS

RIS

RIS

RIS Reporting Worklist for ND

URGENT

1. Joe Bloggs-Chest CT2. Bob Wilson-CT Abdomen

NON-URGENT1. Hannah -Floris-MRI Pelvis

2. Joanne Hampson-MRI Neck

Back to Reporting Worklist

Once report is complete she can move to the next patient on the worklist.

TITLE OF SUBJECT

PACS-CT Abdoment EPR- XDS Registry

EPRPACSPACSEPR

1. ECG

2. Endoscopy

3. Blood Results

4. Histology

Future: Access to Hospital EPR(Manual Context Sync)

Reporting Workflow

Reporting Workflow

Ordercomms Joe Bloggs

CT AbdomenClinical History: Acute

abdominal pain

RIS Imaging History


MRI

DD/VR

Show EPR

In future with adoption of vendor neutral standard like XDS, the radiologist will have access to XDS based EPR. Here CT appearances look like Acute pancreatitis.

TITLE OF SUBJECT

PACS-CT Abdomen EPR- XDS Registry

EPRPACSPACSEPR

Future: Access to Hospital EPR(Manual Context Sync)

Blood Amylase-- 1,500

Reporting Workflow

Reporting Workflow



abdominal pain

RIS Imaging History


MRI

DD/VR

Show EPR

Due to 1 click access to blood results on EPR, a confident diagnosis of pancreatitis can be made

Access to EPR improves...

PATIENT Safety

This improves radiologists reporting accuracy & patient safety.

REVIEW: Cancer MDTM

Now let us look at 2nd opinion reporting. Cancer Multi-disciplinary team meetings have revolutionized cancer care within UK.

PATHOLOGISTRADIOLOGIST

RESPONSIBLE CONSULTANT

SURGEON/PHYSICIAN/ONCOLOGIST

1. REVIEW2. DISCUSSION3. DECISION4. DOCUMENTATION

MDTM PROCESS

The MDTM involves review of the clinical information, radiology & pathology. This is followed by discussions, decision & documentation .

56 year old femaleAbdominal pain Weight lossCT ScanBiopsy

SURGEON/PHYSICIAN/ONCOLOGIST

PATHOLOGISTRADIOLOGIST RESPONSIBLE CONSULTANT

MDTM TRIPLE REVIEW

1

2 3

Radiologist then records a 2nd more refined opinion as a report

TITLE OF SUBJECT


Current Chest X-ray



Reporting Workflow

Reporting Workflow

Ordercomms Joe Bloggs2nd Opinion

Chest X-rayAdditional information:Loss of weight, smoker

RIS Imaging History


MRI

DD/VR

Report: Bilateral chronic shadowing suggestive of

PMF

Show EPR Report: Appearances are

identical to previous film performed --?PMF

2nd Opinion RecordingIT Workflow Support

Second opinions may also be requested via Ordercomms.

TITLE OF SUBJECT


Current Chest X-ray



Reporting Workflow

Reporting Workflow

Ordercomms Joe Bloggs2nd Opinion

Chest X-rayAdditional information:Loss of weight, smoker

DD/VR

Report: Bilateral chronic shadowing suggestive of

PMF

Addendum Report: Given the history of Smoker and

weight loss, I would recommend a CT scan

Request Second OpinionReview at MDTM

RIS : Addendum Given the history of Smoker

and weight loss, I would recommend a CT for further

assessment

In this case, additional information of weightloss & smoker is provided to the radiologist. Thus the radiologist includes a second opinion recommending a CT scan.

Well, yes, we could just fix it in Photoshop, but your arm would still be

broken...

The Death of PACS?

PACS has been the single most successful clinical IT system in NHS in UK. Will we really have a PACS in the future?

BIRTH OF A TRUE

EPR

1. Ordercomms

2. Endoscopy

3. Blood Results

4. Histology

5. Cardiology

6. Audiology

7. Radiology images

8. Clinical Letters/ Discharge Summaries

Patient :Joe Bloggs

I Believe that we will see the death of PACS as we see it today, as we will see radiology images included within a a true EPR.

Past: Fragmented Digital Radiology Record

No DICOM

CT Viewer CR Viewer MRI Viewer

Let us look at the history of Radiology PACS & see how it has evolved and why is it so successful. 10-15 years ago in the absence of DICOM standard, each machine vendor used proprietary image formats Thus we had a CT MiniPACS, MR MINIPACS, CR MiniPACS etc

Print To Film

Past: Integrated Film Record

These proprietary formats resulted in a fragmented digital image record Hence we printed to film to produce an integrated film record

DICOM and PACS

Today...

Due to global adoption of DICOM as the vendor neutral standard for radiology images, we saw emergence of an integrated digital radiology image record popularly called PACS.

Today--PACS & PPR(PPR=Paper Patient Record)

However, today we have a PACS (a digital record for radiology images) & PPR (Paper patient record). Let us see if there are lessons that can be learnt.

X-Ray Packets

Many of us remember the xray film packets of the past. The ouside of the packet had patient demographics & an index of the images contained within the packet.

REQUEST CARDREPORT

Inside X-Ray Packets

Inside were the films & a report folder. The report folder contained the request card & the report These documents had a proper document format which was well laid out & easy to read.

Reports: Poor document display

No request card

PACS FAILURE

However, PACS has failed us today due to poor document display for reportsNo request cards displayed either with the images.

Maternity/A&E System

Discharge Letters

Clinical Correspondence

Clinical Letters

Pathology System

Pathology reports

Critical Care System

ECGLaboratory SystemLab Reports

Ophthalmology Camera

Retinal scans

Audiology System

Audiometry report

EDISEmergency discharge

PAST: Digital Data Silos

Print to Paper/Film

Let us look at the bigger picture. A secondary care hospital with multiple departmental systems. In the past, despite having digital systems we continued to print to paper & films due to lack of standards

Today: PACS and PPR

Today due to adoption of open DICOM standards we have an integrated digital record for radiology images popularly called PACS*But we continue to print to paper for the rest of the patients clinical record. So today we have PACS & PPR.

PACS Radiology Data Silo

However, Today PACS is producing a radiology data silo as it is separate from the rest of the clinical record.

Medical Image Standard= DICOM

The success of today’s PACS due to the widely adopted Medical Image Standard of DICOM

EPR- XDS Registry

EPRPACS

1.ECG ECG

2. Blood Results

3. Clinic Letter

Document Standard=HL7 CDA

The globally emerging standard for medical documents is CDA of HL7. Clinical Document Architecture. It is important we move to document standard for GP referral letters, clinic review letters, lab results, radiology reports etc

Clinical Document Architecture (CDA)=HL7

1. Machine Readable

Headers—Patient, Sender, Receiver , Document,

Coded –optional extras dependent on doc type (modality, accession no. date of doc creation etc for radiology)

2. Human Readable

body of report(Narrative)

• Defining Question

• Findings

• Conclusion

• Recommendation

CDA has both machine & human readable content.Request card & Radiology reports are clinical documents in use in radiology. However, the concept is transferrable to any clinical document type.

Header: Computer Read(XML)

Document TypeSenderReceiverPatient

Body: Human Read

(Narrative)Defining the Question

Findings

Conclusion

Recommendations

Optional: Coded Entries

(differ with doc types)

This is a graphical representation of a radiology report with a CDA document analogy superimposed. For a Radiology Report Template to work, it must bring together the Clinical best practices with IT architecture.CDA as Report Templates satisfy both Clinical & IT needs.Header information is consistent & has Patient, Sender, Recipient & Document InformationBody incorporates the clinical template--Def ining the clinical question, f indings, Conclusion & reccomendationsCoded entries allows f lexibilty to record other information relevant to document type. e.g operator details, exam room etc We must encourage our RIS & Ordercomms Vendors to support CDA structure.

GP/Hospital Referral Letters

Clinic Letters

Discharge Summaries

Prescriptions

Requests

Investigation Reports

Images (radiology, pathology, cardiology, ophthalmology etc)

XDS Registry=

Medical Indexing

XDS Registry provides a patient centric indexing of medical images & documents produced in multi-vendor systems—provided the images & documents are produced in a standard formats of DICOM & CDA.

XDS Metadata Submission Set Radiology Image (by PACS) Radiology Report (by RIS) Radiology Request (By Ordercomms)

Source Patient Info-Name Patient Name Patient Name Patient NameSource Patient Info-DOB DOB DOB DOBSource Patient Info-Sex Sex Sex SexSource ID PAS No. PAS No. PAS/NHS (depending on source)Patient ID NHS No. NHS No. NHS No.HealthcareFacilityTypeCode Location of imaging Location of reporting Patient Location at Request---Outpatient/

Inpatient/GPAuthor-Name Probably fixed hospital/machine name -

could be radiographer or Export System name

Reporter Name Requester

Legal Authenticator In UK, same as Author In UK, same as Author In UK, same as AuthorAuthor-Role Reporter Grade-Cons, Junior doc,

RadiographerReporter Grade-Cons, Junior doc, Radiographer

Requester Grade-Cons, Junior doc, Nurse

Author--Speciality Radiology Radiology Requesting Dept—(General Medicine/Surgery etc)

Author--Institution Hospital Name Hospital Name Hospital/GP surgeryHealthcareFacilityPracticeCode Probably NACS code Probably NACS code Probably NACS codeDocumentClassCode(High level Category) Radiology Image Radiology Report Radiology RequestDocumentTypeCode(fine level category) National Exam Codes National Exam Code National Exam CodeTitle of Document Human readable description - e.g. CT Head Human readable description - e.g. CT Head Human readable description - e.g. request for

CT HeadDocument Unique ID in source system Internal unique ID (Accession is not unique!) Internal unique ID Internal unique IDCreation Time Date & Time of KOS publication Date & Time of Report Authorised Date & Time when Request CompletedService Start Time Date & Time of start of Image Acquisition Date & Time of Report Date & Time of RequestService Stop Time Date & Time of end of Image Acquisition Date & Time of Report Authorised Date & Time of RequestEvent Code ?? ?? ??LanguageCode en-GB (or cy-GB!) en-GB (or cy-GB!) en-GB (or cy-GB!)MimeCode Application/dicom Vary by type - pdf, doc, text etc. Vary by type - pdf, doc, text etc.ConfidentialityCode ?? ?? ??FormatCode 1.2.840.10008.5.1.4.1.1.88.59/1.2.840.10008.2.6.1 "TEXT" or "PDF" Vary by type - pdf, doc, text etc.

EntryUUID in XDS Assigned internally - never seen by users Assigned internally - never seen by users Assigned internally - never seen by users

XDS Submission Set

This is the XDS submission set for PACS, RIS & Ordercomms. All the XDS submission datafields already exist on the source systems and it should not be difficult for any supplier to adopt XDS.

XDS Registry=Medical Indexing

EPR- XDS Registry

EPRPACS

1. ECG

2. Endoscopy

3. Blood Results

4. Histology

XDS-I

By Source systems adopting the EPR standard of XDS/XDS-I, NHS will move to patient centric filing of medical images & documents.The analogy is very similar to DICOM adoption by modality vendors in the early 1990s.Most global PACS vendors ARE already XDS-I complaint.

1. ECG

2. Endoscopy

3. Blood Results

4. Histology

Future: PPR to EPR

Print to XDS

In the future with adoption of XDS & XDS-I we will see emergence of EPRs in NHS.We will see the incorporation of radiology images & reports into a patient centric EPR.

FUTURE: EPR SUCCESS(Lessons learnt from PACS)

Maternity/A&E System

Discharge Letters

Clinical Correspondence

Clinical Letters

Pathology System

Pathology reports


ECGLaboratory SystemLab Reports

Ophthalmology Camera

Retinal scans

Audiology System

Audiometry report

EDISEmergency discharge

CONNECT Existing Departmental

Systems with Open Standards

1. ECG

2. Endoscopy

3. Blood Results

4. Radiology

Print to XDS/XDS-I

I hope that in the future we will learn the lessons from the success of PACS, & use standards to connect departmental systems *using the global emerging EPR standard of XDS & XDS-I to create an XDS based EPR.

Future:XDS EPR

1. ECG

2. Endoscopy

3. Blood Results

4. Radiology

1. ECG

2. Endoscopy

3. Blood Results

4. Radiology

In the future we should see the emergence of XDS based EPR using the ethos of the PACS success.

Text

DICOMPush

DICOM Push via

IEP

Today: COMMUNICATION(Radiology images)

There is something else we can learn from PACS & DICOM standard.Today transport of radiology images from 1hospital to another is electronic –Using global standard of DICOM Push

Post

GP

Snail mail

Today: COMMUNICATION(Request card & Radiology reports)

Paper and Post

However transfer of documents still is largely based on paper & postDue to lack of standards adoption for documents

document types

NHS HospitalSEND

Discharge summaries

Clinic Letter

Lab results

Investigation Reports (radiology, endoscopy,histopathology etc)

GP SurgerySEND

Referral Letter

Lab Requests


Today: PAPER DOCUMENTS

It is very easy to group the types of documents exchanged between organizations into document types:1.Referral Letters2.Discharge Letters3.Clinic Letters4.Lab Requests & reports5. Radiology Requests & reports etc

Transport method --Standard Web exchange protocols—SMTP

USES in RADIOLOGY—Document Transport:

Electronic Radiology Request—From GP system to Trust Ordercomms

Radiology Report---From RIS to GP system

XDR of IHE: Cross-enterprise Reliable Exchange of Documents

XDR=Envelope

CDA=Letter

XDR is a standard for a web-based point to point transfer of clinical documents.XDR could be used to transfer radiology requests from GPs to hospitals& also transfer radiology reports to GP systemsXDR CDA combination is similar to DICOM Push

XDRXDR

GP

CDACDA

Future: XDR & HL7-CDADocuments Push

REPORT:

Hospital to

GP system

REQUEST: GP system

to Hospital

Future is about vendor neutral plug & play interoperability using global standards to communicate.

XDR

NHS HospitalSEND

Discharge summaries

Clinic Letter

Lab results


GP SurgerySEND

Referral Letter

Lab Requests

Investigation Reports (radiology, endoscopy,histopathology etc)CDA

CDA

Future: Healthcare ITDocuments Exchanged

The very same concepts of HL7-CDA & XDR can be applied to all other documents exchanged between primary & secondary care

REQUEST CARD

REPORT

Past: Image, request & report

In the past we had very high standards. The patients film packet contained films, request card & the report These documents had a proper document format which was well laid out & easy to read.

TITLE OF SUBJECT


Current Chest X-ray



Reporting Workflow

Reporting Workflow

RIS Imaging History Chest X-Ray Chest CT MRI

DD/VR

Show EPR

Show EPR

REPORT

REQ

REPORT

REQ

CDA Req

Future PACS: CDA displayRequest card & report

We must not let IT undermine the high clinical standards.

TITLE OF SUBJECT


Current Chest X-ray



Reporting Workflow

Reporting Workflow


DD/VR

Show EPR

Show EPR

REPORT

REQ

REPORT

REQ

Future PACS: CDA displayRequest card & report

CDA REPORT

In future radiology reports must have a proper document structure when displayed by PACS.

XDS Registry

Image & Document Creation

Image & Document

Display

STORAGE/ARCHIVE:

1. DICOM Archives2. XDS Repositories

Let us go back to our EPR discussions, Hospital IT Systems have 4 LayersImage & document creators—departmental systems like RISes, modalities etcImage & document displays---EPRs, PACSXDS Registries & DICOM Directories& Storage layer

Past: No Standards

Single VendorNo standards

20 years ago with no standards—each vendor tied you down to all 4 layers. We all remember the fragmented miniPACS systems

DICOM Directory

Present: DICOM Standard

Choice

PACS Vendors3 Layers

Today due to DICOM standard we have a choice of modalities. The PACS vendor cannot dictate what CT scanner/MRI scanner or ultrasound machine we have to buy.

XDS Registry

Choice Choice

Choice Choice

Future: XDS/XDS-I

Adoption of XDS will offer the user community more choice of best of breed vendors forModalityRegistryStorageDisplay

IT Concerns: Data Tsaunami

IT departments are concerned about the increasing costs of managed storage required by PACS.

EXPENSIVE Managed storage

Clinical standard: 3secs access

Infrastructure: kept updated

Whilst storage hardware reduces in price, managed storage remains expensive as patient data needs to be accessible in a timely manner, one cannot just store patient data & forget about it.

FUTURE PACS

It is naive to think that taxpayers can afford to store digital patient data forever in managed storage. Future PACS systems MUST be able to implement a rules based data culling.

PACS--RULES for CULLING

• PATIENT LEVEL

• 8 years after last visit

• 25 years after birth

• Manual extension (medicolegal, oncology research trials etc)

• EXAM LEVEL

• 25 years for obstetric exam

• Manual extension (slow growing tumours, hip replacements etc)

PACS must have 2 data culling dates:a. Patient level date of deletionb. Exam Level date of deletionWhenever there is a mis-match in the date of deletion for the same exam: The later date must be used.Same logic WAS applied for date of culling in film packet days.

IntegratedPaper

Record

Fragmented Digital Record

Today Due to a fragmented digital clinical record due to lack of document standard *we have had a integrated paper record

XDS RegistryIndexing

1. ECG

2. Endoscopy

3. Blood Results

4. Histology

XDS: Integrated Electronic Record

Adoption of XDS gives us a opportunity* to create an Electronic Patient record from the very departmental systems that currently exist.

1. Ordercomms

2. Endoscopy

3. Blood Results

4. Histology

5. Cardiology

6. Audiology

7. Radiology images


Patient :Joe Bloggs

EPR Viewer (XDS/XDS-1 Consumer)

This slides provides a graphical view of an XDS based EPR. Suppliers like Forcare, GE etc already have XDS displays available off the shelf.

Hospital XDS

RegistryIndexing

Maternity System

Clinical Letters

Pathology System

Cardiology PACS

Laboratory System

Ophthalmology PACS

RISRadiology PACS

XDS EPR- Local Patient Centric View

XDS standard adoption would provide a local patient centric EPR view in each hospital, *without the need to replace your existing functionally rich departmental systems.

XCA Concepts

Majority

NHS Patients—Locally held information is adequate

Sometimes

Ad-hoc access to Information -- outside the local IT boundaries✓Clinical decision making✓Avoid repeat investigations

For the vast majority of cases we treat in Primary or secondary care, the locally held clinical information with the available referral letter is adequate to make management decisions or issue a report (in case of radiology).However, in a small minority access to information held in other organizations becomes important.

XCAHospital GLocal XDS Registry

GP Local XDS Registry

Hospital BLocal XDS Registry

GPLocal XDS Registry

Hospital ELocal XDS Registry

GP Local XDS Registry

Hospital ALocal XDS RegistryGP

Local XDS Registry

XCA Model- Ad-hoc access

XCA or Cross community access-- which is an extension of XDS standard, will allow for regional or cancer-network or national patient related ad-hoc access to information. Patient centric access to information is timely & Prevents delays in patient management.

District General Hospital

XDS Registry

ClinicClinicClinicWardWardWard

X-ray Lab

Tertiary Hospital

XDS Registry


X-ray Lab

GP Surgery

ClinicClinicReferWardWardReq.

XCA

Patient Portal

NHS Number

XDS Registry

XCA

XCA

XCA will allow for ad-hoc access to patient information outside the traditional information governance boundaries--.

District General Hospital

XDS Registry


X-ray Lab

Tertiary Hospital

XDS Registry


X-ray Lab

GP Surgery

ClinicClinicletterWardWardReq.

XCA

Patient Portal

NHS Number

XDS Registry

XCA

XCA

Using the same XCA concepts patients can have access to their clinical documents which maybe held in different hospitals & GP surgery—in a patient centric manner.

import awesome

The Anglerfish Songby Hank Green

Yes it's true that I once went through lifeAs a guy who always had to rhyme life with strifeYes, I've been burned and I've been spurnedAnd through it all, yes, I have learnedThat love is not about whether you get stabbedBut how slow the knife gets turned

But my friends I've found an animalWho doesn't feel this painAnd my life is so much better Now that I can feel the same

Because you can't hate the nightIf you've lived your whole life without lightAnd you can't hate the dishIf you've only ever eaten fishAnd you can't feel aloneIf it's all you've ever known

Yeah the deep sea anglerfishHas no reason to be happyBut it has no frikkin' ideaWhat else to be

DFTBA!

neenasdesign

!!!!!!

Single Sign On

Let us look at the workflow of radiologists in the future. With implementation of Single sign on—a radiologist is able to log on to 4 IT systems RIS, PACS, Ordercomms & EPR with a single windows log-in & password (rather than 4 log-in & passwords)

NHS No: 0123456789Hospital No: PAT12Surname: BLOGGS

Forename: JOEDate of Birth: 27 Mar

Sex: MaleAddress: 1, AB2 3CDClinician: Harry Potter

Location: A PlaceClinical Data: :-)

Radiology PACS

Ordercomms

RIS EPR

Single Sign On

Let us look at the workflow of radiologists in the future. With implementation of Single sign on—a radiologist is able to log on to 4 IT systems RIS, PACS, Ordercomms & EPR with a single windows log-in & password (rather than 4 log-in & passwords)

PACS


PACS

PACS

RIS

RIS

RIS Reporting Worklist

URGENT

1. Joe Bloggs---CXR2. Bob Wilson-CT Head Sarah Jenkins-CT

Chest

NON-URGENT1. Hannah -Floris-CT Head2. Joanne Hampson-CT Neck3. James Bond- CT abdomen and Pelvis

XCA Model- Ad-hoc access

Radiologist draws up a reporting worklist on RIS.

TITLE OF SUBJECT


Current Chest X-ray



Reporting Workflow

Reporting Workflow


DD/VR

Show EPR

Show EPR

REPORT

REQ

REPORT

REQ

CDA Request

Reporting Workflow:Automatic Context Synchronization Automatic display of Relevant prior

With automatic context synchronization current Chest xray appears on middle monitor on PACS. Previous CXR appears on the right PACS monitor due to automatic display of relevant prior.

TITLE OF SUBJECT

PACS-CT Chest 3D PLUG-IN

EPRPACSPACSEPR

Future: PLUG-INS(DICOM 118 standard)

Reporting Workflow

Reporting Workflow


CT AbdomenClinical History: Acute Chest

pain

RIS Imaging History


MRI

DD/VR

Show EPR

3D View

Nowadays specialist softwares are appearing for post processing of thin CT, CAD, Orthopaedic templating etc. These are generally from small innovative vendors. Adoption of vendor neutral plug-ins is key to future proofing of PACS replacements. It is important to buy a PACS from a vendor who supports DICOM 118 standard. Here is a 3rd party Cardiac CT analyisis plug-in.

TITLE OF SUBJECT

PACS-Mammogram CAD PLUG-IN

EPRPACSPACSEPR


Reporting Workflow

Reporting Workflow


MammographyClinical History: Breast

Screening

RIS Imaging History


MRI

DD/VR

Show EPR

CAD

Similarly, here is a 3rd party mammography CAD plug-in.

TITLE OF SUBJECT

PELVIC XRAY Ortho Templating PLUG-IN

EPRPACSPACSEPR


Reporting Workflow

Reporting Workflow


MammographyClinical History: Breast

Screening

RIS Imaging History


MRI

DD/VR

Show EPR

O T

Here is a 3rd party Orthopaedic templating plug-in. With time, it is likely that many of these plug-ins will become a part of a standard PACS software (rather than an optional extra from the suppliers or a a 3rd party)

1. Ordercomms

2. Endoscopy

3. Blood Results

4. Histology

5. Cardiology

6. Audiology

7. Radiology images


Patient :Joe Bloggs

Future PACS: XDS-1 Consumer=EPR Access

In the future PACS will be XDS-I consumer & will have access to images & reports registered to an XDS registry, which means PACS will have access to EPR.

TITLE OF SUBJECT

PACS-CT Abdoment

PACSEPR

Reporting Workflow

Reporting Workflow



abdomenal pain

Imaging History Chest X-Ray Chest CT MRI

RIS

DD/VR

EPR- XDS Registry

EPRPACS

1. ECG

2. Endoscopy

3. Blood Results

4. HistologyShow EPR

REQ

REPORT

CDA Request

Access to Hospital EPR(PACS=XDS Consumer)

As previously shown CT suggests acute pancreatitis. As the PACS is XDS Consumer, radiologist has access to blood results on PACS display.

TITLE OF SUBJECT

PACS-CT Abdoment EPR- XDS Registry

EPRPACSPACSEPR

Reporting Workflow

Reporting Workflow



abdomenal pain

Imaging History Chest X-Ray Chest CT MRI

RIS

DD/VR

Blood Results

Blood Amylase-- 1,500

Show EPR

CDA Request

REQ

REPORT

RIS or PACS =XDS consumerAccess to Hospital EPR

By reviewing blood amylase levels, a confident diagnosis of acute pancreatitis can be made—thus improving patient care.

TITLE OF SUBJECT


Current Chest X-ray



Local Imaging History1. Chest X-Ray2. Chest CT3. MRI

Local Imaging History1. Chest X-Ray2. Chest CT3. MRI

Reporting Workflow

Reporting Workflow

Request Card/Ordercomms-CDA

Local Imaging History Chest X-Ray

Chest CT MRI RIS

DD/VR

CDA REQ

Today: Radiologists’Workflow(Automatic Context Sync)

Today a reporting radiologist has access to local imaging history.

TITLE OF SUBJECT

PACS- Current Chest X-Ray PACS- Previous Chest X-Ray

PACSEPRPACSEPR

Reporting Workflow

Reporting Workflow

National Imaging History Chest X-Ray

Chest CTPET CT

MRI RIS

DD/VR

National Imaging History XDS1. Chest X-Ray2. Chest CT3. PET CT

National Imaging History XDS1. Chest X-Ray2. Chest CT3. PET CT

CDA REQ

Future Radiologists’ Workflow(XCA=National Image Sharing)

In future she will have access to national imaging history if required through XCA model.

TITLE OF SUBJECT

Current Screening Mammogram EPR: XDS Consumer compliant

PACS- Rad..EPRPACS- Bre...PACS- Rad...

Breast Screening

Breast Screening

National Breast

Screening System (NBSS)

1. ECG

2. Endoscopy

3. Blood Results

4. Histology

Breast Screening PACS:XDS Consumer=EPR access

Here the breast screening PACS is XDS consumer compliant & has access to EPR.

TITLE OF SUBJECT

Cardiology PACS EPR- XDS Consumer

EPRPACSPACSEPR

Cardiology Workflow

Cardiology Workflow

1. ECG

2. Endoscopy

3. Blood Results

4. Histology

Cardiology Information

System

DD/VR

National Cardiology History1. Cardiac Angiogram2. ECG3. Echocardiogram

Cardiology PACS:XDS consumer=EPR access

Similarly a Cardiology PACS is XDS consumer compliant & has access to EPR.

TITLE OF SUBJECT

Ophthalmology PACS EPR- XDS Consumer

EPRPACSPACSEPR

Ophthalmology Information System

Ophthalmology Informati...

1. ECG

2. Endoscopy

3. Blood Results

4. Radiology

Ophthalmology Information

System

DD/VR

Ophthalmology PACS: XDS consumer=EPR access

Similarly a Ophthalmology PACS is XDS consumer compliant & has access to EPR.

EPR- XDS Based Registry

EPRClinical Letters System

Clinical Letters System

DD/VR

Clinical Letters System

1. ECG

2. Endoscopy

3. Blood Results

4. Radiology

Clinical Letters System:XDS consumer=EPR access

Similarly a Clinic Management System is XDS consumer compliant & has access to EPR.

EPR- XDS Based Registry

EPRCritical Care System


DD/VR

Critical Care

System

1. ECG

2. Endoscopy

3. Blood Results

4. Radiology

Critical Care System:XDS consumer=EPR access

Similarly a Critical Care System is XDS consumer compliant & has access to EPR.

20131. Patient Centric EPR (XDS-I/XCA-I)

2. Vendor Neutral Plug-ins (DICOM 118) 3. Data Culling

I believe 3 concepts will define PACS replacements in 2013--EPR access, Plug-ins & data culling.