Pathology PACS Lessons Learned from Radiology

Pathology PACS Lessons Learned from Radiology APIII 2005 David L. Weiss M.D. Examine Radiology PACS As It Relates To Pathology  Goals  PACS architecture  Monitors and ergonomic issues  Workflow/user efficiency  Communication  Decision-support  Reporting PACS Goals Filmless radiology  Cost savings  Improved accuracy  Workflow efficiencies  Distance collaboration  Filmless radiology Achievable currently  Mammography will be the last holdout  Completely digital storage   Compression decisions  Slideless pathology? Image capture to PACS  Direct  DR; CT; MR; US; Nuclear medicine; Digital mammography  Indirect  CR  Manual  Film digitizer Computed Radiography  Different vendor offerings detector  Four detectors per cassette  Image  Single stitching  Must be anatomic  36 inch scoliosis series stitching  Alternative – view images sequentially  Image Film digitizer Single film  Stack mode  Automated patient identification   Barcode   Formatting  Magnification factor Speed PACS Cost savings Many different studies  Different pricing models   Capital purchase; operational lease; ASP Varying results  Volume sensitive  Film cost savings  Personnel  Improved Accuracy  Different modalities  CR/DR  CT/MR/US  Mammography Reconstruction workstations  Decision-support tools   CAD  Online references Workflow efficiencies Technologist  Clerical  Radiologist  Clinician  Distance collaboration Teleradiology  Nighthawk radiology   Wet readings Shared work lists between different sites  Offshore reading  Radiology “grid” concept   Load-balancing PACS Pre-history: Teleradiology     1980s Predated PACS Predated modern software platforms Digitized films manually   Camera on a stick Required hands-on user   Film digitizer Direct capture of CT PACS History - Architecture  Distributed architecture      Early PACS Push images  Routing algorithms Thick client High workstation requirements  UNIX Lower bandwidth requirements PACS History - Architecture  Central architecture     Later PACS Pull images  On demand Thin client Lower workstation requirements  Windows PC PACS History - Architecture  Web-based    Thinner client Enterprise distribution  Often less complex GUI Bandwidth dependent PACS History - Architecture PACS History - Architecture  What has history taught us? can be too thin  Be skeptical of trends  You PACS Architecture History  Hybrid    Convergent design Pull images – radiologist workflow Push images – on-call situations; clinician workflow PACS Workstation Requirements    Workstation hardware Monitor requirements Software requirements - End-user efficiency       Work list functionality Hanging protocols Graphic user interface Desktop integration User preferences Alternate user interface devices  Communication Workstation Hardware Requirements         P4 processor 2.8 GHz 2GB RAM 40GB hard drive Gigabit ethernet capability CD-ROM drive/burner XP Pro operating system 350 W power supply Workstation Hardware Requirements  Nonstandard configuration workstation  Speech recognition  Dual-processor  3-D  Other clinical applications requirements  Nuclear medicine; ultrasound; orthopedics  Mainly software Diagnostic Monitor Requirements     Resolution – appropriate for the modalities being read. Contrast – in order to define a suitable number of shades of gray. Brightness Sustainability Diagnostic Monitor Requirements      Resolution – appropriate for the modalities being read. Contrast – in order to define a suitable number of shades of gray. Brightness Sustainability Color Color Monitor Issues  Standardized color temperature  6500 K  Assures consistency from monitor to monitor  Initial calibration  Resolution; luminance; color   QC  Color drift Off-angle viewing As Received Versus ... Factory Calibration Vector III, RGBS Pre-calibration 0.36 95 displays 40 Pass 55 Fail 57.9% 0.36 Vector III, RGBS Post-calibration 95 displays 95 Pass 0 Fail 0.0% 0.35 0.35 0.34 0.34 y 0.33 y Planckian Locus Pre-cal 0.33 0.32 0.32 Planckian Locus 0.31 Post-cal Adj. Test Limits, (+/-.005) 0.3 0.29 6200 0.3 0.31 0.32 0.33 0.34 0.35 0.31 Adj. Test Limits, (+/-.005) 6200 0.3 0.29 0.3 0.31 0.32 0.33 0.34 0.35 x x Courtesy of National Display Systems Off-angle viewing  Monitor pixel has a physical depth  Shining a flashlight through a hollow cylinder  Grayscale monitor  Decreased brightness  Color monitor  Red wavelength washout Long Wave Lengths (red) disappear first, makes image look green-gray … MVA, PVA Technology IPS Technology Courtesy of National Display Systems Ergonomic Issues Room layout  Workstation designed for more sedentary workflow  Background illumination  End-user Efficiency  PACS Workstation Software Requirements End-user Efficiency Minimize time spent in any tasks other than image interpretation  Maximize eye dwell time on images  Eyes and mind on the images, not on the computer  End-user Efficiency 1. 2. 3. 4. 5. 6. Work list functionality Hanging protocols Graphic user interface Desktop integration User preferences Alternate user interface devices Analog film viewing      Films are hung by clerical staff or technologists Read patient history Barcode accession number View film on multiviewer Tools     Wax crayon Ruler Hot light Magnifying glass  Dictate report Analog film viewing Intuitive      Films are hung by clerical staff or technologists Read patient history Barcode accession number View film on multiviewer Tools     Wax crayon Ruler Hot light Magnifying glass  Dictate report PACS Workflow              Choose work list Choose patient Arrange images Window and level Choose and open old study Match paperwork and barcode accession number Scroll through images Annotate electronically Pan and zoom Other applications; 3-D, Nucs, US Dictate Save changes Close case PACS Workflow              Choose work list Choose patient Arrange images Window and level Choose and open old study Match paperwork and barcode accession number Scroll through images Annotate electronically Pan and zoom Other applications; 3-D, Nucs, US Dictate Save changes Close case End-user Efficiency 1. 2. 3. 4. 5. 6. Work list functionality Hanging protocols Graphic user interface Desktop integration User preferences Alternate user interface devices READER’S NAME WEISS, DAVID L Work List Functionality More than one way to remove study from work list  Ability to easily drag case to secondary work list  opinion  Film library  Quality control   Second Compare to analog workflow Work List Functionality Ideally will not see the work list after selection of first patient  Compare to analog workflow  PACS Workflow              Choose work list Choose patient Arrange images Window and level Choose and open old study Match paperwork and barcode accession number Scroll through images Annotate electronically Pan and zoom Other applications; 3-D, Nucs, US Dictate Save changes Close case End-user Efficiency 1. 2. 3. 4. 5. 6. Work list functionality Hanging protocols Graphic user interface Desktop integration User preferences Alternate user interface devices End-user Efficiency  The first task of most radiologists is to check patient history PACS Workflow              Choose work list Choose patient Arrange images Window and level Choose and open old study Match paperwork and barcode accession number Scroll through images Annotate electronically Pan and zoom Other applications; 3-D, Nucs, US Dictate Save changes Close case End-user Efficiency 1. 2. 3. 4. 5. 6. Work list functionality Hanging protocols Graphic user interface Desktop integration User preferences Alternate user interface devices Analog film viewing Intuitive  Tools  Chosen by user  Modality specific Modality specific  Arranged by user    Can use same tool more than once Can change tool without searching desktop PACS Workflow              Choose work list Choose patient Arrange images Window and level Choose and open old study Match paperwork and barcode accession number Scroll through images Annotate electronically Pan and zoom Other applications; 3-D, Nucs, US Dictate Save changes Close case End-user Efficiency 1. 2. 3. 4. 5. 6. Work list functionality Hanging protocols Graphic user interface Desktop integration User preferences Alternate user interface devices Integration Spectrum Separate PC/screen/keyboard/mouse  Same PC/separate applications  Interface: 2 databases/information exchange  Integration: shared functionality/2 databases  Full integration: single database   RIS/PACS Integration Algorithm OPEN CASE PACS OPEN DICTATION VIEW IMAGES DICTATE SR OPEN NEXT CASE PACS CLOSE CASE SR SIGN-OFF PACS PACS SR Integration Algorithm OPEN CASE PACS OPEN DICTATION VIEW IMAGES DICTATE SR OPEN NEXT CASE PACS CLOSE CASE SR SIGN-OFF PACS PACS SR System Integration  How will you retrieve the appropriate image or other data from the archive? How difficult will that be?  System Integration PACS  EMR  Department information system  Reporting system  CAD  Other software  System Integration Bi-directional  Contextually specific  System Integration Standards HL7 (Health level seven)  DICOM (Digital Imaging and Communication in Medicine)   Supp. 15  DICOM standard for visible light (VL)  Automated-stage microscopy (SM) CCOW (Clinical Context Object Workgroup)  IHE (Integrating the Healthcare Enterprise)  Information Exchange Cycle Patient Office Visit Imaging Request RIS EMR Report Generation Rpt PACS Scheduling Image Read Imaging Encounter Information Exchange Cycle Patient Office Visit Imaging Request RIS EMR Report Generation Rpt PACS Scheduling Image Read Imaging Encounter Information Exchange Cycle Context Specific Recon W/S EMR Modality Rpt HIS CAD RIS Decision Support PACS Billing PACS Workflow              Choose work list Choose patient Arrange images Window and level Choose and open old study Match paperwork and barcode accession number Scroll through images Annotate electronically Pan and zoom Other applications; 3-D, Nucs, US Dictate Save changes Close case End-user Efficiency 1. 2. 3. 4. 5. 6. Work list functionality Hanging protocols Graphic user interface Desktop integration User preferences Alternate user interface devices End-user Efficiency Hanging Protocols End-user Efficiency Minimize time spent in any tasks other than image interpretation  Maximize eye dwell time on images  Eyes and mind on the images, not on the computer  End-user Efficiency Minimize time spent in any tasks other than image interpretation  Maximize eye dwell time on images  Eyes and mind on the images, not on the computer  End-user Efficiency 1. 2. 3. 4. 5. 6. Work list functionality Hanging protocols Graphic user interface Desktop integration User preferences Alternate user interface devices Current PACS/SR User Interfaces  Keyboard Mouse  Keyboard history    C. Latham Sholes 1872 typewriter patent  Remington & Sons QWERTY keyboard Historical perspective Hotdog  Traffic light  Typewriter  Dental drill  Telephone  Phonograph  Lightbulb  1860s 1868 1872 1875 1876 1877 1879 Computer mouse history  Douglas Englebart       Stanford Research Institute Augmentation Research Center 1968 Hyperlink User interface Online conferencing 1984  Apple Macintosh  Ideal PACS/SR User Interface “Eyes-free image interpretation” First attempt at eyes-free image interpretation Second attempt at eyes-free image interpretation New Controllers          Philips speech mike 5 Button mouse 8 Button mouse Shuttle pro Twiddler Gyroscopic mouse Joystick Virtual reality glove Speed Pad New Controllers          Philips speech mike 5 Button mouse 8 Button mouse Shuttle pro Twiddler Gyroscopic mouse Joystick Virtual reality glove Speed Pad Microphone Buttons       First alternate UID User defined User specific Seven available Navigation efficiency Minimize distraction 5 Button Mouse        Functions: 7+ Workstation specific Application specific Programming: moderate Use: easy Versatility: very good  Command string   Movement control Right handed Loss of function Shuttle Pro         Functions: 15 Workstation specific Application specific No cursor control Programming: easy Use: easy Versatility: very good Scrolling excellent  Tactile Twiddler       Functions: 1000+ Device specific IBM trackball  De-activated Programming: difficult Use: moderate Versatility: excellent   Command string No dead man function  Use with mouse UIDS      Many choices No single clear ideal device 5 Button mouse simplest and most popular Depends on vendor and other applications Use combination of two   Mouse and Shuttle Pro Mouse and Twiddler    Practice and experience will improve performance Vendor involvement needed Mouse still necessary UIDS      Many choices No single clear ideal device 5 Button mouse simplest and most popular Depends on vendor and other applications Use combination of two   Mouse and Shuttle Pro Mouse and Twiddler    Practice and experience will improve performance Vendor involvement needed Mouse still necessary UIDS      Many choices No single clear ideal device 5 Button mouse simplest and most popular Depends on vendor and other applications Use combination of two   Mouse and Shuttle Pro Mouse and Twiddler     Practice and experience will improve performance Vendor involvement needed Mouse still necessary Dependent on modality; SR use; individual user; PACS software Communication P A Communication S Communication Many of these features are RIS, EMR or reporting functions  Radiologists are more PACS oriented  Must be easily accessible by user  Asynchronous  Bi-directional  Communication  Communicate with self of prior studies  Teaching file  Clinical notes  Access to scanned documents  Access decision-support tools  CAD  List Communication  Communicate with self of prior studies  Teaching file  Clinical notes  Access to scanned documents  Access decision-support tools  CAD  List CAD in Radiology Mammography  Nodule detection  Future applications  Other Decision Support Tools  Online references  Contextual  Automatic with structured reporting Computer comparison with online teaching files  Personal clinical notes  Communication  Communicate with radiologist colleagues – PACS as portal opinion  Interesting case  Teaching file  Performance improvement  Productivity  Other – bulletin board, chat, locate  Second Communication  Communicate with clinical colleagues call  Clinical discussion  Urgent reading  Acknowledgment of report received  Acknowledgment of action taken  Audit trail  Reporting  Facilitate phone 570-555-1212 Alternative Reporting Methods Speech recognition  Structured reporting  Advantages of SR   Cost savings Improved turnaround time Advantages of SR  Felt only indirectly by Radiologist Turnaround Time in Hours 80 70 60 50 40 30 20 10 0 Pre SR Post SR Early PACS PACS Mature PACS Disadvantages of SR   Increased dictation time Distraction from viewing images Disadvantages of SR  Squarely on the shoulders of the Radiologist 16 14 12 10 # of responses 8 6 4 2 0 less than 10 % of Work Using Talk 1020 3 2030 4 3040 0 4050 3 5060 0 6070 1 7080 1 8090 3 90100 16 % on Talk % of Talk Usage Structured reporting advantages      Rapid turnaround time Cost savings Standardized words and phrases Concise reports Potential time savings   No proofreading No impression    Data mining Decision-support Automated billing Structured reporting advantages      Rapid turnaround time Cost savings Standardized words and phrases Concise reports Potential time savings   No proofreading No impression    Data mining Decision-support Automated billing Multimedia Report Combine text and images  Hyperlink thumbnail image with keyword  Requires system integration  Requires electronic report retrieval  PROCEDURE: CT scan of abdomen and pelvis with oral and intravenous contrast. TECHNIQUE: 8mm helical axial sections were obtained from the diaphragms through the symphysis pubis following the administration of intravenous and oral contrast. CLINICAL HISTORY: Abdominal pain. COMPARISON: 5/29/98 CT Abdomen: Liver and spleen are normal in size and CT density. Pancreas is unremarkable. Both kidneys are normal in size. There is a cyst in the right kidney measuring 1.5 cm in diameter unchanged from prior CT scan. No hydronephrosis is identified. Aorta is normal in caliber. No significant paraaortic adenopathy is identified. Visualized bowel loops are unremarkable. CT pelvis: Visualized pelvic organs are unremarkable. Bladder distends normally. No significant pelvic adenopathy is identified. IMPRESSION: 1. 2. Cyst in the right kidney measuring 1.5 cm in diameter unchanged from prior CT scan. No other abnormality in CT scan of abdomen and pelvis. PROCEDURE: CT scan of abdomen and pelvis with oral and intravenous contrast. TECHNIQUE: 8mm helical axial sections were obtained from the diaphragms through the symphysis pubis following the administration of intravenous and oral contrast. CLINICAL HISTORY: Abdominal pain. COMPARISON: 5/29/98 CT Abdomen: Liver and spleen are normal in size and CT density. Pancreas is unremarkable. Both kidneys are normal in size. There is a cyst in the right kidney measuring 1.5 cm in diameter unchanged from prior CT scan. No hydronephrosis is identified. Aorta is normal in caliber. No significant paraaortic adenopathy is identified. Visualized bowel loops are unremarkable. CT pelvis: Visualized pelvic organs are unremarkable. Bladder distends normally. No significant pelvic adenopathy is identified. IMPRESSION: 1. 2. Cyst in the right kidney measuring 1.5 cm in diameter unchanged from prior CT scan. No other abnormality in CT scan of abdomen and pelvis. Summary          Pathology PACS is in early stages Financial models will be different Monitor color requirements Many workflow similarities Workflow improvements Ergonomics Integration of information systems CAD/decision support Reporting Caveat Need close collaboration between physicians and IT David L. Weiss M.D.