Successful adoption of new technology development can be accentuated by learning and applying the scientific principles of innovation diffusion. This is of particular importance to areas within the medical imaging practice which have lagged in innovation; perhaps, the most notable of which is reporting which has remained relatively stagnant for over a century. While the theoretical advantages of structured reporting have been well documented throughout the medical imaging community, adoption to date has been tepid and largely relegated to the academic and breast imaging communities. Widespread adoption will likely require an alternative approach to innovation, which addresses the heterogeneity and diversity of the practicing radiologist community along with the ever-changing expectations in service delivery. The challenges and strategies for reporting innovation and adoption are discussed, with the goal of adapting and customizing new technology to the preferences and needs of individual end-users.
Innovation adoption; Structured reporting; Medical imaging
The pioneering work performed in the social sciences on diffusion of innovation can be applied to medical imaging and shed valuable insights as to how innovation is analyzed and adopted within the population of end-users. Successful innovation must take into account unique stakeholder differences, changes in communication and social interactions, and shifting priorities in market economics. The dramatic changes currently underway in current medical imaging practice provides unique innovation opportunities to those individuals and companies which can utilize this knowledge and effect change in objective and reproducible means. Successful innovation should rely upon data-driven objective analysis, which can scientifically validate the inherent strengths and weaknesses of the innovation, when compared with the idea or technology it supercedes.
Innovation; Technology development; Data mining
Commoditization pressures in medicine have risked transforming service provider selection from “survival of the fittest” to “survival of the cheapest.” Quality- and safety-oriented mandates by the Institute of Medicine have led to the creation of a number of data-driven quality-centric initiatives including Pay for Performance and Evidence-Based Medicine. A synergistic approach to creating quantitative accountability in medical service delivery is through the creation of consumer-oriented performance metrics which provide patients with objective data related to individual service provider quality, safety, cost-efficacy, efficiency, and customer service. These performance metrics could in turn be customized to the individual preferences and health care needs of each individual patient, thereby providing an objective methodology for service provider selection while empowering health care consumers.
Patient empowerment; Quality performance; Data mining
Structured reporting offers a number of theoretical advantages, perhaps the most important of which is creation of standardized report databases. The standardized data created can in turn be used to customize data display, report content, historical data retrieval, interpretation analysis, and results communication in both a context and user-specific manner. In addition, these referenceable report databases can be used to facilitate the practice of evidence based medicine, through data-driven meta-analysis and determination of best practice guidelines. This concept will only be realized if the customized data delivery technology provides real and tangible value to end users, accentuates workflow, can be seamlessly integrated into existing information system technologies, and be shown to yield reproducibility of the evidence domain. The time is here for the medical imaging and clinical communities to embrace this vision in order to improve clinical outcomes and patient safety.
Structured reporting; data customization; evidence-based medicine; data mining; decision support
The need for specialized individuals to manage picture archiving and communications systems (PACS) has been recognized with the creation of a new professional title: PACS administrator. This position requires skill sets that bridge the current domains of radiology technologists (RTs), information systems analysts, and radiology administrators. Health care organizations, however, have reported difficfiulty in defining the functions that a PACS administrator should perform—a challenge compounded when the tries to combine this complex set of capabilities into one individual. As part of a larger effort to define the PACS professional, we developed an extensive but not exclusive consensus list of business, technical, and behavioral competencies desirable in the dedicated PACS professional. Through an on-line survey, radiologists, RTs, information technology specialists, corporate information officers, and radiology administrators rated the importance of these competencies. The results of this survey are presented, and the implications for implementation in training and certification efforts are discussed.
PACS administrator; PACS; radiology management; information systems management
The transformation from film-based to filmless operation has become more and more challenging, as imaging studies expand in size and complexity. To adapt to these changes, radiologists must proactively develop new workflow strategies to compensate for increasing work demands and the existing workforce shortage. This article addresses the evolutionary changes underway in the radiology interpretation process and reviews changes that have occurred in the past decade. These include a number of developments in soft-copy interpretation, which is migrating from a relatively static process, duplicating film-based interpretation, to a dynamic process, using multi-planar reconstructions, volumetric navigation, and electronic decision support tools. The result is optimization of the human–computer interface with improved productivity, diagnostic confidence, and interpretation accuracy.
evolution of radiology practice; radiology interpretation; Transforming the Radiology Interpretation Process (TRIP)
As medical reimbursements continue to decline, increasing financial pressures are placed upon medical imaging providers. This burden is exacerbated by the existing radiologic technologist (RT) crisis, which has caused RT salaries to trend upward. One strategy to address these trends is employing technology to improve technologist productivity. While industry-wide RT productivity benchmarks have been established for film-based operation, little to date has been published in the medical literature regarding similar productivity measures for filmless operation using PACS. This study was undertaken to document the complex relationship between technologist productivity and implementation of digital radiography and digital information technologies, including PACS and hospital/radiology information systems (HIS/RIS). A nationwide survey was conducted with 112 participating institutions, in varying degrees of digital technology implementation. Technologist productivity was defined as the number of annual exams performed per technologist full-time equivalent (FTE). Productivity analyses were performed among the different demographic and technology profile groups, with a focus on general radiography, which accounts for 65-70% of imaging department volumes. When evaluating the relationship between technologist productivity and digital technology implementation, improved productivity measures were observed for institutions implementing HIS/RIS, modality worklist, and PACS. The timing of PACS implementation was found to have a significant effect on technologist productivity measures, with an initial 10.8% drop in productivity during the first year of PACS implementation, followed by a 27.8% increase in productivity beyond year one. This suggests there is a "PACS learning curve" phenomenon, which should be considered when institutions are planning for PACS implementation.
The purpose of this study was to assess the image quality and the rate of failure of the high-resolution (2,048×1536 pixel) monitors used for primary diagnosis in a filmless radiology department and to analyze the type of problems encountered as well as the action taken to repair the monitors. Data were collected from Picture Archival and Communication System (PACS) service logs to determine rates of monitor adjustment and replacement, the symptoms reported, and the action taken. Additionally, random surveys of the high-resolution monitors were performed using a standard test pattern to assess spatial and contrast resolution in the center and outer corners of the monitors. Analysis of monitor service records showed a high rate of monitor replacement (41% per year) resulting in a relatively short “life expectancy” (defined as average time required before replacement) of 2.4 years. Random surveys of monitor quality using a standard test pattern showed suboptimal image quality in approximately 54% of the monitors with moderate image quality degradation present in at least one region of 27% of the high-resolution monitors, despite our vendor’s quality control program. The results of this study support our subjective impression and those of other colleagues in the PACS community of an unacceptably high monitor failure rate and persistent image quality problems with 2,000 pixel monitors used for primary diagnosis. The relatively high incidence of suboptimal quality monitors suggests that more frequent quality control should be performed using a test pattern particularly given the fact that radiologists often are unable to discern degradation of monitor performance using clinical images. The high incidence of problems with image quality on high-resolution monitors indicates that vendors need to develop better quality control in monitor design and testing. Radiologists should review briefly a test pattern on each monitor at the beginning of each day. A computer program should be incorporated into the PACS, which asks radiologists to evaluate a test pattern and records the results in a central database, which is communicated to the service engineers. Further studies should be evaluated to determine the clinical impact of monitor image degradation, which is relatively easily seen using a test pattern but may be difficult to discern on clinical images. Requests for proposals (RFPs) for PACS and service contracts must specify carefully requirements for monitor image quality and conditions under which the vendor is required to replace these monitors.
monitor; workstation; maintenance; reliability; PACS; soft-copy; filmless; Society of Motion Picture and Television Engineers; quality; repair; display; radiology
The interfacing of digital image acquisition modalities to the picture archiving and communication system (PACS) plays a major part in the conversion from a traditional film-based radiology practice to one that relies almost entirely on soft-copy reading. The Baltimore Veterans Affairs Medical Center (VAMC) is one of the first filmless hospitals in the world. Since 1993, it has used computed tomography (CT) scanners connected to a commercial PACS to provide digitized patient images for filmless reading. Over the years, the evolution of Digital Imaging and Communications in Medicine (DICOM) standards, advances in networking technologies, and enhancements in PACS and hospital information system (HIS) software have greatly improved this system’s robustness and patient/study identification accuracy. The result has been a major increase in productivity.
Digital radiography (DR) has recently emerged as an attractive alternative to computed radiography (CR) for the acquisition of general radiographic studies in a digital environment. It offers the possibility of improved spatial and contrast resoltuion, decreased radiation dose due to improved effieincy of detection of x-ray photons, and perhaps most improtantly, holds out the promise of increased technologist productivity. To achieve maximum efficiency, DR must be completely integrated into existing information systems, including the hospital and radiology information systems (HIS/RIS) and, when present, the picture archival and communication system (PACS). The early experience with the integration of DR at the Baltimore Veterans Affairs Medical Center (VAMC) has identified several challenges that exist to the successful integration of DR. DR has only recently been defined as a separate Digital Imaging and Communications in Medicine (DICOM) modality and images obtained will, at first, be listed under the category of CR. Matrix sizes with some DR products on the market exceed the current size limitations of some PACS. The patient throughput may be substantially greater with DR than with CR, and this in combination with the larger size of image files may result in greater demands for network and computer performance in the process of communication with the HIS/RIS and PACS. Additionally, in a hybrid department using both CR and DR, new rules must be defined for prefetching and display of general radiographic studies to permit these examinations to be retrieved and compared together. Advanced features that are planned for DR systems, such as dualenergy subtraction, tomosynthesis, and temporal subtraction, will likely require additional workstation tools beyond those currently available for CR.
The purpose of this study was to determine the impact of filmless imaging on the frequency with which physicians access radiology images and to assess clinician perception of image accessibility using a hospital-wide Picture Archival and Communication System (PACS). Quantitative data were collected at the Baltimore VA Medical Center (BVAMC), prior to and after conversion to filmless imaging, to determine the frequency with which clinicians access radiology images. Survey data were also collected to assess physician preferences of image accessibility, time management, and overall patient care when comparing filmless and film-based modes of operation. In general, there was a significant increase in the average number of radiology images reviewed by clinicians throughout the hospital. However, the one area in the hospital where this trend was not observed was in the intensive care unit (ICU), where the frequency of image access was similar between film and filmless operations. Ninety-eight percent of clinicians surveyed reported improved accessibility of images in a filmless environment resulting in improved time management. The mean clinician estimate of time saved due to the use of PACS was 44 minutes. The study documented a combination of clinician perception of improved accessibility and substantial time savings with the use of a hospital-wide PACS, which was supported by objective measurements. The increased frequency of image review by clinicians and rapid image access should provide a further impetus to radiologists to decrease report turnaround time to provide “added value” for patient care.
Picture archiving and communications systems (PACS) utilize short- and long-term storage to provide both rapid retrieval and large storage capacity. Owing to the practical limitations imposed on the size of the much faster short-term storage, it is important to use an effective algorithm in the retrieval of comparison images from long to short-term storage. A strategy must be used to maximize the likelihood that the relevant historic images have been previously retrieved into short-term memory. Data were collected with a database consisting of 754 consecutive examinations and 7,723 associated historic studies. The most frequent number of previous examinations was zero (11% of patients). In 45% of cases, no previous matching examinations had been performed. Two basic strategies of image retrieval were evaluated. The first algorithm retrieved the lastn studies in chronological order. The second strategy tested was retrieval based on a defined interval of time. This strategy was found to be less efficient. By using the former strategy, a 91% success rate (defined as successful retrieval of the previous matching exam) was achieved with retrieval of only 30% of the prior exams. The second approach required retrieval of 70% of the prior exams to achieve a 90% success rate for the previous matching exam. However, the data from this latter strategy suggest that examinations are often ordered in clusters. Thus, there was found to be a 72% likelihood that a previous matching exam, if present, would available on a PACS after only 1 week of operation, and an 80% chance after only 1 month of operation. The data therefore suggest that digitization of film in a new PACS environment might not be necessary owing to the relatively short period of time required to populate the database with historical studies.
digital; computer; radiology; imaging; algorithm; workstation; efficiency; archival; storage; database; digitization
A workstation monitoring program can be implemented, which automatically creates a log of workstation utilization that can be exported for analysis on a conventional spreadsheet or database analysis program. This methodology has several drawbacks as described, which make it a relatively crude tool in the prediction of peak and average network traffic and optimal workstation deployment. A large-scale PACS should include system administration tools that permit the creation of a utilization log and subsequent analysis of all image and database accesses for each workstation. This tool should not result in measurable degradation of system performance and should be run on an ongoing basis. Such an administrative tool could provide critical information to vendors for system design, to customers for system planning, and to users for system optimization and maintenance.
Careful planning of the study and full support of the radiology staff are essential for collection of such data. It important to obtain pilot data to identify potential problems and adequately train personnel. Such pilot data should be compared with data collected automatically from the HIS, RIS, or PACS to establish the reliability of various data sources. When data was collected without using a study form compliance was low. It is important to automate the data collection as much as possible in order to keep the forms simple and as short as possible. This will increase substantially the consistency at which accurate data are captured.