Picture Archiving

Communication System (PACS)

MED INF 404 – JAY ANDERSON

March 2, 2009
Kenyetta Cole
Derrick Hawkins
Rozmin Pirwani
Candyce Thompson
 Picture Archiving Communication
System (PACS)
Introduction
The field of health care continuously improves. Many medical institutes set aims and allocate the
necessary people and resources in order to improve health care. In 2001, the Institute of
Medicine (IOM) issued a report called “Crossing the Quality Chasm: A New Health System for
the 21st Century, which outlines six overarching "Aims for Improvement" for health care. The
aims identified by IOM are patient safety, effective treatment, equitable attention, and timely
efficient procedures are seen as the healthcare field’s priority. These aims are now a necessity.

A Picture Archive and Communications Systems (PACS), a recent technology, are no longer a
reality but a necessity. PACS system addressees each of the IOM aims. The safety aim is met by
ensuring a consistent environment with reduced clerical errors by using a single source of
information. Effective health care is practiced by allowing radiologist to see minute changes in
Picture Archiving Communication System (PACS) | 3/2/2009

tissue and bone, which allows for more effective health care. A patient centered environment is
the result of restricting access to medical data, while timely healthcare is giving by allowing
radiologist to see images within seconds of acquisition. Efficiency is adhered to with the ability
to retrieve prior studies, which reduces the need for duplicated exams. PACS results in an
equitable system which provides a transparent system of patient radiological studies without
gender or racial bias.

The largest radiology departments have gone digital, smaller imaging centers are not far behind.
Ten years ago, this technology was left unacknowledged because radiologists were not aware
about e-mail and digitalization, but now all radiologists are familiar with these technologies and
implement them on a regular basis. With PACS, a radiologist, any number of referring and
treating physicians can view an image within seconds. CT exams are becoming common, and
thus cannot be managed effectively on film. PACS’ viewing software is used to dissect, analyze,
magnify, or reformat image data in infinite ways. Private networks can transmit whole exams
across the globe for remote consultation within seconds, perhaps in the middle of the night to a

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radiologist who is just starting her day. Today’s archives can keep decades of studies online in a
cost-effective manner and in a much more organized and accessible manner than ever possible in
a traditional file room. As members of the medical field, we see future technologies and aims
transforming into necessities.

Our Issues
Farmchialt Medical Center is a 215 bed hospital in Northwestern, Illinois. Farmchialt is a
teaching hospital for the northern Chicago area. For the last 14 months, Farmchialt has seen its
revenue decrease due to a drop in exams performed by our radiology department. Radiology and
surgery have historically been the largest revenue generators at most hospitals and a drop in
either of these areas has a noticeable impact on our bottom line. The marketing department has
investigated this issue and found that area doctors are sending patients to competing hospitals for
radiology work. After interviewing several physicians in the area, the most common reason was
the speed at which competitors turn around radiology exams and provide the report to the
physician. In some cases, this was a few hours, compared to the days that it took our staff to do
comparable exams. After talking with several patients, it was discovered that wait times at our
facility were double, even triple what they were at other facilities. One of the reasons is because
our methodology for handling radiology patients is inefficient and outdated. Exams are easily

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lost or misfiled which can result in the performing the exams again which can be detrimental to
the patient. This requires longer wait times for our patients and in some cases, repeat exams.

Patient and physician satisfaction are two important issues to any hospital. Our Balanced
Scorecard shows that the ratings from these groups are very low due to the fact that our services
are slow and we are not taking advantage of existing technologies that can be used to improve
the care we give to our patients, and the tools we give to our physicians.

Our current workflow relies on manual processes that introduce errors, compromise patient
safety, and introduces delays to the internal processes of our referring physicians. In addition, the
resources spent on materials and staffing can no longer support this inefficiency and reduces our
return on investment significantly. Each of these issues adds to the amount of time it takes for a
referring physician to send us a patient for an exam, the exam is conducted, and we send a report
back to the physician.

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 The solution to these issues is for us to purchase and maintain a Picture Arching and
Communications System, or PACS as it more common known. A PACS system allows for the
storage, retrieval and display of radiology images. We believe by implementing a PACS system,
and interfacing it with our current radiology information system, we can develop new
methodologies to improve our workflow and allow us to compete with other hospitals in our
marketplace. In this scenario, PACS will acquire and store the image, distribute it, and display
static digital images such as mammograms or CT scans for more efficient diagnosis and
treatment, while the RIS will serve as the repository for patient demographics, modality work
lists, reports and provide this information via an HL7 link with PACS.

Also, new legislation proposed by the new Presidential administration, will mandate the adoption
of new electronic systems by healthcare providers, and PACS will play a substantial role in this.

As with any system, especially one as complex as PACS, there are advantages and
disadvantages. A main advantage of PACS is an increase in the speed with which images can be
obtained, interpreted, and the findings relayed to the referring physician.

Advantages of PACS Disadvantages of PACS

Easy comparison of a patient's current and historical No perfect PACS exists

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examinations

No film budget, film packet cost, or chemical processing Substantial investment of capital
needed

Filing clerks and darkroom technicians not needed ROI difficult to quantify in some areas

Images correctly and permanently reside under the Steep learning curve
appropriate imaging study

All modality images stored in one place Single point of failure

Increase productivity Months of prep time

Another reason for a PACS is the increased effciency in workflow and the creation of faster and
easier to implement high level processes. We will also see a reduction in the cost of materials

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and personnel. Our technologist can perform an increased number of exams in a given amount of
time, thus increasing gross revenue for our hospital.

Our current system requires that a radiologist be onsite to read studies. On nights and weekends,
this can be done remotely by our radiologist or contracting with nighthawk services, who will
perform these service using images in our PACS.

There will be many substantial changes in the workflow of our radiology department and all
personnel including radiologist will need to be trained on these changes. While there are inherent
obstacles to change in any environment, the added stress of ensuring patient health with new
systems will compound this issue, but with proper training and encouragement, we believe a
smooth transition is feasible.

What is PACS?
Picture Archiving and Communications System, more commonly known as PACS, enables
images such as x-rays and computed tomography scans to be stored electronically and viewed on
computer screens, so that doctors and other health professionals can access the information and
compare it with previous images at the touch of a button. Within seconds after an image is
acquired, it can be viewed by the radiologist and any number of referring and treating physicians

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simultaneously. PACS viewing software can be used to dissect, analyze, magnify or reformat
image data in an infinite number of ways. PACS deals with image-based computing functions
such as acquisition, interpretation, storage and local image distribution. Virtual private networks
can transmit whole exams across the globe for remote consultation. PACS enables centralized
storage of images, full interoperability and compatibility with the National Program for IT by
NHS Connecting for Health and its other services. PACS does not only handle x-ray images.
PACS deals with a range of specialties including radiotherapy, CT, MRI, nuclear medicine,
angiography, cardiology, fluoroscopy, ultrasound, dental, and symptomatic mammography. i It
will have a positive impact on any specialty that uses fixed or moving images.

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 Benefits of PACS
PACS allows for a nearly film-less process, with all the flexibility of digital systems. It also
removes all of the cost associated with hard film and releases valuable space currently used for
storage. In addition, PACS offers the following benefits:

Patients - PACS transforms a patient’s experience of the care they receive which include
no transporting of x-ray film between the hospital and other sites, less wait time to
receive results, less time spent between point of treatment and discharge, fewer wasted
appointments and postponed operations due to non-availability of images as a result of
loss or poor quality images, and less re-testing and radiation exposure.

Clinicians - PACS enables radiologists to have efficient, high quality image access.
Digital imaging allows faster delivery of medical images, which can lead to speedier
availability of results, no lost or misplaced images, reliable quality of images, flexible
viewing with the ability to manipulate images on screen which allows for better analysis,
instant access to historic images and patient records, which enables the comparison of
patient images and the measuring of the effectiveness of their treatment or the
development of their condition, and better collaboration of clinicians at the same time, a
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more efficient radiology department.

Hospitals – PACS brings a number of improvements to hospitals that include freeing

valuable space within a hospital as storage rooms will no longer be needed for films,
eliminating the health and safety issues associated with chemical processing, freeing
administrative staff who are responsible for image retrieval and filing to undertake more
productive tasks, allowing patients to be processed more quickly with fewer delays as
well as cost savings – no need to purchase film and processing chemicals.

Costs of Implementation
The costs to implement PACS depend on the sophistication of the enterprise’s existing
information system network and its imaging inventory and needs. Investment in PACS
represents a trade-off: decreased operating costs of film and film personnel versus increased
capital costs together with PACS maintenance and personnel costs. Categories of expenditure
include: imaging equipment, workflow servers, archive, display stations, facility upgrades and

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clinical distribution and viewing. Once the capital and operating costs are defined, the cost
savings and revenue enhancements that will result from implementing PACS need to be
determined.

Case Study
Partners HealthCare System, Inc, founded in 1993 by the Massachusetts General Hospital and
Brigham and Women’s Hospital is an example of how PACS was implemented and how two
hospitals converted to computed radiography. ii Partners were financially justified in
implementing PACS, based on savings from decreased film and film library costs alone. Partners
had a world-class information system infrastructure, consisting of the largest integrated
Intel/Microsoft platform in the world, connected to more than 30,000 desktop computers. The
implementation cost was approximately $12.6 million and the operating costs were $1.5 million.
These numbers were based on 775,000 radiology examinations per year, representing 2.7 million
films at a cost of $3.5 million and a film library cost of $1.7 million. As far as return on
investment, it would take 3 years to cover the initial investment and implementation, 3 years to
break even and 2 years to reach a savings. iii Partners also estimated a savings of $8 per exam for
film and film library expenses, for an additional PACS operating cost of $2 per exam, resulting
in a net savings of $6 per exam. The cost of implementing PACS will be based ultimately on the

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impact that it would have on an organization’s overall revenue and admissions. Many
enterprises, especially integrated delivery networks, will see the decision to implement PACS
simply as a necessary step in maintaining their market position. If PACS is financially justified
and greatly improves patient outcomes, it will provide a competitive advantage.

Integration
The Picture Archiving and Communications System and the Radiology Information System form
the backbone of the digital radiology department. Along with a dictation system, each of these
components can be combined to give a single workspace for examination scheduling, modality
assignments, image acquisition, diagnosis, and reporting. These components integrate with the
Hospital Information System and sub systems in the radiology department to create a streamlines
health care information system that in processes patients, schedules examinations, interpret the
studies, and bills the patient and their insurance companies for the services to be performed.
This integration of these systems allows for greater efficiency in workflow and as a result, allows

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 input into the system which allows us to capture more charges and generate more revenue. PACS
systems are more and more common in large radiology departments and with the advent of more
advanced imaging devices such at 64 and even 256 slice CT machines that can produce
thousands of images. With the advent of such sophisticated imaging devices, it is no longer
practical to have a radiology department that does not have a PACS system.

The modalities are the sub departments of radiology where different types of exams are
performed. Some modalities include Magnetic Resonance Imaging, or MRI, Nuclear Medicine,
Ultrasound, and Computed Tomography, commonly referred to as cat scans. Each of the imaging
apparatuses’ in these departments can be configured with the DICOM protocol to transmit
images to the PACS system.

The radiology information system or RIS is the main source of radiology information in the
department. The RIS is responsible for maintaining the entire life cycle of a radiology order to
include the preliminary and final reports. It produces tasks for each modality in the form of a
DICOM work list, which can be sent to each modality to notify of an exam they need to perform.
A RIS system adds the following benefits to the radiology workflow; electronic scheduling,
multi resource scheduling, ease of billing and charge captures. User definable questionnaires can
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be used to collect information prior to exams and linked to procedures. In addition, relevant prior
images can be pre-fetched from PACS and pull lists for the retrieval of paper records or film
folders can be generated.

In addition, the RIS communicates with the hospital information system to ensure consistency of
patient information, which reduces and in most cases eliminates states related to patient
demographics which can delay billing. By integrating with the PACS the RIS system allows
radiologist to retrieve reports related to previous studies on the same patient, which improves
patient care, by capturing metrics that can be used to produce trends or track medical incidents
before they become far more serious.

The dictation system is used by the radiologist to capture their interpretations of the radiology
studies they read. The system converts human speech into text which is stored in the RIS. These
reports have very small footprints and a modestly spaces system can hold several decades of

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radiology reports. The RIS system also has the capability to fax out reports immediately after
they are finalized by the radiology to community physicians.

The PACS system is the computer system that allows for the capture, storage, and retrieval of
radiology imagines. It allows for faster retrieval and using the current information technology
infrastructure these images can be read within seconds of acquisition or transmitted to offsite
radiologist for reading. These radiologists can be hundreds or thousands miles away, or even on
the other side of the world but with PACS they can be consulted on difficult cases, which
improve patient care. The PACS receives images from each modality and included in this
information is patient demographics such as name, medical record numbers, etc, which again
reduces the amount of time to input this information manually and also reduces chances for
mistakes. The images on the PACS system can also be accessed over the Internet which allows
doctors to view studies also.

Each of the systems (PACS/RIS/Dictation) communicates using a common language. In a digital

radiology environment the two most prevalent protocols are Health Level 7 and DICOM (Digital
Imaging and Communications in Medicine). The protocols create transactions which can be used
to measure process and increase productivity. These protocols are used throughout computerized
medical environments and are standard on vendor devices which ease the burden of integration.

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They organize language to enable vendors and purchases to communicate even if DICOM or
HL7 is not their native language. iv

A PACS system ensures optimal patient care and efficient access to all relevant information. It
has the potential to reduce medical errors, improve efficiency of care providers, and enhance the
overall quality of clinical care.

Cardiology PACS and Gastro Intestinal studies will not be a part of a PACS deployment but may
be revisited at some point in the future.

Film-based workflow vs. PACS workflow

Radiology departments across the world share a common goal, “to provide the highest quality of
care to patients.” v To help radiology departments achieve this goal the term “filmless operation”
has been offered over the past 10 years as the solution. A filmless operation can assist a
radiology department in achieving the aims of improvement - safety, effectiveness, patient-

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 centeredness, timeliness, efficiency and equity, which were developed the Institute of
Medicine. vi The use of PACS to assist with the transition to a filmless operation can allow a
radiology department to have an efficient and productive workflow. PACS can assist the
departmental workflow by reducing case turnaround time, reducing radiologist workflow
interruptions, improving patient satisfaction, reducing retrieval times for film and improving
radiology staff satisfaction, as well as, reducing stress levels of the staff. vii

To truly understand the benefits that PACS can offer an organization, one must truly understand
the workflow of a film-based department versus the workflow of a filmless department. In a
film-based department the process of requesting, obtaining, reporting, and transcribing a case
study is done entirely by using paper (Fig. 1). In general, a paper requisition is completed for an
order, then the patient information and study information is manually reentered into the
radiology information system (RIS). This information is then printed and given to the
technologists, who then must manually reenter the patient information and study information into
the appropriate modality workstation. Once this has been completed, current and previous
images and studies are obtained and then sent to the appropriate workstation for the manual
interpretation process. Once the interpretation process has been completed, the paperwork is
given to the radiologist for the radiologist to being reviewing the study. Once the radiologist has
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completed the review of the study and dictated the report, the report is transcribed, printed and
delivered to the referring physician. This film-based workflow is very lengthy and consuming
when compared to a filmless operation using PACS. viii

A department using PACS will have a more efficient and productive workflow, due to the
implementation of the PACS with the hospital and radiology information systems, as well as, the
hospital’s electronic medical record (EMR). As a result of the PACS, the process of requesting,
obtaining, reporting, and transcribing a case study will be done electronically. In general, the
order for the case study will be placed using the EMR. The EMR orders will automatically
interface with the PACS, triggering the PACS to automatically retrieve previous studies. These
previous studies will be automatically connected to the current pending study, which will reduce
the response time when the previous studies are requested by the radiologist during review. The
modality work list and it connection to the HIS allow for the order to be separated by imaging
modalities, which will ensure that the appropriate technologist are accessing the appropriate

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order. Once the images have been obtained, the studies are then available in PACS and are ready
for the radiologist’s interpretation. The radiologist can access the studies from any workstation
with PACS access and then dictates the findings, which are transcribed directly into the EMR.

An example of a detailed film-based workflow vs. PACS workflow as presented by the

Baltimore Veterans Affairs Medical Center for an in-patient chest x-ray can be seen in Fig 2 and
Fig 3. The workflow demonstrates that a film-based requires approximately 59 steps for the
process of requesting, obtaining, reporting, and transcribing a case study. While the PACS
workflow demonstrates the same process of requesting, obtaining, reporting, and transcribing a
case study being completed in approximately 9 steps. ix

Case study Case study

Case study Case study reviewed and Case study results reported
requested images obtained reported by transcribed to referring
radiologist physician

F IG 1 H IGH LEVEL PROCESS MAP FOR RADIOLOGY DEPARTMENT

Picture Archiving Communication System (PACS) | 3/2/2009

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 Referring Clinician
1. Get chart from clerk
2. Write orders in chart Ward Clerk
3. Give chart to clerk
4. Fill out study request 5. Flat order in chart Nurse
58. Ask ward clerk to pull chart 6. Place chart in pending orders bin Medical Clerk
59. Review report in chart 10. Contact radiology with patient information 7. Take chart from bin
12. Inform nurse of scheduled study 8. Document order in chart 54. Sort radiology reports
13. Contact transportation personnel 9. Ask clerk to schedule study 55. Bring reports to wards
56. Sort reports
57. File reports in chart

Transportation Aide Transcriptionist

Radiology Clerk Film Room Clerk 45. Retrieve tapes
14. Transport patient to department
11. Schedule patient 46. Transport tapes for dictation
32. Transport patient back 18. Check recently pulled films
15. Look up index card 47. Transcribe and print reports
19. Search for films in library 48. Bring report to film root
16. Review card for old studies
20. Write new study on jacket 50. Bring report to front desk
17. Give card to film room
35. Combine with old studies 51. Give report to radiologist
21. Place request in pending bin
36. Bring films to reading room 53. Take report to medical clerk
31. Call transportation
49. File report in film jacket
33. Re-file index card

Radiologist

37. Take films from stack

Technologist 38. Remove films and requests from jacket
Darkroom Technician 39. Hang films
22. Retrieve request and patient 40. Review images and reports
23. Obtain images 25. Bring films to processor 41. Dictate case report
24. Take cassettes to darkroom 26. Process films 42. Take down films
28. Check film for quality 27. Return films to technologist 43. Return films to jacket
29. Update patient index card 44. Return jacket to stack
30. Return study card to clerk 52. Review and sign report
34. Bring films to film room
Picture Archiving Communication System (PACS) | 3/2/2009

x
FIG 2 F ILM - BASED WORKFLOW

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 Radiologist
Referring Clinician
7. Review images and reports
8. Dictate case report with voice
1. Physician order entry on HIS/RIS
recognition system
9. Report available on HIS/RIS

Technologist
Transportation Aide
3. Choose patient from modality
worklist
2. Transport patient to department
4. Obtain images
6. Transport patient back
5. Edit and check images for quality

xi
F IG 3 PACS WORKFLOW

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Importing and Exporting Studies
One of the biggest issues facing a PACS administrator is what to do with outside studies. In
some cases, the patient has arrived with studies either on film or compact disc that were created
at another imaging facility, or the referring physician has instructed the patient to bring their
radiology studies to them for interpretation or storage. It is also not uncommon for the CD or
images to be lost or misplaced, or even left in the ambulance in some cases. Often times, images
on the disc will be in a different or proprietary format. Since we do not want to expose the
patient to the time, expense, and radiation exposure to duplicate the images, we will provide
secondary opinions only, of images we receive on CD. Since we are providing a medical
diagnosis, these images will be imported in our PACS system, but will be annotated to specify
the images were not captured by local technologists. We will issue a report and store it in the RIS
for liability purposes.

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 Most major PACS systems have the ability to import and export patient studies. To assist with
this situation, the following process will be used to receive images on CD or film and to
distribute images on CD and film

Receiving Images on film or CD

• All images received on film will be taken to radiology file room and digitized.

• The images will be annotated with the following information at a minimum

o These images were not captured at this facility

o Patient first and last name

o Medical Record number

o Number of images

• All images on CD will be imported into PACS and the DICOM header information
changed to reflect the scans were not done at this facility

Exporting Images
Picture Archiving Communication System (PACS) | 3/2/2009

• All studies will be burned on CD with viewing software included

• Each CD will have hospital logo, patient, and study information

• First set of CDs are free, subsequent CDs at patient expense

• Film will be provided at patient expense only if the referring physician specifically ask
for film

Conclusion
A PACS system would allow us to improve our patient care and put us in a more competitive

position in relation to the services offered by our competitors. It would address the issues we

face and the initial investment would be recouped in 18-24 months and position us as a leading

healthcare facility in our area, with our physicians, and with our patients.

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i
“What Makes PACS Different?” NHS Connecting For Health. Retrieved February 2009 from
www.connectingforhealth.nhs.uk/systemsandservices/pacs/
ii
Dreyer, K. J. and SpringerLink (Online service) (2006). PACS a guide to the digital revolution. New York,
Springer: 1 v.
iii
Dreyer, K. J. and SpringerLink (Online service) (2006). PACS a guide to the digital revolution. New York,
Springer: 1 v.
iv
“All About IHE – Integrating the Healthcare Enterprise”, Agfa Healthcare, Retrieved February 2009 from
http://agfabeint01.net.agfa.com/bu/mi/Mednet/MedNet.nsf/AllDocs/3EC9A23153D17CB7C125715E003441F5/$FI
LE/IHE%20final%201%201.0.pdf
v
Dreyer, K. J. and SpringerLink (Online service) (2006). PACS a guide to the digital revolution. New York,
Springer: 1 v.
vi
Institute of Medicine (U.S.). Committee on Quality of Health Care in America. (2001). Crossing the quality chasm
a new health system for the 21st century. Washington, D.C., National Academy Press.
vii
Halsted, M. J. and C. M. Froehle (2008). "Design, implementation, and assessment of a radiology workflow
management system." AJR. American Journal of Roentgenology 191(2): 321-7.
viii, ix, x, xi
Siegel, E. L. and B. Reiner (2003). "Work flow redesign: the key to success when using PACS. 2002."
Journal of Digital Imaging 16(1): 164-8; discussion 163.

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