PACS

Oleh Putu Adi Susanta

Sumber : Online Radiology Continuing Education

for Radiology Professionals
www.ceessentials.net
 DEFINISI
PACS is an acronym for Picture Archiving
and Communication System
PACS is hardware and software that stores
and manipulates digital information in the form of
images and text data
Provides a contemporary
(tetap/sejaman/berkelanjutan) radiology
department with optimal storage of images
and patient data files
realize that its software manages patient
information data and radiographic images so that
both can be viewed simultaneously
 Kelebihan PACS
image is captured for PACS is digitally
stored into what is called memory in computer
language
Digital data can be communicated to any computer
or workstation within its network
can interface with most computers commonly used
in medicine to include the hospital information
system (HIS) and radiology information systems
(RIS)
 Patient information and radiology reports can be
displayed with radiology images eliminating the
need to store paper information as well.
 Fungsi Dasar
There are seven basic functions carried
(disalurkan) out by a PACS system and network:
• Image Capture
• Image Transfer
• Short Term Storage
• Long Term Storage
• Retrieval (mendapatkan kembali)
• Image viewing
• Networking
 Keunggulan Digital terhadap Screen+Film

• radiographic darkroom and all of its chemical

vapor hazards are eliminated
• water drainage problems and silver recovery
issues are also eliminated
• diminishes the need for large film storage
areas (radiographic images, patient
information, and radiographic reports )
• images can be viewed from any workstation
within its network.
images can be viewed from any
workstation within its network.
– workstation is a dynamic electronic view box with
enhanced capabilities
– Any workstation in the network can be used
– can be distributed throughout a facility or to off
location facilities.
– PACS workstation adds a new dimension, that of
image manipulation: windowing (density and
contrast), image rotation, and algorithm variation
(bone window, soft tissue window), measurement,
magnification, etc.
– Retrieval of all digital exams in a patient's electronic
file is also permitted with PACS, along with all
associated radiographic reports and printing features
 So why do we need PACS?
• Some benefits of PACS include reduction or
elimination of lost films,
• reduced retakes due to poor image quality,
• significant reduction in storage space and film
printing cost,
• greatly improved communications,
productivity and efficiency between the radiology
department and physicians greatly improves
because images and reports are readily
available to remote sites, clinics, and hospital
wards immediately after acquisition.
 Concepts of Image Capture
• basic functions of any PACS system is capturing
images from all digital modalities.
• This function is managed by a server which is a
computer hardware device driven by complex
computer software programs.
• The server receives digital images from all
sources such as: CT, MRI, Angiography,
Surgery C-arm units, Ultrasound, Nuclear
medicine, Mammography, digitizer, digital
fluoroscopy, and a host of other imaging
"centers
 PACS server
• PACS server has many functions including
image capture, image transfer, data control,
routing, archiving, and data management
• Servers perform these functions in accordance
to DICOM standards
• DICOM  Digital Imaging and Communications
inMedicine
• Pokok-pokok informasi DICOM  Gambar,
bahan ajaran, pasien, laporan dan lainnya
• DICOM specifies Information Objects that
include images, whole studies, patients, reports
and a host of other groupings of digital data
 DICOM
DICOM standards are responsible for the
expansion of PACS systems and interfacing with
medical information technologies systems.
Almost all medical systems producers and
manufacturers subscribe to DICOM standards.
Vendor membership to the DICOM committee
include manufacturers such as General Electric
Co., Siemens, Philips, Agfa Healthcare,
Eastman Kodak, IDX Systems, Sony, and
Toshiba to name a few.
Examples of DICOM service classes are: CR
Image Storage Service Class and Basic
Grayscale Print Management Service Class.
 The scope of DICOM

The scope of DICOM

– DICOM addresses all levels of digital data exchange
and interchange among electronic devices used in
medical imaging.
– It does not specify to manufactures the architecture of
their system or control of functionality of a device. It
only speaks to the behavior of devices used in PACS.
– It defines what are called 5 layers of functionality:
• Transmission
• Query and retrieval
• Performance
• Workflow management
• Quality and consistency of image appearance
 Digitizer
DICOM standards also consider that many institutions are
heavily invested in analog film files.
This need is satisfied by the use a device called a digitizer.
Adigitizer is a device that converts finished film/screen
processed radiographs into digital images.
Institutions that have converted to total digital imaging often
receive radiographs from institutions that are not on a
digital network.
In order to maintain a record of these films and distribute
them within their PACS network the images must be
digitized.
By digitizing analog films into PACS they can be viewed
from any workstation and retrieved without visiting the
film file room.
Contoh Digitizer
The digitizer pictured on the left is used to
scan radiographs and record them in
digital form (bytes, pixels, etc).
They can be stored as an electronic file
retrievable from PACS for viewing.
The picture in the monitor shows the
processed image.
Patient information data can also be edited
into PACS using software linked to the
digitizer.
A digitizer is connected in a PACS network to
the main server.
This allows for manipulating digitized images
like any other PACS document to include:
windowing, magnification, measurement,
rotating, and the like.
 Input data dengan benar
The PACS software will allow for data entry such
as the patient's name, type of study, medical
record number, date received, and other
information normally added by radiology
information system (RIS), or hospital information
system (HIS) server.
The technologists and film clerks should be
trained in the proper orientation of films as
they are loaded into the digitizer.
Correct orientation of films will save time later if
they do not have to be rotated or manipulated
prior to being sent to PACS.
Gambar
 Image Transfer
Once the server accepts DICOM image data into PACS it
must be moved to remote parts of the network such as to
workstations or to the WEB server.
Image packets must also be linked to patient information
data and sent to storage (memory) so that retrieval is
possible.
Other functions that may be pending on the images are
printing, CD-ROM burning, presentation on a
workstation, or distribution through a web browser.
These functions and more are directed throughout the
PACS system along local or wide area networks.
Gambar
 Penting
The PACS server is also a key component in the transfer of
data because it is the first step in image capture into the
PACS system.
Then it must do something with this data according to its
programming. Once the data is acquired in DICOM it is
moved along the network to specific destinations such as
print, storage, workstations, etc.
To avoid delays most PACS networks use Ethernet, twisted
pair cables, coaxial cables and fiber optic cables. The
PACS administration team is able to track the flow of
images and data through the network, and can spot and
correct cable malfunctions, and numerous errors such as
duplicate files that tax server memory as they occur.
Gambar serem
These pictures show the inside of a
PACS networking hardware room.
The white arrow (below) shows the
PACS server and how little space is
required for it.
The picture to the right shows the
networking system that routes data
between the components of the
PACS system.
The PACS administration team is
responsible for all applications of the
software and operations of the hardware
that manages the PACS operational
components.
The main server receives data and
information from all radiology modalities
that are digital and DICOM compatible. It
routes its data throughout the PACS
network to include workstations, to
storage, and to out of network devices
like the CD-ROM burner and to printers.
 Hospital Information Systems
(HIS), RIS, and PACS

One of the most important benefits of a PACS system is the

workstation! Image viewing on a workstation is available within
seconds of being captured by the PACS server.
Because the system recognizes patient information data from
RIS and HIS hubs it is easy to bring up images using the
patient's medical record number, or name and other
connecting data such as their date of birth..
 HIS, RIS, PACS
Patient information such as the medical record
number, name, date-of-birth, type of study, date
of study and the like is entered into the PACS
record through a data bridge.
This is coordinated with the generation of new
images sent to the PACS server from a base
device (CR, CT, MRI, etc). DICOM includes
compatibility of HIS and RIS information systems
networked to a PACS system.
The DICOM standards are structured so that the
PACS server will distribute images and
information as if it were the primary base
installed device that originated the data.
 HIS & RIS
Hospitals input and store patient data using what is known as a
hospital information system (HIS).
The hospital information system is a network of computers used to
enter and store patient’s personal data, such as their full name,
date of birth, social security number, insurance billing information,
and the like. It contains highly personal and sensitive patient
information and legal documents pertaining to the patient.
These documents are specifically privacy protected by Federal
legislation such as the Health Insurance Portability Act (HIPAA).
The Radiology Information System (RIS) is a sub-network of HIS
that uses certain data fields from HIS to compile the radiology
exam and procedures requisition.
HIS and RIS may use the same or different servers to interface with
PACS through what is called a HIS/RIS gateway or PACS broker.
The functions of the HIS/RIS gateway includes managing, sorting,
archiving, distributing, and translating patient text information into
PACS and onto images.
Gambar RIS
The picture to the right demonstrates how the
RIS/HIS gateway is used to add text patient
information to each radiographic image as they
are displayed and archived into PACS.
Because this information comes from a universal
RIS/HIS server that the technologist selected
from a work list, patient information errors are
minimized. And when patient information is
entered incorrectly it can be changed throughout
all of the patient's records image and text data
files because of the interconnectivity of HIS &
RIS to all patient files.
This interconnectivity is the precursor to what will in
the near future be a totally electronic patient
enterprise file made up of Clinical information
Systems (CIS), Hospital information system
(HIS), and Radiology Information System (RIS),
and emerging laboratory and surgical information
systems.
Gambar PACS
The picture to the right
demonstrates how images
can be displayed on the
PACS workstation with
the same image and study
information as contained
on the film.
This is because of the
cooperative nature of
DICOM and HL7 data
sharing. The simple
workstation seen in the
picture is used by
technologist and file room
clerks to verify images on
PACS and to retro print
images and reports.
 Short Term PACS Storage
Images stored on the PACS network by
storage servers are said to be in short-
term storage. Short term storage refers to
those image documents available on the
server that can be immediately viewed
from any network workstation.
Another function of the short term storage
server is to back-up imaging documents in
case of a system failure.
 Long-term storage and data
back-up
An optical disk jukebox is a
long-term storage hardware
device which encompasses
(mencakup) optical disk
drives, optical disk storage
slots, and associated robotic
arms and software for
fetching data disk(s).
PACS is able to provide
disaster file using optical
disk technology and/or
Pictures above shows an Optical disc jukebox
(white arrow) used to store images for long-term
digital linear tape
storage. The pictures with the blue arrows are of an
optical disc with a 2.3 gigabyte capacity and OD
technology.
burner commonly used to back-up CT images
 PACS Workstation

The workstation is a special type of computer display

system that uses high resolution monitor(s) for display
and manipulation of radiographic images.
A primary workstation (a.k.a. Diagnostic workstation) is the
type used by the radiologist. It is equipped with strong
array of tools to manipulate images acquired from all
imaging modalities. A secondary workstation (a.k.a.
clinical workstation) is used for clinical review and is
generally found on patient wards, emergency room
viewing stations, and clinics
 Gambar

Above. Secondary and Tertiary workstations are

available for viewing images and reports;
however, they have fewer image manipulation
capabilities than does the primary diagnostic
workstation the radiologist requires for
multimodality image manipulations.
 Kelebihan dan Kekurangan
advantages a PACS system and particularly the workstation for
viewing over traditional view box and radiographic film
imaging
• The workstation contains computer software that allows for a
complex array of image manipulation tools.
• Its software applications provide optimized viewing functions
such as study filters, measurement capability, data
reconstruction (CT and MR images), 3D, windowing,
magnification, loading studies for review, and transferring
studies over the PACS network, filming, CD-ROM burning,
and a host of other functions.
• Workstation software support almost all radiology modalities:
computed tomography (CT), computed radiography (CR),
digital X-ray (DX), magnetic resonance (MR), nuclear
medicine (NM), radiographic fluoroscopy (RF), secondary
capture (SC) e.g., digitized film (SC-DF), ultrasound (US),
digital C-arm imagers, and x-ray angiography (XA).
one of the important functions of PACS is to
optimize film viewing relative to x-ray film,
and to provide easy access to patient files.
The main network attached server and
workflow manager server will bring all
exams to the worklist. The worklist can be
accessed from the study selection dialog
box by entering the patient's I.D. or
medical record number.
An important advantage of image viewing from a
workstation is that the radiologist only needs the
radiology request to access the patient's file.
This keeps the radiologist reading area simple
and less cluttered. To access a file the patient's
identification number is entered into the
appropriate field. This is easily done using a
keyboard or more commonly by a barcode
reader.
The reason is that it is important for the
technologist working with digital images and
computed radiology images to know that
windowing and leveling options are provided on
the workstation so that they do not get into the
habit of gross density and contrast adjustments
of raw data prior to sending it to PACS.
 Manipulasi Data
Manipulating image data from a CR monitor prior to
sending it to PACS causes it to be permanently
changed.
Then when the radiologist manipulates the data from the
workstation it is not from the total raw data but from that
data sent to PACS following the technologists'
manipulations.
If the image was poor on the remote operator panel, then it
is even further degraded by manipulations at the
workstation.
It is better to send the poor images and let the radiologist
perform their own windowing and leveling of the quality
rather than the technologist manipulating it to their liking
and removing raw data then sending it to PACS
 Merge Functions
merge function very useful because the radiologist is able
to compare studies of different patients side by side for
teaching purposes, or can merge files that are similar to
create an electronic teaching file.
While viewing a study the radiologist may wish to tag
images to be reviewed with the ordering physician during
a consultation.
These features and many more allow for easy access to
information without having to go through an entire image
file.
In addition, integrated modules enables viewing patient
reports previously stored in the Radiology Information
System (RIS) through a RIS broker or Data Bridge. Both
reports and images can be printed from a PACS
workstation, or on to a CD-ROM for teaching files,
lectures, and patient consults.