PACS introduction

Facilitator:
Edward Wong

What is the role of PACS

Administrator?

PACS Administrators roles

Implementing a PACS
System Maintenance
Image and Information Management

For a 200,000 exams/year institution, 2-8

full time PACS Administrator is available!

PACS Administrators roles

Implementing a PACS
- Financial and workflow study
- Request for Proposal and Tender drafting
- Workflow modification including job reallocation
and resource relocation
- Training and Operation Manuals
- Acceptance of system
System Maintenance
Image and Information Management

PACS Administrators roles

Implementing a PACS
System Maintenance
- Contingency plan
- Incompatibility handling
- First line support and problems escalating
- System security and Performance monitoring
Image and Information Management

PACS Administrators roles

Implementing a PACS
System Maintenance
Image and Information Management
- Maintain high Image Quality
- Data Integrity
- Quality Assurance program
- TeleRadiography
- Anytime Available Storage Management

What is PACS ?
P: Picture, Images & Reports
A: Archive, Online, Near line, Offline
C: Communication, Networking, Transfer Protocols
S: System, Components & Architecture
PACS: for storage and distribution of images and
information when necessary

PACS: Small or Large

Web Server Distribution

Scale of PACS
No. of Beds in Hospital/ Exams per year
No. of Modalities
No. of Switches
Considerations:
System connectivity, expandability, reliability
and cost-effectiveness

Types of images
1D, 2D, 3D, 4D
Different DICOM Modality type: Cardiac / PET / 4D

U/S..
Image size: Resolution and bit depth
Image quality: Bit Depth and resolution
Color / Monochromatic
Exam. Size: image size x no. of images
Structured Reports
New DICOM IOD:
Endoscopic & Microscopic images / ECGs / Security
Profiles..

1D, 2D, 3D, 4D, fusion

1D, 2D, 3D, 4D, fusion

Image Resolution/ Bit depth

U/S

DF

CR

CR Mammogram

256 x
256
8 bit

1k x 1k

65
KBytes

10 bit
1.25
MByte

2k x 2.5k
12 bit

4k x 5k

7.5 MByte

12 bit
30
MByte

Properties of image
Bit depth
Grayscale or color
Resolution in pixel
Example image
size of
mammogram = 4k x
5k x 12 bit = 30 MB

PACS Architecture

PACS Central Architecture

DICOM
Modality

Gateway or
Non-DICOM Frame Grabber
Modality

Diagnostic
Workstations (DICOM)

Clinical
Workstations (DICOM)

Image
Server
(RAID)

Diagnostic
Workstation

Film
Digitizer

CR/ DR QA
Computed Workstation
Radiography
or DR

Web Server

Data Base
Server

Archive

RIS

Central Architecture
Image Server and Database Manager is

the HEART
Any image, any where, any time
Unique central copy
Easy update of data
Requires high performance servers
Potential single point of failure at server
Bandwidth demanding

PACS Distributed Architecture

DICOM
Modality

Gateway or
Frame Grabber
Non-DICOM
Modality

CR QA
Workstation

Film
Digitizer

Diagnostic
Workstations
(DICOM)

Clinical
Workstations
(DICOM)

Web Server

Diagnostic
Workstation

Data Base
Server
Archive

Computed
Radiography
RIS

Distributed Architecture
Exams are routed from modality to
selected workstations
Complex routing algorithms based on
department / user preference
Difficult to support concurrent review of
images
Less destructive for failure at database
server

Components of PACS
HIS/ RIS
Broker
ePR gateway
Database Server
Image Server (RAID)
Long Term/ Near line Archive
Networks
Digitizer

Components of PACS
Acquisition Gateways
Non-DICOM modality gateway
DICOM Print Server
Media Server
Reporting Server
Monitor QC Server
Web Server
Workstations

PACS layout 1

PACS layout 2

PACS layout 3

GE Medical Systems

Tuen Mun Hospital PACS System - Ambulatory Care Center

(phase 1)

IT - Radiology System

Image Acquisition Modalities in ACC

Prestiges II

ACC Ortho Dept

Proetus XR/a

RW Film Digitizer
PathSpeed
SP CR

PathSpeed
MP CR

Proteus XR/d

CR ID Preview
1

PathSpeed 1CWS

MIU1

MIU2

CR ID Preview
2
PathSpeed 1CWS

PathSpeed CRQA

1 GBit
Fiber
Link

Kodak Laser Printer 2

KELP 2180

E450 CPU

HSA 1
PCS2

1C PathSpeed
Review Stations

Radwork5.0

MIU3

Server Rm Network Switch Closet

Kodak Laser Printer 1

DryView 8700

US Logic700

Hospital
RIS
Network

600m / 12
Core Gbit
Fiber Link
HIS/RIS I/F (SQL)
(Mitra Broker)

ARC

Main Block
Radiology
Department
CT MR
RT
Network
NetworkNetwork

Layer 3 Sw
Layer 2 Sw

PCS 1

Long Term Archive

MOD Jukebox
RAID 5
ISU
1CWS /
Remote Admin

PARIS 2

PARIS 1

2B Diagnostic 2B Diagnostic
Workstations Workstations

PACS layout 4

PACS Components
ePR gateway

Enterprise Archive

DICOM
Modality

Diagnostic
Workstations (DICOM)

Through Acq.
gateway

W/S QA Server

Image
Server
(RAID)

Gateway or
Non-DICOM Frame Grabber
Modality

Clinical
Workstations (DICOM)
Diagnostic
Workstation

Film
Digitizer

Web Server
Data Base
Server
LTS Archive
SAN/NAS

CR/ DR QA
Computed Workstation
Radiography
or DR
Broker for
RIS/HIS

Media Server

Acquisition (DICOM) Gateway

HIS/RIS
Interface
(Broker)

DG
W/S

RIS

C
T

MR

R&F

NM

PCs

CR QA

Film
Digitizer

CR

XRAY

Frame
Grabber

US

Role of Acquisition gateway

Compression/ decompression and security
Check the images for integrity
Convert to PACS format (header, byteorder, matrix size)
Queue for images (priority) to database
server (background)
Share the workload and no point of failure
for multiple Acquisition gateway

Database Server and Image Server

Database
Server

RAID

HIS/RIS
Interface
(Broker)

DG
W/S

RIS

C
T

MR

R&F

NM

PCs

CR QA

Film
Digitizer

CR

XRAY

Frame
Grabber

US

Database Server (PACS controller)

The Heart of the system
Integration cross point between HIS/RIS

and PACS (status update)

Create and manages patient folders
Manage reading worklists and user profiles
Manage data transfer within the system
Support data mining and teaching folders

Image Server (RAID)

Online (rapid access) exam storage and
distribution device
Support simultaneous exam input and
output transfer operations
Up to Three months of storage capacity
Scalable capacity

What is RAID
Redundant Array of Independent Disks
Bandwidth equal to sum of disk transfer rates
Highest speed disk storage available
Hot Swap

1
2
3
4
5
6
7

Image

8
Parity

Disk Array

2 MB/s

16 MB/s

RAID 5 configuration
If disk fails, disk can be
rebuilt- fault tolerant
High data transfer rate
for read, write slower
Min. 3 disks to start
Array capacity is N-1

Bandwidth
Bandwidth is a measure of the
information (data) carrying capacity of a
network
10/100/1000 MB/sec
Information Flow

Data Pipe (Network)

Network Bottleneck
The bandwidth of an information delivery system is
limited to the bandwidth of the slowest component
in the system

Network Bottleneck

Data Compression
Data compression reduces the information rate
a network must support

Uncompressed Data

Compressed Data

Lossless Image Compression

I-D=0

C
I

Decompressed image is identical to original

image
JPEG lossless compression
Average compression of 2:1 for x-ray images

JPEG 2000 Compression

Selected parts of the image can be defined as

Regions of Interest, they can then be delivered

before other parts of the image, or losslessly,
whilst other parts of the image that are less
critical use normal lossy compression
JPEG 2000 codestream can be ordered to
deliver images of lower resolution before the full
image can be transmitted
Motion JPEG 2000 does not have any form of
extrapolation (and hence potential distortion) in
the time domain. Each frame is a separate
JPEG 2000 coded image

JPEG 2000 images

Storage Device (Long Term)

Database
Server

RAID

MOD

DLT

HIS/RIS
Interface
(Broker)

DG
W/S

RIS

C
T

MR

R&F

NM

PCs

CR QA

Film
Digitizer

CR

XRAY

Frame
Grabber

US

Types of storage media

Media

DVD

MOD

DLT

9840

AIT2

WORM

GB

3.8

5.2

35

20

50

Less
Expen.

Expen.

Expen.

Cheap

Most
Expen.

Load + Very fast Very fast 113 sec

Assess
5
5.1
5
Max. T
rate
MB/s

15 sec

45 sec

10

Cost

Long Term Archive

Used to store digital data for longer periods
of time
Storage ranges from 100 MB to 10 TB
Optical disk most common media
- 5 1/4 MOD
- 2.6 GB and 5.2 GB Capacity

DLT used for longer term storage and

redundancy
ISP module

Storage Device (Near line)

Database
Server

RAID

MOD

SAN/NAS

DLT

HIS/RIS
Interface
(Broker)

DG
W/S

RIS

C
T

MR

R&F

NM

PCs

CR QA

Film
Digitizer

CR

XRAY

Frame
Grabber

US

Storage Area Network

SAN is a high-speed sub

network of shared storage

devices
Contains storage device
(disk) for storing data
SAN's architecture works in a
way that makes all storage
devices available to all
servers
Use of Fiber Channel
High scalability for additional
storage and redundant
networks

PCs

Storage devices

Network Area Storage

NAS is a class of dedicated hard disk-based storage

devices which provide LAN users with additional disk

storage through a standard network connection
In most cases, a NAS device (or NAS server) receives
an IP address, connects to the LAN through an Ethernet
cable, and resides on the LAN as an independent
network device
Users are not demanding the server's processing time
for mundane storage tasks -- often improving the
performance of local application servers
NAS systems also include some onboard memory
(RAM) to cache network data to or from the disks

SAN Vs NAS
Difference between NAS and SAN is subtle
NAS devices are big, single purpose storage

appliances that you plug into network

NAS sits between your application server and
your file system
As perform only 1 task, can serve files very fast
NAS is network-centric
SAN is a defined architecture that sits between
your file system and your underlying physical
storage
SAN is data-centric

Display
HIS/RIS
Interface
(Broker)

Database
Server

RAID

MOD

DLT

Diagnostic W/S

Dedicate W/S

SAN/NAS

DG
W/S

RIS

C
T

MR

R&F

NM

PCs

CR QA

Film
Digitizer

CR

XRAY

Frame
Grabber

US

Workstations
Four Primary Categories
- Advanced Analysis: Used by specialists for advanced
diagnosis - 3D, volume rendering
- Diagnostic: For primary diagnosis; located in reading
rooms; high-end 2K monitors
- Clinical: Used by clinicians and staff to consult; ICU /
ER applications; less costly than diagnostic; 1K
monitors
- At Home Review: low-end; PC based; cost-effective;
review application; lossy compressed for faster
transmit

Standalone Vs direct PACS w/s

Standalone Workstation

Direct PACS Client

Workstation

Hard Disk Storage

Yes, varies

Minimal

Query PACS
number

All PACS system (CT, ACC,

Angio.)

Single PACS system (ACC

PACS)

Retrieval
mechanism

DICOM Q/R and association

made with different vendors

Direct attached, same vendor

Retrieval time

Slower

Faster

Diagnostic value

Depends on Monitor Grade and

Modules like MPR, 3D etc

Depends on Monitor Grade and

Modules like MPR, 3D etc

Suggested usage

1.for meeting/museum purpose

2.for single modality image

Direct PACS workstation for

reporting

reviewing and reporting like

Radworks in U/S Rm

Web distribution
High availability, low cost
Reports / select images to referring

physician desktop
Point of integration with electronic patient
record
Lossy compression for performance
Potential for TeleRadiology
Security issues to be resolved

RIS, HIS, ePR and PACS

integration

Broker HIS/RIS and PACS interface

HIS/RIS
Interface
(Broker)

DG
W/S

RIS

C
T

MR

R&F

NM

PCs

CR QA

Film
Digitizer

CR

XRAY

Frame
Grabber

US

Hospital Information System

Support clinical and medical patient care
activities in the hospital
Administer the hospitals daily business
transactions like finance, payroll etc
Evaluate hospital performances and costs
and make long-term forecast

Clinical System in HA, HK

Patient Administration

In-Patient and Out-Patient Administration System

Accident & Emergency Information System
Medical Record Abstract System
Medical Record Tracking System

Clinical Support

Laboratory Information System

Radiology Information System
Pharmacy Management System
Dietetics Catering Management System

Clinical Management

Clinical Management System (In-Patient) Discharge Summary

Clinical Management System (Out-Patient)
Electronic Patient Records
Clinical Data Analysis and Reporting System

Non-Clinical System in HA
Human Resources and Payroll Systems
Hospital Based Financial System
Materials Management System
Patient Billing and Revenue Collection
System
Executive Information System
Code 9 and view codes

Radiology Information Systems

Similar to HIS but of smaller scale

Interfaces to PACS based on HL7
Department administrative management
- Scheduling and Film tracking
- Resource management and reporting
- Monitor patient status
Link to Hospital Information System (HIS)
- Billing and Master Record
Link to Clinical Management System (CMS)
- Prefetch for Clinical visit
- ePR integration

Exam
Order

Exam
Scheduled

RIS workflow
Web
distribution
to referring
physicians

Modality Worklist
Demographics
Downloaded

RIS

Patient Exam
Is Performed
Images
transferred
in STS

Order
Event

Database
server
/Archive

Prefetch Exams
From Storage

PACS Worklist
Updated

es on er
g
a d rv
Im pie -se
c o eb
w

Images /
Prior Reports

Dictated
status

Image migration STS to LTA

Final report
available

Report
Verified

Exam
Read

Preliminary status

Exam
Transcribed

Broker service
DR
HA
HIS

CR

ADT

HA
RIS
HA CMS

Clinical visit

Appt.,
X-ray
request

Mitra
PACS
Broker
interface

US
DF

Database
server

Modalities: Get WORKLIST

Get REPORT, Get INFO

Broker service
A restricted access account will be created at

Sybase that gives limited authority for the

DICOM Broker solely for the purpose of the
interfaces
In general, for data flow from RIS to the Broker,
the RIS write the supported events to the table,
and the Broker polls against the events table
and calls the associated stored procedures for
the conversion to DICOM messages

Broker service
Broker main function:
- Worklist generation
- Reports storage
Registration + Post
exam data capture (RIS)

Acc # generation +
call broker for update

Need SOME time!!

Modalities query
Broker for worklist
update

Broker poll RIS event

table and convert to
DICOM info

ePR Architecture
Selected images from
individual hospitals
PACS are sent
make use of the ePR
record indexing and
browsing capabilities
to read the radiology
images through CMS
workstations

Data Flow Diagram

RIS

ePR

HA system

Appointment
Attendance
RIS operational
data

Exam records

ePR

Reports
(15mins)

Web
Server

PACS

RIS statistical
data

CMS

Attendance
Exam &
workload units
(daily)

Data
warehouse

Non clinical
system

Characteristics of ePR
Near instant image review
Web distribution can be within hospital, to

other hospitals or even private clinics

TeleRadiography possible
Update of patient information
Lossy Vs lossless
Broken pathway
15 minutes time lag

Guidelines for HIS, RIS, PACS

interface
Each system remain unchanged in its
configuration and function, only data are
shared
Identify the subset data to be shared and
set up access rights/ authorization
Convert the subset data to HL7 standard
Define transfer protocol (TCP/IP or
DICOM)

Typical patient and data flow

Admission: Patient registration, notify HIS (HL7)

Order entry/Arrival: Schedule exam and notify RIS
Broker notified and PACS database server updated (prefetch)
DICOM worklist to modality
Exam completed: data to DICOM gateway (MPPS)
Information/images to database/image server through
gateway (DICOM store)
Images stored in PACS archive
Images to workstations from PACS archive
Dictation, transcription etc: workstation to RIS/PACS
RIS reporting and PACS updated for reports
Transfer: HIS/RIS to PACS, images to other PACS
Discharge: HIS/RIS to PACS, images rub out

http://www.pacs.hk
Thanks!