My PACS is Your PACS

A blur has occurred in the very place doctors would normally associate with absolute clarity. An overlapping of departmental PACS has occurred, both in how doctors use them on the front end and what the systems actually are on the back end. And whereas radiology and cardiology departments may once have controlled distinct systems for accessing, managing and archiving their own sets of patient images, a trend toward broad enterprise image management is shifting PACS into the IT domain of CIOs and PACS administrators.
The desegregation of radiology and cardiology PACS in today’s hospitals can be understood by turning to American history. No, not the Civil War, but much further back to the Founding Fathers, who devised a concept with which Americans are well acquainted: one nation, many states, each comprised of unique, colorful personalities, preferences and even cultures. Like the political infrastructure those statesmen developed for a fledgling union, makers of the picture archiving and communication systems of today emphasize a one-enterprise approach that is equipped to handle the particular, individual requirements of not just the radiology and cardiology departments, but also the many other “ologies” within the hospital enterprise community.
Originating in Radiology, PACS were then retooled to meet the emerging needs of cardiologists, who were blazing a new trail (with very specific training) beyond where, in some cases, traditional radiologists were prepared to go. But sustaining two disparate systems is inefficient, manufacturer sources say, and the theme that dominates the PACS market today — as vendors reach out not only to the individual departments but also address turf-neutral CIOs and PACS administrators — is that one solution with separate tool sets and workstations is not only the wave of the future, but is most certainly the answer for present-day image integration with the EHR.
“There is definitely an advantage to having one single platform,” said Richard Taylor, national sales director for ScImage. “The different departments do have different workflow requirements that need different imaging tools and different kinds of views, but from an IT perspective, [one solution allows you] one application that is handling diagnostic imaging, one link to the EMR and HIS, so you are not managing multiple interfaces with multiple departments.
“Just as there are clinical advantages when you have one electronic medical record for the patient throughout the whole hospital, having one diagnostic imaging system for the entire hospital is also very beneficial.”
Compartmentalizing PACS is, indeed, passé, agrees Rik Primo at Siemens Medical USA.
“A PACS repository that holds or is capable of holding all types of imaging data is a safe and future-oriented strategy,” Primo said. “Separate data-islands for each of the imaging specialties is obsolete. PACS will not only have to hold imaging data from radiology and cardiology, but also pathology, ophthalmology, endoscopy and all other ‘ologies’ that are required for state-of-the-art delivery of cost effective and high-quality healthcare.”

Different Yet Alike
The workflow of cardiologists is undeniably different from that of radiologists, which is why PACS vendors offer separate tools and workstations for each group. Cardiologists are patient-centric, and their workflow is driven around their direct involvement with patient care.
“Cardiology has greater emphasis on intervention and chronic disease management,” said Allen Scales, vice president, Corporate Strategy at Emageon. “There is more emphasis on creating a longitudinal patient record consisting of discrete data as well as multimodality images. Key data such as blood pressure and cholesterol levels must be continuously monitored and controlled through the use of drugs. [And] other key measurements such as ejection fraction and heart wall thickness must also be tracked over time.
“As such, there is greater emphasis on clinical structured reporting through national databases such as the ACC-NCDR.”
The workflow paradigm for radiologists, on the other hand, is more study-centric, with an emphasis on efficiency and productivity as they generate a report for a referring physician as quickly as possible, sources agree.
How cardiologists and radiologists may use the PACS can be similar, though invariably each will require different tools to accomplish their tasks based on their unique workflow priorities. Their need for viewing as well as manipulating static and dynamic images is an example of the intertwining of radiology and cardiology PACS. Moving images are imperative for the cardiologist — assessments of the heart’s motion, wall motion and ejection fraction are among the basics for cardiac diagnostics. And, Primo points out, cardiologists often follow an integrated workflow cycle, where the imaging exam, diagnosis and therapy are performed during the same cath lab procedure.
“Angioplasty is often performed immediately during the angiographic procedure, and a stent could be inserted during the exam to keep the artery open and to widen the lumen,” Primo explained. “The effectiveness of the stent on the arterial blood flow is then assessed by viewing the study and by using the image processing and quantification tools on the modality or workstation.
“Further,” he continued, “the cardiologist will often use a wide variety of various diagnostic modalities to come to a diagnosis: DR/CR, MR, CT, NM, PET, ECG, hemodynamic measurements and more. The results of all these modalities should be accessible at the cardiologist’s workplace, preferably from one workstation.”
But the radiologist requires moving images, as well — CT angiography, MR angiography and MR functional analysis, for example, has made motion an important dimension of their image interpretation.
Yet how they each make use of the dynamic, cine images accounts for the distinct tools that vendors provide to the separate speciality physicians.
“The difference is in the image manipulation tools,” said Joe Darr, global segment manager, Centricity Cardiology at GE Healthcare Integrated IT Solutions. “In cardiology, they need tools that can measure things like stenosis analysis of a coronary artery. And they’ve got tools that help them measure ejection fraction rate. There are analysis tools that are specific to the practice of cardiology versus the radiologist, who would not be interested in those types of tools.”
Crossover in tools and their application does occur in one key place, says Jonathan Elion, M.D., chief medical officer of Agfa and a cofounder of Heartlab.
“Requirements have achieved complete overlap in the handling of multislice CT studies of the heart,” he said. “There are identical needs for 3-D reconstruction and interaction with the display.”
A key differential between cardiologists’ and radiologists’ use of PACS is the need for real-time viewing.
“A cardiologist in the cath lab who is doing a study wants to immediately be able to review those images when he is done, and he wants to create his report as well,” said Bob Baumgartner, BSN, senior product manager, Cardiology, at McKesson. “He needs to to send those images from the X-ray unit over to our PACS unit in real time throughout the procedure, acquire them and register them on PACS, so as soon as he takes his gloves off he can go over and start reviewing them.
“We also have a lot of facilities where they want real-time consultations,” Baumgartner continued. “For example, there may be a physician in the cath lab performing a diagnostic catheterization. He sees there is a lesion here but he is not quite sure if it is treatable by intervention or by surgery. So he might call his partner at the office, who is an interventionalist, and have him go to the Web —  the cardiologist in office goes to the Web client and can pull that patient up in real time and say, while the patient is still on the table, ‘We can treat that interventionally, and I can do it in a few minutes; keep him on the table and I’ll be right over.’“

Single PACS Solution and the EHR
As the picture of  PACS usage and their departmentally-tailored tools fades in and out of focus, one thing that remains in sharp resolution is the fact that a single, enterprise PACS solution is central to realizing hospital-wide efficiency and easier integration with the EHR.
“Imaging really is a big piece if not a driver of the EHR,” Baumgartner said.
Dual systems for radiology and cardiology feeding into the EHR create duplication and extra layers of interfacing — all of which go away when imaging is treated as one unit, regardless of the department from which it originated.
“In the end, you have a study and a report in this PACS infrastructure regardless of whether it came from radiology or cardiology,” said Darr. “There is a common format — we simplify things with a simpler architecture, simpler interfaces and one place that you go to for patient information.”
To this Primo adds: “This consolidated, multispecialty, one-repository [PACS] strategy will facilitate the integration of image information in the electronic medical record. When a healthcare provider is retrieving patient information in the EMR, and the EMR can just query one repository to have ubiquitous access to all imaging information, healthcare providers will have access to all relevant patient information in one simple move.”