Bringing PACS to the cardiology department requires the ability to understand a unique workflow, and an environment that is influenced by factors such as multimodality imaging and turf battles, said Dr. Osman Ratib, professor and vice chair of information systems in the department of radiology at the University of California, Los Angeles.
"The idea that we can just extend what PACS has done in radiology into cardiology might be oversimplistic," he said.
Ratib discussed the functional requirements for PACS in cardiology during a presentation at the PACS 2003: Integrating the Healthcare Enterprise conference in San Antonio, sponsored by the New York-based University of Rochester School of Medicine and Dentistry.
Cardiology relies heavily on imaging for clinical decisions, and it is not unusual for patients to receive two or three procedures for a single clinical question, Ratib said. A combination of different modalities and imaging techniques is typically employed, including an emphasis on quantitative measurements not traditionally seen in radiology.
As the heart is obviously in motion, cardiac imaging generates a large volume of dynamic images, which are reviewed and measured in a dynamic mode. It also requires tight integration with the patient's medical record, giving physicians access to data such as lab results, EKG data, and physical exam information, he said.
"In many cases, you can't interpret the image if you don't have the clinical information, and vice versa," Ratib said.
Traditionally, cardiology images also tend to be much larger than equivalent radiology studies. Support for color is also critical, owing to its use in echocardiography and functional imaging procedures, Ratib said.
Among other technical requirements, the need for 3-D postprocessing and vision analysis is felt more keenly in cardiology than radiology, Ratib said. New imaging techniques require special viewing tools for cardiovascular imaging, such as the ability to "carve out" areas of the body, and zoom in and out, Ratib said.
"These kinds of rendering techniques are not available on standard PACS workstations," he said. "But (vendors) do add these tools for cardiology, and (designing) a cardiovascular workstation is a challenge as well."
Cardiology workflow
Cardiology departments have their own workflow issues, and here turf battles can play a big role, both outside and inside the cardiology department. For example, disputes between echocardiography, angiography, and other labs within cardiology led vendors to introduce digital image management tools for the various cardiac subspecialties, he said.
"That's why you have the very specialized miniPACS for echo," he said. "So the cath lab would have their own environment, and nuclear medicine would have their own specialized environment. That led to really a very distributed, very non-concentric design of cardiology PACS."
Employing multidisciplinary image-based patient management, the practice of cardiology requires the various disciplines to get together to make a clinical decision, Ratib said. There's an overlap of diagnostic and therapeutic procedures, and cardiology has high requirements for image communication and integration.
"Everybody wants the images when they have to make clinical decisions," he said.
UCLA found that one of the main benefits of its cardiology PACS was improving clinical conferences, in which multidisciplinary surgical and clinical teams meet to review imaging and clinical data. In the past, this required advance preparation for the conferences, and time-consuming review of multimodality studies and results.
PACS and information technology improves this process, by offering a single viewing environment for all imaging modalities, including remote retrieval of DICOM images and support for off-line CDs and magneto-optical disks (MODs). Users can select key images and cine sequences for multimodality image display.
Image annotations and measurements can be seen, as well as non-imaging documents and clinical information. It is all designed and engineered to yield more efficient and productive clinical conferences, Ratib said.
"It's essentially an electronic medical record," he said.
Remote conferencing is possible, as well. For additional timesavings, adopting script-driven presentations can be helpful, he said.
The clinical conference workstation was the "seed" component of UCLA's cardiology PACS network, he said. In the next step, UCLA hopes to integrate its cardiology subdepartments into one imaging environment.
There's an industry need, however, for extending image analysis and processing tools, Ratib said.
"That's a huge task, and that's going to be the next challenge for vendors is how (they) provide those analysis tools developed for very specialized areas into a more common platform that still fits all the needs," he said.
By Erik L. RidleyAuntMinnie.com staff writer
June 11, 2003
Related Reading
IHE pursues user adoption, product development, IT expansion, May 12, 2003
Maximizing your investment in enterprise digital imaging, April 18, 2002
HIMSS session: PACS offers unique IT challenges, January 29, 2002
Turf Wars in Radiology, Part III: All is not lost in nuclear cardiology, August 31, 2001
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