Developing a cost-effective image QA workflow with PACS

Nov 20, 2007

In a radiology department, image quality is or should be a primary metric in the department's continuous quality improvement (CQI) arsenal. With PACS becoming an ever-increasing method of viewing studies, institutions need to develop an optimal quality assurance (QA) workflow to fit the new digital viewing paradigm.

With PACS, there is no longer a single sheet of film that everybody will view. Now, there can be as many variations in the display of a single image as there will be people viewing that image.

Here is one scenario: a technologist images a broken ankle in the emergency room late at night. The emergency department physician sees the image on the ER PACS workstation. An orthopedic surgeon is called, who then looks at the image on a Web-based PACS viewer at home. Deciding the surgery cannot wait, the orthopedic doctor comes in and during surgery views the ankle x-ray on the PACS station in the operating room. Meanwhile, the radiographer views the image on a QA workstation, then releases it to the radiologist to read first thing in the morning.

In this scenario alone, the images of that study will be viewed on a minimum of five different workstations, each possibly being slightly different than the previous. If all the variables are aligned at a given time, there could be an equal amount of variation in the study interpretation as there are different monitors on which the study was viewed.

Of all the steps that this or any study takes during the course of imaging, the technologist performing QA on that study and handing it off to the radiologist dictating an interpretation is the most critical in the efficiency of radiology workflow. Not having the correct tools could significantly impact the turnaround time, which is another important metric in radiology CQI.

The increase in turnaround time results when an insufficient image review process is in place or the review process takes place on equipment not designed for the job. The radiologist is then given an image unsuitable for interpretation and significant time is lost tracking the error, finding a technologist to repeat the study, and getting the image turned back in for interpretation.

Equipping the technologist with the correct equipment and developing the right workflow will bring you a long way in reaching your departmental CQI goals. The following questions and thoughts can be used as a guideline for making equipment and workflow decisions:

Will you be performing image QA at a central location, or do you have a decentralized radiology department? This will help you develop the count of needed technologist QA workstations.
Do the technologists have diagnostic monitors on their imaging equipment, or will QA decisions be made from reading off of a QA workstation? Some CR and DR workstations have monitors with diagnostically appropriate size and resolution.
Do I have the following: a trained PACS administrator or QA technologist, DICOM calibration software, and a photometer?
What does my budget look like this year?

Knowing that a radiologist reads diagnostic plain films on a monitor with a minimum resolution of 3 megapixels and that those monitors are too expensive to purchase for every modality area or room, the following conditions should be met:

Monitors should be at least 21" away and be able to rotate from landscape to portrait.
You should purchase video cards that can display up to 2 megapixels and drive the rotation of the monitors rather than using software rotation.
The monitors that the technologists will perform QA with should be in the same orientation that the radiologists will read in.
All monitors in the department should be calibrated to the DICOM standard and have a biannual verification schedule. Additionally, your calibration puck should undergo calibration annually to ensure that it reads luminance correctly.

By shopping around, you can find fiscally responsible prices on hardware that will allow you to equip your technologists with the tools that will allow them to perform a QA on images that will look the same on the radiologist's diagnostic workstation.

My organization is beginning a revamp of technologist QA workflow, and we are finding some affordable pricing on the monitor/video card combination we need to fulfill the requirements I describe above. Combine that with an appropriate workflow and you should see an improvement on some of the critical metrics that define the quality of your department.

By John Sole
AuntMinnie.com contributing writer
November 21, 2007

Mr. Sole is the PACS administrator supervisor at Swedish American Hospital in Rockford, IL. He can be reached at [email protected].

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