MRSC5039 Workflow and PACS PDF

MRSC5039 Medical Radiation Science 3 RIS, PACS and Image Networks Amir Tavakoli Taba, PhD Medical Imaging Science Sydney School of Health Sciences Faculty of Medicine and Health Educational Objectives Explain the principles of Picture Archiving and Communications Systems (PACS) Relate the...

MRSC5039 Medical Radiation Science 3 RIS, PACS and Image Networks Amir Tavakoli Taba, PhD Medical Imaging Science Sydney School of Health Sciences Faculty of Medicine and Health Educational Objectives Explain the principles of Picture Archiving and Communications Systems (PACS) Relate the need of digital radiology to PACS List the four components of PACS Explain errors in each of the four components of PACS Some Abbreviations HIS: Hospital Information System. RIS: Radiology Information System. HL7: Health Level 7. PACS: Picture Archiving and Communication System. DICOM: Digital Imaging and Communications in Medicine. HIS, RIS, HL7 Hospital Information System (HIS) is a system used to store and retrieve patient information. Integrated computer system that may include or be linked to a RIS. Radiology Information System (RIS) is a networked software system for managing radiology data. Especially useful for tracking radiology imaging orders and billing information and is often used in conjunction with PACS to manage image archives, record-keeping and billing. Health Level 7 (HL7) is a set of international standards used to transfer and share data between various healthcare providers. PACS Picture Archiving and Communication System (PACS) is a healthcare technology for the short and long-term storage, retrieval, management, distribution and presentation of medical images. It includes automated systems for acquiring, transmitting, storing, and displaying digital images and associated data. DICOM Digital Imaging and Communications in Medicine (DICOM) is the international standard for medical images and related information. It defines the formats for medical images that can be exchanged with the data and quality necessary for clinical use. Jointly developed by the American College of Radiology (ACR) and the National Electronic Manufacturers Association (NEMA). DICOM is recognised by the International Organization for Standardization as the ISO 12052 standard http://www.dclunie.com/ Why is DICOM used everywhere? DICOM ensures the interoperability of systems used to ‘Produce, Store, Display, Send, Query, Process, Retrieve, Print’ medical images. imaging equipment (CT, MR, Ultrasound, etc) imaging information systems (HIS, RIS, PACS) peripheral equipment (workstations, 3D printers, CD importers, etc) Brief History 1983: The American College of Radiology (ACR) and the National Electrical Manufacturers Association (NEMA) joined forces and formed a Standards committee to meet the combined needs of radiologists, physicists and equipment vendors. 1985 and 1988: The first and second versions of ACR-NEMA 300 were released, gaining increasing acceptance among vendors. 1993: The third version of the Standard (named DICOM) evolved to use local area networks like Ethernet by layering the medical image protocols on top of general networking protocols (TCP/IP). 2005 and 2007: Radiation Dose Structured Reports (RDSR) added for x-ray based imaging and CT. 2013: Second generation RESTful web services defined to retrieve, store and query DICOM images. The suite of web services is re-branded as DICOMweb , and is aligned with the HL7 FHIR web services. 2019: DICOMweb Redocumentation re-organizes Part 18 to provide a comprehensive view of all DICOM web services in a uniform structure oriented toward web implementers. DICOM Information Object Definitions DICOM uses a paired hexadecimal structure for metadata representation, each four characters long. First part: Represents the grouping of data; patient-related data is represented by (0010). Second part: Represents a specific attribute in the group. E.g., patient name is described in tag (0010,0010), and referring physician's name in tag (0008, 0090). DICOM study, series, and instance are identified by unique identifiers (UID). DICOM object hierarchy  0018,1110 650 Distance Source To Detector DICOM Tags 0018,1111 0018,1114 0018,1149 633 1.0268562401264 298238 Distance Source To Patient Estimated Radiographic Magnification Factor Field Of View Dimensions Name Value.Value Value.keyword Status 0018,1150 731 Exposure Time 0008,0020 Study Date 0018,1151 157 X-ray Tube Current 0008,0022 20161202 Acquisition Date Same as Study Date 0018,1152 115 Exposure 0008,0023 20161202 Content Date Same as Study Date 0018,1153 115070 Exposure In uAs 0008,0050 Accession Number Empty 0018,1166 FOCUSEDPARALLEL Grid 0008,0070 SIEMENS Manufacturer 0018,1190 0.3 Focal Spots 0008,0080 Institution Name Empty 0018,1191 TUNGSTEN Anode Target Material 0008,1010 Station Name Empty 0018,7050 RHODIUM Filter Material 0008,1070 Operations' Name Empty 0018,11A0 66 Body Part Thickness 0008,1090 Mammomat Inspiration Manufacturer Model Name 0018,11A2 69.1 Compression Force 0010,1010 Age 0018,1405 35 Relative X-ray Exposure 0010,0030 Patient's Birth Date Empty 0018,5101 MLO View Position 0018,0060 30 KVP 0018,6000 Sensitivity 0018,1110 650 Distance Source To Detector 0018,700C 20161124 Date Of Last Detector Calibration 0018,1111 633 Distance Source To Patient 0018,7011 80885 Exposures On Detector Since Manufactured 0018,1114 1.0268562401264 Estimated Radiographic Magnification Factor 0018,7052 0.05 Filter Thickness Minimum 0018,1149 298238 Field Of View Dimensions 0018,7054 0.05 Filter Thickness Maximum 0018,1150 731 Exposure Time 0018,7060 AUTOMATIC Exposure Control Mode 0018,1151 157 X-ray Tube Current 0018,8150 731000 Exposure Time In uS 0018,1152 115 Exposure 0018,8151 157414.50068399 X-Ray Tube Current In uA 0018,1153 115070 Exposure In uAs 0019,1052 Exposure Mode 0018,1166 FOCUSEDPARALLEL Grid 0020,0012 4 Acquisition Number 0018,1190 0.3 Focal Spots 0020,0020 Patient Orientation 0018,1191 TUNGSTEN Anode Target Material 0028,1051 1500 Window Width 0018,7050 RHODIUM Filter Material 0028,1300 NO Breast Implant Present 0018,11A0 66 Body Part Thickness 0040,0244 20161202 Performed Procedure Step Start Date 0018,11A2 69.1 Compression Force 0040,0306 567 Distance Source To Entrance 0018,1405 35 Relative X-ray Exposure 0040,0314 Half Value Layer 0018,5101 MLO View Position 0040,0316 0.012447 Organ Dose 0018,6000 Sensitivity 0040,0318 BREAST Organ Exposed 0018,700C 20161124 Date Of Last Detector Calibration 0040,8302 4.5276672778851 Entrance Dose In mGy How it all fits together HIS HL7 RIS DICOM PACS Four Major PACS Components Network 2 PACS Network 1 Acquisition 4 Display RIS: status of exams Image Database: status of images 3 Archive The real world… EPR HIS Workstation RIS PACS Modality The Radiology Workflow The Radiology Workflow 1. Schedule an appointment. 2. Patient arrives at department. 3. Patient examination. 4. Radiologist reporting. 5. Physician review. STEP 1: Schedule an Appointment  Centricity RIS Scheduling Module Modality & Staff Schedules Calendar Worklist Patient Context History Patient ‘Scheduled’ STEP 2: Patient Arrives at Department RIS Registration Module Patient ‘Registered’ STEP 3: Patient Examination  Storage of Images  Examination is performed at the modality  Images are losslessly compressed at the DICOM Application Service  Images are inserted in the previously created patient folder Online Storage Long-Term Storage IMS Images are now stored  RIS Service Recording Module Service Recording User-defined Work-Lists Confirm performed procedures  RIS Service Recording Module Service Recording User-defined Work-Lists Confirm performed procedures Documentation of modality performed procedure steps Benefits of DICOM Modality Performed Procedure Step: Do an automated documentation of the examination recording using DICOM MPPS Modality (or DAP) dependent  Quality Assurance Step  After Quality Assurance (QA) is finished  Image data is sent to the Long-Term Archive (LTA)  Reading Worklists are updated Online Storage Long-Term Storage IMS Patient ‘Registered’ STEP 4: Radiologist Reporting  RIS Reporting Module  Radiologists Cockpit offers a Productivity Dashboard  Radiologist controls reporting process with Speech Mic  Synchronized Image Display controlled by Default Display Protocol Recorder Functions Trackball Mouse Buttons  Every tool in one virtual desktop? Diagnostic Screens Fully Integrated RIS Embedded Digital Dictation & Speech Recognition Embedded MS Word Integrated Advanced Clinical Applications Embedded Advanced Clinical Applications  Typist writing patient report  Embedded Report Transcription into MS Word  Typist uses headset and foot control as usual Xray appears normal Patient Patient ‘Dictated’ ‘Written’  Speech Recognition  Improve your reporting workflow by online/offline recognition  30-40% improved report turnaround time  Instantly available reports: WYSIWYS – “What You Say Is What You See” Microsoft Word embedded into Centricity RAD-Cockpit With Online Recognition the transcription step can be skipped for faster report turnaround Patient ‘Written’ Patient ‘Dictated’ & ‘Approved’  Image / Report Distribution  After approval, the report is unchangeably stored in the database  The reports and images are available according to the user rights for entire Enterprise  Web access makes images and reports accessible via Internet VPN connection  Reports can also be transferred to the HIS and sent via print, fax, or email Image Distribution Online Storage Long-Term (DR) Storage via Internet/Intranet IMS Patient ‘Approved’ STEP 5: Physician Review Physician Portal Errors in Radiology https://pubmed.ncbi.nlm.nih.gov/34729603/ Errors in PACS  Errors in PACS Error Cause Consequences Solution Patient ID When actions for one patient occur for another patient Delays Barcode scanning 1 Can be a disaster: a) exposed under wrong file, or b) Unnecessary exposure Rigorous ID check at each stage exposed wrong patient Wrong treatment and/or medication given Laterality Incorrectly labelling the side or region of interest Increase patient morbidity and mortality Make a habit of always using lead markers, 2 Important for image-guided procedures Has resulted in surgery of incorrect side unless time is crucial Technique Poor image quality from suboptimal exposure Interpretative errors: masking or burning out Use EI to guide you 3 related technique pathology Pay attention and lean exposure factors Over post-processing (window width/level) Data Inaccuracies, communication and syncing errors Radiologist cannot start reporting Check that images are sent to PACS after exam 4 accuracy between RIS and PACS completion Can occur if internet goes out Data When decisions are made/based on incomplete No access to prior reports Ensure all information is obtained from the 5 availability information Reporting on incomplete image set patient before finalizing exam Either not available or required additional navigation Data integrity When decisions are made/based on stored data that Difficult for Radiologist to formulate proper Include all images and follow up with PACS IT 6 was deleted or still un-transmitted images diagnosis for possible retrieval Display When a monitor is not calibrated Errors in interpretation Calibrate monitor to ensure most accurate 7 representation Transcription Errors in the speech recognition software May have higher level of error vs traditional Radiologists should not rely on just dictation 8 related transcription They should read over their work  RIS/PACS systems can be used to manage workflow Worklists use filters to restrict the database view to what is relevant at any given workplace Useful filter database fields are Status (i.e. Registered = in department waiting to be scanned) Summary Date (i.e. TODAY) Modality (i.e. I work in CT) Errors in PACS: Not enough to just implement an IT system… We must optimise the way we work too! As a radiographer, chart the processes using workflow diagrams to clearly see what you actually do and how you can possibly improve it Special thanks to Prof. Mark McEntee and Beacon Hospital for providing some of the images used in this presentation