Download PACS Specification - UK Imaging Informatics Group

Specification for PACS procurement or Replacement
Current day PACS Systems perform 2 basic functions
1. Image Archive/Manager—i.e. long term store of images—(this can be
either provided by a Vendor Neutral Archive or the PACS)
2. Image Display—display of images stored in the image archive above---This
can be either a part of PACS or a separate image viewer.
PACS= Image Archive/Manager + Image Display
PACS integrates with the following IT systems :
 PAS (Patient Administration System) for demographics, current location,
current responsible consultant/GP
 RIS (Radiology Information System) for scheduling information & report
information
 Modalities—receives images & image related information
I. Demographics & ADT Information consistency—All demographics & ADT
(Admission Discharge & Transfer information) must be kept up-to-date on all clinical IT
systems within any organization. Any demographics update or patient merges on PAS
must realtime update PACS systems.
IHE Standards--Patient Information Reconcilliation (PIR) Profile: “PIR handles:
unidentified/emergency patient, demographic information updates ( e.g patient name changes
(marriage, etc.) , correction of mistakes, ID space mergers). Such changes are reliably
propagated to all affected systems, which update all affected data. The result is a complete
patient record. “
1. PACS
2. RIS
3. PAS
Must all comply with PIR Profile of IHE.
II. PATIENT BANNER INFORMATION---The patient demograhics and ADT
information for a patient MUST be consistently displayed on the top demographic banner
of any clinical system (PACS, RIS & Ordercomms)---realtime demographics
synchronization with PAS is mentioned above. This is hugely important for patient safety
& care –ensure that timely communication, ensuring correct ID, timely action can be
taken:
1. Name
2. DOB
3. Sex
4. NHS No.
5. PAS No.
6. Current Patient Location
7. Current Responsible Consultant
III. SEARCH CRITERIA FOR A SINGLE PATIENT or GROUP OF PATIENTS: It
should be possible to search for a single/group patients using one or any combination of
the following criteria:
1. Name
2. DOB
3. Sex
4. NHS No.
5. PAS No.
6. Current Responsible Consultant
7. Requesting Responsible Consultant
8. Current Patient Location
9. Operator
10. Reporter
11. Exam Status of study (see section--)
12. Modality
13. Exam Description
14. Exam Room
15. Date Range (for exams)
IV. CLINICAL METADATA FIELDS on Images (PACS=Image Archive): Below
describes Information that needs to be stored & available for display for the clinical
user/Radiologist viewing the PACS image. This also identifies what clinical data fields
should be transmitted as metadata fields or tags to XDS registry/repository (if XDS is
made the standard for including radiology images into the EPR)
1. PATIENT DEMOGRAPHICS (synchronized with PAS)
a.
b.
c.
d.
e.
Name,
DOB,
Sex,
PAS No.,
NHS No. (CHI number for Scotland)—NHS number may not
be present in 100%exams sent to PACS
2. REQUESTER—synchronized with RIS
a.
Name of Requester
b.
Grade of requester
c.
Contact number of requester
d.
Requesting **Responsible Consultant/GP (Team)—(Also
RECIPIENT)
e.
Requesting Speciality/Department/GP surgery
f.
Requesting Institution
g.
Date & time of request made
3. IMAGE DOCUMENT—synchronized with RIS & modalities
a.
Modality
b.
Exam Description---(National Exam Codes & Descriptions)
c.
Exam Status
d.
Date & Time image acquired on modality
e.
Date & time of image sent from modality
f.
Date & time received on PACS
g.
Exam Room (where the exam has been performed)
4. OPERATOR/IMAGE CREATOR –synchronized with RIS & modality
a.
Name of Operator
b.
Grade of Operator
c.
Contact number of Operator
d.
Performing Responsible Consultant
e.
Performing Department/Speciality--Radiology
f.
Performing Institution/NHS Trust
5. REPORTER—synchronized with RIS
a.
Name of Reporter
b.
Grade of reporter
c.
Contact number of reporter
d.
Reporting Responsible Consultant
e.
Reporting Department/Speciality
f.
Reporting Institution/NHS Trust
g.
Date & time report verified
It is important that the relevant data fields are synchronized between PAS, RIS,
modalities & PACS.
VI. EXAM STATUS: This is a key concept for driving a workflow within the radiology
department. The status must be synchronised between Ordercomms, RIS, PACS &
Results Acknowledgement systems.
1. Requested (ORDERCOMMS)
2. Request Vetted (RIS)
3. Request held/deferred--with reason (RIS)
4. Scheduled or appointment given (RIS)
5. Cancelled (RIS/ORDERCOMMS) with reason
6. Arrived/Attended (RIS)
7. Did Not Attend (RIS)
8. Exam started (RIS)
9. Exam Completed (RIS)
10. Exam not performed --with reason (RIS)
11. Report Dictated (RIS)
12. Unauthorised report (RIS)
13. Authorised/Verified Report(RIS)
14. Ammended Report (RIS)
15. Report Viewed (Ordercomms/RAS)
16. Report acknowledged (ORDERCOMMS/RAS)
17. Review requested (Ordercomms)
18. Was not brought (RIS)
VII.
IMAGE RETENTION, STORAGE & TIMELY ACCESS
It should not matter what technical storage structure is chosen for PACS, access to previous
images must be in a timely manner (3-5secs):
Options of PACS Storage Architecture include:
a. everything online
b. 1-3years on line with the rest offline--on DVD, jukebox etc (and dependent on good
prefetch protocols) c. 1-3 years online with the rest in data centres (Cloud Storage)
1. Data retention standards for NHS-"According to DH doc
Xray films (including other image formats for all imaging
modalities/diagnostics)
General Patient Records – 8 years after conclusion of treatment Children & Young People –
Until the patient’s 25th birthday, or if the patient was 17 at conclusion of treatment, until
their 26th birthyday or 8 years after the patient’s death if sooner.
Maternity – 25 years after the birth of the child, including still births Clinical Trials – 15
years after completion of treatment Litigation – Records should be reviewed 10 years after
the file is closed. Once litigation has been notified (or a formal complaint
received) images should be stored until 10 years after the file has been closed.
Mental Health – 20 years after no further treatment considered necessary or 8 years after
death.
Oncology – see Oncology Records"
DH guidance—Records Management –Code of Practice Part 2 (2nd Edition)
It is important that PACS systems support BUSINESS LOGIC, and are able to get the feeds
from PAS which holds information about when treatment is concluded, litigation, maternity
etc therefore image culling can take place. Currently this does not happen, but we hope that
in the next generation PACS this should be possible. Culling of images is required for
comply with DH guidance of data retention & for cost savings in NHS- hence,-this issue is an
important one.
2. There are reporting turnaround standards coming out from DH. We may not have the
luxury of waiting for 24hour to report a x-ray/exam in the future--whilst waiting for previous
images to be retrieved. Hence, technical specifications of PACS must be future proof for
radiologists to work in the future. We are likely to see a reduction in cost of PACS online
storage.
3. Lawyers should not have an advantage over reporting radiologists & NHS doctors.
When a patient becomes medico-legal the full set of images will be sent to the lawyers, and
will be available to then within 3-5secs, when lawyers are viewing them. However, if
radiologists are not provided prior images for review within 3-5secs they are unlikely to
review them--will report in the absence of previous images---this is what most of us do in our
working practice. Hence, whatever long-term storage structures are planned for PACS it is
important that radiologists & NHS doctors working on the coalface are not disadvantaged
(when compared to lawyers who are trying to sue radiologists/NHS doctors).
PREFETCH TRIGGERS for off-line/Cloud Storage: to ensure that images stored offline -DVD/tape or Cloud are available at the point of clinical decision making.
1. Must work for all patients who present to A&E. Triggers must be started from A&E
registration. This will ensure all images related to the patient is available within 20minutes so
that these are available for A&E doctors for review.
2. Must work for outpatient clinic bookings---Any clinic appointment made on the clinic
appointment booking system must generate a prefetch trigger. This will allow doctors
reviewing patients in clinic have access to full imaging history of patients 3. Must work for
walk in patients for xray. If a Trust provides a walk in service for xray/ultrasound. The
prefetch triggers must work when a patient is booked in at reception on RIS with an "arrived"
status or a "requested" status if one is using Ordercomms.
4. PAS admission to hospital --must also trigger prefetch
5. Other IT systems may also be required to trigger a prefetch of images
VIII. Understanding DICOM Modality Worklist—When a patient arrives within a
department a modality (CT, MR, US etc) needs to be “aware” that the patient is in the
department & pull the relevant demographics & study information across to the modality
(to avoid manual data entry on the modality). In simplistic terms, DICOM Modality
Worklist(DMWL) is a list of patients on RIS who have an “arrived” status. As the
scheduling system RIS is responsible for scheduling patients & ensuring logging patients
arrival into the department. Each modality will continuously query the RIS (which
should provide a DMWL) for any exams –based on modality & Exam Room. Normally
the DMWL provider is the scheduling system used for scheduling information to a
modality (In Radiology RIS provides a DMWL for radiology modalities). The following
information needs to be provided by RIS to modalities.
a. Patient Demographics
i. Name,
ii. DOB,
iii. Sex,
iv. PAS No.,
b. Modality
c. Exam Description---(usually National/Local Exam Codes & Descriptions)
d. Exam Room
e. Accession No. (RIS generates this for every exam)
f. Study UID (RIS generates this for every exam)
The modalities query the RIS & display a list of patients--- related to one or
more Exam rooms who have “arrived” status is “arrived”. Once the status is
changed to “exam performed” or “exam not performed” on RIS,-- the exam
should drop off the DMWL and no longer be visible to modalities.
Once the exam is completed on the modality, radiographers must be able to send
images to PACS.
“IHE Standard—Scheduled Workflow Profile-- Scheduled Workflow
establishes a seamless flow of information that supports efficient patient care
workflow in a typical imaging encounter. It specifies transactions that maintain
the consistency of patient information from registration through ordering,
scheduling, imaging acquisition, storage and viewing.
Modalities (as acquisition modality actor),
RIS (as departmental system scheduler actor),
PACS (as Image Manager & Image display)
must all support to Scheduled Worklfow Profile of IHE”
A standardised approach to DMWL provision is key to supporting long term
storage of DICOM images from non-radiology modalities like—cardiology,
retinal images etc
Current Situation in NHS--In many hospitals in NHS, PACS Brokers (often
called Connectivity Managers, RIS Gateway, PACS Broker etc) provide
DMWL functionality. This could be related to the inability of RIS to provide a
DMWL or PACS vendors insist on including brokers as part of their PACS
solution. However, if a RIS is capable of providing a DMWL there is no need
for creating a additional weak link between RIS and modalities--- thus
introducing an additional point of failure. Use of PACS Brokers is a nonstandard implementation. Hence, PACS replacement is a time for NHS to
review their PACS implementations so that they adopt global standards—which
are key to ensuring plug & play interoperability & reducing price of NHS IT.
Exceptional circumstances where a PACS broker may be required: If there
are 2 or more separate information system scheduling for the same modality—
e.g. NBSS & RIS for a mammography modality, Ultrasound modality used for
cardiac echoes & radiology i.e.--- scheduled by RIS for radiology & CIS for
Cardiac Echoes. Use of brokers should only be on exceptional circumstances.
VIII. IMAGE TRANSMISSION FROM MODALITIES to PACS---Images once
created in modalities will be sent to PACS for long term storage. Radiographers
ensure that images are of good quality before transmitting to PACS. It is
important that image quality is kept intact during transmission from the
modality to PACS. Adherence to DICOM standards & IHE will ensure that
quality of images & data are not compromised.
IHE Standards— Consistent Presentation of Images Profile of IHE
“Consistent Presentation of Images maintains the consistency of presentation
for grayscale images and their presentation state information (including user an
notations, shutters, flip/rotate, display area, and zoom). It also defines a
standard contrast curve, the Grayscale Standard Display Function, against
which different types of display and hardcopy output devices can be calibrated.
Thus it supports hardcopy, softcopy and mixed environments.”
Acquisition Modalities &
PACS (as Image Manager & Image Display Actor)
must support Consistent Presentation of Images Profile of IHE
IX. AUDIT DATA: In addition to the DICOM image the following data also need to
be sent to PACS from modalities.
a. Date & Time image acquired on modality
b. Date & time of image sent from modality
PACS should also record the time images arrive on PACS. This information is
important for auditing the performance of PACS & networks---time it takes
for images to arrive on PACS after they are sent, quantify PACS downtime
etc.
It is important that the following data is easily available for System Administrator/PACS
Managers—
a. time of image creation to arrival on PACS,
b. number of exams of a modality per room
c. time from image arrival on PACS to verified report etc
X. SINGLE SIGN-ON (SSO) & DESKTOP INTEGRATION (DTI) OR
CONTEXT SYNCHRONIZATION—
SSO-Process of logging in should be quick & slick. The system should support
single sign-on process as used in a hospital. As a minimum, additional user
name and password should not be required when using RIS & PACS. When a
user logs into RIS for reporting the user credentials must be passed onto PACS
with no need for additional user name and password input.
Desktop Integration (DTI) must be at EXAM level with Information
Systems: Desktop Integration with RIS is well established with PACS.
a. Automatic RIS to PACS Integration. In most NHS Trusts RIS is used
for reporting of radiology images. For efficiency reasons there should
be automatic display of relevant radiology images when an exam is
picked up for reporting on RIS.
b. Manual PACS to RIS integration—when images are displayed on
PACS, it should be able to display the RIS for that episode. This would
be important at MDTMs, or when a request is made for a 2nd opinion
etc, to allow for an addendum to be recorded on RIS.
Similarly DTI is required with other Information Systems, CIS,
Ophthalmology System, Breast Screening System, Endoscopy Systems, as
more images get stored on PACS.
CONTRACT CLARITY: As part of contractual agreement there MUST
Be clarity on the how a desktop integration will be possible with other
Clinical systems i.e. will this be a comms call or will it be a web type url
link.
XI. PLUG-INS--Integration with other specialist display systems: PACS suppliers
(which is largely a DICOM image archive with a basic image display) should
show a willingness to integrate with specialist best of breed specialist display
systems chosen by the customer. However, a 3 sec launch of images into the
specialist display systems must be maintained.
a. 3D display
b. CT colonoscopy display
c. Cardiac CT display & analysis
d. Mammography display (if required)
e. PET-CT fusion display (if required)
f. Optical display
g. Cardiology display
h. CAD for mammography
i. Orthopaedic templating etc
Having access to best of breed plug-ins in key to improving user experience of the
display software.
These will allow for real time 3D, etc images to be created. If a user wishes to
save an image created on the plug-in, the system should allow user to save images
in a DICOM format as a separate series within PACS. Similarities are are seen
with Orthopaedic Templating display where templated images will need to be
saved on PACS as a separate series.
CONTRACT CLARITY: As part of contractual agreement there MUST be clarity
on how the system would allow to have plug-in to other best of breed display
systems. What would be the technical requirements for integrating plug-ins?
What would be the cost of integrating each plug-in? Confirm that images created
in the plug-in would be saved as a separate series on PACS.
XII. TESTING & TRAINING SYSTEM: There should be a separate test &
training system which is separate from the live environment. This should act as a
test-bed for integration/testing new feature prior to roll out into live environment
For training—
a. There should be an e-learning tool provided. The system should be
intuitive enough so as require minimal training.
b. Single user interface –this is key to reducing the training and support
needs for customer & suppliers. (separate PACS display for radiologists &
other clinical users are more cumbersome for training).
c. Separate test system available for training (so that training does not need
to be performed on a live system)
XIII. LOCAL CONFIGURATION OF USER ROLES- User roles should be
defined locally:
a. Clinical Users: All medical users should be able to view images & Reports
b. Radiologists & Radiographers should be able to send images to another
DICOM destination (on-call neurosurgical unit)
c. System Administrators-delete images, correct attributes etc
XIV. SUPPORT, BUSINESS CONTINUITY & DISASTER RECOVERY
a. Support
1. 24/7 support
2. 1 phone number to call
3. Dedicated team of qualified engineers receiving call with ability to
directly deal with Network manager to distinguish whether
network or PACS issue
4. On-line tracking of issues raised
5. Transparency on response time to type of support calls
6. Remote & on-site support capabilities
7. Support should include integration to 3rd party systems
b. Business Continuity & Disaster Recovery: there should be no need for a
planned or unplanned downtime. Business continuity should be aimed for.
There should be a disaster recovery plan identified in the contract
XV. AUDIT TRAILS/VIEW LOG—every time a patient’s image is accessed by
a user. This should be logged and the “view log” should be accessible to any user
to see. This will remind users that their data access is logged & thus improve
patient confidentiality.
“Electronic records are supported by audit trails, which record details of all
additions, changes, deletions and viewings. Typically, the audit trail will
include information on:
■■
who – identification of the person creating, changing or viewing the
record;
■■ what
– details of the data entry or what was viewed;
■■ when
– date and time of the data entry or viewing; and
■■ where
– the location where the data entry or viewing occurred. “
DH guidance—“Records Mangement Code of Practice Part 2 (2nd Edition)
IHE Standard: PACS must support Audit Trail & Node Authenication Profile of
IHE
“The Audit Trail and Node Authentication (ATNA) Integration Profile establishes
security measures which, together with the Security Policy and Procedures, provide
patient information confidentiality, data integrity and user accountability. “
XVI. ELECTRONIC PATIENT RECORD---Radiology images must become
part of a wider clinical record (Electronic Record). With next generation PACS it
is important that we move away from a radiology data silo & make radiology a
part of the holistic patient record. Adoption of global standards is key to this
concept:
a. PACS must act as an XDS-I source actor of Cross Enterprise Document
Sharing Profile-Imaging of IHE
b. PACS must act as XDS &XDS-I Consumer actor of Cross Enterprise
Document Sharing Profile-Imaging of IHE. This will allow viewing of
other clinical documents/images that are registered on XDS registry (will
allow an EPR view of the patient record)
Adoption of XDS by PACS will allow radiologists & other clinical users
access to integrated view of ALL clinical doc & images-ECG, Medical
photographs, radiology images, Discharge summaries, through an viewer
that is XDS consumer compliant.
IHE Standard--Cross Enterprise document sharing for Imaging—XDS-I-- Sharing imaging documents between radiology departments, private
physicians, clinics, long term care, acute care with different clinical IT
systems & thus make it possible for radiology images to become part of the
patient’s EPR.
XVII. REMOTE REPORTING & ON-CALL: Remote working is no longer
limited to private teleradiology companies. Increasingly NHS Trusts are
encouraging radiologists to do on-call from home (as this is more cost-effective
for a tax funded health service). Whilst on-call radiologists MUST be able to
report from home. A verified report on PACS prevents needs of verbal reports
documented on paper notes, and mis-understandings, and thus improving patient
care & safety. In the future we will see some radiologists requesting for part
working from home. Technology needs to support this.
a. access to any image from any location (including home)
b. consistent user interface (in or outside hospital)--with the full set of image
manipulation tools as if within hospital
c. Adaptive Loading---scrolling speed through CT/MRI images. It is
important that over slow networks the solution is able to cache images, so
that once loaded the radiologist is able to smoothly scroll through even
500 to 1000 images very smoothly without any “jumps” or skipping of
images.
d. Consistent DICOM image quality of images (even when reporting
remotely)
e. Access to other information--Request cards, scanned doc, clinic letters etc
f. Ability to DICOM push to other hospitals even when working remotely
(neuro-surgical centres etc).
XVIII. TEACHING FILES CREATION: NHS Radiologists support patient
management, but also provide another important function --train the radiologists
of the future. Hence teaching files is integral to NHS radiology work.
Interoperability standards are key to creation of teaching files. If a non-standard
approach is adopted, then there is a good chance that radiologists will lose their
teaching files, if the PACS vendor is replaced at the end of a 10year contract.
IHE Standard --- Teaching Files & Clinical Trials Export Profile (TCE Profile) of IHE. The
IHE TCE profile describes a method for using existing standards to simplify and standardise
the export of key medical images for education, research, and publication.
To ensure teaching files are future proofed:
a. PACS MUST be compliant with Export Selector & Export Manager
Actors of TCE Profile of IHE
b. If the Radiology PACS is going to be used as a teaching files server, then
make sure that it is specified that it is Receiver actor for TCE Profile.
Alternatively one could use the free MIRC (from RSNA) -http://mircwiki.rsna.org/index.php?title=Main_Page as the teaching file
server which is compliant with receiver actor of TCE profile of IHE.
XIX. STORAGE & PC DISPLAY HARDWARE:
Storage Hardware: The PACS vendors can define the specifications of the
storage hardware. However, they should not be the supplier of storage hardware.
NHS Trusts must be able to look at storage with a holistic view, for all storage
requirements –both for clinical & administrative applications.
Display Hardware: PACS vendors need to specify the display hardware
requirement for adequate display of the images—grey scale, graphics card etc.
However, Trusts must be able to must be able to buy the hardware at open market
competition. The PCs must not be limited to PACS display only. It must be a
multipurpose equipment
XX. IMAGE DISPLAY & MANIPULATION TOOLS: The type of display
dictates the user experience of PACS:
a. user must not be overwhelmed ---“”Workflow is inversely proportional to the
number of buttons on the PACS desktop”
b. number of steps to common tasks minimised
c. consistency of display of tools
The PACS needs to be operable by the least technically-savvy radiologist. Large
number of tools to choose from on the display can be frustrating for a user.
Intelligent display of commonly used image manipulation tools—windowing,
measure, zoom, scroll etc should be activated with 1 mouse click/step. The tools
when configured by user for a modality should be consistently displayed for each
modality. (Should not require set-up every time one logs on.)
a. CR--windowing, measure, zoom etc
b. CT—scroll, windows presents, link studies, measure, zoom etc
c. MRI—synchronized scrolling with position between series in different
planes etc
d. Thumbnails should be displayed for every series
Advice—Drive before you buy.
However, Basic Image Review profile of IHE will ensure that your PACS
display at least has the bare minimum features required for radiology
image display.
IHE Standard: Basic Image Review"Compliant software must provide a predictable user interface and
functionality sufficient to review images for the purpose of clinical decision-
making by ordering physicians: display of grayscale and color images from
any modality, visual navigation of the available series of images through the
use of thumbnails, side-by-side comparison of at least two sets of images (with
synchronized scroll, pan and zoom for cross-sectional modalities) annotation
of laterality, orientation, and spatial localization, annotation of
demographics, management and basic technique information for safe
identification and usage simple measurements of linear distance and angle
cine capability for images that involve cardiac motion (e.g., cardiac US, XA,
500 CT or MR)"
PACS ( as Image Manager & Image Display actors)
must support Basic Image Review Profile of IHE.
XXI. AUTOMATIC DISPLAY OF RELEVANT PRIOR Image & Reports:
This is hugely important for reporting Chest X-rays, oncology CTs in particular. It
is well recognised that prior image and report display will increase the accuracy of
radiologists report & improves patient care. A good dynamic display protocol is
required which automatically displays the prior similar exam on the right hand
monitor of PACS (with the middle monitor displaying the current image for
reporting). The associated report needs to be displayed automatically as well.
Making these display automatically increases the chance of prior images & reports
being reviewed & compared. This improves patient care & clinical quality.
XXII. Radiology Report & Request Display: Radiology Report & Radiology
Request are documents which are created in other clinical systems—RIS for
radiology report & Ordercomms for radiology requests. However, they must
always be linked together with the images & available for display (in the
same way as the traditional film packets in NHS contained both these
documents.) With 1 mouse click these linked documents must be displayed
alongwith the images.
XDS/XDS-I standards adoption by PACS, RIS & Ordercomms should facilitate this. PACS
must be able to query & display radiology reports & request cards from the Trust based
XDS registry & repository.
XXIII. REPORTING WORKFLOW: 3 click reporting workflow should be
possible from the RIS & PACS integration.
a. Draw up a RIS worklist for reporting
b. Launch a patient’s exam for reporting on RIS—automatic display of
images on PACS with automatic display of relevant prior---dictate/VR a
report on RIS
c. Click on the next exam on RIS worklist—which closes the previous PACS
images & launches the next patient on RIS & PACS
XXIV. DICOM CONNECTIVITY WITH NEW MODALITIES ---10 year
contract is a long time. Within a department new modalities will be added in
radiology or there maybe a requirement to store & display non-radiology images
in DICOM--cardiac, retinal images, endoscopy images etc . Adoption of standards
is key to scalability of the PACS solution. Adopting a broker-less solution for
PACS will allow scheduling to be done on scheduling systems (Cardiac
Information System, Ophthalmology Information System etc)The contract should
be transparent on this issue & both sides aware of additional costs of DICOM
connectivity of additional modalities. Customers should not be penalised &
beaurocratic obstructions must not be imposed.
XXV. DICOM CONNECTIVITY OTHER ORGANIZATIONS & IMAGE
SHARING. A 10 year contract period is a long time. There will be changing
needs within an organization. It is vital for continuity of patient care particularly
with centralization of services (cancer,stroke etc).
Current Sharing solutions include
a.DICOM push (direct or via IEP), &
b.burning of encrypted CDs must be possible.
c.Import of CDs containing DICOM images
The contract needs to be transparent regarding the cost of developing DICOM Push links
with other organizations. There needs to be transparency on costs if new DICOM push links
are required.
XXVI. FUTURE IMAGE SHARING NEEDS: DICOM push creates duplication of
images in both PACS systems. As we move into next generation PACS—adoption
of XDS-I source &XDS consumers actors by PACS will allow for ability to share
without duplication using XCA. PACS images must be able to follow a patients
journey. XDS-I/XCA concept is key to this approach.
IHE Standard—Cross Community Access of IHE—“The Cross-Community
Access profile supports the means to query and retrieve patient relevant medical
data held by other communities.”
XXVII.
STABILITY: Software display should be stable & show a consistent
display once a display protocol is set-up by the user. Software errors may occur,
but there needs motivation within the supplier to correct the errors in a timely
manner. The supplier must have local developers who are involved in the product
development, who will be able to understand the user needs & correct errors that
maybe present.
XXVIII.
USER GROUP MEETINGS & PRODUCT DEVELOPMENT
during contract lifetime:
1. The customers must have input into future system design/ functionality
updates. The supplier MUST have a vibrant user group including an electronic
forum (with both clinical users & system administrators involved) which suggests
& votes on product enhancement features
2. There MUST be a rolling agenda for product enhancement during the 10year
contract. How many product development days will be allocated for every year
for every NHS Trust that contracts with the PACS supplier must be defined at the
start of the contract period.
3. Clarity on how will the next upgrade version of the product be rolled out.
(customers must make sure there isn't a charge for software upgrade & that it is
built into the revenue expenditure)
4. A product developer must be present at the User Group meetings and involved
in the electronic discussions to have an honest dialogue between users & suppliers
about what enhancement suggestions are viable for the supplier.
XXIX.
XXX.
CT DISPLAY REQUIREMENTS: CT scanners are the main reason for data
volume explosion in Radiology. Cardiology, Oncology, Colon & Trauma are the
specialities where there has been CT data explosion. Storing of very thin axial
slices has become the norm and will continue.
1.PACS must have an automatic & seamless loading of MPR when thin CT
slices are loaded (stand-alone modality workstations waste radiologists time &
are inefficient) –automatic loading of MPR will save on unnecessary storage
costs (currently many hospitals store MDCT images in 3 planes—rather than
have real time MPR on CT display)
2. Allow for synchronized scrolling in 3 planes for cross sectional imaging
(CT/MRI). This will remove the need for sending MPRs created on modalities
by radiographers–thus reducing storage requirements
3. Automatic display of relevant prior
4. Synchronized scrolling with prior scan
5. Ability to create 3D images—trauma imaging, CT colonoscopy, cardiac
6. During MPR/3D viewing, super-user like radiologists should ability to save
some key images(a coronal image/sag image that shows the key lesion) as a
separate series for reference to the report.
7. User ability to define slab thickness and create images of different thickness
realtime
8. Ability to measure distance, circumference, angle, and volume of lesions.
This should be easy & intuitive.
9. Ability to measure hounsefield density (e.g. average density of a lung nodule,
with maximum & minimum density). This task should be intuitive & easy for
any radiologist.
10. Scrolling speed –even with >1000 images the users should be able to scroll
through images very smoothly. Cine display must be present.
11. Scrolling speed over slow networks. CT is the commonest type of imaging
done on-call. Scrolling speed over slow networks is key to useage of PACS oncall. Local caching maybe a way to improve performance over slow networks.
Nuclear Medicine Image display: In most NHS hospitals radiologists perform
NM Image reporting amongst the other radiology reporting activities. It is
inefficient & costly for a tax-funded health service, if a radiologists have to move
to different workstations or equipment to report NM, Mammography, CT, MRI,
CR etc. Hence, it is vital that the PACS is able to store & display NM images
adequately.
Nuclear Medicine Profile : The Nuclear Medicine profile is a set of specifications as
to how NM systems (Gamma cameras etc) and PACS systems should interact when
dealing with NM data. The primary focus deals with storage and display of such data on
PACS systems.
PACS (as Image Manager & Image Display actors)
Gamma Camera etc (as Acquisition Modality actor)
must conform to of Nuclear Medicine profile of IHE.
XXXI.Mammography Image Storage & Display: In most NHS hospitals
radiologists perform Mammography reporting amongst the other radiology reporting
activities, and also ultrasound, MRI & ultrasound form a group of modalities used in
combination for breast radiology. It brings about in efficiencies if a radiologists have to move
to different workstations or equipment to report Mammography, US, MRI, etc. Hence, it is
vital that the PACS is able to store & display Mammography images adequately.
Mammography Image Profile: Efficient mammography reading requires specific
display quality, behavior, layout and annotation of images, as well as convenient
comparison of prior with current images. The IHE Mammography Image Profile
(IHE Mammo) was developed specifically to define the necessary mammography
requirements.
PACS ( as Image Manager & Image Display actors)
Mammography CR/FFDM (as Acquisition modality actor)
must conform to Mammography Image Profile of IHE.
XXXII.
Radiation Dose---It is important that radiology departments are able to
monitor doses to an individual patient, group of patients (e.g. children, women,)
specific modality, specific exam type etc--- to compare with national
averages/standards.
IHE Standards: “Radiation Exposure Monitoring (REM) facilitates the collection and
distribution of information about estimated patient radiation exposure resulting from
imaging procedures. The REM Profile requires imaging modalities to export radiation
exposure details in a standard format. Radiation reporting systems can either query for
these "dose objects" periodically from an archive, or receive them directly from the
modalities.”
Modalities (as Acquisition modality actor)
PACS (as Image Manager actor)
Must support Radiation Exposure Monitoring Profile of IHE.
This will allow feeding of such information into a national radiation monitoring registry
for NHS in the future.
Current situation in the NHS: Currently radiation dose information is entered in RIS
manually. Support of this profile will provide more accurate information as there wont
be any errors related to manual data entry into RIS & will also improve efficient
working for radiographers who will no longer be required to enter that data manually.
Compiled by Dr. Neelam Dugar
Chairman of RCR Imaging Informatics Group
1/3/11
Acknowledgements: the content of the document is largely provided by members of the
RCR Imaging Informatics Group discussions. Special mention given to the following
PACS Managers: Mr. Parveaz Khan, Mr. Glyn Davies, Mr. Simon Waddington, Mr. John
Parker, & Richard Bulmer & the following radiologists, Dr. William Saywell, Dr. Jon
Benham, Dr. Mark Griffiths, Dr. Peng Hui Lee, Dr. David Robinson, Dr. Andrew
Downie & Dr. Padhriac Connelly who were speakers at the Group meeting on the
topic—Next Generation PACS –”What Radiologists & PACS Managers need”. Other
members who have participated in the forum discussions include Mr. John Skinner, Dr.
Dave Harvey, Mr. Ed Mcdonagh, Mr. Gareth James, Mr. Grant Shaw, Mr. Ben Johnson,
Mr. David Granger
APPENDIX 1
Specifying the IHE standards for PACS
1. PACS must be an Image Manager actor for PIR profile of IHE
Patient Information Reconcilliation (PIR) Profile: “PIR handles: unidentified/emergency
patient, demographic information updates ( e.g patient name changes (marriage, etc.) ,
correction of mistakes, ID space mergers). Such changes are reliably propagated to all
affected systems, which update all affected data. The result is a complete patient record.”
2. PACS must conform to Image Manager & Image Display actor for SWF profile of IHE
Scheduled Workflow Profile-- Scheduled Workflow establishes a seamless flow of
information that supports efficient patient care workflow in a typical imaging encounter. It
specifies transactions that maintain the consistency of patient information from registration
through ordering, scheduling, imaging acquisition, storage and viewing.
3. PACS must conform to Image Manager & Image Display actors for Basic Image Display
profile of IHE
Basic Image Review Profile:
"Compliant software must provide a predictable user interface and functionality sufficient to
review images for the purpose of clinical decision-making by ordering physicians: display of
grayscale and color images from any modality, visual navigation of the available series of
images through the use of thumbnails, side-by-side comparison of at least two sets of images
(with synchronized scroll, pan and zoom for cross-sectional modalities) annotation of
laterality, orientation, and spatial localization, annotation of demographics, management
and basic technique information for safe identification and usage simple measurements of
linear distance and angle cine capability for images that involve cardiac motion (e.g.,
cardiac US, XA, 500 CT or MR)"
4. PACS must conform to Image Manager & Image Display actors of Consistent Presentation
of Images Profile of IHE.
Consistent Presentation of Images Profile of IHE
“Consistent Presentation of Images maintains the consistency of presentation for grayscale
images and their presentation state information (including user an notations, shutters,
flip/rotate, display area, and zoom). It also defines a standard contrast curve, the Grayscale
Standard Display Function, against which different types of display and hardcopy output
devices can be calibrated. Thus it supports hardcopy, softcopy and mixed environments.”
5. PACS must conform to Secure Node/Secure application actor of Audit Trail & Node
Authentication profile of IHE.
“The Audit Trail and Node Authentication (ATNA) Integration Profile establishes security
measures which, together with the Security Policy and Procedures, provide patient
information confidentiality, data integrity and user accountability.”
6. PACS must conform to XDS-I source & XDS/XDS-I consumer actors of Cross Enterprise
document sharing profile of IHE.
Cross Enterprise document sharing for Imaging—XDS-I--- Sharing imaging documents
between radiology departments, private physicians, clinics, long term care, acute care with
different clinical IT systems—thus contributing to the development of an electronic patient
record concept.
7. PACS must conform to Export Selector & Export Manager actors of Teaching Files &
Clinical Trials Export Profile (TCE Profile) of IHE
The Teaching Files & Clinical Trials Export Profile TCE profile describes a method for
using existing standards to simplify and standardise the export of key medical images for
education, research, and publication.
8. PACS must conform to Image Manager Actor of Radiation Exposure monitoring
profile of IHE
“Radiation Exposure Monitoring (REM) facilitates the collection and distribution of
information about estimated patient radiation exposure resulting from imaging
procedures. The REM Profile requires imaging modalities to export radiation exposure
details in a standard format. Radiation reporting systems can either query for these
"dose objects" periodically from an archive, or receive them directly from the modalities.”
9. PACS must conform to Image Manager & Image Display actors of Nuclear Medicine
profile of IHE.
Nuclear Medicine Profile : The Nuclear Medicine profile is a set of specifications as to
how NM systems (Gamma cameras etc) and PACS systems should interact when dealing with
NM data. The primary focus deals with storage and display of such data on PACS systems.
10. PACS must conform to Image Manager & Image Display actors of Mammography Image
profile of IHE.
Mammography Image Profile: Efficient mammography reading requires specific
display quality, behavior, layout and annotation of images, as well as convenient
comparison of prior with current images. The IHE Mammography Image Profile (IHE
Mammo) was developed specifically to define the necessary mammography
requirements.
http://www.ihe-europe.net/external/framework.htm
This link identifies number of vendors participating in worldwide connectathons to show interoperability.
APPENDIX 2
IHE Specifications for RIS
1. RIS must be an Department System Scheduler actor for PIR profile of IHE
Patient Information Reconcilliation (PIR) Profile: “PIR handles: unidentified/emergency
patient, demographic information updates ( e.g patient name changes (marriage, etc.) ,
correction of mistakes, ID space mergers). Such changes are reliably propagated to all
affected systems, which update all affected data. The result is a complete patient record.”
2. RIS must conform to Department System Scheduler actor for SWF profile of IHE
Scheduled Workflow Profile-- Scheduled Workflow establishes a seamless flow of
information that supports efficient patient care workflow in a typical imaging encounter. It
specifies transactions that maintain the consistency of patient information from registration
through ordering, scheduling, imaging acquisition, storage and viewing.
http://www.ihe-europe.net/external/framework.htm
This link identifies number of vendors participating in worldwide connectathons to show interoperability.
APPENDIX 3
IHE Specification of Acquisition Modalities
1. Modalities must conform to Acquisition Modality actor for SWF profile of IHE
Scheduled Workflow Profile-- Scheduled Workflow establishes a seamless flow of
information that supports efficient patient care workflow in a typical imaging encounter. It
specifies transactions that maintain the consistency of patient information from registration
through ordering, scheduling, imaging acquisition, storage and viewing.
2. Modalities must conform to Acquisition Modality actor of Consistent Presentation of
Images Profile of IHE.
Consistent Presentation of Images Profile of IHE
“Consistent Presentation of Images maintains the consistency of presentation for grayscale
images and their presentation state information (including user an notations, shutters,
flip/rotate, display area, and zoom). It also defines a standard contrast curve, the Grayscale
Standard Display Function, against which different types of display and hardcopy output
devices can be calibrated. Thus it supports hardcopy, softcopy and mixed environments.”
3. Nuclear Medicine modality must conform to Acquisition Modality actor of Nuclear
Medicine profile of IHE.
Nuclear Medicine Profile : The Nuclear Medicine profile is a set of specifications as to
how NM systems (Gamma cameras etc) and PACS systems should interact when dealing with
NM data. The primary focus deals with storage and display of such data on PACS systems
4. Mammography modality (CR/FFDM) must conform to Acquisition Modality actor of
Mammography Image profile of IHE.
Mammography Image Profile: Efficient mammography reading requires specific
display quality, behavior, layout and annotation of images, as well as convenient
comparison of prior with current images. The IHE Mammography Image Profile (IHE
Mammo) was developed specifically to define the necessary mammography
requirements.
5. Modalities must conform to Acquisition Modality Actor of Radiation Exposure
monitoring profile of IHE
“Radiation Exposure Monitoring (REM) facilitates the collection and distribution of
information about estimated patient radiation exposure resulting from imaging procedures.
The REM Profile requires imaging modalities to export radiation exposure details in a
standard format. Radiation reporting systems can either query for these "dose objects"
periodically from an archive, or receive them directly from the modalities.”
http://www.ihe-europe.net/external/framework.htm
This link identifies number of vendors participating in worldwide connectathons to show interoperability.