The latest generation of PACS workstations allows hospital-based and remote clinicians to spend more time on patient care and less time requesting, tracking, and reviewing film-based studies. In this installment of PACS & Teleradiology Update, we look at the workstation and its effect on workflow, both in the radiology department and enterprise-wide.
The evolution of the PACS workstation mirrors that of the
personal computerin many ways. Initial PACS workstations were
little more than "digitallightboxes", just as first-generation PCs
were little more than digitaltypewriters. As PACS matured,
workstation functionality began to evolve.Digital imaging
tools-such as measurement, magnification, and
window/leveladjustments-were added to maximize the benefits of
soft-copy diagnosticreading. As a result, radiologists have better
access to past studies and arereading studies faster than ever
The effects of this evolution extend far beyond the radiology
department.Technologists are spending more time performing
procedures and less timecarrying film jackets around the hospital.
ICU clinicians no longer have towalk down to radiology for "wet
reads". Internal medicine physicianscan access radiology reports
within minutes-instead of hours or days-from theiroffices or their
The current generation of PACS workstations enhances
radiologists'productivity and improves enterprise-wide efficiency
for referring physiciansand clinical staff alike.
No more 'one size fits all' workstations
The days of the "one size fits all" PACS workstation are
behindus. Today, three types of workstations prevail: primary
diagnosis, secondaryreview, and low-cost tertiary review. This
portfolio is designed to fit theapplication to the user, rather
than requiring the user to adjust to fit theapplication. Typically,
each workstation contains software and hardwarespecifically
appropriate to its primary users. The most important difference
isthe feature set. Other considerations are monitor resolution,
security, cost,image quality and performance.
Primary diagnostic workstations
The primary diagnostic reading station is the core or
"virtualalternator" of the PACS. These high-powered,
high-resolution (1K x 1.5K or2K x 2.5K) workstations meet the
intensive imaging requirements ofradiologists.
Older primary reading stations focused on tools such as
window/leveladjustments, magnification, panning, and roaming to
enhance imaging andinterpretation. The new generation of primary
diagnostic workstations also isable to take into account the
typical workflow of each radiologist, from thePACS maven to the
infrequent user. The result is flexible solutions that canmake
soft-copy reading easier, faster, and possibly more accurate than
Features such as customizable hanging protocols, bookmarks,
side-by-sideimage stacking, and workgroup collaboration are the
newest tools of the trade.Protocols allow radiologists to "hang"
digital studies in apredetermined format every time a specific type
of study is opened. Forexample, one protocol can be determined for
hanging a CT of the head withcontrast, while a separate protocol
can be created for hanging a CT of the headwithout contrast. With
this capability, radiologists can read studies in theirpreferred
format while reducing the amount of time spent trying to figure
outwhich specific studies are being displayed. In addition, such a
predeterminedhanging protocol allows radiologists to simultaneously
view multiple studiesfrom multiple modalities, and offers
manipulation of each study on theindividual image level.
The use of "bookmarks" allows radiologists to save their place
onthe workstation when interrupted for urgent "wet" or STAT reads.
Inthe film-based reading environment, radiologists typically have
to pull theoriginal study from the lightbox to perform a STAT
request. After the STAT readis completed, the original study would
have to be re-hung, and the radiologistwould frequently have to
start reading the case from the beginning. Thisunproductive process
could consume 15 to 40 minutes per day for someradiologists.
Another useful tool of the new workstation, side-by-side image
stacking canhelp radiologists to more accurately read lengthy CT
and MR studies. Ratherthan scanning from film to film, radiologists
can actually "stack"the images on top of each other and scroll
through two or more side-by-sidestudies. Initial feedback from
radiologists who have used this tool indicatesan increase in
diagnostic accuracy, combined with time savings.
Collaborative workgroups also are becoming prominent within
PACS. Older PACStypically focused on an "end-node" structure. The
end-nodeworkstationwould receive information, but it lacked the
ability to update the system whenadditions were made by the
radiologist. Newer PACS networks allow informationto be shared in
real-time between workstations throughout the network. Forexample,
if a resident makes an annotation on a study, the annotation
wouldimmediately appear on other workstations being used to review
the same study.Similarly, this allows radiologists to review
studies from any supportedmodality at any workstation rather than
requiring a radiologist to go to aspecific workstation to read a
specific type of study. Data and information cantherefore be shared
much more efficiently throughout the network.
Secondary review stations
High-end secondary review workstations typically are reserved
for referringphysicians in the ER, ICU, and orthopedics. These
workstations feature the samehigh-resolution monitors as the
primary reading stations but offer a simplifiedtool palette. Many
of the advanced tools typically reserved for radiologistshave been
removed from such stations in order to allow clinicians to
easilynavigate through images prior to and during surgery.
These workstations are fast, easy to use, and provide reliable
access toradiology studies and reports. When placed in
mission-critical areas, theseworkstations can reduce foot traffic
within the radiology department andthroughout the hospital.
The clinical and financial benefits of implementing a network of
secondaryreview workstations are readily apparent. Many hospitals
suffer from amisplaced film rate of 2 to 15%; often these misplaced
films are lost in the ERand ICU. By reducing or eliminating the
amount of film-based studies used inthese departments, hospitals
can reduce the lost film rate to less than 1%.This process
improvement reduces the potential for lost billing while
producingsignificant savings in labor and time currently spent
searching for these lostor misplaced films.
Secondary review workstations also provide faster access to STAT
studies andreports than is possible in a film-based environment,
enabling real-timecollaboration between clinicians and
radiologists. Network access to digitalimages and reports curtails
unproductive travel for clinicians, allowing themto spend more time
in patient care and less time waiting in the radiologydepartment.
This also reduces interruptions and foot traffic in the
Low-cost, tertiary workstations
The tertiary workstation is, perhaps, the missing link in most
PACSinstallations. These workstations provide low-cost distribution
of imagingstudies and reports to any physician via a hospital
network or secure webinterface. The Internet facilitates
distribution, providing an existinginfrastructure that reduces the
capital investment required. For mostphysicians, rapid, convenient
access to radiology reports is even moreimportant than viewing the
imaging studies themselves. Tertiary workstationsallow two or more
physicians to access the same report or imaging studysimultaneously
and to compare their thoughts on the case with the use ofdrawing
tools. Physicians can make drawings and annotations on a study
whichwill appear on the other physicians' workstations in
real-time, allowing forfaster, more collaborative, review of
Almost any modern desktop computer can be upgraded to function
as a tertiaryworkstation, so the capital investment in hardware is
minimal. Standard monitorresolution usually is acceptable, unless a
physician regularly reviews images.The cost of remote image
distribution can be justified by reducing oreliminating referral
film images, and a competitive advantage is created byenhanced
communication between referring physicians and other physicians
Modern PACS workstations deliver many benefits to a radiology
department andto the hospital. Primary diagnostic workstations
provide digital tools that canmake radiologists more productive.
Secondary review stations offer reliableaccess to STAT imaging
studies and reports in the ER, ICU, and orthopedics, andeliminate
much of the labor and time spent searching for lost films.
Tertiaryworkstations equip referring physicians with rapid access
to reports, and theability to annotate and discuss cases with other
clinicians in real time.
In summary, the latest generation of PACS workstations allows
hospital-basedand remote clinicians to spend more time on patient
care and less timerequesting, tracking, and reviewing film-based