Applied Radiology

Three years into its use of an ultrasound mini-PACS, the University ofPennsylvania Medical Center has successfully met its initial goals and expandedthe system to allow teleradiology from a satellite facility.
When the center first implemented its PACS for ultrasound in 1995, the goalswere simple: to improve access to previous studies, and to improve overallefficiency for sonographers. The center has fulfilled both missions. Todayradiologists can access most historical studies they require from an onlineoptical disk jukebox in less than one minute. Sonographers save an average offive minutes per exam, allowing each to perform one additional procedure perday. The system also supports the center's long-term trend toward reduction ofreliance on film.
In addition, the ultrasound PACS allows remote primary diagnosis forafter-hours exams performed at an allied institution, Presbyterian Hospital.

Background and implementation

The University of Pennsylvania Medical Center (UPMC) is a 700-bed facilityserving greater Philadelphia. The radiology department's ultrasound sectionperforms some 17,000 procedures per year. The section staff includes eighttechnologists, an aide, and seven radiologists.
The ACCESSTM Digital Image Management Network for Ultrasound from KodakTM wasfirst implemented with three ACCESS Acquisition Modules (AAMs), one ACCESSDiagnostic Workstation for interpreting images, an ACCESS Network Fileserver tomanage the electronic workflow, and a high-performance magneto-optical diskjukebox, all located in the ultrasound department. This has since grown toinclude AAMs in nine exam rooms in ultrasound at UPMC, one in thematernal-fetal medicine department, one in the Emergency Department, and two atPresbyterian Hospital, approximately one mile away.
Four workstations for evaluating images are located in the ultrasound sectionof the radiology department, one is in the Emergency Department, and one is atPresbyterian Hospital. The entire system is linked over an integrated datanetwork.
When the Medical Center built a new Emergency Department in 1996 and installedan ACCESS Diagnostic Workstation, we established that the department'sultrasound procedures would be entirely filmless. The Emergency Departmentnetwork is on the same virtual segment of the hospital network as theultrasound PACS network.
The continuing growth of this system testifies to the success ofDICOM-compliant system standards to ensure cross-vendor compatibility. Thesystem is linked to a Codonics thermal printer for hard copy color output, anda laser printer and processor to produce film output. Recent connection to aSiemens Elegra 2000 color flow doppler machine and an ATL HDI 5000 with colorflow doppler capability was accomplished without any outboard acquisitiondevices-in fact, it was nearly "plug and play", taking less thanone-half hour to connect these machines.
Initially, we sent technologists to a five-day training program to orient themto the system and the full range of its capabilities. The training helped themmake the transition to a filmless environment. Acceptance of the system amongsonographers came quickly, as they found it was possible to spend more timewith the patients, see images immediately after the study, and begin writingtheir preliminary notes.

Time savings

Perhaps the most dramatic impact of our PACS network for ultrasound is timesavings. Technologists save approximately five minutes per exam in filmhandling, based on time-motion studies conducted by the hospital. The systemhas eliminated the need to load film into cassettes prior to exams, unload itafterwards, then process, label, and hang the film. Now technologists merelyaccess the study and enter the appropriate patient demographic and clinicaldata.
We estimate that with time savings of approximately one-half hour, eachtechnologist can perform one additional exam per day. Despite a 10% increase inthe volume of ultrasound procedures at our institution, the ultrasound sectionis now operating with one less FTE than before the system was implemented.
Equally important is the time savings associated with accessing previousstudies and improved access to those studies. In the past, a file room clerkspent an hour or more per day pulling previous studies from files. Roughly 20%of the studies requested were unavailable, having been signed out or misplaced.
For patients whose exams were not previously scheduled, the delay to retrieve aprevious study was typically a half hour or more. And like most hospitals, westored the oldest studies (two years old or more) off-site. Retrieving anoff-site study could take two days or longer, as those requests were processedin batches.
Today, ultrasound studies from the past nine months are stored on optical diskin an online jukebox that has a capacity of 144 disks. Accessing thosestudies-which account for 70 to 80% of all requests-requires less than aminute. Older studies, on disks stored outside the jukebox, can be retrieved inthree to four minutes. All disks dating to the beginning of the mini-PACS useat UPMC are stored in the ultrasound suite.

Film-related cost savings

Because the initial implementation of the ultrasound PACS in 1995 was anevaluation test, the department continued to generate film output routinely.The pre-release software was unreliable, which led to some initial skepticismand reluctance to rely solely on soft-copy display.
With the commercial software release, the system became far more reliable. Wedecided to evaluate procedures using the diagnostic workstations and print onesheet of film per study for a period of several months. However, acceptance ofsoft-copy display for primary interpretation was quick and almost universal. Westopped printing film routinely after one month and now produce it only forteaching purposes.
We estimate savings from the virtual elimination of film and processing coststo be approximately $4000 per month. This includes the replacement cost ofusing optical disks for digital storage of images (approximately $600 to $800per month). Our computation of savings does not include reduced costs forprocessor maintenance or reduced film library labor costs.
In addition, the system eliminates the need for further off-site storage andoccasional retrieval from that storage. This further adds to the cost savings,though we have not quantified those savings.

Remote primary diagnosis, future web access

Ultrasound procedures at Presbyterian Hospital can be viewed locally bytechnologists, radiologists, and referring physicians using the diagnosticworkstation there. Typically, Presbyterian Hospital performs only a fewafter-hours ultrasound procedures, and radiologists are not always available.With the mini-PACS in place, those studies travel over the network forimmediate interpretation by staff radiologists at UPMC. This implementation ofthe remote primary diagnosis ensures timely review of after-hours studies.
In the near future, we hope to expand access to the system using the Internet.Referring physicians will be able to log onto our website, enter a password,and view a patient's ultrasound study using a standard web browser. The sectionalready has a PACS viewer for viewing images off the web server; the remaininghurdle is developing an efficient method for exporting images from the PACSsystem to the web server.
We also would like to establish a link between our radiology information systemand the PACS. This would allow technologists to download patient demographicinformation automatically, reducing the need for repetitive data entry andeliminating the opportunity for errors. The system link also has workflowimplications; we estimate the potential time savings from reduced data entry atthree minutes per exam.
Overall, UPMC's experience with PACS for ultrasound has been quite successful.Thanks to the system's high level of reliability, we have made the transitionto filmless operation more quickly than expected. Physicians and technologistsbenefit from the time savings and improved access to images, and have embracedthe system as a result. The ultrasound section has grown more efficient, takingresponsibility for full-time coverage of the Emergency Department and off-hourscoverage of Presbyterian Hospital's emergency ultrasound cases without addingadditional personnel. Looking ahead, we expect to continue expanding the PACSand improving its capabilities to enable even more universal access.