Traditionally, PACS technology has represented a department-specific solution to a problem. For instance, a laboratory PACS would support the movement of clinical data within the various stations of the laboratory. Changes in healthcare and technology and the need for enterprise-wide information sharing have driven an initiative to expand the classical PACS model.

The new model is CIMS a "clinical image management system" that addresses total clinical image management capabilities across an entire healthcare enterprise. The capabilities of CIMS include capture, storage, retrieval, distribution, and display of both clinical images and corresponding diagnostic information.

Although CIMS can be modality-specific, it should be able to integrate with all imaging modalities. CIMS technology should acquire and store any image (radiology, neurology, cardiology, pathology, etc.), join the image with the associated diagnostic information, and transmit data throughout the medical enterprise for review by clinical and non-clinical personnel. In discussing CIMS technology, its ultimate impact on patient care must be addressed. Historically, the medical model has been based on the formulation of a differential diagnosis. This translates into the clinician formulating all possible diagnoses of a patient's disorder and attaching some degree of possible accuracy. Once an array of possibilities is established, the clinician then proceeds with further analysis through additional studies (i.e., imaging from various modalities) in an effort to narrow the possibilities to a single diagnosis. It is at this point in the medical model where CIMS technology has its greatest relevance to patient care. Accurate evaluation, treatment, and disposition are significantly dependent on obtaining clinical information in a timely and accurate manner. The following scenarios demonstrate the potential impact that electronic clinical image management can have on primary care physicians and their patients. These examples also demonstrate how CIMS actually facilitates communication among all caregivers.

Scenario 1: A patient presents to the Emergency Room with symptoms that suggest the possibility of a stroke. A head CT is ordered. In order for the primary care physician to initiate treatment, the CT image must first be read by a radiologist. CIMS results: The ability to transmit the image to an oncall radiologist at his/her home or another medical center within minutes will provide the primary care physician with more rapid access to what may be lifesaving information.

Scenario 2: Some medical centers have satellite clinics equipped with xray capabilities. In order to satisfy regulatory requirements, radiologists are required to read films within a prescribed time period. Occasionally a patient needs to be referred elsewhere for further evaluation and treatment. When this is the case, the films may be released with the patient, which may prohibit the hospital radiologist from having the opportunity to read the films. If the films cannot be released, the patient ends up paying for two sets of films. CIMS results: CIMS technology eliminates this problem as it allows simultaneous, multiple access of images and diagnostic information by any number of physicians.

Scenario 3: A primary care physician often has a questionable finding on an x-ray while evaluating a patient in a clinic. The physician's interpretation may significantly affect the disposition of the patient (i.e., whether he/she is sent home or to the hospital via an ambulance). CIMS results: CIMS technology would enable the provider to get a STAT opinion from a radiologist, ensuring a safe and costeffective disposition.

Scenario 4: A mid-level provider (PA or NP) is evaluating a patient and has a questionable finding on an x-ray. CIMS results: CIMS technology would enable PAs or NPs to discuss their findings with their supervising physician or radiologist. CIMS also facilitates communication between physicians, improving their ability to provide patient care.

Scenario 5: A healthcare provider has questionable findings on an x-ray and disposition of the patient will be determined by the relative age of the findings (i.e., old pulmonary density vs new possible malignancy). The older images happen to reside at another facility and are not available for comparison. CIMS results: CIMS would provide rapid, efficient disposition with timely access to the comparison images. This also could ultimately reduce patient anxiety.

Today's approach to CIMS design is producing many such scenarios where both patients and providers can make decisions based on interconnected databases of relevant clinical information. Linking previously disparate archives of clinical information (i.e., freestanding facilities and satellite clinics) via CIMS produces an integrated approach to the treatment of disease.

Medicine is a collection of specialties and, consequently, research often progresses at a disproportionate rate within discrete areas. CIMS technology can assist in correlating data from various specialties so that research can be better focused and more results-oriented.

The evolution of a CIMS project is complex and by definition involves several areas within the medical facility and enterprise. Those areas that are typically impacted the greatest are Clinical Services, Financial Services, and Information Services.

Prior to a CIMS configuration, baseline data need to be acquired from these areas in order to accurately construct a model of the client's facility and enterprise. Once this acquisition is complete, a configuration diagram is developed to demonstrate an initial solution to the customer's technical problem. Although a complete solution is provided, the customer can elect to implement one modality at a time (a phased approach), due to cost constraints and in order to better ensure enduser acceptance.

Following this stage, "fine tuning" begins, where the CIMS configuration experts and representatives from information services, financial services and clinical services work to ensure that the enterprise has been modeled accurately and that the customer's workflow is correctly described. Once technical validation and agreement have been reached, the implementation phase of the project begins. Also important in this process and throughout the partnership is the role of training and customer service. Each is instrumental in assuring that users are realizing the full benefits of the system.

Once full use of CIMS technology has been achieved, the demonstrated efficiencies can be appreciated. A specific example of such efficiency has been seen with the installation of CIMS technology at Cape Fear Valley Health System (CFVHS), located in Fayetteville, NC. CFVHS is a large, integrated health system comprised of four hospitals, 17 primary care physician practices, and six specialty physician practices. Similar to other acute care facilities, there is significant interest in reducing the length of stay for patients being treated within the facility without decreasing the quality of care being provided.

CFVHS recently implemented a state-of- the-art CIMS product in its radiology department. The system is able to capture digital images directly from the CT, MRI, and ultrasound devices, merge the images with the transcribed reports, and distribute them electronically to various locations throughout the entire health system. A study conducted by CFVHS's CIO looked at the efficiencies incurred by providing electronic access to this information. It was hypothesized that a CIMS would minimize the delays typically encountered in locating, transporting, and distributing traditional x-ray film to clinical areas and other professionals simultaneously. Findings demonstrated a one-day reduction in length of stay for patients in the three ICUs, where the clinical imaging system had been introduced, supporting the original hypothesis with a 95% confidence level.

In addition, a study conducted by the ultrasound supervisor at CFVHS showed that the savings and increase in productivity brought about by their CIMS were projected to increase revenue in the ultrasound department by nearly $1.2 million per year.

While these results are quantifiable, hospitals across the nation utilizing clinical image management systems also have achieved many tangible, though difficult to quantify, results from their systems. In one ultrasound department at a CIMS facility, a technician had inadvertently mislabeled the right/left sides of an image. At no inconvenience to the patient and without having to repeat the procedure, the image was annotated electronically using the system.

In another example, after a patient received a CT examination, a nurse noticed what she believed to be an anomaly on the online image. She then contacted the neurosurgeon, who was able to view the image on the computer and begin treatment of the patient prior to completion of the radiology report.

At one CIMS site in North Carolina, an emergency department received numerous pediatric patients who had sustained multiple orthopedic injuries from a combined motor vehicle/hayride accident. Radiologists on-call were mobilized to assist. Some chose to read using conventional film, while one elected to read directly off the partially implemented CIMS system. At the end of the day, the radiologist using the system was approximately 45 minutes ahead of those who were using conventional methods.

CIMS technology represents a departure from tradition in the radiology field. However, it is certainly in concert with the Integrating the Healthcare Enterprise (IHE) initiative spearheaded by the Radiological Society of North America (RSNA) and the Healthcare Information Management Systems Society (HIMSS). The successful installation and proliferation of CIMS technology supports these more global efforts to integrate clinical information systems, imaging systems, and other information resources with existent systems and standards.     AR