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 before.

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 homes.

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 filminterpretation.

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 radiologydepartment.

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 images.

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 and/orradiologists.

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 studies. AR