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
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,
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
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.
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
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
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
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
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