Fundamentals of PACS

THE SKINNY

Picture Archiving and Communication System (PACS) is the

physical computer network

Digital Imaging and Communications in Medicine (DICOM) is

the set of rules that allows the components of the network to
communicate.
 Contents
Definitions
Introduction
PACS
DICOM
Advantages of PACS
PACS fundamental parts
Image acquisition
Display workstations
Archive Servers
Workflow
Physician Review Stations

Technologist QC Stations

File Room/image Management Stations

Hanging Protocols

Image Management Functions

Summary/Conclusion

PACS PROJECT
Definitions

Digital Imaging and Communication in

Medicine (DICOM)

Teleradiology: The transmission of

radiological patient images, such as
x-rays, CTs MRIs, and Ultrasound

Radiology Information System (RIS)

 DICOM

-DICOM(DigitalImagingandCommunications
inMedicine)istheuniversalformatforPACS
imagestorageandtransfer.
•Non-imagedata,suchasscanneddocuments,
maybeincorporatedusingconsumerindustry
standardformatslikePDF(Portable
DocumentFormat),onceencapsulatedin
DICOM.
Introduction

With the ever-increasing volume of medical imaging studies

performed in a wide range of healthcare facilities, the ability
to easily store and retrieve data helps radiologists and other
physicians maintain an increased workflow while providing
accurate diagnoses and quality of care for their patients.
What can facilities do to make sure their medical imaging
modalities and PACS communicate well, and what solutions
are available to increase interoperability?
In the mid-1980s, early PACS development
started, with limited availability of standards
for exchanging imaging data between
modalities and PACS.
At the time, ultrasound units weren’t
developed with any consideration for DICOM
standards.
In 1994, the publication of the DICOM 3.0 standard resulted in a major

improvement. Communication between PACS and modalities was now

enabled by this standard, using Ethernet and the TCP/IP protocol.

However, ultrasound modalities didn’t yet incorporate DICOM and digital

output.

It wasn’t until later that ultrasound manufacturers began to implement the

DICOM standard in their products. Soon, improvements and new

additions were added, first addressing 2D then 3D, 4D, and color data

sets.
The ultrasound imaging data can be used to provide quantification of blood flow

and anatomic measurements, which are an important aspect of the diagnostic

process. As such, the ultrasound PACS should support this functionality. Often,

hospitals will have a general PACS for all modalities but ultrasound and a PACS

dedicated to ultrasound.

Having interoperability between those two systems will assist the radiologist or

specialist in viewing images from different imaging modalities like CT, MR, and

DR, which again will improve productivity and quality of care.

Improving Workflow

PACS tries to achieve connected workflow throughout the medical care

continuum, allowing physicians to improve workflow through many modalities. It

can connect with ultrasound, cath diagnostic EKG [electrocardiogram], nuclear

medicine, CT, MRI—all in one station—to improve access to the information. By

connecting multiple modalities, it creates more efficiency.

An example of how interoperability can improve workflow is in having a

Radiology Information System (RIS) that is interoperable with ultrasound. For

example: If a medical center uses a RIS which is interfaced with both the PACS

and the ultrasound machines.

This improves workflow and accuracy because DICOM work-lists are generated

through the RIS, which populates the ultrasound data fields automatically without

a technologist having to retype information.

Picture Archiving and Communication Systems (PACS)

As imaging departments move from film-based acquisition and archiving (hard-

copy film and document storage) to digital acquisition and archiving (soft-copy

storage), a complex computer network has been created to manage images.

This network is called Picture Archiving and Communication Systems (PACS)

and can be likened to a “virtual film library.” Images stored on digital media are

housed in PACS archives.

PACS is a sophisticated array of hardware and software that can connect all
modalities with digital output (nuclear medicine, ultrasound, computed
tomography, magnetic resonance imaging, angiography, mammography, and
radiography). The acronym PACS can best be explained as follows:

P—Picture: the digital medical image(s)

A—Archiving: the “electronic” storage of the images

C—Communication: the routing (retrieval/sending) and displaying of the images

S—System: the specialized computer network that manages the complete system
A PACS can accept any image that is in digital imaging and communications in

medicine (DICOM) format, for which it is set up to receive, whether it is from

cardiology, radiology, or pathology. A PACS serves as the file room, reading room,

duplicator, and courier. It can provide image access to multiple users at the same

time, on-demand images, electronic annotation of images, and specialty image

processing.
A PACS is often custom designed for a facility. The software is generally the

same, but the components are arranged differently. Specific factors are involved

in designing a PACS for an institution, such as the volume of patients, the

number of areas where images are interpreted, the locations where images are

viewed by physicians other than radiologists, and the money available for

purchase.
The connection of various equipment types and modalities to a PACS is complex.

Standards have been developed to ensure that all manufacturers and types of

equipment are able to communicate and effectively transmit images and

information. Current standards include DICOM (Digital Imaging Communications in

Medicine) and HL7 (Health Care Level 7). Although standards may not always

provide for an instantaneous functionality between devices, they do allow for

resolution of connectivity problems.

DICOM is universally accepted industry standard for transferring radiologic
images and their medical information between computers.
The HL-7 standard oversees most clinical and administrative data such as

demographics, reports, claims, and orders. As with DICOM, HL-7 is composed

of many parts and is used at many levels within various hospital systems. It is

the standard generally used in communication between the hospital information

system (HIS) and the radiology information system (RIS). The HIS holds the

patient’s full medical information, from hospital billing to the inpatient ordering

system. The RIS holds all radiology-specific patient data, from the patient

scheduling information to the radiologist’s dictated and transcribed report.

Digital Imaging and Communications in Medicine (DICOM) is a communication

standard for information sharing between PACS and imaging modalities.

Health Level Seven standard (HL7) is a communication standard for medical

information.
For optimum efficiency, the PACS should be integrated with the Radiology

Information System (RIS) or the Hospital Information System (HIS). Because

these information systems support the operations of an imaging department

through exam scheduling, patient registration, report archiving, and film

tracking, integration with PACS maintains integrity of patient data and records

and promotes overall efficiency.

When a PACS is used, instead of hard-copy radiographs that must be

processed, handled, viewed, transported, and stored, the soft-copy digital

images are processed with the use of a computer, viewed on a monitor, and

stored electronically. Most PACS use web browsers to enable easy access to

the images by users from any location. Physicians may view these radiologic

images from a personal computer at virtually any location, including their home.
ADVANTAGES OF PACS:

• Elimination of less efficient traditional film libraries and their inherent problem of
physical space requirements for hard-copy images

• Convenient search for and retrieval of images

• Rapid (electronic) transfer of images within the hospital (e.g., clinics, operating
rooms, treatment units)

• Ease in consulting outside specialists—teleradiology. Teleradiography is the

electronic transmission of diagnostic images from one location to another for
purposes of interpretation and/or consultation.

• Simultaneous viewing of images at multiple locations

• Elimination of misplaced, damaged, or missing films

• Increase in efficiency of reporting exams with soft-copy images (compared with

hard-copy images)

• Reduction of the health and environmental impact associated with chemical

processing, as a result of decreased use
In the mid to early 1980s, different versions of PACS were being developed,

primarily by research and academic institutions. They were homegrown and

usually involved one or possibly two modalities. These early systems were hard

to put together because there was little standardization in image formats. Each

vendor had its own proprietary way of archiving images, and there was little need

or desire to share archiving methods. Once DICOM (standards that allow

imaging modalities and PACS to communicate in the same “language”) was

established, more vendors began using it to communicate between modalities

and PACS. Full-scale acceptance of DICOM was pushed by the consumer to

make it possible for equipment from different manufacturers to talk to each other.
The first full-scale PACS in the United States was installed at the VA Medical Center

in Baltimore in 1993. Their PACS covered all modalities except mammography. Soon

after installing their PACS, the Baltimore Medical Center asked the vendor to

interface to their radiology information system (RIS), hospital information system

(HIS), and electronic medical record (EMR).

 PACS fundamental parts:

• Image acquisition

• Display workstations

• Archive servers
Image Acquisition
In modern radiology departments, most images are acquired in a digital format,

meaning that the images are inherently digital and can be transferred via a

computer network. Ultrasound, computed tomography (CT), magnetic resonance

imaging (MRI), and nuclear medicine have been digital for many years and have

been taking advantage of PACS far longer than general radiography has
Display Workstations

A display workstation is any computer that a health care worker uses to view

a digital image. It is the most interactive part of a PACS, and these

workstations are used inside and outside of radiology. The display station

receives images from the archive or from the various radiology modalities and

presents them for viewing. The display workstation has PACS application

software that allows the user to perform minor image-manipulation techniques

to optimize the image being viewed. Some display stations have advanced

software to perform more complex image-manipulation techniques

The display workstation is the most interactive part of a PACS, consisting of a

monitor and a computer with a mouse and keyboard. In addition, each system has

hardware that fits the users’ requirements.

As you know, conventional film/screen radiography uses large multiviewer

lightboxes to display the images . Early in the history of PACS, radiologists

believed that they needed four to six monitors to match the viewing capability they

had with the lightboxes. As the radiologists have become more comfortable

viewing images on monitors, the number of monitors required by the radiologists

has decreased to an average of two

The monitor is one of the most important elements of a PACS display station. The
cathode ray tube (CRT) and the liquid crystal display (LCD) are the most popular
types of monitors in a radiology department. The LCD has decreased in price and
increased in quality during the past few years and will soon take over the entire
PACS display market because of its size, resolution, and lack of heat production.

The LCD also requires less maintenance, gives out more light, and can be used in
areas with a high amount of ambient light. In early PACS reading rooms,
supplemental air conditioning had to be installed to offset the heat put out by
multiple CRTs. Along with the number of monitors used, the resolution and
orientation of the monitor are also factors in determining which type of monitor to
buy for each workstation.
CRT LCD
 Common screen (display) resolution:
• 1280 × 1024 (1K)
• 1600 × 1200 (2K)
• 2048 × 1536 (3K)
• 2048 × 2560 (5K)
Display stations can be categorized by their primary use: primary reading

stations for radiologists, review stations for referring physicians, technologist

quality control (QC) stations where technologists review images, and image

management stations for the file room personnel. Each of these workstations has

one specific main purpose and is strategically located near the end-user of its

designated purpose.
Mammography requires a 5K or 5-megapixel resolution to provide the
viewing capacity needed.

2K monitor is used for CR and DR readings.

1K monitor is sufficient to view the images by a referring physician.

Radiologist Reading Stations

The radiologist reading station is used by a radiologist when making a primary

diagnosis. The reading station has the highest quality hardware, including the
best monitor. The computer hardware meets the needs of the PACS vendor,
but it will usually be very robust, requiring little downtime. The keyboard and
mouse can be customized.
Archive Servers

An archive server is the file room of the PACS. It is composed of a database

server or image manager, short-term and long-term storage, and a computer that
controls the PACS workflow, known as a workflow manager. The archive is the
central part of the PACS and houses all of the historic data along with the current
data being generated. In many institutions the archive serves as the central hub
that receives all images before being released to the radiologists for
interpretation.
Workflow

Workflow is a term that can be used in any industry or in any organization. It

simply means how a process is done, step by step. In radiology, we have always

used the term workflow to describe how we complete an examination from order

entry to transcribed report. The workflow in each radiology department is different

because there are many variables.

Film based workflow
The PACS workflow is in many ways different from the film-based workflow. The
technologist may get the order via an electronic worklist or a paper requisition, but
after that, things begin to change.

▪The technologist needs a requisition to verify the patient ID and to take a patient
history.

▪The order is input into the RIS, and the RIS sends a message to the PACS to find
all historic images and put them on the short-term archive. This eliminates waiting
for the file room to retrieve a film jacket from the off-site storage location.

▪The technologist prepares the room, retrieves the patient, and performs the
patient history. The history is recorded on the paper requisition or input
electronically into the patient’s computerized medical record.
▪The technologist performs the examination, and depending on the type of image
acquisition device, the images are processed and repeated as necessary and sent
to the appropriate PACS device. The patient images have been tagged with
information from the RIS so that historic image reports are available at the PACS
when the new images are sent.

▪The requisition is either taken to the radiologist, or the radiologist may pull the
images from an electronic worklist. The radiologist also pulls up historic images and
reports and compares the previous images with the current images.

▪The radiologist dictates a report and has it transcribed, or voice recognition

software may be used. If the radiologist uses voice recognition software, he or she
can review the report right after dictation, make corrections, and sign the report,
making it final.
Physician Review Stations

The physician review workstation is a step-down model of the radiologist

reading station. Many vendors use the same level of software but may
eliminate some of the more advanced functions. One of the most
important features on a physician review station is the ability to view
current and previous reports along with the images. This can be
accomplished with the integration of RIS functions with the PACS software
mentioned above. Most referring physicians want to read the radiologist’s
report along with seeing the patient’s images, and often the report is more
important to them than the images.
Technologist QC Stations

The technologist QC station is used to review images after acquisition but

before sending them to the radiologist. The QC station may be used to improve

or adjust image quality characteristics, or it may be used to verify patient

demographic information. Many QC stations are placed between the CR and

DR acquisition modalities as a pass-through to ensure that the images have met

the departmental quality standard. The technologist QC station generally has a

1K monitor.
File Room/Image Management Stations

The file room in a PACS environment has seen many changes in the past few years.
Before PACS, the file room was a large open room with endless rows of shelves full
of film jackets. Today a file room in a PACS environment may be as simple as a
couple of computers and a dry laser to make copies for outside needs.

The file room workstation may be used to look up examinations for a physician or to
print copies of images for the patient to take to an outside physician. Many hospitals
are moving away from printing films to save the cost of the film and are instead
moving toward burning compact disks (CDs) with the patient’s images because they
are less expensive. The CD of images can be viewed on any PC and generally
comes with easy-to-use software burned onto it with the images.
The file room may also be responsible for correcting patient demographics. If
images with incorrect demographics are sent to the archive, then it is difficult to
pull those images the next time the patient comes in for an examination. The
archive is a database and is only as good as the information that is put into it.
Navigation Functions

Navigation functions are used to move through images, series, studies, and
patients. The worklist is used to navigate through patients.
Hanging Protocols

Once a patient has been selected from the worklist, the images load into the
display software. In most PACSs, each user has the ability to set up custom
hanging protocols. A hanging protocol is how a set of images will be displayed on
the monitor. For example, when I select a CT examination, I want to view four
images on each monitor, but when I view a CR image, I want to view one image on
each monitor.
Image Management Functions

Most PACSs allow the user to modify patient demographics (Figure 8-30) at the
technologist QC station, the reading station, and the file room station. It is
imperative that the patient demographics are correct. If wrong information is
archived, images will not come up when correct information is entered when trying
to retrieve them. Only make changes when the information is absolutely known to
be wrong. To minimize errors, many hospitals only allow certain people the access
to change demographics.

Another image management function is the query/retrieve function used to retrieve

studies from the archive. The query function allows the user to query a study on
multiple fields such as the patient’s name or ID, date of service, or modality. Some
systems also allow a query based on a diagnosis code or comment field.
 Summary

PACS stands for Picture Archiving and

Communications System

Describes the digital ultrasound laboratory in

which images and additional medical
information are digitized and stored on a
large computer network
 PACS has three major advantages

Virtually instant access to archived studies

No degradation of data, which often happens

over extended time periods with analog
archiving

“Stored and forward” telemedicine: which is

the ability to electronically transmit images
and reports to remote sites.
How are information and images stored
on PACS?

The archival system is an important

component of a PACS and is responsible for
electronic storage of image data.

Computer hard drives are the primary digital

storage devices used in PACS
The standard computer hard drive is a fast
medium from which to retrieve data.
Presently available devices have rapidly
increasing capacity and decreasing cost.
DICOM
DICOM stands for DIGITAL IMAING and
COMPUTERS in MEDICINE.
DICOM is a set of rules, or protocols, that
allows imaging systems to share information
on a network.
When a particular ultrasound system adheres
to DICOM standards, the system can
successfully connect to a PACS medical
information network.
By purchasing only imaging systems that
conform to the DICOM standard, all of the
individual devices will work together to share,
manage, and distribute images, regardless of
the manufacturer.

Not only does DICOM assure that current

imaging modalities can communicate, it
guarantees that all devices developed in the
future will easily attach to the PACS network
as well.
An example of the use of similar standards is
Internet connectivity.
Virtually all manufacturers design their
computers and software with specific
standards that allow their computers to attach
to the internet effortlessly.
Remember?
•PACS is the physical computer network
•DICOM is the set of rules that allows the components of
the network to communicate.
 PACS PROJECT
• Write a paper that describes how PACS is utilized
‘imaging modality’.
• Include in your report:
• Workflow
• Productivity
• Patient care
• Imaging modalities displays
The End