1.

Introduction to PACS Fundamentals

 Context & Objective

o Transition from traditional film libraries to digital PACS (Picture

Archiving and Communication Systems).

o Understand the differences in workflow, components, and

architecture between film-based and PACS-based environments.

 Key Objectives

o Identify and explain the objectives and key terms.

o Learn the components and workflow in a modern radiology

department using PACS.

2. Overview of PACS

 Definition:

o PACS is the digital equivalent of a film library, enabling

radiologists to view, manipulate, and dictate image studies
electronically.

 Main Components:

o Digital Acquisition: The process by which imaging modalities

(e.g., ultrasound, CT, MRI, digital radiography) capture images in
digital format.

o Display Workstations: Computers or devices where images are

viewed and manipulated.

o Archive Servers: Centralized storage systems that house both

current and historical image data.

 Network Integration:

o All components are interconnected via a sophisticated network

ensuring that images and data flow seamlessly among devices.

3. Workflow: Film-Based vs. PACS-Based Systems

Film-Based Workflow
  Process Steps:

o Order Entry: Paper requisitions are filled with patient details

(name, ID, DOB, ordering physician, exam type, reason, chief
complaint).

o Image Acquisition: Technologists acquire images on film.

o Processing & Display: Films are processed, queued, and hung

on view boxes.

o Dictation & Transcription: Radiologists dictate findings;

transcriptionists manually convert dictations to reports.

o Report Distribution: Final reports are printed and physically

filed, often taking days.

 Challenges:

o Labor-intensive, slow turnaround (sometimes up to a week for

reports), and risk of misfiling or delays in retrieving historical
films.

PACS-Based Workflow

 Process Steps:

o Digital Order Entry: Orders are entered electronically (e.g., via

RIS) and instantly transmitted.

o Image Acquisition: Images are captured in a digital format,

tagged with patient data from the RIS.

o Immediate Processing: Images are processed and sent to the

archive server, then distributed to workstations.

o Radiologist Review: Radiologists access images via a worklist,

often using voice recognition for rapid report dictation.

o Faster Turnaround: Reports can be finalized within minutes due

to direct electronic communication.

 Advantages:

o Speed, efficiency, immediate access to historical data, and

reduction of physical storage requirements.
4. PACS System Architectures

A. Client/Server-Based Systems

 Structure:

o A central archive server sends images to client workstations on

demand.

 Advantages:

o Centralized control and up-to-date worklists; any exam is

available anywhere on the network.

 Disadvantages:

o The archive server is a single point of failure; network

bottlenecks may occur if many clients access images
simultaneously.

B. Distributed Systems

 Structure:

o Images are sent from modalities to designated reading stations;

each workstation may store images locally until synced back.

 Advantages:

o Local access continues even if the central archive server is down;

reduced network dependency during viewing.

 Disadvantages:

o Inconsistent worklists across stations; potential delays in syncing,

and inconvenience if a radiologist needs to switch workstations.

C. Web-Based Systems

 Structure:

o Uses web servers to deliver image data and applications to client

devices via web browsers.

 Advantages:

o Flexibility in hardware requirements, remote access

(teleradiology), and use on both high-end and low-end devices.

 Disadvantages:
 o Dependence on network bandwidth; low-end hardware may not
support high-resolution diagnostic displays.

5. Display Workstations and Monitors

 Components of Workstations:

o Monitor, Computer, Mouse, and Keyboard.

 Types of Monitors:

o CRT (Cathode Ray Tube):

 Pros: High brightness, good viewing angles.

 Cons: Heavy, generate significant heat.

o LCD (Liquid Crystal Display):

 Pros: Lightweight, energy efficient, improved resolution,

less heat generation.

 Example: Radiology departments now favor LCDs for

diagnostic quality.

 Resolution Importance:

o Common Resolutions: 1K, 2K, 3K, 5K.

o Specific Needs:

 Mammography and detailed imaging require higher

resolutions (e.g., 5K or five megapixels).

 Cross-sectional imaging may be adequately viewed on 1K

or 2K displays.

6. Types of Workstations by Function

 Radiologist Reading Stations:

o Equipped with high-end hardware and top-quality monitors for

primary image interpretation.

 Physician Review Stations:

 o Simplified versions of reading stations; allow referring physicians
to view images and reports without advanced manipulation tools.

 QC (Quality Control) Stations:

o Used by technologists to verify image quality and correct patient

demographics before images reach the radiologist.

 File Room Workstations:

o Facilitate the scanning of physical films and burning of

CDs/DVDs; ensure images are correctly archived.

7. Common Functions on PACS Workstations

A. Navigation Functions

 Purpose:

o Move through image series, studies, and patient records.

 Key Feature:

o Hanging Protocols: Customized display setups that arrange

images (e.g., two-on-one, four-on-one, nine-grid, current vs. prior
studies) according to radiologist preference.

B. Image Manipulation and Enhancement Functions

 Windowing:

o Window Width and Level: Adjust the range of gray values to

change brightness and contrast.

 Annotation:

o Add text or graphical markers (must be used correctly to avoid

misinterpretation or legal issues).

o Note: Digital annotations should not replace physical lead

markers, as they may not be admissible in legal settings.

 Flip and Rotate:

o Reorient images to ensure correct anatomical display.

 Pan, Zoom, and Magnify:

 o Focus on areas of interest (e.g., detect fractures or examine
subtle details).

 Measurements:

o Tools to measure distances, angles, and regions of interest (ROI)

to assess tissue density (e.g., Hounsfield units in CT).

C. Image Management Functions

 Query/Retrieve:

o Search and access patient images using identifiers like name, ID,
or date of birth.

 CD Burning and File Transfer:

o Create digital copies for patients or referring physicians while

maintaining HIPAA compliance.

 Copy and Paste (Anonymization):

o Remove patient demographics for educational or presentation

purposes.

D. Advanced Workstation Functions

 Multiplanar Reconstruction (MPR):

o Reformat axial images into coronal or sagittal views (e.g., useful

in CT studies).

 Maximum/Minimum Intensity Projection (MIP/MINIP):

o Visualize structures such as vessels (MIP) or air-filled structures

(MINIP) after contrast administration.

 Volume Rendering and Shaded Surface Display:

o Provide 3D visualization by assigning colors based on tissue

intensity and removing irrelevant structures.

 Stitching:

o Combine multiple images (e.g., for leg length measurements)

into one continuous image.

8. Best Practices and Considerations

  Maintaining Image Integrity:

o Do not permanently alter the original acquired image (e.g., avoid

saving adjusted window/level settings) as it may limit further
manipulation by the radiologist.

 Proper Use of Markers:

o Ensure physical or digital markers (e.g., left/right orientation) are

correctly placed; annotations cannot legally substitute for these.

 Patient Demographics:

o Verify and correct patient data early in the workflow to avoid

duplicate records or loss of data.

 Network and System Limitations:

o Recognize that network performance can affect image

transmission; design systems to minimize bottlenecks.

9. Summary and Next Steps

 Key Takeaways:

o PACS systems revolutionized radiology by replacing film-based

workflows with efficient digital processes.

o Understanding the components, workflows, and architectures

(client/server, distributed, web-based) is essential for modern
radiological practice.

o Workstations are tailored to specific roles (radiologist reading,

physician review, QC, file management) and include various
image manipulation tools to aid diagnosis.

 Looking Ahead:

o The next chapter (Chapter 10) will cover PACS archiving and
peripheral functions, building on the fundamentals discussed
here.
These notes should help you review the chapter systematically and provide
clear connections between the different concepts. If you have any questions
or need further clarification, feel free to ask, Rabie!