Radiation Protection in Digital

Radiology

Picture Archival and

Communication System (PACS)
L09

IAEA
International Atomic Energy Agency
 Educational Objectives

• Understand how digital radiology depends

on Picture Archiving and Communications
Systems (PACS)
• List the four components of PACS
• Explain how errors in each of the four
components of PACS can contribute to
unnecessary radiation exposure to patients

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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
 Digital Radiology

• The application of modern information

technology to the practice of radiology
• Depends on automated systems for
acquiring, transmitting, storing, and
displaying digital images and
associated data
• Broader than just systems, includes
how the systems are used

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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
 Picture Archiving and
Communication System (PACS)
• A system capable of acquiring, transmitting,
storing, retrieving, and displaying digital
images and relevant patient data from
various imaging sources, and capable of
communicating the information over a
network
• Depends on interfaces to other medical
information systems, such as the Radiology
Information System (RIS)

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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
 Digital Imaging and
Communications in Medicine
(DICOM)
• An international standard (ISO)
describing how radiology images are
identified and formatted and how
imaging devices communicate with each
other
• Jointly developed by the American
College of Radiology and the National
Electronic Manufacturers Association
• Based on the ISO Open Standards
Intercommunications (OSI) model
• http://dicom.nema.org/
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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
 (0008,0020) : Study Date : 04/12/2003
(0008,0022) : Acquisition Date : 04/12/2003
(0008,0060) : Modality : CR
(0008,0070) : Manufacturer : AGFA
(0008,0080) : Institution Name : HCSC
(0008,1010) : Station Name : ADCC2
(0008,103E) : Series Description : lumbar AP
(0010,1010) : Patient's Age : 020Y
(0018,0015) : Body Part Examined : LSPINE
(0018,1004) : Plate ID : U13-35
(0018,1401) : Acquisition Device Processing : 60025Ia712Ra
(0018,1403) : Cassette Size : 35CMX43CM
(0018,1404) : Exposures on Plate : 342
(0018,5101) : View Position : AP
(0018,6000) : Sensitivity : 4.00000000E+02
(0019,1010) : Image processing parameters :
MENU=60025 CC=0 MC=3.00 EC=0.00 LR=2.00 NR=4.00
(0019,1013) : Sensitometry name : NK5
(0019,1015) : Dose monitoring list : 1.54
(0020,0013) : Image Number :1
(0020,1002) : Images in Acquisition :1
(0028,0010) : Rows : 3730
(0028,0011) : Columns : 3062
(0028,0100) : Bits Allocated : 16
(0028,0101) : Bits Stored : 12
(0028,0102) : High Bit : 11

Example of some of the DICOM

tags in the header

• DICOM headers store information for all images.

• A rich source of information for prospective or retrospective
patient exposure monitoring.

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Radiation Protection in Digital Radiology L06 Avoiding Artefacts in Computed Radiography
 Some key points:

• Images stored in some PACS cannot be

(sometimes) post-processed.
• This will be known in advance and appropriate
post processing should be applied before the
image is archived.
• Allowing easy access to PACS and teleradiology
to look at previous images can save exposures.
• Except of the “for presentation” images, PACS
save also images “for processing”. These may
retrospectively be processed to recover
information preventing re-exposures

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Radiation Protection in Digital Radiology L06 Avoiding Artefacts in Computed Radiography
 Hospital Information System (HIS)

• A system used to store and retrieve

patient information.
• An integrated computer system that
may include or be linked to a radiology
information system (RIS)

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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
 Health Level Seven (HL7)
• An American National Standards Institute (ANSI) -
accredited Standards Developing Organization
(SDO) operating in the healthcare arena.
• A messaging standard that enables healthcare
applications to exchange key sets of clinical and
administrative data
• Defines data to be exchanged, timing of the
interchange, and communication of certain errors to
the application.
• Supports functions such as security checks,
participant identification, availability checks,
exchange mechanism negotiations and, most
importantly, data exchange structuring.
• The most widely implemented standard for
healthcare
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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
 Integrating the Healthcare
Enterprise (IHE)

• IHE is an initiative to improve the way computer

systems in healthcare share information
• IHE promotes use of established standards such
as DICOM and HL7
• Systems developed in accordance with IHE
• communicate with one another better
• are easier to implement
• enable care providers to use information more effectively
• http://www.ihe.net/

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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
 Four Major PACS Components

1. Acquisition 2. Network 4. Display

-CR -CRT
-DX -LCD
-CT -Laser Film
-MR
RIS Image Database
-US
Status of Status of
-DF Exams Images
-OT
3. Archive

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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
 Examples of errors within and
between PACS components

• Acquisition errors • Archive errors

• Improper technique • Storage media
selection corrupted
• Wrong exam • Storage failure
performed • Sequestered exams
• Image deleted • Display errors
• Network errors • Mis-calibration
• Image lost • Associated data not
• Image corrupted displayed
• Unable to transmit • Artificial shutters

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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
 Acquisition: Improper Technique
Selection

• Digital detectors are more tolerant of

over-exposure than conventional
detectors
• Excess digital signal is scaled to
provide consistent appearance

• Consequence: is unnecessary radiation

exposure to patient
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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
Acquisition: Wrong exam performed

• Radiographer may image thorax using

digital examination intended for
abdomen
• Digital signal is rendered
inappropriately for review

• Consequence: may be repeated

examination and unnecessary radiation
exposure to patient
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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
 Acquisition: Image deleted

• Radiographer may delete image at

acquisition station without transmitting
to PACS
• It may not be possible to restore
deleted image

• Consequence: may be repeated

examination and unnecessary
radiation exposure to patient
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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
 Network: Image lost

• Interruption in network service may result in

losing the image
• It may not be possible to retransmit image
from acquisition station

• Consequence: may be repeated examination

and unnecessary radiation exposure to
patient

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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
 Network: Image corrupted

• Interruption in network service

may degrade image
• It may not be possible to
retransmit image from
acquisition station

• Consequence: may be
repeated examination and
unnecessary radiation
exposure to patient
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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
 Network: unable to transmit

• Interruption in network services

prevents transmission of images from
acquisition station
• Local storage capacity of acquisition
station is limited
• If acquisition continues, images can be
lost, causing repeated examinations
and unnecessary radiation exposure to
patients
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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
 Archive: storage media corrupted

• Storage media failure can prevent images

from being retrieved
• May require repeated examinations and
unnecessary radiation exposure to patients

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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
 Archive: storage failure

• Storage failure can prevent images from

being archived
• If images have already been deleted from
acquisition station, may require repeated
examinations and unnecessary radiation
exposure to patients

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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
 Archive: images sequestered

• When demographic and examination

information on images does not match
information from RIS, images may be hidden
from view
• Unless reconciliation is performed,
radiographer may repeat examination with
unnecessary radiation exposure to patients

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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
 Display: mis-calibration

• Improperly calibrated display can make

digital images appear under-exposed
• Radiologist may instruct radiographer to
repeat examinations or increase radiologic
technique causing unnecessary radiation
exposure to patients.

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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
 Display: associated data not
displayed

• Data accompanying the image may

not be displayed for the radiologist
• If missing data includes information on
the radiographic technique or patient
exposure, the radiologist cannot
oversee radiographer practice
• Without radiologist oversight,
radiographers may perform
examinations with unnecessary
radiation exposure to patients
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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
 Display: artificial shutters
• To improve contrast,
radiographer may add
artificial collimation
• When artificial shutters are
non-transparent, radiologist
cannot oversee
radiographer practice
• Without radiologist
oversight, radiographers
may perform examinations
without appropriate
collimation, resulting in
unnecessary radiation
exposure to patients Where was the actual radiation field

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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
 Sources of Errors in PACS

• Mistakes in configuration of PACS

• Improper calibration of PACS devices
• Discrepancies between PACS and hospital processes
• PACS design flaws
• Inherent limitations of human operators
• Inadequate training and documentation of PACS and
hospital processes
• Insufficient planning for PACS service interruptions

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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
Mistakes in configuration of PACS

• Inappropriate software settings and

values
• Outdated or inconsistent versions of
software
• Incompatible Department Orthopedic
combinations
Main Clinic
of software
and hardware

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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
 Improper calibration of PACS
devices
• Includes monitors, Digital Radiography (DR), film digitizers,
laser cameras, analogue interfaces, phototimers, etc.
• Methodology for calibrations not well-established
• Frequency of calibrations not well-established
• Consequences of mis-calibration not widely acknowledged

Before Afte
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Radiation Protection in Digital Radiology L09 Picture Archival
 Discrepancies between PACS and
hospital processes => false
assumptions
• Patient identification data is invariant.
• Only one radiologist is associated with a report.
• Only one physician is associated with a request.
• Images are used in surgery in the same manner as
images are used in clinics.
• The patient scheduled for an exam in Room 4 will be
examined in Room 4.
• The exam started in Room 4 will be completed in
Room 4.
• Outpatients are only examined in the Outpatient
Center.
• The same supervisors of exams on 1st shift are also
present on 3rd shift.
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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
 PACS design flaws

• Some software and hardware features either do not

function, or act in an undesired manner (bugs)
• Some processes that are absolutely required for
clinical practice are not supported.
• Limited connectivity
• Incomplete implementation of DICOM
• Incompatible interpretations of DICOM
• Divergence from Integrating the Healthcare Enterprise
(IHE)
• Lack of adherence to software design principles
• Lack of application of Reliability Engineering

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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
“To err is human, but to really foul
things up requires a computer!”
• Electronic images are imperfect: they are subject to
deletion, mis-association, mis-routing, and mis-
interpretation.
• Electronic devices and media are im-permanent
records: the consequence of loss is greater than one
film or one film jacket.
• A single bad electronic image can be proliferated: a
single bad film image can be controlled.
• Bad electronic images can disappear without a trace:
bad films disappear, but leave a signature. How many
films were in the box at start-of-shift?

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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
The best maintenance is preventive
maintenance.
• Calibrations need to be performed on-schedule.
• Operators need to clean, inspect, and document.
Start-of-shift routines or checklists are
helpful.
• Schedule PM to occur at convenience of clinical
operation.
• Software upgrades are major service events that
demand re-verification of proper function.

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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
 Insufficient planning for PACS
service interruptions
• How is PACS affected by loss of utility services, i.e., power,
HVAC, or network?
• How do I maintain continuity of clinical operations during
downtime of an individual PACS component?
• Can local components operate during downtime of a
central PACS component (database, archive, gateway, RIS
or RIS interface)?
• How does PACS recover after service is restored?
Software upgrade is a service interruption!

“Weather never cooperates”

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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
 Conclusions

• Unfortunately, errors will always occur in PACS.

• Some of these errors cause unnecessary radiation
dose to patients
• QC is the key to detecting errors.
• Training is key to averting errors.
• Reliability engineering is key to continuity of clinical
operations.
• Disaster recovery is key to restoring normal clinical
operations.
• Optimisation includes all of the above.
• Other lectures in this series concentrate on errors
that occur in acquisition and display, rather than
those that affect network quality of service and
archive reliability.
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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
 Answer True or False

• PACS is a system to store and retrieve

patient information
• Reason for retake of radiographic
examination could be due to network
problems
• Improperly calibrated display can
involve unnecessary radiation exposure
to patient

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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)
 Answer True or False

• False. Hospital information system (HIS) is

used to store and retrieve patient
information. This can be linked with the
radiology information system (RIS)
• True. Interruption in network service may
result in losing the image, hence repeated
radiographic examination would be required.
• True. Improperly calibrated display can
make digital images appear under-exposed.
The radiologist may instruct radiographer to
repeat examinations or increase radiologic
technique causing unnecessary radiation
exposure to patients
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Radiation Protection in Digital Radiology L09 Picture Archival and Communication System (PACS)