Picture Archiving and Communication System (PACS)

PACS

1 Picture Archiving and Communication System (PACS)

Introduction Among the greatest miles in the field of radiology is the invention of the Picture Archiving and Communication System (PACS). This is because PACS has enabled digital imaging in the medical imaging field, as opposed to the traditional X-ray film (Van et al. 2005).

Another remarkable feature of PACS is its ability to link imaging study reports with the study itself, thus providing a chance to view the diagnostic report and the images side by side.

With the invention of PACS, most of the challenges that came with use of the film have now been resolved. Another benefit that has come with PACS in higher productivity as recorded in hospitals' imaging departments and the medical practice in general, compared to the era of films. This is because workflow has undoubtedly improved.

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PACS

2 Hospitals and other health institutions have seen an exponential increase in digital data

owing to increasing growth in digital sensors in the medical field. Technological improvement has made analog technologies transform to digital. Such has been the case with the X-ray technology. The shift from analog to digital comes in a time when new digital technologies such as the Medical Resonance Imaging (MRI) and Computed Tomography (CT) among others have come into the market. The emergent of PACS, therefore, offered a platform for handling medical imaging in a more efficient way (Huang, 2010). Other advantageous implementations that followed the PACS include ability to incorporate audio technology. Improvements on PACS are still ongoing, with ability to store and convert medical data into different forms and media currently being in practice in the medical field.

The converted data is readily transferrable and accessible from various locations. In addition, there is the advantage of being able to edit the data, and also store the data for a long time. Moreover, the image data is made available to different users in different locations at the same time. Sophisticated graphics software help in viewing such images without losing image quality. The above capabilities have resulted to reduced costs as well as increased speed in flow of medical information and processes associated with medical imaging.

One of the complications with PACS is that there is a complicated process involved in implementing a PACS since there is no established standard as of today. For a PACS to be efficient and successful there is need to have a workstation in place. The workstation acts as the human interface which displays PACS information. Initially, radiologists and other concerned physicians were using light boxes to perform digital radiology (Huang, 2010). However, workstations have come up and replaced the light boxes. With workstations, it is possible to have

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communication, database, processing information, and display of images handled by software (DUERINCKX, 2003).

A look at the proposed products The rise in demand for efficient and effective medical services has called for manufacturers of medical devices to move fast in coming up with advanced medical equipment.

This has been the case for companies such as GE and Fujifilm, who constantly upgrade their medical equipment. Despite the difficulty in choosing the best equipment to use due to variety of good choice, this report settled on three brands of display monitors: RadiForce RX430, Dome E4c and Barco Nio color 3 MP. The software of choice for use in the workstations were Fujifilm Synapse, Impax 6.2, and the All-In-One by EESi. The choice of these products was based on the fact that the manufacturers were found to be reputable and established in providing state of the art medical technology. The fact that product description for all the equipment is readily available in the company websites as opposed to having to contact the companies directly influenced the decision to settle for these products. It was also considered that the company proposal was vital in finalizing the agreement, thus it was resolved that these companies had favorable administration procedures. In specific, it was noted that maintenance is available if need be, trainings will be offered if need be, replacement of vital parts is possible, and that prices are affordable.

Display Monitors Display monitors in medical imaging could be used for teaching purposes or for research and diagnosis. Display monitors for teaching purposes have a lower resolution compared to the high resolution monitors used in research and diagnostic labs (Royal College of Radiologists,

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2008). This report's focus was the high resolution monitors with over 2MP for diagnostic purposes.

Discussion It is pertinent to note that all monitors have their strong points as well as their limitations.

A comparison of the monitors will, however, help explain the choice of display monitor that was selected for this case. The cathode-ray tube display monitors have been phased out by the liquid crystal display (LCD) monitors, which have flat screens. The LCD monitor is advantageous compared to the CRT in that linearity and luminance is to the maximum, combined with the ability to perform calibration automatically and remote quality assurance (The Royal College of Radiologists, 2008). The choice monitor for this study, therefore, was the LCD monitors which complied with the ACR Technical Standard for Electronic Practice of Medical Imaging (ACR TSEPMI). In other words, our choice monitors could display information which is legible at a 60 cm distance. The RadiForce, for instance, has a sizeable screen of 29.8 inches.

Image resolution is of critical importance in medical imaging. As such, the higher the resolution of the monitor, the better the display since resolution is simply the number of pixels an image is made of (Huang, 2010). The resolution feature of the monitor can, therefore, not be ignored. The resolution of both RadiForce RX430 and Dome E4c is much her than that of Barco Nio. This is because Barco Nio displays images at 2048x1536 pixels per inch, as opposed to a resolution of 2560x1600 pixels per inch for the other two brands of monitors. All in all, these monitors meet the minimum requirements for medical imaging display monitors. A superb viewing angle for the monitors is pertinent since it is often necessary to view displays from more than one angle. This is where Barco Nio beats the other two brands since it has a viewing angle

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of 176° compared to 170° for Dome E4c and Eizo (RX430). Advancements in technology have seen the IPS technology come to facilitate optimal angle viewing and meet the market demands.

Image quality can be influenced by brightness (cd/m2), also called luminance, and this makes resolution to be affected. Luminance level comes in handy when viewing low contrast structures located in high absorption regions. Among the three monitors of choice, Dome E4c scores the least in luminance (370 cd/m2), followed by Barco Nio (800cd/m2), while the RadiForce RX430 has the best luminance of 1,000 cd/m2 (ACR, 2007). The choice monitors in this report met the ACR Technical Standard for Electronic Practice of Medical Imaging specifications. This is because a mammography grayscale monitor should have a luminance of 250cd/m2 at the maximum.

Contrast ratio is also a vital consideration in the choice of monitor for medical imaging.

Contrast ratio is measured by considering luminance in relation to the background of the object, i.e. Cr=Lmax/Lmin. The recommended contrast ratio for medical display monitors is a minimum of 250, with the ambient illumination level factored. This is according to the 18 guidelines for medical display by the AAPMTG (The Royal College of Radiologists, 2008). In clinical imaging, the recommended contrast ratio should be ≥ 500:1. The contrast ratio for Dome E4c was the lowest at 700:1, followed by that of Barco Nio at 750:1, while Eizo (RX430) had the highest contrast ratio at 1100:1. A higher contrast ratio results to greater accuracy of diagnosis; more so with low contrast features such as those witnessed in mammography (Huang, 2010).

Bit depth is also a considerable feature in medical imaging. The recommended bit depth by the ACR TSEPMI is a minimum of 8 bits. If image processing is needed, the bit length should be at least 9 bits. There is a direct correlation between the luminance ratio and the bit-depth resolution (ACR, 2007). In this report, the monitor with the highest bit depth is Eizo (RX430) at

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30 bits, followed by the Dome E4c at 24 bits. This makes Eizo (RX430) more expensive, selling at AUD 13,313. Dome E4c sells at a price of AUD 8,370 and it is the cheapest.

Authorized distributors for all the three display monitors have similar offers, including complimentary shipping, 5-year limited warranty coverage with advanced exchange, overnight replacement, and they can connect you directly to technical support. The three monitors are also similar in that they have an operating temperature range of 0- 35 ±5°. All the monitors have incorporated a facility for aiding display of information which is color-encoded. Such information can be input from ultrasound, positron emission tomography, magnetic resonance imaging, and nuclear medicine. Datasets sourced from cross-sectional image stacks and in 3-D form can also be displayed in any of the three display monitors.

It is paramount to state that the clinical situation at hand can be handled appropriately in the three display monitors. This implies that the monitors are useful for use in diagnosis and reporting medical cases. The choice display monitor in the clinical situation below was the Barco Nio 3MP. The choice was based on a clinical and administrative rationale indicated at the end of the report.

Clinical Situation Saudi Arabia’s health care system is classified into dispensaries, general central hospitals and specialist hospitals. Dispensaries provide primary health care and are, thus, centers for handling common health concerns such as vaccinations, routine examination, and flu among others. General central hospitals are secondary health institutions which offer higher professional services including inpatient and outpatient services, some emergency cases such as fractures and some specialties. Specialist hospitals are mandated with providing healthcare services in specialized areas like urology, cardiology, and organ and tissue transplants among other

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specialized services. It is in the third level of Saudi Arabia's health care system where advanced care and medical facilities are mainly found. However, in this report, the clinical situation focuses on the secondary health care level in the Saudi Arabian health care system.

The Dammam Central Hospital is the choice of secondary health care center for our clinical situation. The hospital's geographic location is the eastern city of Saudi Arabia, the Dammam City. The hospital serves a wide range of patients, local and international, and it offers inpatient and outpatient services. Some of the specialties that one can find at Damman Central Hospital include general surgery, orthopaedic, ENT, GI, and vascular surgery. The emergency department (ED) at the hospital handles emergency cases such as advanced life support, road accident victims, and serious fractures. The ED also provides health care services even after normal working hours. Dammam Central Hospital has a bed capacity of 450. There is a medical imaging department which is equipped with 3 CRT scan machines, 2 MRI machines, 7 X-ray rooms, 5 ultrasonography machines, and it offers nuclear medicine. However, the department lacks in mammography services. Most of the medical cases that present at the hospital are handled within the hospital, and only a few complicated cases are referred to tertiary health institutions.

In a year, the medical imaging department attends to approximately 200,000 cases. A majority of these cases involve vascular examinations, gastrointestinal examinations and orthopaedic check ups.

Conclusion On a technical note, the discussion above portrays Agfa impax 6.2 as having some superior specifications, with some features being unique to Impax 6.2. A good example is the high privacy offered by the six key users feature available in Impax 6.2. With this feature, patient

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as well as hospital data is highly secured since users can be put into six categories. Moreover, one user has the ability to open up to 10 studies simultaneously, thus maintaining fluent workflow without having to inconvenience other users by having them close the same examination. Despite the differences in display monitor specifications, such as luminance, dip length and resolution, all the three monitors meet the recommended specifications. Since Dammam Central Hospital, which is the clinical situation here, does not attend to very complicated imaging examinations, there is no need to provide display monitors with the highest specifications, as long as minimum display requirements are met. As such, Dome and Barco monitors can still find use at Dammam Central Hospital.

On a careful examination of the guarantees and administrative support provided the manufacturers of the three display monitors, there are differences in terms and conditions in Saudi Arabia, compared to the case of a western country. The main cause of the differences is the fact that the manufacturers are not based in Saudi Arabia; neither do they have subsidiaries there. The manufacturers, therefore, use authorized distributors to reach the Saudi Arabia market.

Given that Algusaibi GTC acts as the authorized agent for Barco and Agfa in Saudi Arabia, it is prudent to settle for Barco 3 MP and Impax 6.2. Agfa is sold as a full package comprising of both hardware and software. As such, the cost of maintenance and guarantee fee is lower, more so if a single agent provides the entire package. GTC is an established company with a record 65 years of experience in the Saudi Arabia medical industry. This guarantees reliability to hospitals since specialist and maintenance services can be readily offered by GTC's team of engineers.

Another added advantage of choosing GTC as an agent for Impax 6.2 and Barco is that at least 2 PACS administrators from Dammom Central Hospital will get a chance to attend workshops and symposiums on imaging informatics.

PACS

9 Conclusively, we settled for Barco Nio 3 MP and Agfa Impax 6.2 owing to ease of

administrative issues and availability of guarantees. Moreover, it will be possible to offer customized services to different diagnostic needs at the hospital. As an illustration, it would be possible to provide a color monitor specifically to a radiologist who would need to interpret nuclear medicine reports which require color display.