Edward J Harvey M.D., MSc, FRCSC
McGill University Health Centre
Digital imaging is here to stay- and not just because digital cameras are now so omnipresent. Every orthopaedist's patient care will be impacted by the new technology of digital radiology. New imaging modalities (spiral CT, PET/CT, total body MRI) have resulted in studies with hundreds of slices. Traditional archiving and film technologies make for bulky, awkward and difficult situations as the physician tries to sort through 60-80 sheets of out-of-order plastic in a film bag. Currently, most radiology departments are implementing digital film and archiving for all types of films and imaging. This is better known as PACS (picture archiving and communication system) although you may come to know it by many other names; the most polite being Pretty Awful Clinical Scenario.
PACS implementation comes in many forms to individual hospitals. Basically, in order for a system to work, hospital and radiology information systems that communicate seamlessly must be in place. Without this there is no validation of patient data and a vast reduplication of effort. Currently there is no hospital in Canada in which this really exists. Thus, practically everyone is dealing with a sub-standard system. In most hospitals, the radiology department announces that at a certain time, there will be PACS in place and you will no longer get films for viewing. This is the time to get involved. Each hospital has a different idea of what PACS means to them. Most hospitals already have a CT or MRI that has a storage system optimized for radiology viewing. The hospital will have bought (or worse, been given) a system that takes digital images of plain films and sends them to computerized storage. This could include technologies for image capture (computed radiology or digital radiology) in the radiology suite, similar to old plain films, but could also include portable digital machines for the operating room and ward x-rays. The hospital establishes a protocol for storage and distribution of images that is usually optimized for radiology reporting and billing. Distribution of images is dependent on many things: location of terminals for viewing, software, bandwidth (communication pipeline between computer stations). Quality of images depends on parameters including, but not limited to, education of radiology technicians and orthopaedic staff, compression modes used to make images smaller for easier transport, type of terminal, type of screen used for viewing and even ambient light in the viewing area.
Before deployment of infrastructure and assignation of resources, it is extremely important for the orthopaedic department and other users to strictly define functional requirements for their day-to-day clinical usage. The PACS systems are set up so radiologists in a dark room (in more ways than one) can view films at their leisure. Unfortunately, that is not adequate for an orthopaedic surgeon. Download times to a clinic viewer of one minute when you view 300 films a day can mean your clinic stretches on to 11 p.m. The ability to view images in the operating room is paramount. If you see patients at sites other than the clinic, then your ability to deliver care will be altered. Most hospitals have been told that PACS is cheaper and therefore the switchover will pay for itself. This is absolutely untrue. The only way to nearly break even is for the radiology department to completely stop printing hard copy. Thus, you need to sit down with the radiology department and dictate exact functional requirements in order to switch over to PACS. A PACS implementation team should include not just the radiology department and the consultants, but at least one orthopaedic surgeon. In a busy hospital, orthopaedics is one of the largest consumers of information. Stay away from technical details (types of storage, exact bandwidth, types of terminal etc) and instead define exact usage parameters. Tell them exactly how long you can wait for images, where those images must be delivered, when access is needed and other requirements. I recommend an initial setup which allows preloading of images into clinic terminals. A list of patients is sent to radiology (electronically or on paper) and all images of those patients on the list are downloaded the night before to the clinic. This at least ensures your booked patients will have films available. There are some companies who deliver images to the viewer in a just-in-time mechanism that obviates the need to have images pre-fetched. This type of system is great for clinics that have add on patients where you need to retrieve a number of patients quickly. These programmes are at the upper end of price for PACS systems and many hospitals do not splurge for these. Orthopaedic surgeons require a way to template for OR planning. Some PACS systems have templates but might not necessarily have your implant's templates. Special consideration needs to be given to long leg or alignment views as well as scoliosis series. The ability to print films needs to be retained for these types of situations. A global backup plan is definitely needed in case the system is down. The ability to print some type of film or plastic simile will be needed no matter what radiology says about 100% reliability.
Because the hospital is forcing a change to this system, you may be able to get them to pay for terminals and screens. Remember you need data delivery at every place you normally see patients: your office, your clinic, emergency, operating room, patient units, radiology department, where you hold teaching or working rounds etc. The added benefit is that you can see images at home but you have to ensure that you have a high-speed connection. Education for everyone dealing with the system - and especially the ancillary users - must be established on a regular basis. The best approach is to establish a standard of care through your functional requirement demands and hold the hospital to this standard.
An ICL was presented on this subject at the 2000 COA Annual Meeting in Edmonton, AB. More information from that instructional course can be found in the presentations at: http://ww2.mcgill.ca/orthopaedics/presentations/presentation_list.html.
If there is enough of a response, we could lobby to repeat a similar ICL at a future COA meeting. I am always willing to discuss any of these ideas -