PACS

A GUIDE TO
THE DIGITAL
REVOLUTION
Second Edition
PACS
A GUIDE TO
THE DIGITAL
REVOLUTION
SECOND EDITION

KEITH J. DREYER, DO, PHD

DAVID S. HIRSCHORN, MD
JAMES H. THRALL, MD
AMIT MEHTA, MD
EDITORS

With 97 Illustrations
Keith J. Dreyer, DO, PhD David S. Hirschorn, MD
Assistant Professor of Radiology Research Fellow in Radiology Informatics
Harvard Medical School Harvard Medical School
Vice Chairman of Radiology Informatics Massachusetts General Hospital
Massachusetts General Hospital Boston, MA 02114
Boston, MA 02114 and
USA Director of Radiology Informatics
Staten Island University Hospital
James H. Thrall, MD Staten Island, NY 10305
Professor of Radiology USA
Harvard Medical School
Chairman of Radiology Amit Mehta, MD
Massachusetts General Hospital Director of Interventional Radiology
Boston, MA 02114 St. Josephs Health Center
USA Toronto, Ontario
Canada M6R 1B5

Library of Congress Control Number: 2005925976

ISBN 10: 0-387-26010-2

ISBN 13: 978-0387-26010-5

Printed on acid-free paper.

© 2006 Springer Science+Business Media, Inc.

All rights reserved. This work may not be translated or copied in whole or in part without the written
permission of the publisher (Springer Science+Business Media, Inc., 233 Spring Street, New York,
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 To my parents
and to my family and loved ones
whose genuine enthusiasm
inspires my passion for new ideas
KJD

To my wife Elisheva,
for your love and warmth
DSH

To my wife Jean, who manages information technology in our household

and my children, Trevor and Keely, who have joined me in working
in the digital world
JHT

To my parents, MHM and NM for their guidance and support,

and my family, SAM, CKM, SKM, HKM, and RM (on her way)
for their constant humor,
and my teachers and colleagues for their help along the way
AM
 PREFACE

he digital transformation of radiology marches on. Slow and inefficient

T film- and paper-based methods are giving way to quicker and simpler
computer-based ones. Report turnaround times are being measured in
minutes or hours instead of days. There are more than a hundred informa-
tion technology vendors in the radiology market; they all claim that they
have best system to suit your needs. How can you tell which ones really are
best for you? How can you distinguish between truly important features and
ones that are just marketing ploys? How can you know the right questions
to ask to make sure you are getting all that you need and avoiding hidden
costs? This book covers the full spectrum of radiology information technol-
ogy in the digital department. It brings together the expertise of many of the
respected leaders in PACS, RIS, and speech recognition systems from aca-
demic centers such as Harvard and the University of Maryland, community
hospitals, and even international teleradiology practices. Recent changes in
image display technologies are explored, as well as the maturation of digital
mammography, three-dimensional imaging, the electronic medical record,
and teleradiology.
The process of assessing the needs of the institution and developing a
request for proposal that matches those unique requirements is covered in
 Preface
viii

depth. This includes information on writing the primary evaluation criteria,

evaluating proposals from different vendors, and choosing appropriate
vendors. To justify the considerable investment of a PACS, financial con-
cepts and tools are included that are useful in the financial evaluation. Legal
issues that arise with teleradiology and formal policies that address these
issues are also discussed.
This book is intended for radiologists, technologists, administrators,
and IT professionals who want to better understand these technologies and
their impact. It is also useful for industry vendors, consultants, and health-
care leaders who have an interest and modest knowledge of IT management
issues.
What's new in the second edition? It presents some of the latest
research on reading room design and radiologist workflow. Recent develop-
ments in CR and digital mammography are also included. Major changes in
display and storage technologies which can have a huge impact on the cost
of PACS are discussed. Experience gained from maturing teleradiology prac-
tices is shared. The role of decision support tools for order entry and digital
teaching files are also explored. These updates and additions will provide you
with the most current information about the digital transformation of
radiology.
We would like to acknowledge our developmental editor, Merry Post,
for keeping track of the myriad of details needed to make this second edition
a reality. She also deserves credit for dealing with all of our crazy schedules.
Her persistence is what kept this book on track. Kudos to the chapter authors
for sharing their expertise with all of us, and thanks to my fellow section
editors for organizing and keeping track of progress of the chapters in their
sections. I also can not thank my wife, Elisheva, enough for supporting me
in editing this book. The warm and loving home that she provides allows
me to focus on the task at hand; write, edit, and review chapters; and send
out countless e-mails.

David S. Hirschorn, MD
 CONTENTS

PREFACE vii
CONTRIBUTORS xiii

SECTION I INTRODUCTION 1
Keith J. Dreyer

1 INTRODUCTION 3
David S. Hirschorn

SECTION II ADMINISTRATIVE ISSUES 7

Gordon Smith

2 INTRODUCTION TO RIS AND PACS 9

Gordon Smith

3 PACS STRATEGIC PLAN AND NEEDS

ASSESSMENT 27
Leonard A. Levine
 Contents
x

4 CREATING THE PACS REQUEST FOR PROPOSAL

AND SELECTING A VENDOR 45
Alan L. Schweitzer and Gordon Smith

5 REENGINEERING WORKFLOW: A FOCUS ON

PERSONNEL AND PROCESS 73
Bruce I. Reiner and Eliot L. Siegel

6 REENGINEERING WORKFLOW: THE

RADIOLOGIST’S PERSPECTIVE 97
Eliot L. Siegel, Bruce I. Reiner, and
Nancy Knight

7 FINANCIAL MODELING 125

Syrene R. Reilly and David Avrin

8 LEGAL ISSUES AND FORMAL POLICIES 145

Gordon Smith and David S. Hirschorn

SECTION III TECHNICAL ISSUES 171

Thomas J. Schultz

9 COMPUTER FUNDAMENTALS 173

Keith J. Dreyer

10 DIGITAL IMAGING FUNDAMENTALS 183

Keith J. Dreyer and Mannudeep K. Kalra

11 IMAGE ACQUISITION 189

Katherine P. Andriole

12 IMAGE COMPRESSION 229

Bradley J. Erickson

13 PACS ARCHITECTURE 249

Kenneth Heckman and Thomas J. Schultz

14 NETWORKING FUNDAMENTALS 269

Scott M. Rogala

15 SERVERS AND OPERATING SYSTEMS 303

Kenneth M. Nesbitt, Thomas J. Schultz, and
Roberto Dasilva
 Contents
xi

16 STORAGE AND ENTERPRISE

ARCHIVING 319
Paul G. Nagy and Thomas J. Schultz

17 IMAGE DISPLAYS 347

David S. Hirschorn

18 DIGITAL MAMMOGRAPHY 363

Martin J. Yaffe

19 WEB DISTRIBUTION 373

Keith J. Dreyer

SECTION IV CLINICAL ISSUES 383

David S. Hirschorn

20 PACS WORKSTATION SOFTWARE 385

Steven C. Horii

21 BREAST IMAGING, COMPUTER-AIDED

DETECTION, AND COMPUTER-ASSISTED
CLASSIFICATION 433
Shalom S. Buchbinder

22 THREE-DIMENSIONAL IMAGING IN
RADIOLOGY 447
Gordon J. Harris

23 VOICE RECOGNITION 467

Michael J. Mardini and Amit Mehta

24 ORDER ENTRY IN RADIOLOGY 483

Daniel I. Rosenthal

25 DIGITAL TEACHING FILES AND

EDUCATION 495
Khan M. Siddiqui and Barton F. Branstetter IV

26 TELERADIOLOGY 523
Giles Boland, Jonathan T. Schlakman, and
James H. Thrall

INDEX 561
 CONTRIBUTORS

Katherine P. Andriole, PhD.

Associate Professor of Radiology, Harvard Medical School, Assistant
Medical Director, Imaging IT, Director of Imaging Informatics, Center for
Evidence-Based Imaging, Brigham and Women’s Hospital, Boston, MA
02120, USA
David Avrin, MD, PhD
Professor of Radiology, Adjunct Professor of Medical Informatics, Univer-
sity of Utah, University of Utah Hospital and Clinics, Salt Lake City, UT
84132, USA
Giles Boland, MD
Associate Professor of Radiology, Harvard Medical School, Vice Chairman,
Business Development, Massachusetts General Hospital, Boston, MA 02114,
USA
Barton F. Branstetter IV, MD
Assistant Professor of Radiology and Otolaryngology, Director of Head and
Neck Imaging, Associate Director of Informatics, University of Pittsburgh
Medical Center, Pittsburgh, PA 15213, USA
 Contributors
xiv

Shalom S. Buchbinder, MD
Clinical Associate Professor, Albert Einstein College of Medicine, Chairman
of Radiology, Clinical Associate Professor of Radiology, Obstetrics, Gyne-
cology and Womens’ Health, Staten Island University Hospital, Staten
Island, NY 10305, USA
Roberto Dasilva, MCSE
Data Center Manager, Department of Radiology, Massachusetts General
Hospital, Boston, MA 02114, USA
Keith J. Dreyer, DO, PhD
Assistant Professor of Radiology, Harvard Medical School, Vice Chairman
of Radiology Informatics, Massachusetts General Hospital, Boston, MA
02114, USA
Bradley J. Erickson, MD, PhD
Associate Professor of Radiology and Medical Informatics, Director, Radi-
ology Informatics Laboratory, Department of Radiology (E-2), Mayo Clinic,
Rochester, MN 55905, USA
Gordon J. Harris, PhD
Director, 3D Imaging Service, Massachusetts General Hospital, Boston, MA
02114, USA
Kenneth Heckman, BSN
Information Systems Analyst, Partners HealthCare System, Inc., Boston,
MA 02115, USA
David S. Hirschorn, MD
Research Fellow in Radiology Informatics, Harvard Medical School, Mass-
achusetts General Hospital, Boston, MA 02114; Director of Radiology
Informatics, Staten Island University Hospital, Staten Island, NY 10305,
USA
Steven C. Horii, MD
Professor of Radiology, University of Pennsylvania, University of Pennsyl-
vania Medical Center, Philadelphia, PA 19104, USA
Mannudeep K. Kalra
Director of CT Research, Assistant Professor of Radiology, Emory Univer-
sity Hospital, Atlanta, GA 30322, USA
Nancy Knight, PhD
Coordinator, Research Publications and Grants, Veterans Affairs Maryland
Healthcare System, Baltimore, MD 21201, USA
 Contributors
xv

Leonard A. Levine, BS, MSIE

Manager, Radiology Data Services, Department of Radiology, Massachusetts
General Hospital, Boston, MA 02114, USA
Michael J. Mardini, MBA
Chief Executive Officer, Commissure, Inc., New York, NY 10011, USA;
Founder and Former CEO, Talk Technology, Inc.
Amit Mehta, MD
Director of Interventional Radiology, St. Josephs Health Center, Toronto,
Ontario, Canada M6R 1B5
Paul G. Nagy, PhD
Assistant Professor of Radiology, University of Maryland, University of
Maryland Medical Center, Baltimore, MD 21201, USA
Kenneth M. Nesbitt
Systems Engineer, Partners IS—Enterprise Medical Imaging, Boston, MA
02114, USA
Syrene R. Reilly, MBA
Director of Quality Management Services, Partners HealthCare System,
Inc., Boston, MA 02199, USA
Bruce I. Reiner, MD
Director of Radiology Research, Veterans Affairs Maryland Healthcare
System, Baltimore, MD 21201, USA
Scott M. Rogala
Corporate Manager Network Engineering, Partners Healthcare,
Charlestown, MA 02129, USA
Daniel I. Rosenthal, MD
Professor of Radiology, Harvard Medical School, Vice Chairman for Admin-
istration, Department of Radiology, Massachusetts General Hospital,
Boston, MA 02114, USA
Jonathan T. Schlakman, MD
Radiologist, Remote Radiology International, Efrat, Israel 90435
Thomas J. Schultz, BSE
Chief Engineer, Partners HealthCare System, Inc., Boston, MA 02114, USA
Alan L. Schweitzer, MEE
Chief Technology Officer, Radiology Consulting Group, Boston, MA 02114,
USA
 Contributors
xvi

Khan M. Siddiqui, MD
Chief, Imaging Informatics and Body MR Imaging, Veterans Affairs Mary-
land Healthcare System, Baltimore, MD 21201, USA
Eliot L. Siegel, MD
Professor of Diagnostic Radiology, University of Maryland School of Med-
icine, Director of Imaging, Veterans Affairs Maryland Healthcare System,
Baltimore, MD 21201, USA
Gordon Smith, MBA
Director of Radiology Informatics, Department of Radiology, Massachusetts
General Hospital, Boston, MA 02114, USA
James H. Thrall, MD
Professor of Radiology, Harvard Medical School, Chairman of Radiology,
Massachusetts General Hospital, Boston, MA 02114, USA
Martin J. Yaffe, PhD
Professor, Department of Medical Imaging and Medical Biophysics, Uni-
versity of Toronto, Senior Scientist, Imaging/Bioengineering Research,
Sunnybrook and Women’s College Health Sciences Centre, Toronto,
Ontario, Canada M4N 3M5