Electronic healthcare solutions are attracting a new wave of converts. PACS pioneers from leading institutions in the U.S, Western Europe, and Asia now find themselves sharing the conference podium with speakers accustomed to working in more basic healthcare facilities. Markets for digital data communication and management systems are emerging in the Far East, Central and Eastern Europe, and in the former Soviet states, as hospitals in these regions turn to IT to improve patient services and maximize resources.

The growing worldwide interest in e-health was apparent at CARS 2003, where more than 1000 delegates assembled in London for the three-day meeting. While a sizable proportion of delegates cited affiliations in Japan, Germany, or the U.K., the total congress fellowship was truly international, said Prof. Heinz Lemke, who initiated and continues to organize the CARS annual meetings. At least 40 country names could be spied on conference badges. A record number of U.S. participants also made the transatlantic trip.

"The letters of invitation I wrote seemed to cover the entire world," said Prof. Stephen Golding, chair of the 17th International Congress and Exhibition on Computer Assisted Radiology, the longest running and largest of the six strands within CARS 2003.

Attendance might have been even higher-and more diverse-had British bureaucrats not interfered. A number of preregistered delegates had to cancel their trips at the last minute because of problems in obtaining entry visas to the U.K. Prospective participants from China and a sizable delegation from Ukraine were among those forced to pull out of the conference, Golding said during the official opening session.

The exclusion of these groups from CARS was clearly frustrating for all involved, but it is unlikely to stem the growing enthusiasm for e-health systems in countries modernizing their healthcare services.

PACS is a hot topic in Eastern Europe, where hospitals are making great advances toward integrating IT systems, according to Dr. Davide Caramella, an associate professor of radiology at the University of Pisa in Italy and president of EuroPACS. While investment and infrastructure problems can sometimes cause difficulties, the fact that healthcare managers are starting completely from scratch has certain advantages.

"It is sometimes easier to deploy new technology where you do not have legacy systems, rather than trying to implement it in a situation where you have some equipment that is not state of the art, but you are still reluctant to get rid of it," he said.

EuroPACS 2004 will be held in Trieste, Italy, with the hope of attracting more delegates from Eastern Europe, Caramella said. The society also elected new board members from Norway, Spain, and Poland during its annual general meeting in June, in recognition of the expansion of digital imaging and medical communication systems throughout the continent.

INTEGRATING UNITS

New EuroPACS board member Prof. Ewa Pietka, a professor of electronics at Silesian University of Technology in Gliwice, Poland, is determined that the hospital IT system she oversees meet the same standards adhered to by her international colleagues. But ensuring that the large-scale hospital information system keeps up with the ever-expanding recommendations can be an uphill battle.

"I had almost caught up with the seven IHE integration profiles for radiology, but then they created three more. Yesterday, I found that there were two more in progress," Pietka said at CARS 2003. "I would like to have the system up to international standards. This is why we have DICOM and HL7, and we have XML for the electronic patient record."

Efforts to implement the hospital-wide electronic data management system at the central teaching hospital of the Medical University of Silesia in Katowice, Poland, began in 2000. Project planners first divided the proposed system structure into two main sections, one managing any activity involving patients, and the other concerned with administrative functions. The patient-oriented section was subdivided into activities involving all departments, for which a single system module could be implemented (kernel modules), and activities requiring department-specific workflow (stand-alone modules) (see table).

Team members focused first on integration of radiology examinations and laboratory tests into the schedule workflow. After patients are admitted to the hospital, referring physicians can place an order for a scan via the order entry module. This information is sent direct to the radiology information system, which in turn generates a service request to the PACS and assigns an accession number. Procedural steps will appear on the modality work list, and the resulting images are sent to a diagnostic workstation, where reporting workflow is also displayed. The final report is sent via HL7 back to the order entry module, where the referring physician can access it. Non-RIS users can also click on an image icon to view diagnostic DICOM images.

If the same physician also orders a laboratory test, the order entry module communicates this request to the laboratory information system, Pietka said. The LIS organizes the request into separate procedures when necessary and adds these to work lists attached to the relevant analytical equipment. Validated results are transferred back to the LIS server and then to the order entry module as HL7 messages.

Approximately 100,000 outpatients and 24,000 inpatients were registered on the system in the first two years of its use. At least 150,000 requests for laboratory tests were made during this period, and 60,000 images were stored on the PACS. The addition of a charge-posting module for accurate billing and the introduction of a postprocessing workstation for bone age assessment has further improved the system's functionality. The hospital is now working to integrate HL7 communication with the pharmacy.

Realization of the project has involved four separate vendors to date. Pietka selected a small Polish company to supply the RIS and PACS so that she could have more input on the precise system specifications.

"If you are talking to big vendors, you just have to use an off-the-shelf product. They will do some modifications, but they do it according to the needs of all users, not just one particular user. I had the opportunity to work with a vendor who supported my project and made adjustments according to what we wanted," she said.

The hospital has a remote service agreement for system maintenance. Error messages generated by the RIS or PACS are sent as a text message to a dedicated on-call mobile phone. On receipt of such a message, a service engineer will log in to the system to assess the problem.

"They have an online connection, so whenever something goes wrong, they log in and check it, and they routinely check the system on a daily basis. They do this remotely because they are more than 360 km away from us," Pietka said.

SHARING EXPERTISE

Another group of Polish radiologists is using IT systems to share expert imaging knowledge between institutions. Radiologists at Jagiellonian University Medical School in Krakow set up a teleradiology link with colleagues at a smaller, regional hospital in 1998. The system was designed to transfer CT images between the two institutions when doctors at the regional hospital required specialist advice or its radiologists were not available.

Radiologists at the university hospital opted for an ISDN line as the transmission medium and for DICOM over TCP/IP as a transmission protocol. This method proved superior to previous attempts at digital transfer of medical images in Poland. Those efforts involved bitmap images, which resulted in the loss of original information, according to Jagiellonian radiologists, who described the project in a poster at CARS 2003.

The implementation phase revealed a number of difficulties, said Dr. Robert Chrzan, lead author of the poster. Radiologists encountered technical problems with the ISDN line, and there were issues related to configuration of the teleradiology stations. Further, the regional hospital partnering in the project decided to pull out and manage its patients without external help.

"So in the first few years, the transfer was rather symbolic," Chrzan said. "But in 2000, we found another regional hospital to cooperate, and we now perform up to 10 CT teleconsultations per week."

The radiology reporting system used at Jagiellonian University is not yet incorporated into the teleradiology workstation. When doctors there receive a CT scan for teleconsultation, they must create a report using their local RIS and transmit it back by coded e-mail and fax.

But it is lack of funding for healthcare, not lack of software integration, that is hampering the system's uptake, Chrzan said. Most public regional hospitals have contracts that allow them to perform only a small number of specialist diagnostic procedures.

"If there is not enough public money for CT examinations in regional hospitals, then there is no money for teleradiology equipment or for additional payments for consulting specialists," he said.

The Jagiellonian University project was economically feasible only because regional hospitals did not have to purchase hardware. All teleradiology workstations were included in a contract for a new CT scanner at the university hospital. Plans are under way to connect the system with a new MRI unit at the regional hospital. Because MRI has not previously been available at that hospital, the department has no radiologists experienced in reading the scans, Chrzan said.

FAR EASTERN PROMISE

Economic growth in China is fueling considerable interest in e-health in many of the country's larger hospitals. China is rapidly evolving into a promising market for IT healthcare systems, said Haihong Fu, an engineer in the department of radiology at Peking Union Medical College Hospital in Beijing.

By the end of 2000, China had well over 16,500 hospitals, providing 2.2 million patient beds and employing two million doctors, Fu told CARS 2003 delegates. About 1% of these have more than 800 beds, while 12% have 300 to 800 beds. It is this "top tier" that is actively investigating RIS and PACS.

"The requirements for PACS and healthcare IT systems in different types of hospital are clearly different from one another," Fu said. "Fundamental hospitals may need only the simple function of image storage to save film costs and archive digital images. Top-level hospitals need more customized, specialized requirements; for instance, integration of their healthcare IT systems."

MiniPACS solutions first reached China four years ago, Fu said. Between February 1999 and October 2001, 11 hospitals installed miniPACS from five vendors. Another five hospitals purchased a full PACS in 2001 and 2002, while two upgraded their miniPACS to a full PACS.

The outbreak of SARS in China slowed hospitals' efforts to integrate their PACS hospitalwide. Time, energy, and resources were directed to controlling the spread of disease and managing infected patients in specifically designated hospitals, Fu said.

"As one of three specialized SARS hospitals in Beijing, Xuanwu Hospital has been completely isolated from the end of April onwards," he said. "Anyone coming to the hospital cannot enter without the permission of an administrator, and anyone working in the SARS ward cannot work in other parts of the hospital."

Digital image and communication systems played their part in keeping infection to minimum in isolated institutions. Hospitals were divided into three areas: an isolation area, a changing area for staff entering and leaving an infected area, and a clean area. A CR unit in the isolated area was used to examine SARS patients. This area also contained a viewing workstation. Diagnostic workstations were set up in the changing area and in a clean area where radiologists did all reporting.

Looking to the future, Fu considers the implementation of fully integrated electronic healthcare systems a major challenge for in hospitals in China. Hospital managers must be persuaded that integrating HIS with RIS, PACS, and LIS is viable; hence, the need for demonstration sites.

"PACS is still in a period of development, deployment, and diffusion in China," he said. "One fully integrated healthcare solution in a show-site hospital will be more significant to acceleration of PACS development than many PACS islands."

---

STRUCTURE OF INTEGRATED HIS AT THE CENTRAL TEACHING HOSPITAL OF MEDICAL UNIVERSITY OF SILESIA, KATOWICE, POLAND

Patient-oriented modules

Kernel modules

Admission

Discharge

Transfer

Order entry

Stand-alone modules

Radiological modules

Laboratory modules

Pharmacy modules

Hospital-oriented modules

Administrative modules

Finance and billing

Management information and decision support