Matthijs Oudkerk, MD, PhD

Most of the literature on PACS in radiology has focused on the quality and implementation of the systems themselves.(1-9) Other articles have described the use of multiple monitor systems, discussing the optimal number of monitors per PACS workstation(10) or whether LCDs can replace conventional CRT monitors.(11) The prime concern of radiologists, however, is the design of the PACS workstation and how it functions in practice. Some recent articles on this topic(12,13) update earlier publications that evaluated user satisfaction with commercially available workstations.(5,14-16) 

PACS workstations replace the radiologist's light box, and they must provide the same functionality or more. Key requirements must first be defined when establishing workstation quality. Some, such as fast and easy availability of image data, relate to the core of PACS usability. Other requirements refer to the workstation software, including availability of standard viewing capabilities such as window/level and measurement. Finally, the workstation's software must be able to integrate with other software packages and additional resources. Examples include the fast and easy availability of 3D on the desktop, and the ability to use digital speech recording and voice recognition technology. 

An optimal workstation would address all these requirements at a single multiscreen site, with minimal login procedures. Effective integration would spare radiologists from typing (and retyping) information, while flexible access would permit every radiologist to use every workstation. 

Many investigators have opted to build PACS workstations from scratch, designing their own software or even their own hardware.(17,18) We decided to configure our workstation by combining and integrating multiple components already available from different vendors. We selected components to meet the requirements mentioned above. One additional general requirement was the use of Windows/Intel-based software. This choice simplifies the integration of several software packages from multiple vendors in one workstation and allows for the use of commercial off-the-shelf hardware.(19) 

We chose HyperVIEW (Delft Diagnostic Imaging) as our standard PACS viewer. This viewer is marketed by our PACS provider and integrator and works in combination with the Rogan PACS (Rogan Delft) to provide rapid access to patients' complete history.(20) All HyperVIEW workstations are configured using a domain controller that enables centralized distribution of software and settings, while also allowing radiologists to log in to any workstation and obtain their preferred settings automatically. 

The HyperVIEW workstation uses one or two high-resolution, high-luminance black-and-white LCD monitors to display medical images (Planar DOME C3, Planar Systems or Eizo G31, Eizo Nanao). A second color monitor (Eizo R21) is attached to display information from other sources such as the intranet and the electronic patient dossier. 

Three-D viewing requires a color monitor. We decided to implement a server-based 3D viewing solution to meet requirements on speed and availability (AquariusNET, TeraRecon). This means that only a small client application runs at the PACS workstation, and those data are loaded and rendered at a central server. Only resulting images are transferred to the local PACS workstation. The local server database is first checked, and if required data are not available there, they are automatically retrieved from the PACS. 

The reliance on one server for all work has not slowed availability of 3D images. A test of 10 CT data sets (mean size 540 slices) showed mean loading times from the PACS and server database as 67 seconds and four seconds, respectively. 

We have installed digital speech recording and voice recognition on the same workstation. The system we chose also provides server-based operation (ISP, INS Europe). Speech profiles and reports are all stored on the server, enabling radiologists to work at any workstation. Radiologists can stop a dictation on one workstation and commence the same report on another. Voice recognition is also performed on a server. 

Access to additional information from the hospital information system (HIS) is provided by a Web interface (PoliPlus). This provides an interface for laboratory and radiology reports, ECG test results, and so on. Because this interface is a Web-based application, it can be executed from the viewing workstation as well. 

Integration of these components is vital to using their capabilities fully at our workstation. One of the few pieces of paper remaining in the radiological review process is the referral form. We added a barcode containing the patient identification number to each of these forms and attached a barcode scanner to the viewing station. When the barcode is scanned, the patient's history appears on the workstation automatically. 

When a desired data set is loaded into the standard PACS viewer, we can then load the exact same data set into the 3D viewer by pressing one button. At first, this integration worked on patient ID, and radiologists selected the required data set manually from the server using the 3D viewer user interface. We improved integration by rewriting the interface to load data based on the accession number. One click now automatically loads and displays the PACS viewer's current study into the 3D viewer. 

Once image data are presented to the radiologist, a single click on the microphone icon will start a dictation. The system logs into the speech system automatically and starts a new dictation based on the accession number of the viewer's current data set. Dictated reports, when finished, are transferred to the server and processed using voice recognition software according to the specific voice profile.A future issue is adaptation of the RIS to transmit HL7 notices on report status, in order to transform this process into a knowledge-driven integration. The PACS will always "know" the exact status of any report, and any radiologist seeking to dictate a report that has already been dictated will receive a warning to prevent that radiologist from overwriting the previous version. 

Studies that are not archived properly cannot be reported. These could include reports with unknown accession numbers or those with a combination of patient ID and accession number that does not match any combination in the DICOM work list from the RIS. PACS administrative staff must resolve these problems before dictation can start. 

The Web interface that accesses information from other sources is started from within the PACS viewer. No integration is yet available for this application, so radiologists must rescan request barcodes to enter the patient ID. 

Our hospital employs 30 radiologists and trainee radiologists. They have access to 25 workstations, all configured as described above. The radiology department is digital, with the exception of referral forms and final approval of reports. Thus, we are filmless but not entirely paperless. By the end of 2004, the whole hospital will be filmless. 

A hospital-wide project on order management is running at the moment, and a vendor has already been selected. Our department will be participating in the first pilots scheduled to start in March 2005. One of the main advantages of this project will be the introduction of digital referral forms, which will eliminate the use of barcode readers for patient selection. 

Another planned improvement is automatic update of report status from RIS to PACS. All status updates after dictation, correction, and final approval will also be stored in the PACS. Radiologists can then be guided during reporting. The system may, for example, refuse reporting access when a report has already been corrected or give a signal when final approval has been issued. 

Integration between our general information dashboard (PoliPlus) and our PACS viewer is also under development. This will eliminate manual entry of patient information, making workflow much easier. 

Shortcomings in our setup include the multitude of input devices-keyboard, mouse, speech microphone, barcode reader-and the nonoptimal surroundings for many of the reporting sites. A comprehensive study will address these issues over the coming months and guide efforts to attain desirable radiology workspaces. 

Our setup shows that combining different vendors' software and hardware into a single integrated workstation is feasible. This integration between different components is essential and should be a requirement for purchase. Responsibility for this integration should reside with the vendors as much as possible. We have obtained a high level of integration, but improvements are still needed to improve radiologists' working environment. 

DR. VAN OOIJEN is a staff researcher, and PROF. OUDKERK is radiology department head, at Groningen University Hospital in the Netherlands. 

1. Steckel RJ. Current applications of PACS to radiology practice. Radiology 1994;190(3):50A-52A. 

2. Shimamoto K, Yamakawa K, Ishigaki T, et al. Clinical evaluation of newly developed PACS at Nagoya University Hospital. Radiology 1994 (abstract for RSNA meeting);193:175. 

3. Carrino JA, Unkel PJ, Miller ID, et al. Large-scale PACS implementation. J Digit Imaging 1998;11(3 Suppl 1):3-7. 

4. Bick U, Lenzen H. PACS: the silent revolution. Europ Radiol 1999;9(6):1152-1160. 

5. Foord KD. PACS workstation respecification: display, data flow, system integration, and environmental issues, derived from analysis of the Conquest Hospital pre-DICOM PACS experience. Europ Radiol 1999;9(6):1161-1169. 

6. Strickland NH. Hospital wide PACS: the Hammersmith solution. Current state of the art and future trends. In: Siegel EL, Kolodner RM, eds. Filmless radiology. New York: Springer-Verlag, 2001:378-398. 

7. Hayt DB, Alexander S, Drakakis J, Berdebes N. Filmless in 60 days: the impact of picture archiving and communications systems within a large urban hospital. J Digit Imaging 2001;14(2):62-71. 

8. Hirschorn D, Eber C, Samuels P, et al. Filmless in New Jersey: the New Jersey Medical School PACS project. J Digit Imaging 2002; 15(Suppl 1):7-12. 

9. Sacco P, Mazzie MA, Pozzebon E, Stefani P. PACS implementation in a University Hospital in Tuscany. J Digit Imaging 2002;15(Suppl 1):250-251. 

10. Bennett WF, Vaswani KK, Mendiola JA, Spigos DG. PACS monitors: an evolution of radiologists' viewing techniques. J Digital Imaging 2002;15(Suppl 1):171-174. 

11. Reiner B, Siegel E, Hooper F, et al. Effect of screen monitor number on radiologist productivity in the interpretation of portable chest radiographs using a picture archiving and communication system. J Digit Imaging 1997;10(3 Suppl 1):175. 

12. Arenson RL, Chakraborty DP, Seshadri SB, Kundel HL. The digital imaging workstation. J Digital Imaging 2003;16(1):142-162. 

13. Harisinghani MG, Blake MA, Saksena M, et al. Importance and effects of altered workspace ergonomics in modern radiology suites. Radiographics 2004;24(2):615-627. 

14. Honea R, McCluggage CW, Parker B, et al. Evaluation of commercial PC-based DICOM image viewers. J Digital Imaging 1998;11(3 Suppl 1):151-155. 

15. Bazak N, Stamm G, Caldarone F, et al. PACS workstations 2000: evaluation, usability and performance. Presented at 18th international EuroPACS conference, Graz, Austria; September 2000:133-142. 

16. Pollak T, Heuser H, Niederlag G, et al. Evaluation of 7 PC-based diagnostic workstations. Presented at 18th international EuroPACS conference, Graz, Austria; September 2000:114-125. 

17. Tahayori B, Soltanian-Zadeh H, Zoroofi RAZ. A PC-based PACS display workstation with a language transparent interface. J Digital Imaging 2002;15(Suppl 1):206-209. 

18. Kim Y, Fahy JB, DeSoto LA, et al. Development of a PC-based radiological imaging workstation. J Digital Imaging 2003;16(1):104-113. 

19. Wendt G, Peppler W, Edwards W. Proof of commercial off-the-shelf hardware scalability in an on-line clinical PACS. J Digital Imaging 2002;15(Suppl 1):13-14. 

20. van Ooijen PMA, Bongaerts AHH, Oudkerk, M. Everything On-Line (EOL) PACS: A new concept in PACS. Presented at 18th international EuroPACS conference, Graz, Austria; September 2000:77-83. 

Articles

Most of the literature on PACS in radiology has focused on the quality and implementation of the systems themselves. Other articles have described the use of multiple monitor systems, discussing the optimal number of monitors per PACS workstation or whether LCDs can replace conventional CRT monitors. The prime concern of radiologists, however, is the design of the PACS workstation and how it functions in practice. Some recent articles on this topic update earlier publications that evaluated user satisfaction with commercially available workstations.

Integration bolsters workstation design

Most of the literature on PACS in radiology has focused on the quality and implementation of the systems themselves.

 Other articles have described the use of multiple monitor systems, discussing the optimal number of monitors per PACS workstation

 or whether LCDs can replace conventional CRT monitors.11 The prime concern of radiologists, however, is the design of the PACS workstation and how it functions in practice. Some recent articles on this topic

 update earlier publications that evaluated user satisfaction with commercially available workstations.

PACS workstations replace the radiologist's light box, and they must provide the same functionality or more. Key requirements must first be defined when establishing workstation quality. Some, such as fast and easy availability of image data, relate to the core of PACS usability. Other requirements refer to the workstation software, including availability of standard viewing capabilities such as window/level and measurement. Finally, the workstation's software must be able to integrate with other software packages and additional resources. Examples include the fast and easy availability of 3D on the desktop, and the ability to use digital speech recording and voice recognition technology.

An optimal workstation would address all these requirements at a single multiscreen site, with minimal login procedures. Effective integration would spare radiologists from typing (and retyping) information, while flexible access would permit every radiologist to use every workstation.

Many investigators have opted to build PACS workstations from scratch, designing their own software or even their own hardware.

 We decided to configure our workstation by combining and integrating multiple components already available from different vendors. We selected components to meet the requirements mentioned above. One additional general requirement was the use of Windows/Intel-based software. This choice simplifies the integration of several software packages from multiple vendors in one workstation and allows for the use of commercial off-the-shelf hardware.

We chose HyperVIEW (Delft Diagnostic Imaging) as our standard PACS viewer (Figure 1). This viewer is marketed by our PACS provider and integrator and works in combination with the Rogan PACS (Rogan Delft) to provide rapid access to patients' complete history.

 All HyperVIEW workstations are configured using a domain controller that enables centralized distribution of software and settings, while also allowing radiologists to log in to any workstation and obtain their preferred settings automatically.

The HyperVIEW workstation uses one or two high-resolution, high-luminance black-and-white LCD monitors to display medical images (Planar DOME C3, Planar Systems or Eizo G31, Eizo Nanao). A second color monitor (Eizo R21) is attached to display information from other sources such as the intranet and the electronic patient dossier.

Three-D viewing requires a color monitor. We decided to implement a server-based 3D viewing solution to meet requirements on speed and availability (AquariusNET, TeraRecon). This means that only a small client application runs at the PACS workstation, and those data are loaded and rendered at a central server. Only resulting images are transferred to the local PACS workstation. The local server database is first checked, and if required data are not available there, they are automatically retrieved from the PACS.

The reliance on one server for all work has not slowed availability of 3D images. A test of 10 CT data sets (mean size 540 slices) showed mean loading times from the PACS and server database as 67 seconds and four seconds, respectively.

We have installed digital speech recording and voice recognition on the same workstation. The system we chose also provides server-based operation (ISP, INS Europe). Speech profiles and reports are all stored on the server, enabling radiologists to work at any workstation. Radiologists can stop a dictation on one workstation and commence the same report on another. Voice recognition is also performed on a server.

Access to additional information from the hospital information system (HIS) is provided by a Web interface (PoliPlus). This provides an interface for laboratory and radiology reports, ECG test results, and so on. Because this interface is a Web-based application, it can be executed from the viewing workstation as well.

Integration of these components is vital to using their capabilities fully at our workstation (Figure 2). One of the few pieces of paper remaining in the radiological review process is the referral form. We added a barcode containing the patient identification number to each of these forms and attached a barcode scanner to the viewing station. When the barcode is scanned, the patient's history appears on the workstation automatically.

When a desired data set is loaded into the standard PACS viewer, we can then load the exact same data set into the 3D viewer by pressing one button. At first, this integration worked on patient ID, and radiologists selected the required data set manually from the server using the 3D viewer user interface. We improved integration by rewriting the interface to load data based on the accession number. One click now automatically loads and displays the PACS viewer's current study into the 3D viewer.

Once image data are presented to the radiologist, a single click on the microphone icon will start a dictation. The system logs into the speech system automatically and starts a new dictation based on the accession number of the viewer's current data set. Dictated reports, when finished, are transferred to the server and processed using voice recognition software according to the specific voice profile.A future issue is adaptation of the RIS to transmit HL7 notices on report status, in order to transform this process into a knowledge-driven integration. The PACS will always "know" the exact status of any report, and any radiologist seeking to dictate a report that has already been dictated will receive a warning to prevent that radiologist from overwriting the previous version.

Studies that are not archived properly cannot be reported. These could include reports with unknown accession numbers or those with a combination of patient ID and accession number that does not match any combination in the DICOM work list from the RIS. PACS administrative staff must resolve these problems before dictation can start.

The Web interface that accesses information from other sources is started from within the PACS viewer. No integration is yet available for this application, so radiologists must rescan request barcodes to enter the patient ID.

Our hospital employs 30 radiologists and trainee radiologists. They have access to 25 workstations, all configured as described above. The radiology department is digital, with the exception of referral forms and final approval of reports. Thus, we are filmless but not entirely paperless. By the end of 2004, the whole hospital will be filmless.

A hospital-wide project on order management is running at the moment, and a vendor has already been selected. Our department will be participating in the first pilots scheduled to start in March 2005. One of the main advantages of this project will be the introduction of digital referral forms, which will eliminate the use of barcode readers for patient selection.

Another planned improvement is automatic update of report status from RIS to PACS. All status updates after dictation, correction, and final approval will also be stored in the PACS. Radiologists can then be guided during reporting. The system may, for example, refuse reporting access when a report has already been corrected or give a signal when final approval has been issued.

Integration between our general information dashboard (PoliPlus) and our PACS viewer is also under development. This will eliminate manual entry of patient information, making workflow much easier.

Shortcomings in our setup include the multitude of input devices-keyboard, mouse, speech microphone, barcode reader-and the nonoptimal surroundings for many of the reporting sites. A comprehensive study will address these issues over the coming months and guide efforts to attain desirable radiology workspaces.

Our setup shows that combining different vendors' software and hardware into a single integrated workstation is feasible. This integration between different components is essential and should be a requirement for purchase. Responsibility for this integration should reside with the vendors as much as possible. We have obtained a high level of integration, but improvements are still needed to improve radiologists' working environment.

DR. VAN OOIJEN is a staff researcher, and PROF. OUDKERK is radiology department head, at Groningen University Hospital in the Netherlands.

1. Steckel RJ. Current applications of PACS to radiology practice. Radiology 1994;190(3):50A-52A.

2. Shimamoto K, Yamakawa K, Ishigaki T, et al. Clinical evaluation of newly developed PACS at Nagoya University Hospital. Radiology 1994 (abstract for RSNA meeting);193:175.

3. Carrino JA, Unkel PJ, Miller ID, et al. Large-scale PACS implementation. J Digit Imaging 1998;11(3 Suppl 1):3-7.

4. Bick U, Lenzen H. PACS: the silent revolution. Europ Radiol 1999;9(6):1152-1160.

5. Foord KD. PACS workstation respecification: display, data flow, system integration, and environmental issues, derived from analysis of the Conquest Hospital pre-DICOM PACS experience. Europ Radiol 1999;9(6):1161-1169.

6. Strickland NH. Hospital wide PACS: the Hammersmith solution. Current state of the art and future trends. In: Siegel EL, Kolodner RM, eds. Filmless radiology. New York: Springer-Verlag, 2001:378-398.

7. Hayt DB, Alexander S, Drakakis J, Berdebes N. Filmless in 60 days: the impact of picture archiving and communications systems within a large urban hospital. J Digit Imaging 2001;14(2):62-71.

8. Hirschorn D, Eber C, Samuels P, et al. Filmless in New Jersey: the New Jersey Medical School PACS project. J Digit Imaging 2002; 15(Suppl 1):7-12.

9. Sacco P, Mazzie MA, Pozzebon E, Stefani P. PACS implementation in a University Hospital in Tuscany. J Digit Imaging 2002;15(Suppl 1):250-251.

10. Bennett WF, Vaswani KK, Mendiola JA, Spigos DG. PACS monitors: an evolution of radiologists' viewing techniques. J Digital Imaging 2002;15(Suppl 1):171-174.

11. Reiner B, Siegel E, Hooper F, et al. Effect of screen monitor number on radiologist productivity in the interpretation of portable chest radiographs using a picture archiving and communication system. J Digit Imaging 1997;10(3 Suppl 1):175.

12. Arenson RL, Chakraborty DP, Seshadri SB, Kundel HL. The digital imaging workstation. J Digital Imaging 2003;16(1):142-162.

13. Harisinghani MG, Blake MA, Saksena M, et al. Importance and effects of altered workspace ergonomics in modern radiology suites. Radiographics 2004;24(2):615-627.

14. Honea R, McCluggage CW, Parker B, et al. Evaluation of commercial PC-based DICOM image viewers. J Digital Imaging 1998;11(3 Suppl 1):151-155.

15. Bazak N, Stamm G, Caldarone F, et al. PACS workstations 2000: evaluation, usability and performance. Presented at 18th international EuroPACS conference, Graz, Austria; September 2000:133-142.

16. Pollak T, Heuser H, Niederlag G, et al. Evaluation of 7 PC-based diagnostic workstations. Presented at 18th international EuroPACS conference, Graz, Austria; September 2000:114-125.

17. Tahayori B, Soltanian-Zadeh H, Zoroofi RAZ. A PC-based PACS display workstation with a language transparent interface. J Digital Imaging 2002;15(Suppl 1):206-209.

18. Kim Y, Fahy JB, DeSoto LA, et al. Development of a PC-based radiological imaging workstation. J Digital Imaging 2003;16(1):104-113.

19. Wendt G, Peppler W, Edwards W. Proof of commercial off-the-shelf hardware scalability in an on-line clinical PACS. J Digital Imaging 2002;15(Suppl 1):13-14.

20. van Ooijen PMA, Bongaerts AHH, Oudkerk, M. Everything On-Line (EOL) PACS: A new concept in PACS. Presented at 18th international EuroPACS conference, Graz, Austria; September 2000:77-83.