PACS phase two: If it looks easy, look again

June 12, 2003

We have entered phase two of our department's filmless conversion. Phase one was the transfer of our digital modalities (CT, ultrasound, MRI, nucs) to soft copy. Phase two involves converting our radiographic and fluoroscopic modalities to a soft-copy

We have entered phase two of our department's filmless conversion. Phase one was the transfer of our digital modalities (CT, ultrasound, MRI, nucs) to soft copy. Phase two involves converting our radiographic and fluoroscopic modalities to a soft-copy format. Like most important things in life, if it looks easy and straightforward, look again.

Phase one went better than expected. There is almost no learning curve for reading these modalities on PACS, since we all trained looking at images on the scanner. From day one, PACS made these modalities a breeze.

I assumed that less complex modalities would be easier still, but switching our radiographic modalities to PACS has been a Nor'easter. Like everyone who makes The Transition, I have learned a lot along the way. Warnings are in order.

We converted all our radiographic rooms to computed radiography (CR) over one weekend. This is not the ideal situation, but we had no room for the processing equipment to do both film and CR at the same time. The following week, everyone in the department felt like a trainee again, and we had a lot of really mad clinicians.

Plain films on PACS are very clear, but you quickly realize that either the whole world has gone into pulmonary edema, or the pulmonary interstitium looks different digitally. In fact, a lot of things in the chest look different. I felt pretty stupid having to learn to read a chest x-ray at this point in my career.

I had gone to several PACS courses prior to this change. If they included a lecture on the key differences in digital versus plain-film images and, more important, the artifacts and image variables, I slept through it. Not good. After 20 years, plain-film artifacts and technique variables were intuitive for me. I read right through them, only noticing when a clinician would point one out to ask what it is. CR has a whole new bag of artifacts, and we're learning them the hard way.

If you haven't bought your PACS viewing stations yet, get a catalog from AFC Industries. I saw their variable height table at the RSNA meeting. We ordered three, and they are wonderful. The monitor table and your work/keyboard table have independently variable heights, adjusted at the touch of a button. You can instantly put the monitors at the right height for you. This is important for us geezers with bifocals.

Before installing our system, we debated about the number of monitors at each workstation. Initially, we had two four-bankers and three two-bankers. The four-bank neuro station proved to be overkill, but we're still using a four-banker for our main ER/plain-film station. I'm not sure if we really need four monitors, but it feels more like a standard viewbox, which probably makes the transition to CR easier.

It is amazing how quickly these systems spoil you. Our efficiency has gone up tremendously. I now spend about eight seconds between exams barcoding patient data and pulling up studies. Recently, one of my partners had an extra reading station installed in our ER area. This way, the techs can open multiple studies for him, so he just turns around to the other monitors and starts the next batch of readings. At 150 exams a day, he saves almost 1000 seconds!

Regardless of how much you try to prepare them, clinicians will create a lot more interruptions when you make the change. They come down in droves to go over studies with you. Not because they want your opinion, but simply because you can drive the machine. Oh well, at home or at work, I try to savor any moment when someone acts like I'm needed.

Dr. Tipler is a private-practice radiologist in Staunton, VA. He can be reached by fax at 540/332-4491 or by e-mail at btipler@medicaltees.com.