Physicians at Brooke Army Medical Center see MDIS as precursor to larger PACS

Physicians at Brooke Army Medical Center see MDIS as precursor to larger PACS

Army's consulting radiologist has ambitious plans for PACS links

The U.S. military is finding that PACS can play a major role in helping reduce cost, boost efficiencies, and improve quality of patient care in hospital operations, according to physicians at Brooke Army Medical Center in Fort Sam Houston, near San Antonio. As one of the first sites in the military's Medical Diagnostic Imaging Support (MDIS) project, Brooke has been a proving ground for many of the theories used to support PACS implementation. And on the whole, radiologists at Brooke would rate their experience with PACS an unqualified success.

Indeed, PACS industry observers curious about the military's intentions toward PACS can look to Brooke for a glimpse of the future. Based on the Brooke experience, it seems likely that the military is prepared to spend millions implementing the next stage of PACS, the Defense Imaging Network-Picture Archiving and Communications Systems (DIN-PACS).

Brooke was one of the first hospitals slated by the Department of Defense to receive an MDIS installation when the contract was awarded in 1992 to Loral and its partner, Siemens Medical Systems. Clinicians at Brooke began considering PACS in the late 1980s, after analyzing the patient-care demands the hospital would come under in future years and the resources those demands might require, according to Col. Michael Cawthon, assistant chairman of radiology at the hospital. These demands included timely image and report delivery and adequate film archives. After some analysis, however, the hospital found that it would have to boost staffing to unacceptable levels in some key areas to provide such services.

"We had two file-room clerks," Cawthon said. "Some people said we'd need 22 or 23 file-room clerks to provide the services we wanted to provide."

Brooke saw PACS as a way out of its dilemma, and began to participate in the MDIS acquisition process in 1989. Work was interrupted in 1991 by the Persian Gulf War, but the hospital was named one of the first MDIS sites after the war ended. Brooke's PACS network was originally installed when the hospital was located in an older building, then was moved to a new 450-bed facility that opened in March 1996.

Impact of PACS

A tour of the hospital finds several interesting anomalies caused by Brooke's adoption of PACS. Because the building was designed before the PACS network was installed, it was built with a film archive room that is about three times larger than the hospital's needs. The extra space is used for offices. The calm, uncluttered atmosphere at Brooke also belies the high level of activity at the facility, according to Cawthon. In the old days, the hospital's halls would be crowded with file clerks transporting films. Those duties are now handled by the facility's computer network.

Brooke has about 124 diagnostic and clinical workstations installed throughout the facility. The central reading room consists of six workstations, each in a four-monitor 2K x 2.5K configuration. Clinicians at Brooke estimate that the facility is about 90% filmless, with Fuji computed radiography used to digitize conventional x-ray studies. Images are archived to a short-term RAID archive until patients are discharged or for a length of time determined by clinicians, while a Kodak 2-terabyte optical disk jukebox is used for long-term storage.

Mammography is the only modality that is not filmless, although Brooke is a beta site for Fischer Imaging's SenoScan full-field digital mammography unit. Ultrasound networking is handled using Acuson's Aegis system, connected to MDIS via a gateway, while the facility uses the military's CHCS information system rather than a commercial HIS. One of the most difficult aspects of Brooke's PACS implementation was integrating MDIS with CHCS, which was developed years ago, before the use of SQL databases.

The only teleradiology link Brooke has implemented thus far is with Wilford Hall Medical Center, a 1000-bed facility 22 miles away. The DOD is encouraging military facilities to eliminate duplicate services, so Brooke and Wilford Hall each are specializing in services that are eliminated by the other hospital. Brooke has ambitious plans to add additional links, however.

Some of Brooke's major concerns in implementing PACS included workstation technology and image compression, according to Cawthon. Workstation functionality was vital, and Brooke's radiologists wanted viewing algorithms that were modifiable according to their preferences. As for compression, Brooke settled on 10:1 lossy compression for CR images, he said.

For the most part, Brooke has been very satisfied with its PACS, in particular the system's reliability, Cawthon said. The core network is up 99.5% of the time, with the longest down time lasting about two hours. There are three GE Medical Systems engineers on site, with seven support people in San Antonio. GE inherited the Brooke PACS network after it bought Lockheed Martin, Loral's successor, in April (PNN 5/97).

PACS is also saving Brooke a considerable sum in healthcare expenditures. The hospital is saving $750,000 a year on film costs alone. When adding in labor and other costs, the amount Brooke is saving runs into the millions, according to Col. Anna Chacko, chief of radiology at Brooke.

Virtual radiology department

The military's positive experience with MDIS has prompted the Army to look at a broader implementation of PACS, according to Chacko. The Army is considering the implementation of a "virtual radiology department," in which an imaging study acquired at one Army facility can be interpreted at any other facility in the Army's network, be it across the hospital or across the globe. As the Army's designated consultant on radiology issues, Chacko is in a good position to make that happen.

"We've been asked to downsize and become more efficient," Chacko said. "We've come up with an idea that is going to help us do that: to have a virtual radiology environment, and have a complete network that straddles the whole globe, wherever our troops are and wherever our beneficiaries are, so that we can read our exams anytime, anywhere."

One of the greatest technical challenges to such a project would be the establishment of a computer network large enough to handle its volume, but the Department of the Army already has a network in place with sufficient bandwidth, Chacko said. Another project that has not yet been implemented is the development of an intelligent database that is capable of managing the work-flow of radiologists spread across such a broad geographic area. A central credentialing procedure for radiologists would also be required.

The Army has established a technology assessment committee to examine the imaging services needs of smaller facilities, and how they can be integrated in hub-and-spoke fashion with larger centers like Brooke. The next step would be installing PACS at these sites and connecting them to the Army's network. Chacko hopes to have the entire virtual radiology department in place by 1999.

PACS networks installed as part of this initiative would be acquired using DIN-PACS specifications, Chacko said. Brooke's experience with MDIS has been positive, but PACS technology has advanced since then to such a degree that the DOD wanted a more modern system (PNN 6/97). MDIS, for example, is a proprietary system, while DIN-PACS specifications require the use of off-the-shelf hardware.

Despite some MDIS-bashing that has occurred in the private sector, it is the Army's experience with the project that has prompted the military to pursue further applications of PACS, with the goal of establishing the enterprise-wide, geographically distributed network that is the technology's Holy Grail.

"I don't think anyone should have a film-based system at this point, because the amount of money that you save and the value to healthcare is so great," Chacko said. "I'm a complete convert. The value to healthcare is so great that anything else would be folly."

Brooke Army Medical Center
Fort Sam Houston, TX
3851 Roger Brooke Drive
Fort Sam Houston, TX 78234-6200
Phone: 210/916-4218
Fax: 210/916-5193

Key personnel:
Col. Anna Chacko, M.D., chair, department of radiology
Col. Michael Cawthon, assistant chair

Number of beds: 450

PACS vendor:
GE Medical Systems (formerly Lockheed Martin/Loral)

Year PACS installed: 1992

Cost of installation: $12 million

Percent filmless: 90%

Number of workstations: 124

Teleradiology links:

Wilford Hall Medical Center, San Antonio