Salt Lake City's Primary Children's Medical Center, a pediatric referral hospital serving five states of the Intermountain West -- the largest geographical service area of any U.S. children's hospital -- lists nearly 90 specialty and subspecialty care areas from allergy, asthma, and bone marrow transplant to trauma, urology, and weight control.
PCMC had over 9800 inpatient admissions in 2000. It is affiliated with the University of Utah School of Medicine Department of Pediatrics, enabling patients to benefit from faculty research and clinical expertise.
Founded in 1922 in a private home by the Primary Association of the Church of Jesus Christ of Latter-day Saints, PCMC moved in 1952 to permanent quarters, where it stayed for the next 38 years. Ownership changed in 1975 to the nonprofit Intermountain Health Care, operator of 22 regional hospitals, 24 clinics, and 14 urgent-care stations. It opened the new 232-bed facility adjacent to the University of Utah College of Medicine in 1990 with the goal of one day becoming a filmless hospital.
An Agfa Impax system was installed in stages beginning in 1997.
"The hospital has been filmless since March 1999. First, we installed a mini-PACS (digitizer and three workstations) when we moved to the new hospital in 1990. Then in 1997, we installed the core PACS components, including CR. By 1999, we were filmless in the radiology department, and by March 2000, we were filmless throughout the hospital. One obvious benefit: in 1997 we spent $128,131 on film; in 2000 we spent only $5802." -- Darin Day, PACS Administrator
Paper documents are no longer generated during the admissions process. Instead, information is scanned and stored electronically into the hospital information system. Each patient receiving services at an Intermountain Health Care facility is assigned a unique patient identifier (an EMMI number for enterprise master member index). The EMMI number identifies a single patient throughout the enterprise at any of IHC's hospitals, InstaCares, or clinics. The unique IHC EMMI number and the site-specific accession number, along with other patient demographics, are sent to the PACS broker and used to validate studies as they arrive in the PACS from the modalities.
"The EMMI and accession numbers are an important part of IHC's regional PACS approach, as they provide important database keys that uniquely identify patients within our regional and enterprise PACS systems." -- Darin Day, PACS Administrator
The radiology department at PCMC performed about 63,000 imaging studies in 2000 with these modalities: computed radiography, three ultrasound units, one nuclear medicine camera, one MRI, one CT scanner, two flouroscopy units, and a special procedures lab.
"Our operation is faster with PACS, especially for getting images to neonatal ICU on the fourth floor, the pediatric ICU, the OR, or ER. Rather than us running films around, physicians can just pull images up on a monitor. Some of the radiologists can view from home, which eliminates them having to come in in the middle of the night. PACS has also cut our processing time in half. It used to take about five minutes to process the film. Now we send the picture out electronically in less than two minutes." -- Darin Day, PACS Administrator
"With the CR, the repeat rate has gone down because if your technique is off a little you can adjust it electronically and then send it out. If it's too dark you can lighten it. If it needs more contrast you can do that. The only repeats we have now are for positioning, hardly ever for technique." -- Daren Andrews, Diagnostic Division Manager
"PACS has made the technologists more efficient by eliminating several functions they were previously required to do -- printing film, transporting films to radiology reading sites. We've maintained about the same number of FTEs despite increasing our exam volume by approximately 25% since PACS." -- Dr. Keith White, PCMC radiologist
PCMC has several radiology reading rooms, including two 2K workstations in what used to be the conventional plain film reading room, where two physicians interpret radiographic images. Ultrasound is also interpreted at that site. Two other reading rooms include one dedicated to nuclear medicine and CT, and another for MR interpretation, each with 1K monitors. Image throughput has increased from 49,000 studies before PACS in 1997 to approximately 63,000 in 2000.
"We've increased our workload by 25% with no increase in full-time employees. That in itself shows a lot of productivity. The radiology department attempts to have reports available within five hours." --Darin Day, PACS Administrator
Digital images are available to physicians throughout PCMC through the enterprise-wide PACS. Images are transmitted over an ATM (50 Mbps) network, although a gigabit Ethernet (1 Gbps) conversion is under way. This enterprise-wide image distribution allows physicians anywhere in the hospital to access images from any PC using the system's Web browser.
The hospital also has remote reading stations in critical care units, such as the emergency department, pediatric ICU, and neonatal ICU, all of which are equipped with high-end PACS workstations.
"It took us a few days to become accustomed to the idea of looking at images on screen instead hard copies that we had before, but once we got over the hurdle of learning a new skill, it's been fantastic. We essentially never have a missing image now, which was a constant problem before PACS. We can view the images we want to view much faster, and we can view them directly in the clinic without having to travel down to radiology. I almost never look at images anywhere else. They have sufficient resolution to view them completely up here in our office. The quality of image is ample." -- Dr. Francis Filloux, a neurologist in the pediatric neurology department
"One of the things not fully appreciated is that PACS is a powerful tool for nonradiologists -- for physicians outside the radiology department. PACS has dramatically improved the efficiency of clinicians. Now they spend much less time each day in nonproductive activity, like walking around the radiology department looking for studies." -- Dr. Keith White, PCMC radiologist
"The emergency physicians like it because they can zoom in on detail. Being able to adjust the brightness and contrast- - impossible to do with film -- has changed the way they do business. We give them full-fidelity images, so they're actually finding small fractures that they wouldn't have been able to find before PACS." -- Darin Day, PACS administrator
The image archive on-site at Primary Children's Medical Center contains an external RAID (redundant array of inexpensive disks), plus a 256-platter magneto-optical-drive jukebox. The RAID, which provides immediate three-second access, contains approximately one month of images. The optical jukebox -- the deep archive -- contains another 1 terabyte of data online, equivalent to about 20 months of images. Off-line there's another terabyte of data stored. The organization is in the process of purchasing a second -platter jukebox.
"Archive prefetch protocol pulls the most recent relevant prior, which must be the same body part or organ system imaged on the same modality. In other words, if we have a CT thorax, it's not going to pull the most recent chest x-ray -- it's going to pull the most recent CT thorax." -- Darin Day, PACS Administrator
"Every failure of PACS to do this electronically translates into difficulties for the radiology department, because you have to then have a parallel film-based system in place or you have to have people running the CT scanner turn around and try to figure out how to pull up a study, film it, and do all of that- - it's inefficient. We've developed an in-house solution, a home-grown system called Di-Communicator that we'll be showing at SCAR. Di-Communicator helps us to export images, create teaching files, conference with clinicians, and submit images for research studies. While it will be used primarily in the radiology department, it could be used in other areas of the hospital." -- Dr. Keith White, PCMC radiologist