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Implementation of a Web-based teleradiology management system

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Five Queensland hospitals have been equipped with picture archiving and communication systems (PACS). Patient transfers from one facility to another involve transferring images from PACS to PACS. We have developed a Web-based teleradiology management system (TMS) that automates the transfer of images and radiologists' reports, as well as the quality control and housekeeping associated with teleradiology. The TMS was installed at all five hospitals. During a two-month study period, 752 studies were transmitted. All studies and associated radiologists' reports arrived correctly at the destination hospital, together with the notification email for the system administrators. PACS support personnel agreed that the TMS significantly reduced the amount of time they spent on image transfers. Staff at the busiest site estimated that the time they spent on image transfer had decreased from 10 h per week to 1 h per week.
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Implementation of a Web-based
teleradiology management system
Liam Caffery* and Ken Manthey{
*Department of Medical Imaging, Royal Brisbane and Women’s Hospital, Brisbane; {Department of Medical Imaging,
Princess Alexandra Hospital, Brisbane, Australia
Summary
Five Queensland hospitals have been equipped with picture archiving and communication systems (PACS). Patient transfers
from one facility to another involve transferring images from PACS to PACS. We have developed a Web-based teleradiology
management system (TMS) that automates the transfer of images and radiologists’ reports, as well as the quality control and
housekeeping associated with teleradiology. The TMS was installed at all five hospitals. During a two-month study period,
752 studies were transmitted. All studies and associated radiologists’ reports arrived correctly at the destination hospital,
together with the notification email for the system administrators. PACS support personnel agreed that the TMS significantly
reduced the amount of time they spent on image transfers. Staff at the busiest site estimated that the time they spent on
image transfer had decreased from 10 h per week to 1 h per week.
Introduction
...............................................................................
Picture archiving and communication systems (PACS) have
recently been installed at five Queensland hospitals, namely
the Royal Brisbane and Women’s Hospital (RBWH), the Royal
Children’s Hospital (RCH), the Princess Alexandra Hospital
(PAH), the Prince Charles Hospital (TPCH) and the Townsville
Hospital (TTH); the first four hospitals are located in Brisbane.
All hospitals are now filmless. There are frequent patient
transfers between these hospitals and the need to transfer the
patient’s radiological history when care is transferred from one
facility to another was recognized long before the imple-
mentation of the PACS. Before the PACS this was achieved
by transferring the film packets via courier or post. With the
introduction of filmless hospitals, it became necessary to
transfer images and radiologists’ reports electronically.
The tools provided by the PACS manufacturer can be used to
transfer images from one PACS to another. However, various
problems prevented this being done efficiently:
(1) The patient’s medical record number (MRN) was not
unique across Queensland. Therefore it was necessary to
append the hospital prefix to make the MRN unique
(e.g. PAH123456).
(2) The routing of images is based on the name of the
modality station producing them. It was found to be
impossible to maintain a table of all modalities for all
PACS hospitals that could be used for automatic image
routing. Thus the station name had to be set manually,
before image transfer, to include the hospital name.
(3) The radiologist’s report could not be transferred
electronically from PACS to PACS, and so it was necessary
to print and fax it at the time of image transfer.
(4) For quality control reasons, PACS administrators needed
to notify, by email, their colleague at the receiving
hospital.
(5) Because of the steps required, image transfer could be
performed only during the office hours of the PACS
support unit.
For successful teleradiology to be implemented, it was
necessary to have a means of image transfer that:
(1) automated the manual steps of image transfer, to reduce
the time required of the PACS administrator;
(2) reduced human error in image transfer, so images were
automatically routed to the intended clinical recipient;
(3) allowed transfer of images outside normal office hours.
We have developed and implemented a Web-based
teleradiology management system (TMS) to improve the
teleradiology service.
Methods
...............................................................................
The TMS was installed at the five PACS hospitals and all image
transfers requested by clinicians were dealt with using this
system during March and April 2004. The TMS transferred the
full DICOM image set and the radiologist’s report from PACS
L Caffery and K Manthey Web-based teleradiology management system
Journal of Telemedicine and Telecare 2004; 10 (Suppl. 1): S1:22–25
Correspondence: Liam Caffery, Department of Medical Imaging, Level 3,
Ned Hanlon Building, Royal Brisbane and Women’s Hospital, Herston 4029,
Australia (Fax: +61 7 3636 3064; Email: liam_caffery@health.qld.gov.au)
.....................................................................................................................................................
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to PACS. The existing PACS infrastructure was used to route,
archive and display the images. PACS support personnel at
each site were asked to estimate the reduction in their time
spent on image transfers, compared with using the tools
provided by the vendor.
System overview
The TMS was implemented using a series of Web pages for
both the image transfer and the configuration of the system at
each site. The system performs the following functions:
(1) image transfer;
(2) radiology report transfer;
(3) automatic updating of a patient MRN to create a unique
MRN;
(4) automatic updating of the details necessary for the clinical
routing of images;
(5) email notification for quality control purposes.
The transfer of images can be initiated at a location
remote from the PACS support unit via a Web browser;
this allows other authorized personnel to transfer studies
(Fig 1).
One of the early limitations of electronic transfer of medical
images was a lack of availability of the radiologist’s report on
viewing the studies at the destination facility. To overcome
this limitation, the report text is converted to a DICOM image
when the transfer is initiated. At the time of the image
transfer, an email notification is sent to the destination site
informing the PACS support unit of transfer details, including:
(1) patient details (name, identification number, date of
birth);
(2) study details (accession number, description, number of
images);
(3) contact details (who requested the study).
This allows the PACS support unit to confirm the arrival of
the study and that all images have been received. Each site
configures all destination hospitals on its TMS with details
such as:
(1) description;
(2) DICOM application title;
(3) IP address;
(4) addresses for recipients of email notification messages.
This is done by completing an HTML form on one of the
transfer Web pages (Fig 2). The PACS support units at each site
can thus keep the destination lists up to date. Short-term
changes due to upgrades, system outages and personnel
changes can be accommodated easily.
Technical details
Image delivery takes place via the Queensland Health intranet.
This network connects the health-care sites using ATM
(Asynchronous Transfer Mode) at speeds ranging from 4 Mbit/s
(PAH–TTH) to 155 Mbit/s (PAH–RBWH). Each PACS site has a
core installation comprising an Apache Hypertext Transfer
Protocol (HTTP) server1and the Windows port of Perl by
ActiveState Corporation2. The Apache HTTP server is installed
on an existing PACS computer, which is typically a Pentium III
1 GHz (or greater) PC running the Windows 2000 Professional
operating system.
The TMS comprises Common Gateway Interface (CGI)
scripts written in Perl, Javascript, Cascade Style Sheets (CSS)
and a collection of Perl modules. These include modules for
database functions, Hypertext Markup Language (HTML)
functions, common data conversion functions and a module
to convert the report text to a DICOM image.
Each site is configured with site-specific information,
maintained via CGI scripts. Access to the system is limited to
valid users by username and password authentication. The
transfer CGI script consists of four main parts: image transfer,
L Caffery and K Manthey Web-based teleradiology management system
Journal of Telemedicine and Telecare Volume 10 Supplement 1 2004 S1:23
Fig 1 User interface to the transfers Web page. Fig 2 Method of configuring destination sites.
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report transfer, email notification and update of image details.
When called, the CGI script connects to the PACS system
(Impax 4.5 AGFA) via an Open Database Connectivity (ODBC)
connection and studies are then selected using an HTML form,
which is dynamically generated from the return of all
available studies for a particular patient.
The HTML form allows entry of contact details of the doctor
who requested the image transfer and selection of the
destination site from a drop-down list. The transfer of the
DICOM data-sets is initiated by calling a PACS command line
utility for each study to be transferred. The DICOM fields
‘station name’, ‘institution name’, ‘department name’ and
‘patient ID’ are altered so that the destination PACS site treats
each site as an individual modality for automatic image
routing purposes and ensuring that the patient MRN is
unique.
The transmission of the report text as a DICOM image
follows successful image transfer. The report text for each
study to be transferred is acquired as plain text via an ODBC
connection to the PACS Broker (Mitra). This plain text, along
with patient demographic information, is written to a Portable
Greymap (PGM) image file. The PGM file is then converted to
a DICOM pixel data file using Perl. A DICOM header is
generated for each study, merged with the pixel data and the
resultant DICOM file is transferred to the destination site
using the StoreSCU utility from the Offis DICOM Toolkit
(DCMTK)3.
To complete the image transfer process, an email
notification is automatically sent to the PACS support unit
personnel at the destination site identified in the transfer
configuration CGI script. Successful completion of each step is
noted on the Web page used to perform the transfer (Fig 3).
The workflow between hospitals was audited for the period
1 March to 30 April 2004.
Results
...............................................................................
During the study period, 752 studies were transmitted
between the five sites using the TMS (Table 1).
All 752 studies and associated radiologists’ reports arrived
correctly at the destination hospital, together with the
notification email for the system administrators. The
transmission speeds of 177 studies transferred during a two-
week period were analysed (Table 2). The time taken for
transfer was proportional to the size of the image files.
There was no capital outlay and no recurrent costs for
implementation of the TMS, as all sites installed it on existing
PACS hardware and the software was developed using free-
licence products. PACS support personnel agreed that the TMS
significantly reduced the amount of time they spent on image
transfers. Staff at the busiest site, RBWH, estimated that this
had decreased from 10 h per week to 1 h per week.
Discussion
...............................................................................
Since implementation of the TMS, all images have routed
correctly because of the automatic update of the station name
in the DICOM header of the images. Human error in updating
L Caffery and K Manthey Web-based teleradiology management system
S1:24 Journal of Telemedicine and Telecare Volume 10 Supplement 1 2004
Fig 3 Success messages for a user of the TMS.
Table 1 Total number of studies transferred in March and April
2004 using the TMS
Transfer to:
Transfer from: PAH RBWH/RCH TPCH TTH
PAH 61 11 1
RBWH/RCH 97 287 13
TPCH 36 162 0
TTH 42 42 0 —
PAH, Princess Alexandra Hospital; RBWH, Royal Brisbane and Women’s Hospital;
RCH, Royal Children’s Hospital; TPCH, the Prince Charles Hospital; TTH, the
Townsville Hospital.
Table 2 Image transfer times for a sample of 177 studies
Image transfer time (s)
Studies Minimum Maximum Average
Computerized radiography
(60 studies)
2.3 44.0 11.0
Computerized tomography
(67 studies)
0.5 1.6 0.8
Magnetic resonance (15 studies) 0.5 1.3 0.8
Ultrasound (7 studies) 0.9 1.7 1.2
X-ray angiography (28 studies) 0.7 1.4 1.0
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this field was a significant problem in the previous (manual)
system. The transmission speed was considered acceptable
because the TMS was used in parallel to patient transfers and
not as a realtime teleradiology system. During the study, there
were two periods when image transfers were significantly
delayed. These occurred when the sasser worm and Blaster
virus infected Queensland Health’s intranet.
Clinicians searching the local PACS for transferred images
experienced some confusion because they are recorded under
the sending hospital’s MRN. This has been addressed through
training, and Queensland Health’s plan to implement a
statewide MRN will obviate this confusion in the future. By
making image transfer possible via a simple Web-based user
interface, late-shift radiographers can perform image transfer
with little training. This has allowed after-hours transfer to
occur. Converting the radiologist’s report to a DICOM image
file and attaching it to the corresponding images has
eliminated problems associated with lost faxes.
The implementation of the Web-based teleradiology system
has successfully addressed the problems associated with the
manual transfer of images. It has reduced the staff time
required to perform the transfers, improved accuracy and
allowed a transfer service to be offered after hours.
References
1 Apache Software Foundation. See http://www.apache.org/. Last
checked 7 July 2004
2 Active State. See http://www.activestate.com. Last checked 7 July
2004
3 DCMTK DICOM Toolkit. See http://dicom.offis.de/dcmtk.php.en.
Last checked 7 July 2004
.....................................................................................................................................................
"
Implementation of a radiology information
system/picture archiving and communication
system and an image transfer system at a
large public teaching hospital — assessment
of success of adoption by clinicians
Bernard Crowe* and Lawrence Sim{
*Bernard Crowe and Associates, Canberra; {Princess Alexandra Hospital, Brisbane, Queensland, Australia
Summary
In 2001 a radiology information system/picture archiving and communication system (RIS/PACS) was installed at the
Princess Alexandra Hospital (PAH) in Brisbane, with electronic image transfer links to other major hospitals in Queensland. An
assessment study is being performed of the effect of the ready availability of radiology results on clinicians, clinical decision
making and the time taken to treat patients. A series of structured interviews with senior clinicians at the PAH began in July
2002. Administrative data are being collected from the PAH computer system. Preliminary results from the first six months of
the study suggest that the introduction of the RIS/PACS at the PAH has been well received by senior clinicians and has been
helpful in clinical decision making. Patient management has been improved and the time taken to arrive at clinical decisions
has been reduced, particularly in neurosurgery. The RIS/PACS has significantly improved access to imaging resources for
teaching, owing to the ability to retrieve reference images and to project high-quality images during teaching sessions.
However, the introduction of the RIS/PACS has not reduced patient length of stay.
Introduction
...............................................................................
In 2001 a radiology information system/picture archiving and
communication system (RIS/PACS) was installed at the
Princess Alexandra Hospital (PAH), a large public teaching
hospital in Brisbane. The system provides image transfer links
to other major hospitals in Queensland1. The supporting
information systems at the PAH are mainly those selected on a
state-wide basis by the Queensland Department of Health. The
Department of Health is a large organization, employing some
60,000 staff and providing services to a population of over
3 million. It has tended to take a coordinated approach to the
implementation of hospital computer systems.
B Crowe and L Sim Implementation of an RIS/PACS
Journal of Telemedicine and Telecare 2004; 10 (Suppl. 1): S1:25–27
Correspondence: Mr Bernard Crowe, 10 Warren Place, Chifley, ACT 2606,
Australia (Fax: +61 2 6285 1797; Email: ycrowe@webone.com.au)
at UQ Library on July 7, 2016jtt.sagepub.comDownloaded from
... Reducing duplicate imaging improves the overall health care system efficiency and associated costs [2][3][4][5]8,9]. Technology-enabled models of electronic image sharing include institutional and multi-institutional regional picture archiving and communication systems (PACSs), onsite and offsite vendor neutral archives, cloud-based image transfer, and cross-enterprise document image sharing [10][11][12][13]. The technology environment of a health care organization or a clinical practice (ie, technology infrastructure, storage, and resources) influences the platform availability and channels of access for internal and external imaging studies [7]. ...
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... De esta manera, las imágenes médicas pueden ser accedidas simultáneamente desde distintas ubicaciones. Utilizada de manera apropiada, la teleradiología puede mejorar la interpretación de los estudios y, en consecuencia, mejorar la atención al paciente (Caffery y Manthey, 2004). ...
... The more widespread use of digital images in medical imaging such as digital X-rays, CT, MRI imaging, and the advancement of micro-computer, makes digital image processing a powerful yet feasible and economical analysis choice. With the comprehensive use of the digital Hospital Information System and picture archiving and communication systems (PACS) throughout Australia (Caffery and Manthey, 2004;Crowe and Sim, 2004), digital images can be transferred easily across hospitals, fascinating collaborations as well as information sharing. ...
... Ce type de communication peut être préféré pour la téléexpertise de cas non urgents, laissant à chacun la liberté d'interpréter quand il le peut. Internet peut aussi aider à organiser et synchroniser une chaîne de téléradiologie comportant un nombre important d'acteurs [288]. ...
... 2003), including several projects based within developing nations(Heinzelmann, Jacques, & Kvedar, 2005;Vassallo, Hoque et al., 2001;Vassallo, Swinfen, Swinfen, & Wootton, 2001). Researchers from Australia have focused on improving efficiency and lowering the cost of existing Picture Archiving and Communication Systems (PACS) by utilizing email notification systems and developing software applications using freelicense products(Caffery & Manthey, 2004). However, even with the past successes of store-and-forward telemedicine projects, as of 2004 only 2% of clinicians use email for the purpose of medical consultations(Struber, 2004).Data Transmission. ...
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ResearchGate has not been able to resolve any references for this publication.