Spiral CT and PACS How to Arrange a Marriage Gary J. Wendt, MD, MBA Vice Chair of Informatics University of Wisconsin - Madison Department of Radiology

or What is PGP and IHE?

IHE and PGP n Integrating the Healthcare Enterprise n Presentation of Grouped Procedures

What is the Clinical Problem? n Multislice CT and high speed MR generate HUGE quantities of images quickly u Images u Too large for virtual memory in a 32 bit operating system n Multiple orders and / or requested procedures done in one acquisition n Entire exam may not read by one radiologist n Clinicians often not interested in entire exam n Cant track status of each requested procedure

What is PGP? n n IHE definition: Presentation of Grouped Procedures (PGP) provides a mechanism for facilitating viewing images and reporting on individual requested procedures that have been fulfilled by a single acquisition u Single CT may consist of CT Head, Chest, Abdomen, Pelvis u This is done as one exam acquisition and generates one dataset

University of Wisconsin Hospital and Clinics – UW Health n 800 Physicians n 30 Radiologists n 463 bed main hospital n 60 clinics u 6 large clinics with digital modalities n Over 250,000 exams per year n HIS / RIS with Web based EMR and integrated DICOM Modality Worklist

University of Wisconsin Hospital and Clinics – UW Health

UW PACS History n Incremental approach to PACS implementation u US mini-PACS u 99 – CR softcopy reading from 2 remote clinics u – initial evaluation of web interface to digital modalities

UW PACS History u new large clinics filmless (except mammo) u PACS RFP u 5/00 - Selected PACS Vendor F 2 softcopy workstations for CT/MR u 11/00 – Install PACS archives and servers u 2000 – Spiral CT u 3/01 – 12 Additional diagnostic workstations installed u 2001 – Multislice CT u 11/02 – 55 Diagnostic workstations F Over 150 clinical review workstations u 11/02 – 1 Spiral and 7 Multislice CT

Workflow at the University of Wisconsin - Madison CT GE Lightspeed MR GE Signa CR – Fuji DR - GE US NM Mammo VL Visible Light XA/RF HIS/RIS Siemens Modality Worklist MPPS PACS Radiology and Clinical ALI / McKesson PACS Archive 307 TB ADIC Scalar 1000 PACS Offsite Archive 307 TB ADIC Scalar 1000 PACS Office and Teaching UltraVisual Thick Client Diagnostic Workstations Web Review Workstations Thin Client JAVA Workstations GSPS PGP Image Data (SC) Dictation & Electronic Signature Report Data HL7 – ADT, orders, reports Web Based EMR WISCR-IT

PGP Details n IHE Template defines u Order u Requested Procedure u Scheduled Procedure u Acquisition u Store u Report n This is not a one to one relation

Several Possible Combinations n Non grouped case n Grouped acquisition n Grouped acquisition with physical split n Grouped acquisition with logical split

Non-grouped Case n Common in older devices n Similar to a film based environment n Don’t get benefits of newer devices

Grouped Acquisition n The real problem child u image series u image exams n Impossible to deal with in a film environment n Difficult to deal with in a radiology department n Potentially devastating to electronic enterprise distribution

Grouped Acquisition With Physical Split n Potential solution n No easy option to modify split if the initial split is wrong n Duplicates many images – 120 – 140% u 100% - need to store entire original in case the splits were wrong u 20-40% for overlap n Not easy to review entire exam

Grouped Acquisition With Logical Split n The best solution n No duplication of images n Easy to modify virtual split u New GSPS n Potential to re-combine multiple virtual splits

What will PGP do for me? n Multiple orders and /or requested procedures done in one acquisition n Entire exam may not be read by one radiologist n Clinicians often not interested in entire exam n Enable tracking status of each requested procedure n Reduce impact of huge datasets on clinical and system infrastructure

Multiple Orders and / or Requested Procedures Done in One Acquisition n A single exam acquisition may consist of several requested procedures u Trauma scan may have head, chest, abdomen, pelvis, spine n Grouping / splitting portion of PGP u Done at modality u Should (Must) be on worklist at time of exam

Entire Exam May Not be Read by One Radiologist n Common in academic and large private practices where there are sub-specialists u Neuro, body, chest… n PGP virtual or physical splits could present a problem with too fine of a granularity u Splitting abdomen and pelvis and requiring that each be opened and read separately u Virtual splits would be easiest to solve by combining the GSPS objects and opening multiple virtual splits as one larger combined exam

Clinicians Often Not Interested in Entire Exam n The orthopedic surgeon does not want to wait for and look at the first 2000 images of the head, chest, abdomen… to find the 50 images of the fractured hip

Enable Tracking Status of Each Requested Procedure n Performed procedure step (PPS) for each requested procedure can now be tracked by the HIS / RIS, PACS and modalities n Radiologists know what needs to be read n Clinicians can track status of exams – decreases phone / pager tag

Reduce impact of huge datasets on clinical and system infrastructure n Clinical impact n System impact u Network u Workstation hardware F Diagnostic workstations F Clinical review workstations F Web viewer

Barriers to Clinical PGP Implementation n PGP requires that worklist entries are present prior to exam n Implementation on modality n Implementation on PACS n RIS support

PGP Requires that Worklist Entries are Present Prior to Exam n Problem with unidentified patients (e.g. trauma patients) n Potential solutions u Manual entering of orders on RIS u Auto generation of predefined set of orders for unidentified trauma patient – cancel orders not done u Generation of new orders on modality console u Generation of GSPS after the study is sent

Manual Entry of Orders on RIS n Time consuming n Technicians often not prepared or able to enter orders n May delay scan

Auto Generation of Predefined Set of Orders for Unidentified Patient n Have RIS auto generate a “Top 10” entry of orders for trauma or unidentified patients n Cancel orders that are not done at a later time (or on the scanner) n Minimal user intervention n Orders ready before patient gets to scanner

Generation of New Orders / Scheduled Procedures on Modality Console n Best solution n Radiology workflow is often driven at (or by) the scanners n Would require HIS/RIS vendors to acknowledge that they are not the center of the universe

Generation of GSPS After the Study is Sent to the PACS n Possible but does little to resolve workflow issues in a trauma environment

Implementation on modality n Prospective – at time images are prescribed on the topogram n Retrospective – after axial / spiral images are acquired n Separate console – potential add-on for older systems

Implementation on PACS n Get multiple “In-Box” entries n Accession number for each performed procedure n All point to same image set

RIS support n Need multiple unique orders for patient n DICOM Modality Worklist

UW Proposed Solution n Integrated selection of images for PGP on scanner console n Multiple in-box entries on PACS n Worklist from RIS or PACS

Vendor Partners at UW n General Electric – CT and MR n ALI – PACS, DICOM Worklist n Siemens / SMS - RIS

Implementation Plan n Define user interface requirements u Scanner u PACS n Vendor implementation n Lab to lab testing n Preliminary install on one scanner and PACS test server n Refine user interface n Test RIS vs. PACS Worklist n Full production PACS and scanner implementation

Current Status of PGP Implementation at the UW n Lab to lab testing completed n Initial CT scanner install n Test PACS system n Refine workflow issues

PGP on the CT Scanner n Select multiple orders on modality worklist n Scanner generates MPPS at start and end and groups scans n Retrospective generation of GSPS objects to do virtual split

PGP on the CT Scanner

Example of PGP In-Box

Abdomen

Chest

Full Exam

Save Presentation State on Workstation – While Reading Exam

Save Presentation State on Workstation – As Exam Close

Summary n PGP will enable filmless and paperless PACS operation n Exam can be effectively read by multiple radiologists n Clinicians can access only the parts of the exam they are interested in n Enable tracking status of each requested procedure n Reduce impact of huge datasets on clinical and system infrastructure

Comments and Suggestions n Gary Wendt, MD n University of Wisconsin - Madison n n