TELERADIOLOGY Networks

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TELERADIOLOGY Networks
Supporting PACS Teleradiology In A State-Wide
Virtual Radiology Environment 2001 Indian Health
Service Technology and Support Conference Albuquer
que, NM Denver A. Lodge M.E., CCE Alaska Native
Tribal Health Consortium Alaska Clinical
Engineering Services
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Alaska Native Medical CenterImaging Services

• 150 Bed
• gt50,000 Radiology Exams / Year

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Alaska is Teleradiology Country
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Alaska is Teleradiology Country

• Great Distances

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Alaska is Teleradiology Country

• Great Distances
• Routine Need for Orthopedic and
• Radiographic Consults

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Alaska is Teleradiology Country

• Great Distances
• Routine Need for Orthopedic and
• Radiographic Consults
• Proven Technology Is Available
• Ideal for Virtual
  Radiology Environment

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TELERADIOLOGY

• DEFINED
• A Teleradiology System acquires, transmits,
  archives, and displays Diagnostic or Clinical
  Images between two or more sites.

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STATE-WIDE VIRTUAL
RADIOLOGYENVIRONMENT

• DEFINED
• Technology which enables provision of efficient
  remote Radiology Services throughout the state by
  links to multiple healthcare facilities via
  teleradiology.

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Alaska Federal Healthcare Partnership State-Wide
Virtual Radiology Environment
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• P icture
• A rchive
• C ommunication
• S ystem

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• P icture
• A rchive
• C ommunication
• S ystem

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• Image Acquisition
• Acquisition Technique
• Arriving at a Digital Image

• P icture

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Digital Image Acquisition Devices

• Computed Radiography
• Digital Fluoroscopy (GI, Angio)
• Digital C-Arm
• CT Scan
• MR Scan
• Nuclear Med
• Ultrasound
• Digitized Film

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Digital Image Acquisition Devices

• Computed Radiography
• Digital Fluoroscopy (GI, Angio)
• Digital C-Arm
• CT Scan
• MR Scan
• Nuclear Med
• Ultrasound
• Digitized Film

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Digital Image Acquisition Devices

• Computed Radiography
• Digital Fluoroscopy (GI, Angio)
• Digital C-Arm
• CT Scan
• MR Scan
• Nuclear Med
• Ultrasound
• Digitized Film

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Digital Image Acquisition Devices

• Computed Radiography
• Digital Fluoroscopy (GI, Angio)
• Digital C-Arm
• CT Scan
• MR Scan
• Nuclear Med
• Ultrasound
• Digitized Film

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Digital Image Acquisition Devices

• Computed Radiography
• Digital Fluoroscopy (GI, Angio)
• Digital C-Arm
• CAT Scan
• MR Scan
• Nuclear Med
• Ultrasound
• Digitized Film

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Digital Image Acquisition Devices

• Computed Radiography
• Digital Fluoroscopy (GI, Angio)
• Digital C-Arm
• CT Scan
• MR Scan
• Nuclear Medicine
• Ultrasound
• Digitized Film

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Digital Image Acquisition Devices

• Computed Radiography
• Digital Fluoroscopy (GI, Angio)
• Digital C-Arm
• CT Scan
• MR Scan
• Nuclear Medicine
• Ultrasound
• Digitized Film

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Digital Image Acquisition Devices

• Computed Radiography
• Digital Fluoroscopy (GI, Angio)
• Digital C-Arm
• CT Scan
• MR Scan
• Nuclear Medicine
• Ultrasound
• Digitized Film

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• Image Acquisition
• Acquisition Technique
• Arriving at a Digital Image
• Image Display
• Spatial Resolution
• Diagnostic (2Kx2.5Kx12-Bit)
• Clinical (1.5Kx2Kx12-Bit)
• Monitor Calibration
• Monochrome
• Color

• P icture

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• P icture
• A rchive
• C ommunication
• S ystem

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• A rchive

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Digital Archival Devices

• Short-Term Digital Image Storage
• Information Storage Unit (ISU) Sun Solaris UNIX
• Image Management System (IMS) GE Vantage
• Redundant Array of Inexpensive Disks (RAID) 64GB

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Digital Archival Devices

• Long-Term Digital Image Storage
• Archive Controller
  Write Once / Read Many (WORM)
• Archive Optical Disk Jukebox (ODJ)
• 100 14-Inch Optical Platters (1.5 TeraByte)

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• P icture
• A rchive
• C ommunication
• S ystem

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• A nd
• C ommunication
• S ystem

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Communication System

• Network
• Physical Interconnectivity
• Copper Cat 5 (UTP) - 100Mbps Ethernet
• Glass Fiber Optics - Sun RAID Fiber (SuRF)
  200 Mbps FDDI

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Communication System

• Network
• Physical Interconnectivity
• Copper Cat 5 (UTP)
• Glass Fiber Optics
• Functional Interoperability
• HL-7 Informatics
• Broker
• DICOM Images
• Gateways

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Communication System

• Hospital Information System (HIS)
• Patient Demographics
• Name
• Age
• Date of Birth
• Sex
• Address
• Allergies
• Identification
• Number

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Communication System

• Radiology Information System (RIS)
• Exam Order (Radiology Order Entry)
• Exam Scheduling
• Indication for Exam
• Referring Physician
• Old Exams and Reports
• Technologist ID
• RIS/PACS Broker
• DICOM Worklist
• Mini-PACS vs. PACS

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ANMC PACS Components

• 3 Digital R/F Rooms
• 3 Ultrasound Scanners w/KiNetDx Mini-PACS
• 2 C-Arms
• 1 CT 1 MRI Scanner
• 3 CR Image Plate Readers
• 7 4A Diagnostic Display Work Stations
• 36 2B Clinical Display Work Stations
• 3 QA Work Stations
• 13 Home Consultation Telerad Work Stations

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PACS OPERATIONS SYSTEMS SUPPORT TEAM

• Imaging Services
• Radiologists
• Manager
• Technologists
• Clerical Support
• Clinical Engineering
• Clinical Engineer / Systems Administrator
• Biomedical Equipment Technicians
• (Imaging Specialists)
• Information Resource Management
• Network Admin - LAN HIS/RIS Support

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AFHP Teleradiology Project( Wide-Area PACS )

• Hub
• ANMC
• Spokes
• Barrow
• Bethel
• Dillingham

• Fairbanks
• Juneau
• Ketchikan
• Kodiak
• Kotzebue
• Nome
• Sitka

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AFHP Teleradiology Plan
Phase I - Pilot Project Dillingham, Alaska
(450,000)
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AFHP Teleradiology Plan
Phase I - Pilot Project Dillingham, Alaska
(450,000) Phase II - 9 Sites Barrow, Bethel
Dillingham, Juneau, Ketchikan, Kodiak, Kotzebue,
Nome, Sitka (2.2M)
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AFHP Teleradiology Plan
Phase I - Pilot Project Dillingham, Alaska
(450,000) Phase II - 9 Sites Barrow, Bethel
Dillingham, Juneau, Ketchikan, Kodiak, Kotzebue,
Nome, Sitka (2.2M) Phase III - 33 More Sites
(6.8M)
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AFHP Teleradiology Plan
Phase III - FY2001 More Equipment For Sitka,
Klowak, Haines, Fairbanks, Tanana, Galena,
McGrath, St. Paul, Dillingham
(2.2M)
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TELERADIOLOGY SYSTEMS SUPPORT TEAM

• Imaging Services
• Radiologists
• Manager
• Technologists
• Clerical Support
• Clinical Engineering
• Clinical Engineer / Systems Administrator
• Teleradiology Network Engineers
• Information Resource Management
• HIS/RIS Support Technicians
• Network Administrator - WAN

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TELERADIOLOGY SYSTEMS SUPPORT TEAM

• Imaging Services
• Radiologists
• Manager
• Technologists
• Clerical Support
• Clinical Engineering
• Clinical Engineer / Systems Administrator
• Teleradiology Network Engineers
• Information Resource Management
• HIS/RIS Support Technicians
• Network Administrator - WAN

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Philosophy Expertise Needed for PACS /
Teleradiology Support

• TO TUNE ... or
• Typical Information Systems Network
  Engineer
• OS NOS
• Breadth of Knowledge (Familiarity with OS/NOS)
• Depth of Knowledge (involvement in optimizing
  or tuning system parameters)

• NOT TO TUNE TITQ?
• Clinical Engineer (PACS Systems Admin) or
  Teleradiology Network Engineer
• OS1 OS2 OS3 NOS1 NOS2 NOS3
• Systems Configuration
  
  
  
  
  Troubleshooting

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ANMC PACS Teleradiology Components

• Server Operating Systems
• Sun Solaris UNIX
• Apple Macintosh
• Microsoft Windows
• DEC VMS
• IBM OS2 Warp
• Databases
• Sybase
• Informix
• Microsoft SQL Access
• Image Acquisition
• GE Medical
• Fuji
• Acuson
• Lumisys

• Teleradiology / Compression
• EMed / Aware Wavelet
• Image Storage
• Sun Raid Fiber
• Kodak Sys 2000 ODJ
• Liebert UPS
• Interfacing / Gateways
• Analogic SD-100
• Dejarnette IM1000
• DEC Alpha RIF
• Mitra Broker
• High-Resolution Displays
• Megascan
• DataRay
• Barco
• Richardson

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Alaska Federal Healthcare Partnership State-Wide
Virtual Radiology Environment
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AFHP TELERADIOLOGY
What we have achieved to date - Expanded
Virtual Radiology Environment - Regional
Referral / Regional Hubs (4)




- Increased Services (
12,000/Yr)



- Reduced
Turn-Around Times









From 9-21
Days



To lt
24 Hours
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IMPLEMENTIING PACS
TELERADIOLOGY

• Observations
• Conclusions
• Lessons Learned ...

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PACS Implementation Lessons Learned

• PACS is a System, NOT a Modality
• Cant instantly go filmless
  or get to all softcopy
  interpretation
• Example MR Hanging Protocols

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PACS Implementation Lessons Learned

• PACS is a System, NOT a Modality
• Cant instantly go filmless
  or get to all softcopy
  interpretation
• Example MR Hanging Protocols
• Affects all patient care departments

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PACS Implementation Lessons Learned

• PACS is a System, NOT a Modality
• Cant instantly go filmless
  or get to all softcopy
  interpretation
• Example MR Hanging Protocols
• Affects all patient care departments
• Expensive technology, however price is dropping
• Example Cost of diagnostic workstations

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PACS Implementation Lessons Learned

• PACS is a System, NOT a Modality
• Cant instantly go filmless
  or get to all softcopy
  interpretation
• Example MR Hanging Protocols
• Affects all patient care departments
• Expensive technology, however price is dropping
• Example Cost of diagnostic workstations
• Doesnt improve Radiologist efficiency -
  but rather - overall Physician efficiency

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PACS Implementation Lessons Learned

• PACS is a System, NOT a Modality
• Cant instantly go filmless
  or get to all softcopy
  interpretation
• Example MR Hanging Protocols
• Affects all patient care departments
• Expensive technology, however price is dropping
• Example Cost of diagnostic workstations
• Doesnt improve Radiologist efficiency -
  but rather - overall Physician efficiency
• Identify performance and uptime expectations
  for the whole facility or health system (24x7?)

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PACS Implementation Lessons Learned

• PACS is a System, NOT a Modality
• Cant instantly go filmless
  or get to all softcopy
  interpretation
• Example MR Hanging Protocols
• Affects all patient care departments
• Expensive technology, however price is dropping
• Example Cost of diagnostic workstations
• Doesnt improve Radiologist efficiency -
  but rather - overall Physician efficiency
• Identify performance and uptime expectations
  for the whole facility or health system (24x7?)
• Usually dealing with a multi-vendor environment
• Finger-pointing slows troubleshooting process

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Teleradiology Implementation Lessons
Learned

• Proven Technology, But ...
• Diagnostic digital images?
• Image Quality (Digitized or CR)?
• Proprietary or DICOM output?
• Compressed or Uncompressed?

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Teleradiology Implementation Lessons
Learned

• Proven Technology, But ...
• Diagnostic digital images?
• Image Quality (Digitized or CR)?
• Proprietary or DICOM output?
• Compressed or Uncompressed?
• Know your E-Business Plan
• Do you have a Radiologist?
• Patient referral pattern / Regional image
  archives
• Ongoing Cost of Bandwidth (gt56Kbps Frame Relay)
• Identify regional value-added services
  (dont loose business to someone
  else)

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Teleradiology Implementation Lessons
Learned

• Proven Technology, But ...
• Diagnostic digital images?
• Image Quality (Digitized or CR)?
• Proprietary or DICOM output?
• Compressed or Uncompressed?
• Know your E-Business Plan
• Do you have a Radiologist?
• Patient referral pattern / Regional image
  archives
• Ongoing Cost of Bandwidth (gt56Kbps Frame Relay)
• Identify regional value-added services
  (dont loose business to someone
  else)
• Work flow re-engineering
• Clerical Steps or Integration? (avoid triple
  data-entry)
• Need to print films locally?

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PACS / Telerad Implementation
Lessons Learned

• Before Making A Selection
• Shop around!
• Make many site visits
• Ask for on-site demonstrations
• Ask lots of questions
• Hire a consultant
  (one whos been over the road
  before)
• Designate an on-site Project Manager
• Write a good System Specification or Scope
• Use a Request for Proposal (RFP)
• Insist on scalability (go filmless by modality)
• Insist on redundancy (always have a back-up)

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PACS / TELERAD FUNDING SUPPORT

• It Takes A Village
• A system, not modality
• Use a team approach
• Acquisition
• Capital Purchase
• Lease / Purchase
• Lease - Application Service Provider (ASP)
• Maintenance
• Service Contracts
• Shared Maintenance
• Staff Train

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PACS / TELERADIOLOGY ACQUISITION TEAM

• Imaging Services
• Radiologist
  (Physician Champion)
• Rad Tech (Work Flow)
• Clinical Engineering
• Clinical Engineer (Systems Administrator)
• Biomedical Equipment Technicians (Hardware)
• Radiological Physicist (Image Quality)
• Information Resource Management
• CIO (Administrative Support)
• Network Administrator
  (Bandwidth / Network Performance)

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PACS / TELERADIOLOGY Ongoing Maintenance Issues

• Diagnostic Display Image Quality Assurance
• Routine monitor luminescence calibration
• Routine monitor color calibration
• Monitor replacement service (gt50,000/WS)

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PACS / TELERADIOLOGY Ongoing Maintenance Issues

• Diagnostic Display Image Quality Assurance
• Routine monitor luminescence calibration
• Routine monitor color calibration
• Monitor replacement service (gt50,000/WS)
• Archive Obsolescence / Media Transition Plan
• Monitoring remaining storage space
• Archive hardware or media obsolescence
• Data conversion / transfer plan

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PACS / TELERADIOLOGY Ongoing Maintenance Issues

• Diagnostic Display Image Quality Assurance
• Routine monitor luminescence calibration
• Routine monitor color calibration
• Monitor replacement service (gt50,000/WS)
• Archive Obsolescence / Media Transition Plan
• Monitoring remaining storage space
• Archive hardware or media obsolescence
• Data conversion / transfer plan
• Network Infrastructure
• Increase or prioritization of bandwidth

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PACS / TELERADIOLOGY Ongoing Maintenance Issues

• Diagnostic Display Image Quality Assurance
• Routine monitor luminescence calibration
• Routine monitor color calibration
• Monitor replacement service (gt50,000/WS)
• Archive Obsolescence / Media Transition Plan
• Monitoring remaining storage space
• Archive hardware or media obsolescence
• Data conversion / transfer plan
• Network Infrastructure
• Increase or prioritization of bandwidth
• System Stability (Software Updates, Revisions,
  Upgrades !!!)

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TELERADIOLOGY Networks
Supporting PACS Teleradiology In A State-Wide
Virtual Radiology Environment 2001 Indian Health
Service Technology and Support Conference Denver
A. Lodge M.E., CCE Alaska Native Tribal Health
Consortium Alaska Clinical Engineering Services
THE END