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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. Integrating the Healthcare Enterprise Presentation of Grouped Procedures.

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spiral ct and pacs how to arrange a marriage

Spiral CT and PACSHow to Arrange a Marriage

Gary J. Wendt, MD, MBA

Vice Chair of Informatics

University of Wisconsin - Madison

Department of Radiology

ihe and pgp
IHE and PGP
  • Integrating the Healthcare Enterprise
  • Presentation of Grouped Procedures
what is the clinical problem
What is the Clinical Problem?
  • Multislice CT and high speed MR generate HUGE quantities of images quickly
    • 3000+ Images
    • Too large for virtual memory in a 32 bit operating system
  • Multiple orders and / or requested procedures done in one acquisition
  • Entire exam may not read by one radiologist
  • Clinicians often not interested in entire exam
  • Cant track status of each requested procedure
what is pgp
What is PGP?
  • 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
    • Single CT may consist of CT Head, Chest, Abdomen, Pelvis
    • This is done as one exam acquisition and generates one dataset
university of wisconsin hospital and clinics uw health
University of Wisconsin Hospital and Clinics – UW Health
  • 800 Physicians
  • 30 Radiologists
  • 463 bed main hospital
  • 60 clinics
    • 6 large clinics with digital modalities
  • Over 250,000 exams per year
  • HIS / RIS with Web based EMR and integrated DICOM Modality Worklist
uw pacs history
UW PACS History
  • Incremental approach to PACS implementation
    • US mini-PACS
    • 99 – CR softcopy reading from 2 remote clinics
    • 98-99 – initial evaluation of web interface to digital modalities
uw pacs history1
UW PACS History
  • 99 - 2 new large clinics filmless (except mammo)
  • 99 - 00 - PACS RFP
  • 5/00 - Selected PACS Vendor
    • 2 softcopy workstations for CT/MR
  • 11/00 – Install PACS archives and servers
  • 2000 – Spiral CT
  • 3/01 – 12 Additional diagnostic workstations installed
  • 2001 – Multislice CT
  • 11/02 – 55 Diagnostic workstations
    • Over 150 clinical review workstations
  • 11/02 – 1 Spiral and 7 Multislice CT
slide10

Workflow at the University of Wisconsin - Madison

Web Based EMR

WISCR-IT

HIS/RIS

Siemens

Report Data

Modality Worklist

Dictation &

Electronic Signature

MPPS

HL7 – ADT, orders, reports

Image Data (SC)

CT

GE Lightspeed

PACS

Radiology

and Clinical

ALI / McKesson

PACS

Archive

307 TB

ADIC Scalar 1000

GSPS

PGP

MR

GE Signa

Web Review

Workstations

PACS

Offsite Archive

307 TB

ADIC Scalar 1000

CR – Fuji

DR - GE

Thick Client

Diagnostic

Workstations

US

PACS

Office and

Teaching

UltraVisual

NM

Thin Client

JAVA

Workstations

Mammo

VL

Visible Light

XA/RF

pgp details
PGP Details
  • IHE Template defines
    • Order
    • Requested Procedure
    • Scheduled Procedure
    • Acquisition
    • Store
    • Report
  • This is not a one to one relation
several possible combinations
Several Possible Combinations
  • Non grouped case
  • Grouped acquisition
  • Grouped acquisition with physical split
  • Grouped acquisition with logical split
non grouped case
Non-grouped Case
  • Common in older devices
  • Similar to a film based environment
  • Don’t get benefits of newer devices
grouped acquisition
Grouped Acquisition
  • The real problem child
    • 1000+ image series
    • 3000+ image exams
  • Impossible to deal with in a film environment
  • Difficult to deal with in a radiology department
  • Potentially devastating to electronic enterprise distribution
grouped acquisition with physical split
Grouped Acquisition With Physical Split
  • Potential solution
  • No easy option to modify split if the initial split is wrong
  • Duplicates many images – 120 – 140%
    • 100% - need to store entire original in case the splits were wrong
    • 20-40% for overlap
  • Not easy to review entire exam
grouped acquisition with logical split
Grouped Acquisition With Logical Split
  • The best solution
  • No duplication of images
  • Easy to modify virtual split
    • New GSPS
  • Potential to re-combine multiple virtual splits
what will pgp do for me
What will PGP do for me?
  • Multiple orders and /or requested procedures done in one acquisition
  • Entire exam may not be read by one radiologist
  • Clinicians often not interested in entire exam
  • Enable tracking status of each requested procedure
  • Reduce impact of huge datasets on clinical and system infrastructure
multiple orders and or requested procedures done in one acquisition
Multiple Orders and / or Requested Procedures Done in One Acquisition

A single exam acquisition may consist of several requested procedures

Trauma scan may have head, chest, abdomen, pelvis, spine

Grouping / splitting portion of PGP

Done at modality

Should (Must) be on worklist at time of exam

entire exam may not be read by one radiologist
Entire Exam May Not be Read by One Radiologist
  • Common in academic and large private practices where there are sub-specialists
    • Neuro, body, chest…
  • PGP virtual or physical splits could present a problem with too fine of a granularity
    • Splitting abdomen and pelvis and requiring that each be opened and read separately
    • 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
Clinicians Often Not Interested in Entire Exam
  • 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
Enable Tracking Status of Each Requested Procedure
  • Performed procedure step (PPS) for each requested procedure can now be tracked by the HIS / RIS, PACS and modalities
  • Radiologists know what needs to be read
  • Clinicians can track status of exams – decreases phone / pager tag
reduce impact of huge datasets on clinical and system infrastructure
Reduce impact of huge datasets on clinical and system infrastructure
  • Clinical impact
  • System impact
    • Network
    • Workstation hardware
      • Diagnostic workstations
      • Clinical review workstations
      • Web viewer
barriers to clinical pgp implementation
Barriers to Clinical PGP Implementation
  • PGP requires that worklist entries are present prior to exam
  • Implementation on modality
  • Implementation on PACS
  • RIS support
pgp requires that worklist entries are present prior to exam
PGP Requires that Worklist Entries are Present Prior to Exam
  • Problem with unidentified patients (e.g. trauma patients)
  • Potential solutions
    • Manual entering of orders on RIS
    • Auto generation of predefined set of orders for unidentified trauma patient – cancel orders not done
    • Generation of new orders on modality console
    • Generation of GSPS after the study is sent
manual entry of orders on ris
Manual Entry of Orders on RIS
  • Time consuming
  • Technicians often not prepared or able to enter orders
  • May delay scan
auto generation of predefined set of orders for unidentified patient
Auto Generation of Predefined Set of Orders for Unidentified Patient
  • Have RIS auto generate a “Top 10” entry of orders for trauma or unidentified patients
  • Cancel orders that are not done at a later time (or on the scanner)
  • Minimal user intervention
  • Orders ready before patient gets to scanner
generation of new orders scheduled procedures on modality console
Generation of New Orders / Scheduled Procedures on Modality Console
  • Best solution
  • Radiology workflow is often driven at (or by) the scanners
  • 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
Generation of GSPS After the Study is Sent to the PACS
  • Possible but does little to resolve workflow issues in a trauma environment
implementation on modality
Implementation on modality
  • Prospective – at time images are prescribed on the topogram
  • Retrospective – after axial / spiral images are acquired
  • Separate console – potential add-on for older systems
implementation on pacs
Implementation on PACS
  • Get multiple “In-Box” entries
  • Accession number for each performed procedure
  • All point to same image set
ris support
RIS support
  • Need multiple unique orders for patient
  • DICOM Modality Worklist
uw proposed solution
UW Proposed Solution
  • Integrated selection of images for PGP on scanner console
  • Multiple in-box entries on PACS
  • Worklist from RIS or PACS
vendor partners at uw
Vendor Partners at UW
  • General Electric – CT and MR
  • ALI – PACS, DICOM Worklist
  • Siemens / SMS - RIS
implementation plan
Implementation Plan
  • Define user interface requirements
    • Scanner
    • PACS
  • Vendor implementation
  • Lab to lab testing
  • Preliminary install on one scanner and PACS test server
  • Refine user interface
  • Test RIS vs. PACS Worklist
  • Full production PACS and scanner implementation
current status of pgp implementation at the uw
Current Status of PGP Implementation at the UW
  • Lab to lab testing completed
  • Initial CT scanner install
  • Test PACS system
  • Refine workflow issues
pgp on the ct scanner
PGP on the CT Scanner
  • Select multiple orders on modality worklist
  • Scanner generates MPPS at start and end and groups scans
  • Retrospective generation of GSPS objects to do virtual split
summary
Summary
  • PGP will enable filmless and paperless PACS operation
  • Exam can be effectively read by multiple radiologists
  • Clinicians can access only the parts of the exam they are interested in
  • Enable tracking status of each requested procedure
  • Reduce impact of huge datasets on clinical and system infrastructure
comments and suggestions
Comments and Suggestions
  • Gary Wendt, MD
  • University of Wisconsin - Madison
  • gjwendt@wisc.edu
  • www.radiology.wisc.edu