# Solutions

Introduction to problem solving

Designing a customized solution to the problems presented in a particular installation is what we do. Our approach to the problem solving and the modules we have developed has its background in my physics training at MIT. Anyone who has gone through third year advanced physics has heard of the Shrodinger wave equation.

A Shrodinger wave equation is the solution to fit certain boundary conditions. When presented with a potential well with a flat bottom, the student can solve the equation explicitly to solve those boundary conditions. However, if you put a small bump, a little raised area, in the bottom of the well, it is impossible to solve the equation to satisfy those conditions. What does the student do then?

The student breaks the problem into two smaller problems, one with the well with a flat bottom, the the other with only the small bump. The equation can be solved for each of those sets of boundary conditions without problem. The student then adds the two equations together to get a solution for the well with the bump.

The lesson here is…

If a problem is too big to solve as a whole, break it up into smaller problems and solve them, then put all the solutions together to solve the big problem.

That approach to problem solving is the basis for the development of our modular PACS. We have developed over 15 different modules that can be applied, or applied with some modification, to solve the different parts of any problem, no matter how big. In addition, because each of the modules is small and has specific functions, it is easier to make modifications to them and still have robust products than if the modules were large and complicated.

Some of the modules are going to be larger to begin with because there is a lot of functionality that must be present. Our ViewBox diagnostic workstation is a large, complex module. However, it has in it a basic viewer module for handling, displaying, and manipulating images (internally called DICOM panel) that is a separate module by itself. This DICOM panel is also used in other viewer modules such as ConnectWeb and the CD Browser software burned to a CD along with a study. In this way all our viewer products have the same basic look and feel, and any enhancements in DICOM panel are automatically propagated through all the viewer modules.

Case studies – examples of problem solving

The case studies listed below are illustrations of how we apply our problem solving to meet particular user needs. By reading them you can see, by example, just how we approach the user requirements presented and what modules we use and modify to exactly meet those requirements. The examples given below illustrate particularly interesting or complicated problems and our solution presented to solve them. Perhaps they will illustrate how we would use our problem solving approach to meet your specific requirements.

Case study – Clinical trials research group

Case study – Critical Access Hospital converting to digital mammography

Case study – Community hospital with need for discrepancy tracking

Case study – Multi-facility Maternal Fetal Medicine practice

Case study – Mammography practice converting to digital

Case study – Mobile imaging service with unique study workflow needs

Case study – Critical Access Hospital converting to digital mammography

A rural health non-profit health network had obtained budget approval to add digital mammography to its imaging services. They discovered they could upgrade their entire PACS for about the cost of the mammogram machine manufacturer’s dedicated workstation.

Challenge

A regional health services group which included two critical access hospitals, two outpatient clinics, and a 60 bed nursing facility received approval from its Board of Directors to purchase a digital mammography machine and the manufacturer’s dedicated mammography workstation. Getting the best value and staying within budget were of paramount importance.

Solution

While researching available 510(k) approved mammography workstations, the radiology manager learned of the Mammo ViewBox workstation from Connect Imaging. Further investigation by the manager showed that for about the price allotted for the mammography workstation manufactured by the mammography machine vendor, he could obtain a full Connect Imaging PACS, including archive, web access, and digital mammography workstation software.

Connect Imaging’s proposal also included having Connect Imaging’s personnel migrate studies from the department’s old PACS archive to that of the Connect Imaging archive, making the studies immediately available for review as prior studies. Included in Connect Imaging’s proposal was the cost of providing the PACS interface with the hospitals’ existing HIS system.

The radiology manager also obtained equivalent proposals from other PACS companies for comparison. However, no other proposals had the same range of features to meet the workflow needs of the group at a price within their budget.

Benefits

Installation of the Connect Imaging PACS enabled the health services network to meet all project goals. The group added digital mammography services, staying within the budget approved by the Board of Directors.

Total installation for the PACS and digital mammography workstation took less than a week, including migration of prior studies. Most of the software was installed remotely on existing hardware, including a server already in place. Migration of existing studies was done outside of the radiology department’s normal work hours. This, too, was completed before the service technician arrived on site. His work at the facility was completed in three days.

One week after the PACS had been installed and all data transferred to the new PACS, the server that had been provided by the hospital failed in the afternoon. Without a PACS server, the radiology department was unable to access studies that had been archived, so it was necessary to get the facility up and running as quickly as possible.

Fortunately, the facility was able to make a replacement server available within a few hours. Connect Imaging personnel then remotely uploaded all the necessary software in the evening, and installed and configured it the next morning. Studies from the old archive were again migrated to the new archive; new studies that had not been saved to the old archive were re-sent from the modalities.

As a result of the fast response by Connect Imaging, access to studies on the PACS was interrupted for less than 24 hours, and no studies were lost.

Additional benefits were discovered after the PACS had been in use for a while. Studies were now accessible to clinical staff from either of the two hospitals and the two outpatient clinics. With the use of web-based ConnectWeb, clinical staff could immediately access studies from any computer. Radiology personnel also discovered that the software allowed complex tasks involving the DICOM studies very easily, without confusing multiple menus. A favorite program was the QA manager module, which allows correction of errors in the DICOM header tags after a study had been archived. As one user explained, “Mistakes happen. This software lets us remove a study from the PACS archive, make corrections, then re-save it very easily and quickly.”

Case study – Community hospital with need for discrepancy tracking

A community hospital doing about 24,000 studies per year was evaluating offerings from different PACS vendors to meet their needs. They needed studies to be delivered quickly to the radiologist for reading; they needed access to studies from inside and outsite the hospital for staff and referring physicians; and they needed a system that was solid, easy to maintain, and easy to learn for new users, as they had limited IT staff.

Challenge

A final requirement was the need to automate their discrepancy reporting system. Most of the hospital admissions came through the Emergency Department. It was important to have initial interpretations by the ED physicians verified by the radiologist, and if a discrepancy was discovered, the ED physician and patient be notified of the change in interpretation. The previous manual system was cumbersome and prone to error, so it was important that this system be made electronic and incorporated into the PACS. Finally, it must be possible to report on monthly discrepancies discovered and the time the discrepancy was reported to ED and to the patient. Queries to other hospitals in the area revealed that none of the PACS currently in place had this feature.

Solution

The Connect Imaging PACS, as configured for the hospital, met all the initial requirements. It is a fast, solid, easy-to-maintain, easy-to-use system. This is because the user interface design was performed by a Ph.D. cognitive scientist with specific knowledge on how people best interact with the user interface of software. The core PACS consisted of FileRoom and FileClerk services for receiving, archiving, and forwarding studies to workstations. ViewBox diagnostic workstations were put in radiology, and a ViewBox Basic workstation was put in ED for the ED physician review. ConnectWeb provided web access to studies inside and outside the hospital. A Tech Workstation was provided for printing films, burning CD’s, and sending studies to off-site locations. An HL7 interface with the Hospital Information System allowed the PACS to get study orders to populate the modality worklist server and also get completed reports for access from within the PACS

The solution to the discrepancy reporting system was provided by an expansion of an existing Text Notes feature. The Text Notes feature allowed a user to enter a preliminary diagnosis is a text note window for review by others. Some users had used the feature for wet reads by the radiologist on night call, while other users used the feature to store the final diagnostic report on the study.

The Text Notes feature was expanded in two ways. The first change was to include a feedback mechanism from the radiologist to ED when a discrepancy was discovered, and a location for the ED physician to record the action he took. The second change was to add a data collection and reporting function to the web-based Dashboard management panel for reporting statistics collected on the discrepancies reported for the past month or other time period.

Benefits

In addition to getting a fast, solid, easy-to-use PACS to ease the conversion to digital imaging, the hospital was also able to eliminate a cumbersome, error-prone manual discrepancy tracking system and replace it with an automatic electronic system. As an additional improvement to workflow in the ED, the hospital is implementing an innovative electronic charting system called TAPSemr for the emergency department. Because of the ability of developers at Connect Imaging to make custom changes to meet specific needs of a client, the discrepancy reporting system that was developed for the hospital will be modified to take charting input from the TAPSemr system, simplifying even further the process for recording a preliminary diagnosis by the ED physician and responding to feedback from the radiologist on the diagnosis.

Case study – Multi-facility Maternal Fetal Medicine practice

A national group of MFM practices was looking to convert from paper-based to digital storage and reading of their OB ultrasound studies. They evaluated solutions from a range of PACS providers, both large and small.

Challenge

As a practice with perinatologists, they had a special workflow they wanted to follow where the sonographer could collect and review images captured by the ultrasound machine before sending them to the perinatologist for review.

The perinatologist would review the images, sometimes deleting images that were not definitive. Many times the perinatologist would go into the ultrasound room to acquire more images, which would then be sent to his workstation for review. After reviewing the additional images on his workstation, the perinatologist would complete his report in the facility EMR system and send the study to PACS for archiving.

A summary of the workflow is shown below:

Solution

Connect Imaging proposed a solution that utilized the ViewBox workstation module with some changes. One modification involved the addition of a feature that would allow images to be received directly to the workstation and displayed on the screen as they were received. This is not the standard feature already available with ViewBox where studies are received in the background and added to the worklist for display and reading by the radiologist. Rather, images would be received and displayed in real time so the sonographer could review the images collected as they were acquired by the ultrasound machine.

A second feature that was added to ViewBox was the ability to send studies from ViewBox via DICOM transfer to multiple DICOM recipients. This feature allowed the sonographer to send the partially completed study to the perinatologist for review, and also allowed the perinatologist to send the completed study to FileRoom for archiving after he completed his report.

This workflow has recently been further enhanced by adding features to automatically send studies to the perinatologist when the sonographer had completed the current study, and to provide tracking to make sure additional images were sent to the perinatologist workstation when they had been acquired.

As the Connect Imaging PACS was installed in more of the practices, a corporate decision was made to establish a deep archive and backup at the corporate data center so that backups would not need to be done at each practice. Connect Imaging responded to this additional need by creating a Deep Archive FileRoom service that would maintain multiple backups and long term archives for each practice, allowing studies to be removed from the local FileRoom archives after a year while still maintaining a link to the studies on the deep archive.

Benefits

The immediate benefit to the MFM group practice was that they could utilize a productive workflow that no other PACS company could provide. An additional benefit of these additional features in ViewBox was that other users of ViewBox, such as radiologists in a hospital using a traditional study workflow, now had the ability to send studies from their workstation to another DICOM recipient, such as a dedicated 3D reconstruction workstation.

Case study – Mammography practice converting to digital

After reviewing studies comparing digital and analog mammography, a mammography radiologist decided it was time to convert to digital. He was concerned, however, about the cost of conversion and his reading efficiency after converting to digital.

Challenge

He reviewed all available mammography workstations to determine which one would make his reading time most efficient. He found all of them (other than Connect Imaging) required multiple button clicks or key strokes to emulate his prior film-viewing protocols. In addition, he required the ability to read his mammography studies remotely, often from a mobile van, a requirement that could not be met by most PACS companies. Finally, he required the conversion process, including digitizing of three years prior studies for each patient, to be accomplished with his existing staff.

Solution

At the time the only mammography workstations available were dedicated to reading digital mammograms and could not be used to read CT’s or x-rays also. Thus, a radiologist reading both mammography and other modalities had to move from one workstation to another for each task. The software designers at Connect Imaging designed additional features into the existing ViewBox diagnostic workstation to make it an IHE compliant mammography workstation whenever a mammography study was loaded, while still maintaining its full capability for reading CT, CR, US, MR, XA, or other modalities when those studies were loaded.

In addition to the addition of an IHE compliant viewer to ViewBox, enhancements were made to other modules to make the process of digitizing prior films and reviewing the digitized films for proper labeling as efficient as possible:

* The SureScan film digitizer module was enhanced to automatically apply laterality and view labels to standard screening studies. The software also allowed white areas of the digitized films to be blackened for easier reading by the radiologist.
* The QA Manager module was enhanced to allow fast QC review of digitized studies for proper labeling. This module allowed clerical personnel to perform the relatively time-consuming task of actually digitizing the prior studies, while mammographers could quickly review the digitized studies.
* A Mammographer Workstation module was created with the same functionality as the radiologist’s Mammo ViewBox diagnostic workstation, but with significantly lower cost because it ran on lower resolution monitors. This module allowed the mammographer to review prior studies, as well as images from current studies before the study is completed and sent to the FileRoom PACS archive.

To respond to the need to remotely read his mammography studies, the DICOM Forward module was enhanced to be more efficient in transferring studies over a satellite connection. Images were batched together and sent over a single association, reducing the normal ‘chatty’ nature of a DICOM connection, and a DICOM TLS connection was used for secure transfer over an open connection to the satellite.

Benefits

The result was a PACS that met the radiologist’s initial requirements. The existing receptionist was trained to digitize prior studies for patients, while the mammographer performed quality control review of the digitized studies with QA Manager. No additional personnel were required after the conversion to digital.

Case study – Mobile imaging service with unique study workflow needs

The largest mobile imaging services provided conducted a two year search for a PACS to meet their unique workflow needs. Traditional PACS systems were designed for large hospitals and did not adapt to the company’s distinct and comples workflow. In addition, the price tag of a conventional PACS was price prohibitive.

Challenge

The study workflow was the opposite of a traditional radiology imaging center workflow. Normally, a patient is registered, the study is performed, and the study is interpreted. In the case of the mobile imaging service, patient information was entered manually in the field, and as such was sometimes incorrect. Some patients were scheduled in advance, but many times the studies were performed in the field before actually being registered in the practice management system.

Studies were performed during the day at more than 35 vans and trailers. Many of the vans had a need for a ‘lite-PACS’ in the van to receive studies from the modalities, allow corrections or additions to header information in the studies, then batch download the studies to the PACS.

At the end of the day, the studies were downloaded to the PACS for distribution when the vans returned from the field. The PACS had to process a full day’s worth of studies in about 1 hour so they could be sent out to the reading radiologists.

There was no set of rules that could be set up to determine which reading radiologist received which studies, so it was necessary to provide a quick and easy way to electronically duplicate the manual method for sorting and distributing studies that had previously been use.

Finally, studies were sent to reading radiologists for interpretation. The reading workstations needed to operate like a miniPACS, which would populate the radiologist worklist with studies to be read, plus store studies for a certain time to be available for later review. The workstations needed to operate independently of the central PACS.

Solution

The advantage of a modular PACS was demonstrated in every aspect of the solution Connect Imaging implemented.

The first requirement of a very fast module to receive studies from the vans and process them into the archive was satisfied with FileRoom and FileClerk. These software services do the basic job of processing studies, and as such do their job very fast. These services can process studies to the limit of the incoming network connection.

The second requirement of a distribution engine to allow studies to be easily sent to the reading radiologists was satisfied with Distributor. Studies were forwarded from FileRoom to Distributor, where they were kept in a local cache for several days to be available for sending out to the radiologists. Since Distributor ran on a separate computer, the distribution of studies did not slow down the processing of incoming studies, nor did it compete with FileRoom for network bandwidth. Modifications were made to the program to satisfy the need to manually forward goups of studies to individual radiologists, plus see which studies had not been forwarded to anyone. Detailed tracking documentation was built into the program to allow users to see exactly how many images of which studies had been sent, along with the date/time of when they were sent.

The third requirement for a ‘lite PACS’ in the van to receive studies from the modality and allow the user to modify the demographic information was satisfied with Tech Workstation. Tech Workstation is a simple program that can receive studies via DICOM transfer from the modalities, allow changes to be made in the patient demographic data in the DICOM header, then send the studies to another DICOM receiver, this time the PACS archive. Since the original installation, features have been added to Tech Workstation to alert the user if he tries to delete a study from Tech Workstation that has not been sent to some other location.

Finally, the requirement for a diagnostic workstation that could run independently of the main PACS and also store studies for an extended period was satisfied by combining the FileRoom module and the ViewBox module. The FileRoom is very fast, but is also very small and takes up limited machine resources. Studies sent to the workstation are stored in a mini archive on the workstation, then pushed to the ViewBox workstation. Since both FileRoom and ViewBox use different databases on the same Microsoft SQL server database system, the overhead of database maintenance is also minimized. The FileRom service has a separate purge module that prunes the studies periodically, so the workstation hard drive does not fill up.