A brief introduction to PACS along with its pros and cons. General PACS workflow of a medical imaging department and a general PACS configuration. Guide for Integration of PACS into a department with already existing PACS and several configuration set up that can be adapted to maintained the workflow of the imaging department along with their requirement, advantages and disadvantages.

1. Optimization of Radiology System:
PACS Configuration
_Ramzee Small

2. OUTLINE
 Introduction
 Pros and Cons of PACS
 PACS workflow
 General Radiology PACS Configuration
 System Integration
Guide for integration implementation
Configuration I
Configuration II
Recommendation
References

3. INTRODUCTION
 PACS is an acronym for Picture Archiving and Communications System
Aids in;
 viewing,
storing and retrieving,
communication and managing of medical digital images and related information
 A mini-PACS is used for a single or a couple of DICOM imaging modalities
and process very limited

4. PROS AND CONS OF PACS
Advantages;
PACS can solve the issue of images loss, stolen, or misfiled.
Two physicians will be able to view same image at different sites.
Allows full range of tools for better visualization of image.
Economically efficient
Increase in efficiency of data management.

5. PROS CON OF PACS
Disadvantages;
It is not a new technology but still has not been deployed at
various health care institutes.
The financial cost may be huge, preventing hospitals to
install it.
Utilize large amounts of bandwidth on a system, can "crash"
even a very strong network. Strong internet technology
needed to handle PACS traffic efficiently.
To read PACS report high resolution monitors are needed
and they are too expensive.

6. PACS WORKFLOW

7. GENERAL PACS CONFIGURATION

8. INTEGRATION OF NEW SYSTEM
Scenario
An existing Radiology facility has the following elements: 2 CR x-ray
systems, ultrasound without DICOM, Digital fluoroscopy, mini PACS for
the CR X-ray to enable reporting and remote viewing; and plans to install
a CT unit. Design and propose at least TWO (2) configurations for PACS
integration for the new system, without disrupting the workflow of the
existing department.

10. INTEGRATION OF NEW SYSTEM
For the integration of a new system the following procedures guide
a facility for smooth implementation;
1. Prepare the network and addressing infrastructure
2. Request the DICOM conformance statement of the new device
3. Check compatibility for image and related information to be exchanged
4. Check the Modality Worklist interface for its filtering capability and
completeness
5. Simulate the PACS core and viewing capability

11. INTEGRATION OF NEW SYSTEM
The main focus of an integration procedure is on two interfaces:
1.Patient scheduling interface
Additional scheduling interface required for new system
Update to offers the worklist directly to the modalities

12. INTEGRATION OF NEW SYSTEM
2. PACS viewer integration with the RIS client
The RIS client (reporting station, remote viewing) must be configured to use
patient ID to search all checked network nodes for studies and display a list
with all search results in the study browser
Offer the possibility to select the desired studies which shall be displayed or
display one study if just one study matched with the search criteria
Computed tomography viewer specification

13. INTEGRATION OF NEW SYSTEM
Computed tomography viewer integration specification
The PACS image display application must have an automatic and seamless
loading for multiplanar image reconstruction to manipulate CT thin slices
Allow for synchronize scrolling in 3 plane for cross-sectional imaging
Ability to create 3D images

14. INTEGRATION OF NEW SYSTEM
During MPR/3D viewing, radiologist should be able to save key images as a
separate series for reference to the report
Ability to measure Hounsfield density (e.g. average density of lung nodule,
with maximum and minimum density)
Scrolling speed should be such that image transition is smooth- even with
>1000 images.

15. INTEGRATION OF NEW SYSTEM
PACS viewer integration with RIS client

16. CONFIGURATION I

18. CONFIGURATION I
Specification
RIS Registration and Scheduling Computer software must be updated to accommodate
selection and scheduling of specific examination for CT procedure. Worklist setting must
change
Computed Radiography, Computed Tomography and fluoroscopy are to be connected to the
same PACS system
New PACS system with larger storage capacity must be installed into facility
A new reporting station or an updated computer system must be installed to facilitate
specificity in selection, viewing and manipulation of examination/procedures images for
computed tomography and fluoroscopy
Remote viewing PACS system may remained unchanged depending on its storage capacity,
but needs software updating for computed tomography and fluoroscopy viewing

19. CONFIGURATION I
Advantages
Beneficial to facility in future if another system is to be integrated,
without having to proposed for additional storage capacity of PACS
Accelerated radiological workflows
Ease of access to all radiologic studies off one database (restricted
access based on level of authority).
Access to all radiologic studies via a single user interface that was
already familiar to all referring physicians and radiologists, with images
and immediate results available.
Ease of comparing exams from multiple modalities off the one database,
including CR, fluoroscopy and CT

20. CONFIGURATION I
Disadvantages
Expensive (Cost and implementation of new PACS system)
Tools for migration of data for existing CR system has to be develop to transfer to new
PACS system. Require smooth planning and preparation for effective and economical data
migration to optimize the use of time, manpower, and equipment resources
Changes in facility’s infrastructure
PACS training for personnel, incurring more cost and time lost

21. CONFIGURATION II

23. CONFIGURATION II
Specification
 RIS Registration and Scheduling Computer software must be updated to accommodate
selection and scheduling of specific examination for CT procedure. Worklist setting must
change.
 New PACS system with storage capacity for computed tomography must be installed into
facility
 A new reporting station or an updated computer system must be installed to facilitate
specificity in selection, viewing and manipulation of examination/procedures images for
computed tomography
 Remote viewing PACS system may remained unchanged depending on its storage capacity, but
needs software updating for computed tomography viewing
 Second PACS archive server must connect to reporting station, remote viewing station and
printer for CT individual system

24. CONFIGURATION II
Advantages
 Computed tomography individual PACS system eliminate tedious search and query
of patient record and images (configuration 1)
 Workflow is maintained
Eliminate discrepancy in data retrieval, transference, query etc. since system is CT
specific alone

25. CONFIGURATION II
Disadvantages
Complicated configuration prone to error during arrangement
Require additional parameters on the network interface for second PACS
Require high-volume bandwidth and Web access for data retrieval from separate PACS
system for CR and CT
Modification of infrastructure to accommodate second PACS
Separate software at registration for exam selection and scheduling for CR and CT along
with worklist respective to separate PACS
Expensive

26. OTHER CONFIGURATIONS
Configuration III
Installed new PACS connected to computed tomography and fluoroscopy
Configuration IV
Update Ultrasound with DICOM format and implement into configuration
one (1)
Configuration V
New system entirely for CT (PACS, registration, reporting and viewing
station etc.)

27. RECOMMENDATION FOR INTEGRATION
Get a “prenuptial agreement” from the PACS vendor
 Establish realistic and firm change-over dates
 Don’t count on reusing old PACS hardware
 Run parallel system
 Appoint an “informatics historian” who will record the dates of all systems
and hardware installations, keep track of all software version descriptions
etc.

29. REFERENCES
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 Trambert MA, Kywi A, Haramati N: Cost effective three hospital enterprise CR on PACS: profits and
productivity. Radiology 225:412, 2002
 Carter, E. C., & Veale, L. B. (2010). Digital Radiography and PACS. (L. H. al, Ed.) St. Louis, Missouri, USA:
Library of Congress Cataloging-in-Publication
 Mahoney CD, Berard-Collins CM, Coleman R, Amaral JF, Cotter CM: Effects of an integrated clinical
information system on medication safety in a multi-hospital setting. Am J Health Syst Pharm 64(18):1969–
1977, 2007
 Vaccari G, Saccavini C: Radiology informatics and work flow redesign. PsychNology J 4:87-101, 2006.
 Mäkelä T, Vitikainen M. A, Laakso A, Mäkelä P. Y. Integrating nTMS Data into a Radiology Picture Archiving
System. J Digit Imaging (2015) 28:428–432 DOI 10.1007/s10278-015-9768-6
 Horii C. S. Avoiding pitfalls in adding to a PACS or changing PACS vendors. Appl Radiol. December 14,
2008.