PACS Americana

Digital imaging systems revolutionize military health care.

Developments in military medical electronics have sped the delivery of diagnostic images from the examination room to the eyes of expert specialists who can provide advice for patients. The U.S. military long has been a leader in staggering innovations, such as the drive to eliminate X-ray film in favor of digital images.

Leading providers of digital communications software are working to distinguish themselves by making certain that DoD can capitalize on past innovations while continuing to lead medical imaging breakthroughs into the future. To understand where DoD may go with its medical imaging, it’s important to remember why the armed forces were in the unique position of being early adopters of electronic images in the first place.

Currently, DoD encourages the use of Picture Archiving and Communications Systems (PACS) through an acquisition vehicle called the Digital Imaging Network– PACS (DIN-PACS) contract. The second iteration of the contract, DIN-PACS II, started up in 2004 after a successful five-year run of the first DIN-PACS contract. A PACS system acquires and transmits diagnostic electronic imagery between various U.S. military medical installations, often hundreds if not thousands of miles away.

These PACS systems generally follow international imaging standards, relaying pictures in the medical image format known as Digital Imaging and Communications in Medicine (DICOM) and applying medical electronic data exchange standards under Health Level 7 (HL7, version 2.4). An entire PACS system may include acquisition devices (CT, CR, MR, etc.), networks, diagnostic and clinical displayworkstations, image servers, and other hardware and software components.

DIN-PACS II is designed to enable companies to join the contract and thereby bring their innovations to the Military Health System on an annual basis. The contract recipients at present include Agfa Corp., Eastman Kodak Co., FujiFilm Medical Systems USA Inc., General Electric Medical Systems, IBM Global Services Federal, Philips Medical Systems and Siemens Medical Solutions USA Inc. Many of those companies shared their thoughts on the evolution of PACS systems in interviews with Military Medical Technology.

Archiving Solutions

DICOM images are very large because they have to relay a level of detail that enables medical specialists to make accurate judgments. A study of medical images can reach 1 gigabyte in size in many cases. That makes the transfer and archiving of these images more challenging than that cute photo of your dog you e-mailed recently.

Dr. Richard Bakalar, chief medical officer at IBM, told MMT that his company has developed an infrastructure solution called the Grid Medical Archives Solution (GMAS) to deal with the challenge of mirroring archives of these large images in remote locations.

“The GMAS solution is one that is very interesting and very applicable to the Department of Defense specifically because it offers the ability to aggregate archives around the world for medical applications,” Bakalar explained. “It provides intelligent management of archives, which are now pretty much manually managed at local facilities and have very little backup in other locations for disaster recovery or business continuance because the archives are isolated or fragmented within the Department of Defense.

IBM has been in discussion with the military services about possibilities for aggregating their archives through GMAS and providing a comprehensive enterprise storage management solution, Bakalar revealed.

GMAS operates through gateway nodes through servers that would provide access to existing PACS systems applications, he said. So GMAS could tie together Agfa or GE or Philips systems, for example, with a software grid that could mirror archives in a local hospital or through designated locations thousands of miles away.

“Plus if they wanted to add new resources for storage and grow their infrastructure, the software grid would automatically migrate data from the old resources to the new resources. Once it was migrated, it would let the administrator know that that they could just disconnect the old resource, just unplug it, and they would never have to manually do any processing of that at all,” Bakalar noted.

The grid is self-healing, enabling it to instantly detect errors that may occur in the digital signatures of medical image studies and fix any corruptions that occur.

The solution answers challenges with which Bakalar is intimately familiar. Before joining IBM in 2003, he served as the executive assistant to the U.S. Navy Surgeon General for Global Telemedicine initiatives, where he managed PACS systems and helped to draft the first DIN-PACS contract. (IBM and Agfa were the only prime vendors on that original contract.)

The U.S. Navy PACS program started around 1995 with a prototype onboard the aircraft carrier USS George Washington, which could relay digital medical images from ship-to-shore at the Bethesda Naval Hospital. Meanwhile, IBM became involved in PACS implementations for the Department of Veterans Affairs and U.S. Army under the original DIN-PACS contract.

Currently, IBM uses components manufactured by BRIT Systems Inc. of Dallas, Texas, in its PACS implementations. In the past, however, it has used an integrated solution called PowerPACS, which was later acquired by GE and is now in use with that company’s solution. IBM entered DIN-PACS II with another solution set that was later acquired by Philips.

IBM also regularly collaborates with Eastman Kodak Co., Rochester, N.Y., as in the case of a recent migration of PACS systems at the University of Iowa Hospitals and Clinics. IBM Global Services and Healthcare Information Systems outfitted the hospital network with Kodak PACS System 5 and IBM Enterprise Storage Server 800 units. The new IBM servers provide peer-to-peer remote copy and flashcopy “to provide redundancy and disaster recovery capabilities by enabling the automatic reproduction of critical image information in disaster-safe facilities,” according to IBM.

The system gave the University of Iowa Hospitals and Clinics the ability to gain access studies that contain large images very quickly and to manipulate them for deeper viewing or advanced diagnoses.

Data Exchange

DoD is hard at work preparing for the rollout of the new version of its Composite Health Care System (CHCS). The military services have been releasing requests for proposals in support of CHCS II, which will upgrade the original CHCS system developed under contract by Science Applications International Corp. into a more robust system.

CHCS II will include a composite hospital information system that will link to PACS systems as well as other data transmission systems and databases, said Vijay Tanjore, marketing manager for GE Centricity PACS.

General Electric Medical Systems today evolved from its parent company’s eventual acquisition of Loral Aerospace, which installed the first precursor to PACS at the Madigan Army Medical Center in Tacoma, Wash., under the Medical Diagnostic Imaging Support (MDIS) contract in 1992.

“The technology they had at that time was hub-and-spoke technology, where you have one big center that acts like a hub,” Tanjore commented. “That still exists today. Madigan Army Medical Center is like a hub, and other facilities around it are like spokes. They send images between those two sites and all of the data centers sit at the hub.”

But in addition to linking to its “spoke” sites, Madigan links to other hospitals through CHCS, Tanjore noted.

“Once the system is up and running, and they plan to do an enterprisewide scheduling system, and they will have the interfaces to the lab and the pharmacy and the radiology information system,” Tanjore remarked. “Then they can easily access information not specific only to GE PACS or any other PACs, but they can get information across worldwide any third-party system and also leveraging the IHE [Integrating Healthcare Enterprise] framework.”

IHE, jointly led by the Radiological Society of North America and the Healthcare Information Management Systems Society, aims to establish a common framework for “connecting radiology imaging devices to other information systems in the hospital through existing protocols,” according to the organizations.

“GE is forefront in IHE,” Tanjore continued. “In any test of a new product, we should be able to communicate with each other. Leveraging that concept, they can use a bunker mentality where they have all of the radiologists sitting in one huge bunker and all of the images can go into that location irrespective of what vendor you are using.”

GE Centricity PACS provides radiologist and clinicians with a family of information technology products, including specialized workstations. The workstations provide diagnostic displays quickly and easily.

The Centricity workstations enable the customization of individual viewing preferences in a profile that can follow a radiologist throughout the PACS system. They also provide one-step access to recent and archived examinations and reports. Their built-in imaging tools include search and sort functions, flip, rotate, magnify, measure and pan or zoom.

Advanced functions limit the need to work between multiple workstations, as the Centricity workstation can provide volume analysis, volume rendering and navigation functions.

In terms of future technologies, medical specialists in military hospitals want the same things that those in civilian hospitals want: ease of access to the information they require to make diagnoses or analyses.

“I have heard that they would like to have technology where they have radiologists in the field and if any images show up they would have a beeper or a page telling them there is an examination sitting in their system,” Tanjore said. “We are trying to look into those kinds of technologies because all of the doctors are not going to be sitting in front of a monitor all of the time. But you could give some kind of notification on your Palm or your mobile technology.”

Electronic Patient Record

Agfa has been working with the department on a pilot project to place images in AHLTA, the electronic health record system of the U.S. military. Enabling the flow of PACS information into the electronic patient record is a priority for Agfa, Tim Artz, director of the Global Government Program at Agfa HealthCare, told MMT.

“That will give all of the providers worldwide the ability to view images at the press of a button. When they are browsing a patient’s records in AHLTA, they would immediately also be able to see the images at the press of a button. When they are browsing a patient’s records in AHLTA, they could immediately see the images that are associated with that patient’s information. That’s a very powerful tool,” Artz stated.

Embedding medical imagery from radiology and cardiology and other disciplines will become a greater focus for making the electronic patient record more valuable, which is important to active duty military servicemembers and their families as they move from site to site on orders. Such capability enables medical records to follow warfighters and their dependents without the need to transport hard copy films that could be lost or damaged, Artz noted.

Artz estimates that Afga is the current leader in government PACS systems with 120-130 sites presently implemented by the company. Working with the U.S. government in the past decade and beyond has strengthened Agfa’s products, and it has been able to take those innovations into the civilian sector, Artz added.

“One notable area is in security,” Artz said. “We are one of the few if not the only vendor that has completed the government’s security certification and accreditation. There are others working their way through it, but we have the formal certification.

“That’s of value to us as we go back to a commercial customer and they ask about IT security. We can say here is a benchmark that we have passed in this government security testing. If we can apply those same concepts to the commercial market, so much the better for our position there,” he said.

“Recent PACS product innovations include the release of our IMPAX version 6 which uses Web-deployable Smart clients, a service-oriented architecture for agility in adding new features and inserting technology as it continues to evolve, and Personnabased design which means that any user’s profile are available to them wherever they log into the system,” Artz added.

The individualized profile provides medical specialists with the same customized options every time they log into the system, so that they have easy access to the same features and the same look and feel for their graphical user interfaces. Agfa IMPAX 6.0 manages workflow to provide a consolidated view and centralized management of information, according to the company.

Although the use of PACS systems is largely similar among military and civilian hospitals, the military does experience some variations due to its unique mission and its operational needs. So, for example, DoD might depend on PACS systems for efficiencies that are not necessary in a civilian setting.

“DoD has trouble retaining radiologists. They have a decline in the number of radiologists throughout the three military departments,” Artz said. “So they wanted to take the smaller sites digital. PACS is a technology that enables the sites to do digital soft copy imaging, so they can transmit the digital images to another facility where the radiologists are. It has a twofold advantage. Now you don’t have to have a radiologist at every site. Secondly, you can maximize the utilization of the few radiologists that you have. It allows them to minimize or reduce the number of contract radiologists that they have.”

Remote Consulting

The ability of radiologists and other specialists to examine PACS imagery from the other side of the globe has led to a great deal of remote consulting, an application of the PACS systems largely unique to the military, according to Rik Primo, director of Marketing and Strategic Relationships for Siemens Medical Solutions Image Management (RIS-PACS) group.

Remote consulting has become very popular for the treatment of U.S. warfighters in the wars in Afghanistan and Iraq, Primo noted.

“In such a scenario, you would see a soldier who is injured in a remote location somewhere in Afghanistan or Iraq,” Primo explained. “The soldier would have an X-ray. From the X-ray, someone could see some shrapnel dangerously located close to a vital organ or a nerve or an artery, and they wonder what would be the best therapeutic approach. You do not always have a great vascular surgeon available on the spot. They might then ask for advice from an Army or Air Force medical center.”

In Afghanistan, military units often turn to Army medical centers in Germany, particularly the Landstuhl Army Medical Center, which has PACS systems installed by Siemens.

Siemens Automation and Devices (A&D)—another unit of Siemens AG, headquartered in Munich, Germany—has introduced innovations to PACS systems for installation by Siemens Medical Solutions Image Management. Earlier this year, for example, Siemens A&D announced the availability of 1 megapixel and 2 megapixel flat screen monitors for its product line.

The SCD 19100, a 19-inch 1 megapixel monitor, and the SHD 21205, a 21-inch 2 megapixel monitor, provide new viewing angle technology and cold cathode fluorescent lamp backlighting. The SHD 21205 provides particularly high luminance at 450 candelas per square meter as well as a long service life (about twice as long as conventional displays), according to Siemens. The 21-inch monitor also can display color and grayscale case studies as well as hybrid presentations.

At Landstuhl, top experts are available every hour of the day, every day of the year, to put this equipment to good use, Primo noted. Specialists can receive images at their workstations from Army and Air Force medical units over the Air Force tactical network.

“In Landstuhl, the specialists are taking a look at these images and they will then decide if the soldier can be treated locally there in Afghanistan or if that soldier has to be flown in. In that case, they will fly them into Landstuhl, where the soldier receives surgery,” Primo said. “After a while, the shrapnel is removed, the wound is closed. After two or three weeks, the soldier is feeling good and he can go back to where he came from. So there is no need anymore to bring soldiers from all the way over there to the United States.”
 
Still, despite the military’s leadership in PACS applications and innovations, the goal of the DIN-PACS II contract is to make the best use of commercial off-the-shelf technology supplied by the medical manufacturers.

“For the military, PACS is used for what civilian hospitals use PACS. That is to be able to eliminate X-ray film. You don’t have to store the X-ray film. You don’t have to handle it. You don’t have the environmental issues involved in development and chemicals involved in film. The military has embraced PACS in the first place to basically replace the film operations in the military hospitals,” Primo said.

“So the generic use of PACS in the military is the same as in civilian hospitals where it is used to improve workflow, improve quality and decrease costs,” Primo concluded. “The special use that the military is making of PACS is the possibility of having diagnosis from specialists who are thousands of miles away from the theater and can make decisions that benefit the soldier.” ♦

Back_To_Top