Abstract:  The radiology field of health care is greatly advancing.  Hospitals all over the country are getting rid of the old ways of film, and moving on to PACS.  PACS has become a wonderful advantage to patient care.  PACS is a computer software for radiology.  It is a wonderful new technology because of its speed and its availability.  It is much faster than regular film and it allows physicians to view images wherever and whenever they need to.  It also helps the radiologist and physicians read the x-rays.  Just like a picture from your digital camera, you can manipulate the image so you can see things better.  You can lighten or darken it, you can magnify or zoom in on it, and the radiologists can even annotate on it so physicians who are not trained to read x-rays can see what they see.  No matter how you look at it PACS is a wonderful new technology, and I hope in the near future every hospital uses it because it really is better for the patient.

            Introduction

            Radiology has come a very long way since the discovery of x-rays in 1895.  Although the way radiographs are taken has changed drastically, their purpose has remained the same: to better patient care.  Radiographs play a very important role in health care.  The doctors need to be able to see what is going on inside the patient’s body.  Up until the last few years, radiographs were always taken on film.  The doctor would then look at the radiograph on a view box, and then it would be put into the patient’s folder and filed away.  Now there is a new kind of imaging on the rise.  This new technology is called PACS, Picture Archiving and Communication System.  PACS is a computerized replacement for conventional radiologic film.  Doctors no longer have to look at radiographs on a piece of film.  They can now look at them on their computer.  You may wonder how this advancement in radiology can help with patient care.  It does help in many ways, mainly radiation exposure and speed.  Welcome to the new world of diagnostic imaging, the world of PACS.

            Before I discuss exactly how PACS benefits patient care, I should first discuss how PACS works.  Through my clinicals I have had the opportunity to work at both Laughlin Memorial Hospital and the Johnson City Medical Center.  Laughlin has been digital for four years now, and the Med Center still uses film but they are planning to get PACS very soon.  Since I have experienced both digital and film, I have found that they are different in many ways.  With regular x-ray film, the blank film is inside a cassette.  Once the film is exposed, it is run through a processor that extracts the film, develops it, and reloads the cassette with a new blank film.  PACS, of course, is filmless radiography so there is not film inside the cassettes.  Instead it is a digitized plate.  These cassettes are used exactly the same way as regular film cassettes.  They even are run through a processor after they are exposed.  The difference is that in the processor, the digitized information inside the cassette is sent to a computer.  From this computer, the radiology technologist can critique the radiographs they have taken.  This form of radiography is called CR, or computerized radiography.

            There is an even newer form of radiography on the rise.  It is called DR, or digital radiography.  The concept is the same, that the radiographs are shown on a computer.  The difference with DR is there are no cassettes.  The radiographs are taken at a special digital board that sends the picture directly to a computer screen.  This saves the technologist from having to run the cassette through the processor.  This may not seem like such a big deal, but the processor takes 90 seconds to get the picture to the computer screen.  With DR it takes about 5 seconds for the image to show up on the screen.  This enables the technologist to work much faster.  They can take a radiograph and quickly see if it is good or if it needs to be repeated.  This also saves the patient a lot of time.  For a plain chest x-ray, a patient could be in and out in less than a minute.  

            There are a number of things a tech has to consider when critiquing a radiograph: is the patient positioned well, is it too dark or too light, is all of the desired anatomy demonstrated?  Regular x-ray film is permanent.  What you get is what you get.  There is no fixing it.  PACS is much more lenient.  If the positioning of the patient is bad, there is nothing the tech can do to fix it, except repeat it.  If the radiograph is too dark or too light, then the tech can adjust it.  This is one of the great things about PACS.  For instance, if a technologist were taking a chest x-ray and the lungs showed up too dark, or burnt, then they can click a button and lighten it up.  This saves the patient from having to be exposed again. 

Review of Literature

            Lou Perez, M.D., the Northern Westchester Hospital site director for imaging services says, “there’s a saying that the best time to plant a tree was ten years ago, and if you didn’t do it then, you should do it now.  It’s the same with PACS.  If you do not already have a PACS system in place, now is the time to do it.”  Recent estimates from Frost and Sullivan, a health care industry research firm, suggests that over 80 percent of hospitals in the U.S. do not have a PACS system.  A case study of Northern Westchester Hospital installing a PACS system shows that PACS provides a variety of functions and improvements that were impossible with film.  The digital system allows the user to zoom in on the image.  This allows the radiologist to magnify an area that they might not be sure about, and get a better idea of what might be going on with the patient.  (PACS Advantage, 2005)

            Another wonderful advantage is speed.  The PACS system allows the user to scroll through a stack of CT or MRI slices very quickly.  This obviously results in the patient getting a much faster diagnosis.  The user can also instantly access a patient’s history, which can help with diagnosing the patient.  (PACS Advantage, 2005)

            One of the biggest advantages of having the PACS system over film is in the emergency department.  Patient care in the emergency department relies heavily on radiology.  Anyone brought into the emergency department obviously needs care very quickly.  PACS allows for immediate access to the patients radiographs (White, 2004).  As soon as the technologist has released the patient’s images to the archive, the emergency room doctor and the radiologist can immediately view them.  This real-time, on-demand viewing enabled by PACS can accelerate the clinical decision making and treatment processes (Fratt, 2005).   

            PACS provides access to images throughout the hospital, at different hospitals, or from a home workstation (De Backer, 2004).  This helps the emergency department by allowing more than one doctor and the radiologist to view the patient’s images at the same time.  “Rather than being limited to diagnostic information existing on a single piece of film, digital images can be viewed simultaneously at different locations” (White, 2004).  This advantage enhances the quality of interpretations by combining the emergency doctor’s opinion and the expertise of the radiologist.  This is very good for the patient because their radiographs will get the best interpretation possible. 

            PACS is not only beneficial inside the hospital, but outside as well.  “Current web-based PACS are helping facilities greatly increase their referring physician user base, creating speedier in-house operations to boot, and providing greater patient care.  To put it simply, they’re fantastic” (Vemmer, 2005).  Web-based PACS allows the radiologist and other physicians to view the radiographs anywhere there is an internet connection.  This is great for patient care because if a physician needs a radiograph read quickly and there is no radiologist in the hospital, the radiologist can view the image at home or wherever they are at (as long as they have internet access). 

            Here is an example of how fully distributed digital imaging works:  The ER sends a patient to radiology for some chest x-rays.  The radiologist pulls up the images on a view station and makes a diagnosis.  Back in the ER, the physician accesses the patient’s x-rays and the radiologist’s diagnosis on a view station.  The physician sends the patient to the operating room, where the surgical staff pulls up their x-rays on a surgical view station.  In post-op and ICU, those same x-rays, plus more, are pulled up on a view station at the nurses station.  The patient’s general practitioner is notified and views the x-rays from home and notices something unusual and asks for it to be reviewed by a radiologist.  The radiologist reviews it again on a view station to determine if malignancy is present.  Weeks later, the hospital physical therapist accesses the x-rays on a view station to plan the patient’s rehab treatment (Harris, M., 2005).  With film, the patient’s x-rays would have been passed from place to the other and the general practitioner would have had to come to the hospital to view them.  It also would have been a much slower process than with the digital system. 

            The University of California Irvine Medical Center has had many improvements with their web-based PACS system.  Some improvements include: undictated studies dropped from 4,700 to less than 130 a month, no lost films, turnaround time dropped from 4 to 10 days to less than 24 hours.  Patient care for trauma victims improved because the physician at home can ask the ER staff to prep the patient accordingly based on his or her review of the images.  UCIMC has also placed viewing stations in every physician exam room, so they can share the images with the patients, increasing patient satisfaction. (Lauzier, 2005)

            Image manipulation also offers a tremendous diagnostic advantage over film (White, 2004).  With this software, clinicians are able to zoom in on the image, use digital subtraction (black-white reversal) for improved image definition, stacking of images for serial viewing (CT scans), contrast enhancement, and other benefits.  Important findings on an image can also be annotated by the radiologist.  This can help subsequent readers of the image be able to see subtle abnormalities not easily seen. 

            Prior x-ray films are something that plays a big part in reading x-rays.  This enables the radiologist to see if something was already there before or if it is just now showing up.  PACS makes these images very available.  The can be transferred from the archive to the radiologists computer in less than a minute.  “In the film era, it took hours and even days to retrieve relevant priors” (Mandler, 2005). 

            This is only the beginning of PACS.  It is still advancing and will continue to advance for a very long time.  In the future, PACS will also have semi-intelligent functions.  Some of these functions are keeping track of patient’s progress, pre-fetch images for interpretation, automatically route images to predetermined physicians, and provide radiologists with an alert for stat readings (Saha, 2004).  It just keeps getting better and better.

Methods

            Since I have had the experience of working at a facility that uses digital radiography and a facility that uses film, I have seen how PACS can benefit patient care.  For those who do not know anything about PACS and those who are unsure about, I would conduct a study to prove that is better for patients. 

            The actual study would consist of two parts.  The first part would be a survey for radiologists and physicians at a hospital that uses PACS to fill out.  On this survey I would have questions about all the advantages of PACS that I have stated thus far to see if they feel that PACS creates better patient care.  I would also have radiology technologists and PACS administrators take this survey.

            The second part of the study would be to prove that PACS helps reduce patient exposure.  To do this I would set up a study at a hospital with film and a hospital that uses PACS.  For this study, I would have the technologist document any time that they had to repeat an image because it turned out too dark or too light.  With the PACS system it may be possible to save the image by making it darker or lighter, thus saving the patient from being exposed again.  With film there is no saving the image.  They would have to repeat it and expose the patient again.  I would conduct this experiment for one month and then compare the two facilities.  This should tell me whether or not PACS creates less repeats and less patient exposure.

Discussion

            I believed, before I even started researching, that PACS was a great advantage for patient care.  After doing the research, I still believe that.  From working at a facility that has PACS, I already knew a great deal about it.  I did not know exactly how beneficial it actually is.  The article about the University of California Irvine Medical Center shocked me.  I never would have thought that a facility could have 4,700 undictated studies.  I guess that is what happens when the x-rays are on a tangible piece of film.  When they are in the archive on the computer, you always know exactly where they are and you never have to wait to look at them. This allows the department to be much more efficient, as the UCIMC found out.  The efficiency enabled by the deployment of PACS has enhanced patient care and has allowed for more effective use of clinician time (Harris, C., 2005). 

Conclusion

            Digital radiography is the future of diagnostic imaging.  It makes everything much faster and easier.  There are many advantages to having PACS over film, but the most important is patient care.  The patient is always the top priority for any health care worker.  PACS reduces patient exposure to radiation, and also has a much faster turnaround rate than with regular x-ray film.  It enables more than one physician to view a patient’s images at a time, resulting in a better interpretation of the image.  Therefore, there is less of a chance of a physician missing something on the x-ray.  There are just so many reasons for a facility to implement PACS.  I have no doubt that every hospital in America will eventually go digital.  There is no good reason not to.