Pathology PACS Lessons Learned from Radiology

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Pathology PACSLessons Learned from Radiology

• APIII 2005

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• David L. Weiss M.D.

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Examine Radiology PACS As It Relates To Pathology

• Goals
• PACS architecture
• Monitors and ergonomic issues
• Workflow/user efficiency
• Communication
• Decision-support
• Reporting

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PACS Goals

• Filmless radiology
• Cost savings
• Improved accuracy
• Workflow efficiencies
• Distance collaboration

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Filmless radiology

• Achievable currently
• Mammography will be the last holdout
• Completely digital storage
• Compression decisions
• Slideless pathology?

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Image capture to PACS

• Direct
• DR CT MR US Nuclear medicine Digital
  mammography
• Indirect
• CR
• Manual
• Film digitizer

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Computed Radiography

• Different vendor offerings
• Single detector
• Four detectors per cassette
• Image stitching
• Must be anatomic
• 36 inch scoliosis series
• Image stitching
• Alternative view images sequentially

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Film digitizer

• Single film
• Stack mode
• Automated patient identification
• Barcode
• Formatting
• Magnification factor
• Speed

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PACS Cost savings

• Many different studies
• Different pricing models
• Capital purchase operational lease ASP
• Varying results
• Volume sensitive
• Film cost savings
• Personnel

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Improved Accuracy

• Different modalities
• CR/DR
• CT/MR/US
• Mammography
• Reconstruction workstations
• Decision-support tools
• CAD
• Online references

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Workflow efficiencies

• Technologist
• Clerical
• Radiologist
• Clinician

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Distance collaboration

• Teleradiology
• Nighthawk radiology
• Wet readings
• Shared work lists between different sites
• Offshore reading
• Radiology grid concept
• Load-balancing

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PACS Pre-history Teleradiology

• 1980s
• Predated PACS
• Predated modern software platforms
• Digitized films manually
• Camera on a stick
• Required hands-on user
• Film digitizer
• Direct capture of CT

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PACS History - Architecture

• Distributed architecture
• Early PACS
• Push images
• Routing algorithms
• Thick client
• High workstation requirements
• UNIX
• Lower bandwidth requirements

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PACS History - Architecture

• Central architecture
• Later PACS
• Pull images
• On demand
• Thin client
• Lower workstation requirements
• Windows PC

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PACS History - Architecture

• Web-based
• Thinner client
• Enterprise distribution
• Often less complex GUI
• Bandwidth dependent

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PACS History - Architecture

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PACS History - Architecture

• What has history taught us?
• You can be too thin
• Be skeptical of trends

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PACS Architecture History

• Hybrid
• Convergent design
• Pull images radiologist workflow
• Push images on-call situations clinician
  workflow

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PACS Workstation Requirements

• Workstation hardware
• Monitor requirements
• Software requirements - End-user efficiency
• Work list functionality
• Hanging protocols
• Graphic user interface
• Desktop integration
• User preferences
• Alternate user interface devices
• Communication

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Workstation Hardware Requirements

• P4 processor
• 2.8 GHz
• 2GB RAM
• 40GB hard drive
• Gigabit ethernet capability
• CD-ROM drive/burner
• XP Pro operating system
• 350 W power supply

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Workstation Hardware Requirements

• Nonstandard configuration
• 3-D workstation
• Speech recognition
• Dual-processor
• Other clinical applications
• Nuclear medicine ultrasound orthopedics
• Mainly software requirements

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Diagnostic Monitor Requirements

• Resolution appropriate for the modalities being
  read.
• Contrast in order to define a suitable number
  of shades of gray.
• Brightness
• Sustainability

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Diagnostic Monitor Requirements

• Resolution appropriate for the modalities being
  read.
• Contrast in order to define a suitable number
  of shades of gray.
• Brightness
• Sustainability
• Color

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Color Monitor Issues

• Standardized color temperature
• 6500 K
• Assures consistency from monitor to monitor
• Initial calibration
• Resolution luminance color
• QC
• Color drift
• Off-angle viewing

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As Received Versus ...
Factory Calibration
Courtesy of National Display Systems
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Off-angle viewing

• Monitor pixel has a physical depth
• Shining a flashlight through a hollow cylinder
• Grayscale monitor
• Decreased brightness
• Color monitor
• Red wavelength washout

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Long Wave Lengths (red) disappear first, makes
image look green-gray
IPS Technology
MVA, PVA Technology
Courtesy of National Display Systems
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Ergonomic Issues

• Room layout
• Workstation designed for more sedentary workflow
• Background illumination

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End-user Efficiency

• PACS Workstation Software Requirements

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End-user Efficiency

• Minimize time spent in any tasks other than image
  interpretation
• Maximize eye dwell time on images
• Eyes and mind on the images, not on the computer

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End-user Efficiency

• Work list functionality
• Hanging protocols
• Graphic user interface
• Desktop integration
• User preferences
• Alternate user interface devices

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Analog film viewing

• Films are hung by clerical staff or technologists
• Read patient history
• Barcode accession number
• View film on multiviewer
• Tools
• Wax crayon
• Ruler
• Hot light
• Magnifying glass
• Dictate report

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Analog film viewingIntuitive

• Films are hung by clerical staff or technologists
• Read patient history
• Barcode accession number
• View film on multiviewer
• Tools
• Wax crayon
• Ruler
• Hot light
• Magnifying glass
• Dictate report

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PACS Workflow

• Choose work list
• Choose patient
• Arrange images
• Window and level
• Choose and open old study
• Match paperwork and barcode accession number
• Scroll through images
• Annotate electronically
• Pan and zoom
• Other applications 3-D, Nucs, US
• Dictate
• Save changes
• Close case

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PACS Workflow

• Choose work list
• Choose patient
• Arrange images
• Window and level
• Choose and open old study
• Match paperwork and barcode accession number
• Scroll through images
• Annotate electronically
• Pan and zoom
• Other applications 3-D, Nucs, US
• Dictate
• Save changes
• Close case

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End-user Efficiency

• Work list functionality
• Hanging protocols
• Graphic user interface
• Desktop integration
• User preferences
• Alternate user interface devices

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WEISS, DAVID L
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Work List Functionality

• More than one way to remove study from work list
• Ability to easily drag case to secondary work
  list
• Second opinion
• Film library
• Quality control
• Compare to analog workflow

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Work List Functionality

• Ideally will not see the work list after
  selection of first patient
• Compare to analog workflow

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PACS Workflow

• Choose work list
• Choose patient
• Arrange images
• Window and level
• Choose and open old study
• Match paperwork and barcode accession number
• Scroll through images
• Annotate electronically
• Pan and zoom
• Other applications 3-D, Nucs, US
• Dictate
• Save changes
• Close case

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End-user Efficiency

• Work list functionality
• Hanging protocols
• Graphic user interface
• Desktop integration
• User preferences
• Alternate user interface devices

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End-user Efficiency

• The first task of most radiologists is to check
  patient history

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PACS Workflow

• Choose work list
• Choose patient
• Arrange images
• Window and level
• Choose and open old study
• Match paperwork and barcode accession number
• Scroll through images
• Annotate electronically
• Pan and zoom
• Other applications 3-D, Nucs, US
• Dictate
• Save changes
• Close case

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End-user Efficiency

• Work list functionality
• Hanging protocols
• Graphic user interface
• Desktop integration
• User preferences
• Alternate user interface devices

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Analog film viewingIntuitive

• Tools
• Chosen by user
• Modality specific
• Arranged by user
• Modality specific
• Can use same tool more than once
• Can change tool without searching desktop

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PACS Workflow

• Choose work list
• Choose patient
• Arrange images
• Window and level
• Choose and open old study
• Match paperwork and barcode accession number
• Scroll through images
• Annotate electronically
• Pan and zoom
• Other applications 3-D, Nucs, US
• Dictate
• Save changes
• Close case

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End-user Efficiency

• Work list functionality
• Hanging protocols
• Graphic user interface
• Desktop integration
• User preferences
• Alternate user interface devices

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Integration Spectrum

• Separate PC/screen/keyboard/mouse
• Same PC/separate applications
• Interface 2 databases/information exchange
• Integration shared functionality/2 databases
• Full integration single database
• RIS/PACS

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Integration Algorithm
OPEN CASE
PACS
DICTATE
OPEN DICTATION
VIEW IMAGES
SR
SR
PACS
SIGN-OFF
CLOSE CASE
OPEN NEXT CASE
PACS
PACS
SR
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Integration Algorithm
OPEN CASE
PACS
DICTATE
OPEN DICTATION
VIEW IMAGES
SR
SR
PACS
SIGN-OFF
CLOSE CASE
OPEN NEXT CASE
PACS
PACS
SR
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System Integration

• How will you retrieve the appropriate image or
  other data from the archive?
• How difficult will that be?

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System Integration

• PACS
• EMR
• Department information system
• Reporting system
• CAD
• Other software

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System Integration

• Bi-directional
• Contextually specific

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System IntegrationStandards

• HL7 (Health level seven)
• DICOM (Digital Imaging and Communication in
  Medicine)
• Supp. 15
• DICOM standard for visible light (VL)
• Automated-stage microscopy (SM)
• CCOW (Clinical Context Object Workgroup)
• IHE (Integrating the Healthcare Enterprise)

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Information Exchange Cycle
Office Visit
Patient
Imaging Request
EMR
RIS
PACS
Rpt
Report Generation
Scheduling
Imaging Encounter
Image Read
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Information Exchange Cycle
Office Visit
Patient
Imaging Request
EMR
RIS
PACS
Rpt
Report Generation
Scheduling
Imaging Encounter
Image Read
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Information Exchange CycleContext Specific
EMR
Recon W/S
HIS
Modality
Rpt
RIS
CAD
PACS
Decision Support
Billing
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PACS Workflow

• Choose work list
• Choose patient
• Arrange images
• Window and level
• Choose and open old study
• Match paperwork and barcode accession number
• Scroll through images
• Annotate electronically
• Pan and zoom
• Other applications 3-D, Nucs, US
• Dictate
• Save changes
• Close case

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End-user Efficiency

• Work list functionality
• Hanging protocols
• Graphic user interface
• Desktop integration
• User preferences
• Alternate user interface devices

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End-user EfficiencyHanging Protocols
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End-user Efficiency

• Minimize time spent in any tasks other than image
  interpretation
• Maximize eye dwell time on images
• Eyes and mind on the images, not on the computer

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End-user Efficiency

• Minimize time spent in any tasks other than image
  interpretation
• Maximize eye dwell time on images
• Eyes and mind on the images, not on the computer

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End-user Efficiency

• Work list functionality
• Hanging protocols
• Graphic user interface
• Desktop integration
• User preferences
• Alternate user interface devices

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Current PACS/SR User Interfaces

• Keyboard
• Mouse

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Keyboard history

• C. Latham Sholes
• 1872 typewriter patent
• Remington Sons
• QWERTY keyboard

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Historical perspective

• Hotdog 1860s
• Traffic light 1868
• Typewriter 1872
• Dental drill 1875
• Telephone 1876
• Phonograph 1877
• Lightbulb 1879

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Computer mouse history

• Douglas Englebart
• Stanford Research Institute
• Augmentation Research Center
• 1968
• Hyperlink
• User interface
• Online conferencing
• Apple Macintosh
• 1984

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Ideal PACS/SR User Interface

• Eyes-free image interpretation

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First attempt at eyes-free image interpretation
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Second attempt at eyes-free image interpretation
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New Controllers

• Philips speech mike
• 5 Button mouse
• 8 Button mouse
• Shuttle pro
• Twiddler
• Gyroscopic mouse
• Joystick
• Virtual reality glove
• Speed Pad

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New Controllers

• Philips speech mike
• 5 Button mouse
• 8 Button mouse
• Shuttle pro
• Twiddler
• Gyroscopic mouse
• Joystick
• Virtual reality glove
• Speed Pad

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Microphone Buttons

• First alternate UID
• User defined
• User specific
• Seven available
• Navigation efficiency
• Minimize distraction

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5 Button Mouse

• Functions 7
• Workstation specific
• Application specific
• Programming moderate
• Use easy
• Versatility very good
• Command string
• Movement control
• Right handed
• Loss of function

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Shuttle Pro

• Functions 15
• Workstation specific
• Application specific
• No cursor control
• Programming easy
• Use easy
• Versatility very good
• Scrolling excellent
• Tactile

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Twiddler

• Functions 1000
• Device specific
• IBM trackball
• De-activated
• Programming difficult
• Use moderate
• Versatility excellent
• Command string
• No dead man function
• Use with mouse

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UIDS

• Many choices
• No single clear ideal device
• 5 Button mouse simplest and most popular
• Depends on vendor and other applications
• Use combination of two
• Mouse and Shuttle Pro
• Mouse and Twiddler
• Practice and experience will improve performance
• Vendor involvement needed
• Mouse still necessary

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UIDS

• Many choices
• No single clear ideal device
• 5 Button mouse simplest and most popular
• Depends on vendor and other applications
• Use combination of two
• Mouse and Shuttle Pro
• Mouse and Twiddler
• Practice and experience will improve performance
• Vendor involvement needed
• Mouse still necessary

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UIDS

• Many choices
• No single clear ideal device
• 5 Button mouse simplest and most popular
• Depends on vendor and other applications
• Use combination of two
• Mouse and Shuttle Pro
• Mouse and Twiddler
• Practice and experience will improve performance
• Vendor involvement needed
• Mouse still necessary
• Dependent on modality SR use individual user
  PACS software

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Communication

• P
• A
• Communication
• S

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Communication

• Many of these features are RIS, EMR or reporting
  functions
• Radiologists are more PACS oriented
• Must be easily accessible by user
• Asynchronous
• Bi-directional

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Communication

• Communicate with self
• List of prior studies
• Teaching file
• Clinical notes
• Access to scanned documents
• Access decision-support tools
• CAD

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Communication

• Communicate with self
• List of prior studies
• Teaching file
• Clinical notes
• Access to scanned documents
• Access decision-support tools
• CAD

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CAD in Radiology

• Mammography
• Nodule detection
• Future applications

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Other Decision Support Tools

• Online references
• Contextual
• Automatic with structured reporting
• Computer comparison with online teaching files
• Personal clinical notes

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Communication

• Communicate with radiologist colleagues PACS as
  portal
• Second opinion
• Interesting case
• Teaching file
• Performance improvement
• Productivity
• Other bulletin board, chat, locate

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Communication

• Communicate with clinical colleagues
• Facilitate phone call
• Clinical discussion
• Urgent reading
• Acknowledgment of report received
• Acknowledgment of action taken
• Audit trail
• Reporting

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570-555-1212
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Alternative Reporting Methods

• Speech recognition
• Structured reporting

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Advantages of SR

• Cost savings
• Improved turnaround time

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Advantages of SR

• Felt only indirectly by Radiologist

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Turnaround Time in Hours
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Disadvantages of SR

• Increased dictation time
• Distraction from viewing images

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Disadvantages of SR

• Squarely on the shoulders of the Radiologist

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Structured reporting advantages

• Rapid turnaround time
• Cost savings
• Standardized words and phrases
• Concise reports
• Potential time savings
• No proofreading
• No impression
• Data mining
• Decision-support
• Automated billing

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Structured reporting advantages

• Rapid turnaround time
• Cost savings
• Standardized words and phrases
• Concise reports
• Potential time savings
• No proofreading
• No impression
• Data mining
• Decision-support
• Automated billing

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Multimedia Report

• Combine text and images
• Hyperlink thumbnail image with keyword
• Requires system integration
• Requires electronic report retrieval

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• PROCEDURE CT scan of abdomen and pelvis with
  oral and intravenous contrast.
• TECHNIQUE 8mm helical axial sections were
  obtained from the diaphragms through the
  symphysis pubis following the administration of
  intravenous and oral contrast.
• CLINICAL HISTORY Abdominal pain.
• COMPARISON 5/29/98
• CT Abdomen Liver and spleen are normal in size
  and CT density. Pancreas is unremarkable.
• Both kidneys are normal in size. There is a cyst
  in the right kidney measuring 1.5 cm in diameter
  unchanged from prior CT scan. No hydronephrosis
  is identified.
• Aorta is normal in caliber. No significant
  paraaortic adenopathy is identified. Visualized
  bowel loops are unremarkable.
• CT pelvis Visualized pelvic organs are
  unremarkable. Bladder distends normally. No
  significant pelvic adenopathy is identified.
• IMPRESSION
• Cyst in the right kidney measuring 1.5 cm in
  diameter unchanged from prior CT scan.

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• PROCEDURE CT scan of abdomen and pelvis with
  oral and intravenous contrast.
• TECHNIQUE 8mm helical axial sections were
  obtained from the diaphragms through the
  symphysis pubis following the administration of
  intravenous and oral contrast.
• CLINICAL HISTORY Abdominal pain.
• COMPARISON 5/29/98
• CT Abdomen Liver and spleen are normal in size
  and CT density. Pancreas is unremarkable.
• Both kidneys are normal in size. There is a cyst
  in the right kidney measuring 1.5 cm in diameter
  unchanged from prior CT scan. No hydronephrosis
  is identified.
• Aorta is normal in caliber. No significant
  paraaortic adenopathy is identified. Visualized
  bowel loops are unremarkable.
• CT pelvis Visualized pelvic organs are
  unremarkable. Bladder distends normally. No
  significant pelvic adenopathy is identified.
• IMPRESSION
• Cyst in the right kidney measuring 1.5 cm in
  diameter unchanged from prior CT scan.

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Summary

• Pathology PACS is in early stages
• Financial models will be different
• Monitor color requirements
• Many workflow similarities
• Workflow improvements
• Ergonomics
• Integration of information systems
• CAD/decision support
• Reporting

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Caveat

• Need close collaboration between physicians and IT

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• David L. Weiss M.D.