Wednesday, September 25, 2013

Critical Results reporting, the missing link from a PACS.

The more mature PACS systems have become, the more it becomes obvious that there are still certain key functionalities missing, which have to be purchased as an “add-on” to have the system to meet the clinical requirements of reliable and timely physician communication.

These add-on critical test results messaging (CTRM) systems, as they are called, are especially important if there are critical test results that need to be acted on within a very short and defined time period. This is important for radiology results and for other imaging specialties, especially cardiology, but even more for lab results.

The classic example of such a result is when a radiologist observes a critical finding at 5 pm on Friday afternoon, which needs to be taken care of within the next four hours, and the patient has already been discharged, and the referring physician is unavailable after hours. In these cases, there has to be a well-defined chain of communication of that test result to the appropriate physician, with confirmation of the interpreted result and the action taken.

A special case of a critical result report is the ER discrepancy report, whereby an ER physician might have discharged the patient having missed a fracture or other important finding. I have first-hand experience with such a situation when my daughter, a few years back, went on a school trip to Colorado in the winter. The car with six students ended up in a ditch because of slippery weather. The students were transported to the ER, and subsequent X-rays did not show anything at first reading. The students continued on their school trip, and a radiologist came in the next morning and noticed a neck fracture in my daughter’s friend’s X-ray, and it took them another day or so to locate the girls in the lodge where they were staying. She was instructed to go back to the hospital immediately to be fitted with a neck brace. If a reliable means of communication between the ER physician, radiologist and patient had been in place, the potential risk would have been avoided.

CTRM systems are provided by several vendors, each with varying functionality. They can be integrated with the PACS, RIS, reporting system, or EMR. Most systems are tightly connected through a proprietary API interface. The workflow supported by these systems depends on the configuration capabilities. One should also make sure it supports the workflow that is used within your institution. It is possible to use one system for multiple specialties, or having multiple systems for each department, each with their own interfacing challenges.


When planning to purchase a CTRM system, one should perform a due diligence investigation that includes defined specifications for the requirements, test and acceptance criteria and site visits of installed systems in a similar environment. Otherwise it might not meet the requirements.  More details can be found in this video showing a discussion about the implementation steps.

Monday, September 9, 2013

CD’s vs the Cloud.

View of clouds in the Rockies, Co
Our recent on-line discussion regarding image sharing, which focused on advantages with regard to using a cloud solution for sharing information vs image exchange using CD’s, has gotten quite a few comments and created an interesting discussion on the various use groups. First of all, if you have not watched the video of this discussion, I encourage you to do so, at this link.

There were questions raised about security and encryption, which seems to be a major concern. One should realize that cloud solutions always provide either a secure dedicated link, or, in case they use a public communication infrastructure, it uses a VPN which provides encryption at the lower communication level, or at the transport level using https or similar. The information exchange is as secure as your credit card number when purchasing an on-line item in a store such as Amazon or eBay.

There are some distinct advantages of the CD exchange over cloud solutions: CD exchange is typically less inexpensive compared with a cloud solution, the integration of a report might be challenging using the cloud (they are typically added to the CD), and CD exchange is very simple: one can just pop in the CD and look at the images. Importing and/or viewing the images on a CD does not require an administrator in contrast to when importing images from an external source such as the cloud.

Even although these could still be considered a niche applicator, there are also challenges with exchanging video streams over the cloud because of bandwidth limitations and support by the receiver PACS of the MPEG encoding.


In my opinion, cloud transfer will prevail over the exchange of images using CD’s, but it will take some time. Cost reduction, and simplicity will certainly accelerate the acceptance of the cloud.