NHRMC PACS SERVICES

1. 1 NHRMC PACS SERVICES Guide 11/2006

2. 2 PACS SERVICES GOALS To promote safest and highest quality patient care by efficient management of diagnostic images. Reduce time and increase accuracy of reading, reporting, and reviewing. Increase opportunity for market outreach with remote PACS services. Improve after hours reading and reviewing with remote PACS services. Manage costs of storage and retrieval while reducing or eliminating film costs.

3. 3 PACS Services List Synapse native access Synapse native access via VPN (Discouraged) Synapse via SSL (second choice) Synapse access thru portal on campus Synapse remote access thru portal (first choice) Synapse from/to Delaney & NHRMC images Access outside images on CD�s Access to Stryker Ortho PACS images from jump drives & CD�s PACS access in Operating Rooms Heartlab native access Heartlab Web access Heartlab Portal access Currently gives rights to change reports. Working on fix. Powerscribe Voice Recognition Transcription Access to Misys Radiology remotely (Vendor problems to fix)

4. 4 We Have a Connection Method to Fit Your Needs The following graphic presents the logical connection options

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8. 8 FUJI ISSUES LIST page 1 CT speed issue (full resolution by 2/28/06) Fourfold improvement with loaner server from FUJI Purchase 2 new servers to replace loaner server. Schedule upgrade to 3.1.1 (coordinate with Delaney) Post January 1, install and configure Content Switch and Storage Cluster servers. After Content Switch and Storage Cluster server installation, rebuild storage servers as Dicom/Web servers one at a time to minimize downtime. 64 Slice Scan Preparation Expect approximately 35 more images per scan or additional 7 seconds. Orthoview Philosophy is to favor integration Potential start in June 2006 Commonview (January 5, 2006) Will ease access between multiple image databases Outside Images CD�s Read in at Cape Fear, Med Mall, and Main campus filerooms. Manual accession number and MR# assigned We create CD�s for patient through PACS Cube product. Workflow & Powerscribe FUJI, Dictaphone, & IS have been on site to analyze workflow issues (i.e. Running the board, etc.) Combined Studies (dyseCT) � Study titled CT HEAD but contains all images from trauma run. Makes it difficult to find relevant priors. (BIG REENGINEERING EFFORT. NO PROJECTION) [dyseCT works as designed, and will provide overlap required between associated studies such as CHEST-ABDOMED-PELVIS. (WORKS AS DESIGNED. Radiologist need to agree on overlap measurement) In addition, with images in each study � each study now needs to be individually dictated vice associated on the back side by transcription. New version of Synapse supposed to allow Group Dictation option where multiple studies can be associated to a single dictation on the front end. (REASSESS AFTER 3.1.1 UPGRADE)

9. 9 FUJI ISSUE LIST page 2 OR 21 [Still having issues with subtracted images (without bone) and working with vendors] (FIXED) OR 5 � Quality of image (FIXED) CVOR�s � Rooms 9 & 22 [Plan to put 32� monitors in both rooms] (By March) Cape Fear OR�s [In progress, but slow due to Facilities. (FIXED) Cape Fear OR4 needs repositioning and extra monitors. (February) Content Switch and associated H/W to improve performance (January)] Vascular studies with no reports in PACS [Working with vascular techs to determine how to get reports/OP Notes into PACS � possibly scanning] (April) We are planning a joint reading program with cardiology�.we will need access to cath images and 2d echo�.they will need to be able to dictate from the room where the AW workstation will be in radiology. (March) Batch Mode Reading � �Running the Board� (Will reassess after PACS 3.1.1 upgrade) Wants fast method to read based on integration of PACS and PowerScribe � too much overhead on CR due to large volumes at NHRMC and CFH List of all unread studies regardless of location, vice by site Need efficient way to transfer from batch reading to Call Reports/ED studies where a barcode swipe is necessary, and back to batch mode Tech notes not in PACS, but on paper requisition � does req need to be scanned into PACS documents? Hanging Protocols - (CT Fixed, MR, CR left) Need consistent naming conventions of series descriptors for all modalities across network [Terry Gentry and Barbara Hyatt to lead effort to remedy � Meeting set for Thursday of this week] Feels we should have pre-configured protocols delivered by vendor [Randy has done most on server since Fuji profile-based protocols do not seem to stick]/actually most of us have individual ways to look at cross sectional studies like ct and mr�but the time to do all of the cr studies, particularly complicated by our ris system, is unrealistic�.this is an obvious problem that was overlooked at implementation�and an �expert� on site would be helpful to fine tune our hanging protocols

10. 10 FUJI ISSUE LIST page 3 Need Office and Home Access Implementing CITRIX software access (February 2006) Will establish pilots (November � December) Will eliminate keyfobs Awaiting completion of Security Policy and Service Level Agreement (December)

11. 11 In order for the Radiologist's personal Reading Protocols to work as designed, all of the Series descriptors coming from the CT and MR sacnners need to be standardized across the Network. Synapse allows Radiologists to "build" their own Reading protcols and save them. That way, the next time they open that same Order Code and, if wanted, a prior, it will display the way they built it. Synapse uses the Series descriptors to remember where to "hang" the Series. Since each scanner uses different descriptors, there are an exponential amount of Reading Protocols that would have to be built. If we are able to standardize these decriptors coming from the modalities (This is not a RIS issue) then there will be a lot less building on the Radiologists' part. It was decided that CT departments would take out all added descriptors, thus leaving the default descriptors. This may help. The Rads want "combination" scans, i.e. CT Chest, Abdomen & Pelvis, separated in Synapse, but not until after they have been read. CT and MR scanners scan multiple body parts at once, versus scanning a head, stopping, setting up new accession number, scanning next body part, stopping, etc... Dr. Remington wanted these studies split up into their respective accession numbers in Synapse. We bought dyseCT. It worked as designed, for the most part. It did a really good job of separating into the appropriate accession numbers. But the Radiologists didn't like that because they had to dictate each body part separately, instead of all at once. So we discontinued dyseCT. Now there are one or two Radiologists that request someone go in and separate after they've been read. Very time consuming for a Tech or Administrator to do. The Department Chair, or Medical Director, or someone from Delaney Radiology needs to help us by stating how they'd be happiest - either let dyseCT split up the studies and read them separately, or read them together and have the images stored together. FUJI ISSUE LIST page 4

12. 12 POWERSCRIBE ISSUES PowerScribe - Skipping words � �monkey chatter� on all PCs, but especially bad on CT Body and Neuro Reading Rooms [Ordering super PCs for CT Body and Neuro RRs] (No Projection) Alt / D cumbersome to enact PACS Bridge � combo of keystrokes and mouse clicks [Working on keystroke converter solution, and pushing ALT-D mouse click to all radiologist profiles] (Reassess after 3.1.1 updgrade in December) Proxy signing for others difficult in PowerScribe due to sorting options [Issue submitted to Dictaphone for action] (FIXED due to USER Decision to Cease Practice) Still spelling unknown words on Listen Line (Works As Designed) Needs way to make a �Call Report� in PowerScribe/ this is VERY important�ACR standards make it clear that abnormalities that are unexpected or urgent need to be communicated�.we all personally communicate immediately life threatening findings�an example is an abnormality on a CXR�I would not call someone at 8pm at nite to tell them that I saw a possible mass�but we need for the transcriptionist/correctionist to be able to call the report and document it in the report (�called to missy at dr smiths office by vp at 450pm,7/17)�this prevents a medicolegal nightmare for the radiologist AND the hospital(Reassess after 3.1.1 updgrade in December) Notification to ED when report is ready - (FIXED) Currently FAXING report to ED and would like reports to print to ED directly from PowerScribe/PACS [Radiology working on printing solution in ER]/only one or two people will do this�it involves desire/facility with self correcting that most of us have no interest in�you should NOT assume that self editing mode will become the default for radiologists Support � Wants a PACS and PowerScribe �expert� to call for support 24/7/365. (Not enough resources. No resolution yet. Possibly train more current staff to take call)

13. 13 HeartLab Issues Have easy way to distinguish between read and unread studies in Encompass Web product . (Fix in March. Will add radio button for read, unread, all studies) Have �physicians� column in Encompass (thick client) mapped to �procedure physicians� column in Encompass Web (Fix in March) Have �institutions� column in Encompass (thick client) configured in Encompass Web to be used as a look up tool (Fix in March) Aortic measurements in cath tool not accurate (obvious dilitations confirmed by other modalities � are registering within acceptable limits per Encompass) (RESOLVED) Not all read studies highlighting to gold in Encompass (RESOLUTION BEING VERIFIED) All exam images not fully crossing to workstations (RESOLUTION BEING VERIFIED) Measurements intermittently not scraping across for Echo Lab (RESOLUTION BEING VERIFIED) Unable to scrape measurements from image to report in vascular package (WILL NOT FIX, WAD*) Encompass Web is recommended for viewing only. (Withdrawn except for Cath (view only) Ultrasound is okay. Will produce 2 viewers, one for general physician viewing through portal, one for diagnostic. (No Estimate) Reports not displaying properly in Image Manager due to reports from HeartLab displaying in sections instead of lines. (RESOLVED). Sections of the report are missing; graphics and conclusions. (RESOLVED) We continue to reviewing potential replacement for HEARTLAB ($1.3 million and 1 year).