The pros and cons of implementing PACS and speech recognition systems.

The installation and implementation of a hospitalwide image management system and a speech recognition dictation system has had a dramatic and positive impact on radiology report turnaround times at Elmhurst Hospital Center, a 543-bed municipal teaching hospital located in New York City's Borough of Queens. The "lost film" problem has been eliminated. As a result, the percentage of unreported examinations has dropped from 25% to less than 1%. These performance improvements have significantly benefited the entire medical staff. With the successful implementation of a HL-7 standards-based radiology information system (RIS), a speech recognition dictation system, around-the-clock staffing of Board Certified radiologists, and a picture archiving and communication system (PACS), report turnaround time improved dramatically. Eighty-six percent of all examinations now are reported formally within a 12-hour period compared with a 3% average before implementation of the changes. However, with the use of the PACS and speech recognition technologies, new problems have arisen within the radiology department. These technologies, designed to enhance communications capabilities, also have significantly reduced the amount of clinician/radiologist dialogue. Easy and rapid access to patient images and reports has had a detrimental effect on that face-to-face consultations with clinicians, which were commonplace before PACS, and now have almost completely disappeared. The radiologist/clinician interchanges, which occurred frequently before a final report was dictated, often resulted in better understanding of the clinical problem and, hence, a more meaningful final report. Although a conferencing feature to facilitate communication exists within the PACS, it is not utilized by the clinicians. The dilemma is that as information about patients is made more available to the hospital staff, less information is provided about patients to the radiologists. Although the speech recognition system benefits the hospital, its staff, and the patients served by reducing clinician time awaiting a diagnostic report and reducing clinic and emergency room waiting time by the patients themselves, it does not necessarily benefit the radiologists who use it. Speech recognition dictation systems slow down the individual productivity of the radiologists' dictation process by at least 25%. Radiologists are assuming the role of transcriptionists as well as diagnosticians. Mistakes occur that would not with the use of a traditional dictation system and professional transcriptionists.

Filmless in 60 days: the impact of picture archiving and communications systems within a large urban hospital.

Many large urban hospitals converting to filmless radiography use a phased approach for digital imaging implementation. In fact, this strategy often is recommended by picture archival communication systems (PACS) experts and vendors alike for large, busy hospitals installing PACS in existing physical facilities. The concern is that comprehensive conversion from film-based to digital imaging may be too overwhelming an adjustment in operations for a medical staff to effectively handle without serious disruption of workflow for patient treatment and care. Elmhurst Hospital Center is a 543-bed hospital located in the Borough of Queens in New York City. Owned by the New York City Health and Hospitals Corporation, this municipal teaching hospital provides services to a patient mix that is 38% indigent with no insurance, 50% covered by Medicaid or Medicare, and 12% affiliated with HMOs. Most inpatients are admitted through the emergency department. Forty-five percent of all radiology procedures conducted are for emergency patients. Historically, up to 25% of all diagnostic imaging examinations were never reported formally by radiologists. Report turnaround time for the remaining 75% was unacceptable, with only 3% of all imaging examinations reported within a 12-hour period in 1996. Both situations existed in great part because physicians and residents who felt they needed access to films simply took them. Many were never located or returned days after they were taken. In 1998, Elmhurst Hospital Center replaced its RIS and added voice recognition dictation capabilities in January 1999. A hospitalwide PACS was deployed 10 months later. With the exception of mammography, the hospital converted to filmless radiography within 60 days. The critical objectives to maintain control of films and radically improve the reporting process were achieved immediately. Over 99% of all examinations now are formally reviewed and reported. Only 7% of all reports take 1 or more days to generate. This report describes Elmhurst Hospital's efforts to make improvements in the delivery of radiology services and the reasons attributed to its rapid conversion to becoming a filmless (mammography excluded) medical center. The impact of the PACS on radiology department operations and service is discussed.

A high-resolution networked computer system for radiologic instruction of medical students.

A network of 18 Macintosh II-based workstations (Apple Computer Corp, Cupertino, CA) having high-resolution 1,024-line monitors is used for the radiologic instruction of medical students in our institution. Although this is an expensive system, it is time-shared with the Departments of Pathology, Physiology, Neuroscience, Biochemistry, Parasitology, and Microanatomy. The number of workstations available allows the entire class to access the system simultaneously by working in small groups. Because of its high resolution, medical imaging studies and text may be displayed on the same monitor side by side. We have chosen a question-and-answer format (Carousel). Forty-one radiologists in our affiliated medical institutions contributed cases. These cases in question-and-answer form supplement the lectures and film-based tutorials given as part of our mandatory third year radiology clerkship.

Hypervascular presentation of multiple myeloma involving the skull, demonstrated on encephaloscintigraphy.

We present two cases of myelomatous involvement of the skull. Correlative studies with routine radiography, angiography, and encephaloscintigraphy were performed. The areas of involvement of the skull were confirmed as autopsy. A mixed pattern of photon-deficient and photon-abundant lesions was noted. The clinician should be aware of such mixed patterns.

Renal cyst puncture: utilization of pediatric guide wire technique and upright radiographic changers.

After puncture of a renal cyst with a polytetrafluoroethylene needle a pediatric 0.021-inch guide wire is inserted through a polytetrafluoroethylene sheath needle. The sheath is then advanced over the wire. The technique is controlled by fluoroscopy or performed under ultrasonography. Aspiration of the contrast material is performed, and then air and diatrizoate meglumine and diatrizoate sodium are injected to outline the borders of the cyst. The patient is then taken to an upright and lateral radiographic changer for routine radiography in the upright and decubitus positions.

Gray-scale ultrasound: utility preoperatively and postoperatively in a patient with obstructive jaundice.

We present a case of obstructing calculi of the common bile duct diagnosed by ultrasonography. Postoperatively, a sterile abscess due to bile leakage at the distal common bile duct developed, and was also diagnosed by ultrasound Ultrasonography was useful in following the course of clearing of the bile collection. Preoperative ultrasound evaluation of the jaundiced patient should be followed by postoperative sonography, especially if complications occur.

Radionuclide venography of the lower extremities and inferior vena cava by continuous injection and moving bed gamma camera technique.

Radionuclide venography has proved to be a tedious procedure because of the need for multiple imaging set-ups with coordinated, repeated injections of radionuclide. The use of a moving bed gamma camera has shortened the procedure. This method enables the entire sapheno-femoral-iliac-caval system to be visualized in continuity on a single film. The moving table top system also adequately imaged the suspected areas of thrombi or endothelial damage on the post-exercise study on a single film.

Clinical experience with technetium-99m stannous polyphosphate for myocardial imaging.

Myocardial imaging with technetium-99m stannous polyphosphate was performed on 46 patients. Eleven patients had no cardiac disease, 22 had acute myocardial infarction, and 13 had stable arteriosclerotic heart disease. Distinct patterns of myocardial activity were noted: (1) the patients with no obvious cardiac disease showed no cardiac activity; (2) stable arteriosclerotic heart disease showed faint, ill-defined cardiac activity, primarily in the anterior or inferior aspect of the left ventricle; (3) acute myocardial infarction showed intense, focal, well-defined activity, with a shape that characterized the location of the infarct.

Localization of myocardial disorders other than infarction with 99mTc-labeled phosphate agents.

Myocardial studies with 99mTc-labeled phosphate agents were obtained in 20 patients without demonstrable cardiovascular disease, 24 patients with unstable arteriosclerotic heart disease (ASHD) without acute infarction, and six patients with myocardiopathy. The patients without cardiovascular disease showed no localization or tracer; the patients with unstable ASHD and without acute infarction showed nonfocal ill-defined accumulation of tracer; and the patients with myocardiopathy showed diffuse accummulation of tracer throughout the confines of an enlarged cardiac outline. Careful evaluation of both the distribution and intensity of the activity, in conjunction with the clinical picture, allows differentiation among these disease processes. Since ischemic areas around infarcted tissue may show increased activity, the value of this technique for sizing acute myocardial infarction may be limited.

Cervical venous reflux in dynamic brain scintigraphy.

Cervical venous reflux, shown by dynamic brain scintigraphy, was investigated through three avenues of approach: (A) by reviewing 371 randomly chosen routine dynamic intracerebral bloodflow studies to estimate its incidence; (B) by correlative positive-contrast superior venacavography in patients with characteristic cervical venous reflux; and (C) by performing dynamic brain scintigraphy while utilizing various positional and physiologic maneuvers to attempt to produce cervical venous reflux in patients who did not exhibit this phenomenon on earlier examination. Although any obstruction of the superior vena cava or a properly timed Valsalva maneuver in selected patients can produce the scintigraphic picture of cervical venous reflux, in most cases it is a normal phenomenon due to incompetent or absent cervical venous valves.

Experience with modified remotely controlled fluoroscopic equipment for gastrointestinal examination in debilitated patients.

The concept and realization of a highly automated remotely controlled fluoroscopic system, applicable to the examination of debilitated or uncooperative patients, have been described. The addition of a rotating cradle, remotely controlled barium administration, magazine-fed roll film camera, remotely inflated paddle for prone-pressure spot filming, and a vacuum restraining device have been described for the examination of uncooperative as well as cooperative patients. These patients can be examined with as high a degree of sophistication and automation as is now available. Future developments in this area may lie in the realm of multitable remotely controlled fluoroscopic rooms, operation of the above equipment by a super technologist, programmed gastrointestinal examinations utilizing the above equipment and automated programming, and teleremote controlled fluoroscopy from a centralized location with coaxial cable or microwave transmission.

Effects of phentolamine on coronary blood flow in patients with recent myocardial infarction.

The myocardial clearance of rubidium may be obtained by praecordial counting after intravenous injection of Rb-minus 86 Cl. Eight patients with recent myocardial infarction had this determination performed before and after the infusion of 10 mg phentolamine at a rate of 0.3 mg/minute. The average predrug myocardial clearance of Rb was 89.3 plus or minus 29.9 ml/min per 100 g myocardium. After phentolamine, the average myocardial clearance rose to 117.3 plus or minus 33.3 ml/min per 100 g myocardium (P LESS THAN 0.01). An explanation for this findings is presented as well as its possible clinical applications.

Dosimetry of portable image intensifiers in pacemaker insertions.

With the increased utilization of portable image intensifiers for pacemaker insertions, an investigation of the radiation hazards to operative personnel was undertaken. The personnel were tested first utilizing a Rando phantom and later during actual pacemaker insertions. Studies of medical personnel show the critical organs to be the thyroid (approximately 15mR per procedure) and the lens of the eye (approximately 13mR per procedure). While the MPD/week was not exceeded, the radiation dosage was substantial and could increase under operating conditions other than those measured. Recommendations to insure safer operation of this equipment are presented.