PACS development in Austria: a discussion of success criteria and success factors.

OBJECTIVES: The paper uses the example of PACS (Picture Archiving and Communication System) in Austria (where some of the earliest large PACS projects were realised and led to a high penetration with state-wide networked PACS installations) to discuss success criteria and success factors of medical information systems. METHODS: The paper describes the development of digital imaging in medicine and classifies the impact of systems according to their first or second order effects on patient care. The historic goals of PACS and the technical infrastructure in the eighties are shortly described. The paper then outlines the early PACS projects in Austria and their different approaches as well as the present state of PACS in Austria. RESULTS: After giving a definition of success, success criteria (which allow to decide whether a system is in fact a success or not) are discussed in general--the final criterion being routine use--and in detail and it is concluded that PACS in Austria was and is indeed successful. CONCLUSION: The analysis of success factors shows a multitude of influences but the most decisive ones are the practical ability of the system to deliver a real service to health care and the ability to support the (key) users in their work and goals.

SAP and partners: IS-H and IS-H* MED.

OBJECTIVES: The Styrian Hospital Organization with 21 hospitals including the Graz University Hospital, and the Heidelberg University Hospital implemented a new HIS based on SAP/R3, ISH, ISH* MED with the objective to have an integrated system to support patient administration and management, patient care, clinical documentation, research etc. METHODS: Heidelberg University Hospital chose a step by step method for the introduction of the system, beginning with patient administration (ISH) and proceeding with clinical functions (ISH* MED). In Styria, the full functionality was implemented--as part of the selection process--in one peripheral hospital and in the Ear, Nose and Throat (ENT) Department of the Graz University Hospital, including special documents to support the processes in the highly specialized ENTunits. RESULTS AND CONCLUSIONS: The standard modules are performant, stable and basically well accepted. Particularly in Graz, it has been shown that the requirements of highly specialized departments for work flow management, documentation and integration of subsystems and data from different sources can be fulfilled by special documents and programs--although at the expense of additional workload particularly in the initial phases of such a project.

Side effects and responsibility of medical informatics.

Medical informatics systems have the ultimate goal to improve the quality of health care. However, these systems have also the potential to compromise the quality of health care if they are misused, intrinsically faulty or entail unexpected side effects. The purpose of the paper is to discuss examples from the experience of the author, where well-intended medical informatic applications proved to have potentially harmful effects or side effects. It is argued that medical informaticians (MI) have an extended professional responsibility, which covers not only the state of the art technical planning, an implementation of information processing systems in medicine, but also the final result for the patient. In order to discuss professional duties of medical informaticians, a modification of the Software Engineering Code of Ethics and Professional Practice developed by ACM/IEEE is proposed as a guideline. For several examples, these guidelines are used to analyze possible actions and professional responsibility.

The reality of picture archiving and communication systems (PACS): a survey.

Toward the end of 1997 vendors were succeeding in installing picture, archiving and communication systems (PACS) in larger numbers. It was hard to separate fact from fiction at times. This survey was undertaken by 2 members of the academic community to confirm what was operational, how well the installed systems worked, and what they were doing. Fax questionnaires were sent to nearly 1,000 facilities worldwide to identify PACS of any size in clinical operation on a date certain, February 1, 1998. A total of 177 PACS were identified. Facilities furnished responses during the first survey period from May 1 to November 1, 1998. A second survey, done in February and March of 2000, sought long-term follow-up data. Many systems operated 5 or more types of modalities. Computed tomography (CT) was the most common modality type at 83%, but the distribution of the rest held surprises. There also was an unexpectedly large use of soft copy reading and filmless operation in 1998. Clear trends toward increased use of computed radiography and digital radiography and a significant expansion on the percentage of all of a facility's examinations on the PACS were seen over the 2 years. Satisfaction with original PACS vendors was relatively high. Eighty-nine percent remained with their original vendor. Only 10 sites reported they changed vendors, and 4 facilities said they abandoned their system. The users reported their expectations of the PACS had been met in 81% of cases. Some (65%) declared their systems were cost effective. The most striking response was that 97% of the users would recommend PACS to others.

HIS purchase projects in public hospitals of Styria, Austria.

The Steiermärkische Krankenanstaltenges. m.b.H (KAGes) is a company, owned by the province of Styria in Austria, which operates 21 hospitals with about 8000 beds and 14000 employees, serving a population of ca. 1.2 million people. KAGes has purchased a new hospital information system (HIS) for its hospitals. Within the strategic IT plan and the 'system structure new' (SSN) project, a methodology was developed for making an effective HIS purchase. Several steps of this project are described in the paper, request for product information, evaluation of vendor proposals, product presentations, test site evaluation, reference site visits and selection of vendor finalists. The authors present the internal project management methodology, including the structure of the project team, project information management through intranet, criteria for different steps of the evaluation and evaluation site organization. Four major HIS vendors with leading HIS products qualified for this stage of the project (evaluation site). About 60 teams with 400 members (end users and IT-experts) have assessed all the products installed, during one or more, repeated test sessions. The decision on which new HIS to purchase were based on the recommendations derived from this evaluation. After completing SSN-project with the suggestion to KAGes-top-management for negotiations with two vendor finalists, the new project named MEDOCS was started mid-1999. Two pilot installations (one general hospital and one teaching hospital department) are nowadays in the pilot implementation and subsequent roll-out (including substitution of the legacy system) is scheduled until the year 2003.

Paperless hospital: reality, dream or a nightmare?

Public Hospitals of Styria (KAGes) are implementing new hospital information system (MEDOCS--MEdical and nursing DOcumentation and Communication network of Styria) in its 21 hospitals. One of the outstanding features of this system is the coverage of virtually all communication and documentation functions related to the patient. This should be the way to fulfill the conditions for gradually removing the paper as an information medium from daily hospital practice. This approach will be tested in the MEDOCS project at two evaluation sites. In this paper the authors discuss in form of "pros and contras" the chances and risks of this approach, as well as possible strategies during the steps of implementing the "paperless" hospital. Besides of general technological, medical and cultural considerations the paper discuss also the technical and economical aspects of "paperless" hospital implementation and production.

Research at the Department of Medical Informatics, Statistics and Documentation of the University of Graz.

The Department of Medical Informatics, Statistics and Documentation of the University of Graz has a double responsibility: research in medical informatics, and implementation and operation of information systems in the hospital. Research is therefore application oriented with emphasis on departmental information systems, image management, and information integration. Other topics include analysis of the preconditions for the acceptance and successful use of information systems in medicine, and the ethics and professional responsibility of medical informatics.

HIS purchase project: preliminary report.

The KAGes (Krankenanstaltenges.m.b.H) is a company, owned by the state of Styria in Austria, which operates 20 hospitals with about 8,000 beds and 14,000 employees, serving a population of ca. 1.2 million people. KAGes is on its way to purchase a new hospital information system (HIS) for it's hospitals. Within the strategic IT plan and the "System Structure New" (SSN) project a methodology was developed, for making an effective HIS purchase. Several steps of this project are described in the paper: request for product information, evaluation of vendor proposals, product presentations, test site evaluation, reference site visits and selection of vendor finalists. The authors present the internal project management methodology, including the structure of the project team, project information management through intranet, criteria for different steps of the evaluation and evaluation site organization. Four major HIS vendors with leading HIS products qualified for this stage of the project (evaluation site). About 60 teams with 400 members (end users and IT-experts) have assessed all the products installed, during one or more, repeated, test sessions. The decision on which new HIS to purchase will be based on the recommendations derived from this evaluation. Two pilot installations (one general hospital and one teaching hospital department) are planned for implementation in the year 1999/2000 and subsequent roll-out (including substitution of the legacy system) is scheduled until the year 2003.

The Austrian Academic Computer Network and its usefulness for teleradiology.

To study the value of the Austrian Academic Computer Network (ACOnet) for teleradiology, 1740 test image data-sets and 620 image data-sets were exchanged between the departments of diagnostic radiology of the Universities of Innsbruck and Graz using the ACOnet service. Data transmission was reliable and fast with an average transfer capacity of 170 kByte/s (range 94-341). During the test phase, no major problems with image transfer occurred. Assuming that problems like security of patient data-sets, data compression and data verification can be solved, the ACOnet service would be a useful additional tool for telemedicine applications throughout Austria and eastern Europe.

[ACOnet (Austrian Academic Computer Network) as data carrier for teleradiologic consultations]. / Das ACOnet (Austrian Academic Computer Network) als Datenträger für teleradiologische Konsultationen.

PURPOSE: To assess the feasibility of image transfer for teleradiologic consultations using the Austrian Academic Computer Network (ACOnet). The ACOnet corresponds between the main universities to a MAN (Metropolitan Area Network) with a transfer rate of 4 Mbps. Its use is free of charge for university institutions. MATERIALS AND METHODS: 1740 test image data sets and 620 image data sets for teleradiological consultations were exchanged without annotations between the Departments of Diagnostic Radiology of the universities of Innsbruck and Graz, using the ACOnet. RESULTS: Data transmission was reliable and fast with an average transfer capacity of 170.2 kBytes/s (94-341 kBytes/s). There were no major problems with image transfer during the test phase. CONCLUSION: Due to its high transfer capacity, the ACOnet is considered a reasonable alternative to the ISDN service.

The internal challenges of medical informatics.

Haux's [7] basic assumption that the object of medical informatics is: "... to assure and to improve the quality of healthcare as well as the quality of research and education in medicine and in the health sciences ..." is taken as a starting point to discuss the three main topics: What is the meaning of medical informatics (i.e. what should be the main activities of medical informatics to bring maximum benefit to medicine)? What are the achievements and failures of medical informatics today (again considering the impact on the quality of healthcare)? What are the main challenges? Concerning the definition of medical informatics it is argued that one should not hide the link to basic informatics and, for that matter to computers, completely behind abstract definitions. After an analysis of the purposes of the definition of a discipline, a differentiated definition of the scope of medical informatics, rather general when concerning the field of scientific interest, more focused when concerning the practical (constructive) applications, is proposed. Contrasting Haux's chapter on achievements of medical informatics we concentrate on and analyse non fulfilled promises of medical informatics to derive lessons for the future and to propose 'generic' (or core) tasks of medical informatics to meet the challenges of the future. A set of 'internal challenges' of medical informatics to change priorities and attitudes within the discipline is put forward to enable medical informatics to meet the 'external challenges' listed by Haux.

Large picture archiving and communication systems of the world--Part 2.

A survey of 82 institutions worldwide was done in 1995 to identify large picture archiving and communication systems (PACS) in clinical operation. A continuing strong trend toward the creation and operation of large PACS was identified. In the 15 months since the first such survey the number of clinical large PACS went from 13 to 23, almost a doubling in that short interval. New systems were added in Asia, Europe, and North America. A strong move to primary interpretation from soft copy was identified, and filmless radiology has become a reality. Workstations for interpretation reside mainly within radiology, but one-third of reporting PACS have more than 20 workstations outside of radiology. Fiber distributed data interface networks were the most numerous, but a variety of networks was reported to be in use. Replies on various display times showed surprisingly good, albeit diverse, speeds. The planned archive length of many systems was 60 months, with usually more than 1 year of data on-line. The main large archive and off-line storage media for these systems were optical disks and magneto-optical disks. Compression was not used before interpretation in most cases, but many systems used 2.5:1 compression for on-line, interpreted cases and 10:1 compression for longer-term archiving. A move to digital imaging and communication in medicine interface usage was identified.

Large picture archiving and communication systems of the world--Part 1.

This is the report of a worldwide survey of 82 institutions done to identify large scale picture archiving and communication systems (PACS) in clinical operation in 1995. This survey found a continuing strong trend toward the creation and operation of large PACS. In the 15 months since the first such survey, the number of clinical large PACS went from 13 to 23, almost a doubling in that short interval. New systems were added in Asia, Europe, and North America. A strong move to primary interpretation from soft copy was identified, and filmless radiology has become a reality.

[PACS-2000]. / PACS-2000.

Digital radiology and picture archiving and communication systems (PACS) with filmless reporting at electronic workstations are a great challenge for radiology. There are the possibilities of improving the quality of diagnosis, of working more efficiently and of achieving economic savings, but on the other hand the position of radiology within the hospital may be put at risk. The technical means for the implementation of PACS are largely available. Wide acceptance in the market depends inter alia on the availability of open systems with standardized interfaces.

Expert systems as a support for radiological diagnosis.

Given the fact that despite high expectations, expert systems have still an almost negligible impact on the practice of medicine, the present trends and methods for medical expert systems are discussed. An analysis of the diagnostic process in radiology leads to a discussion about possible computer support and on the conditions of use and acceptance of such systems.

An integrated picture archiving and communications system-radiology information system in a radiological department.

In this report we present an integrated picture archiving and communication system (PACS)--radiology information system (RIS) which runs as part of the daily routine in the Department of Radiology at the University of Graz. Although the PACS and the RIS have been developed independently, the two systems are interfaced to ensure a unified and consistent long-term archive. The configuration connects four computer tomography scanners (one of them situated at a distance of 1 km), a magnetic resonance imaging scanner, a digital subtraction angiography unit, an evaluation console, a diagnostic console, an image display console, an archive with two optical disk drives, and several RIS terminals. The configuration allows the routine archiving of all examinations on optical disks independent of reporting. The management of the optical disks is performed by the RIS. Images can be selected for retrieval via the RIS by using patient identification or medical criteria. A special software process (PACS-MONITOR) enables the user to survey and manage image communication, archiving, and retrieval as well as to get information about the status of the system at any time and handle the different procedures in the PACS. The system is active 24 hours a day. To make the PACS operation as independent as possible from the permanent presence of a system manager (electronic data processing expert), a rule-based expert system (OPERAS; OPERating ASsistant) is in use to localize and eliminate malfunctions that occur during routine work. The PACS-RIS reduces labor and speeds access to images within radiology and clinical departments.

Some software requirements for a PACS: lessons from experiences in clinical routine.

In the Department of Radiology of the University of Graz a PACS which includes CT-scanners as modalities was installed. Parts (communication and archiving) of this PACS are used in routine work. Summarizing our experiences from routine work we discuss a minimal set of software requirements that a PACS must meet to allow a fast and non-problematic operation concerning communication and archiving. Most of the functionality of the PACS is provided by software processes which are running automatically in the background. These processes convert images into the ACR-Nema format, submit data in the image database and so on. If a process does not work correctly or crashes, it may happen that examinations are only partially or even not archived. If the user recognises a malfunction too late the troubles spread over the whole system and great time delays or loss of data may occur. Examples of such malfunctions are software crashes, interruptions of the connection between 2 processes or a hardware crash. A PACS that is used in routine work should conform to a set of requirements like autonomous supervising of the single processes, automatical elimination of malfunctions, communication with the user and others. Then the PACS will operate without problems and safely. An intelligent process-structure which conforms to these requirements will be discussed.