- Email: [email protected]
Results and experience with four years of development work on a filmless department in Mjölby health care centre
Computer Methods and Programs in Biomedicine 57 (1998) 51 – 54
Results and experience with four years of development work on a filmless department in Mjo¨lby health care centre Go¨ran Karner a,*, Silas Olsson b a
Radiology Department, Primary Healthcare Centre, Sma˚lands6a¨gen 24, S-595 30 Mjo¨lby, Sweden b Department of Health Economics, Spri, PO Box 70487, S-107 26 Stockholm, Sweden Accepted 3 February 1998
Abstract Since the end of 1994, the radiology department in Mjo¨lby has been running their activity without X-ray films. When the film developing machine at the department was discarded in April 1995, after six months of test-running of the new system, the film epoch was definitely abandoned. The practical experiences from working with digital images are all good. The background to this change lays in a four years development work, which has been supported financially by the O8 stergo¨tland County Council, Swedish National Board for Industrial and Technical Development (NUTEK), and a regional foundation for development of new ways to organise and perform work (Arbetslivsfonden). © 1998 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Radiology; Digital radiography; Teleradiology; Telemedicine; Evaluation
1. Background In 1971, development of a radiology information system (RIS) had already started in the O8 stergo¨tland county council, in close co-operation with O8 stgo¨tadata — a software company at the time owned by the County Council — and all the radiology departments in O8 stergo¨tland. At the end of the 1980’s, the time was right for the * Corresponding author. Tel.: + 46 141 42171; fax: + 46 141 42073; e-mail: [email protected]
fourth upgrading of the RIS-system, a work that started in 1989. In relation to the introduction of this updated RIS-system in Motala and Mjo¨lby, a co-ordinated function between teleradiology and RIS was tested. At about the same time, Swedish National Board for Industrial and Technical Developments, NUTEK, announced a call for proposals to a new R&D-programme called ‘Medical image and knowledge based systems’, with the aim to strengthen and further develop Swedish research and industrial activity within this sector. In the co-operation between the radiology depart-
0169-2607/98/$19.00 © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S0169-2607(98)00044-3
52
G. Karner, S. Olsson / Computer Methods and Programs in Biomedicine 57 (1998) 51–54
ment at Mjo¨lby and various central representatives within O8 stergo¨tlands county council, an application was drawn up for NUTEK in 1991, which granted the project 0.9 million SEK. The application was about a feasibility study to draw up requirements and specifications concerning ‘Digitalisation of smaller and medium-sized radiology departments’. The study was accomplished by the company SECTRA AB in Linko¨ping, Sweden, O8 stgo¨tadata (at present Radisoft AB, Sweden) in Linko¨ping, and the radiology department in Mjo¨lby, with the responsible radiologist as the project leader, throughout the whole project and the development work. No fully digital radiology departments existed at that time in Sweden [1,2]. The radiology department of Mjo¨lby is situated at the primary healthcare centre in the same town, but is organised as a satellite department to the radiology department in Motala, a medium sized town, also belonging to O8 stergo¨tland’s county council. One radiologist works in Mjo¨lby (parttime, 60%), together with four radiology nurses, and one radiology assistant (all part-time, 85%). The patient catching area for the radiology department in Mjo¨lby covers 35000 inhabitants, and is annually performing 7,000 X-ray examinations. 2. Working site programme Strengthened from preliminary results of the work with the requirements and specifications project, the county council submitted an application for grants to the regional foundation for development of new ways to organise and perform work (Arbetslivsfonden). Amongst other things, the aim with the application was to get development resources to: Turn the work with film into computer work (‘digital department’). Start up the work by replacing the manual image handling to simplify and increase the capacity of the work. Give the staff an increasing competence and altered duties. Development of computer programme for image handling to simplify and increase the capacity of the work.
Improved access of radiology images for referring physicians. Create confidence in digital image handling. Take part in a scientific evaluation of the diagnostic image quality on digital images. The regional foundation granted the radiology department in Mjo¨lby 4.1 million SEK in project funds in autumn of 1992. In addition, the O8 stergo¨tland county council has invested seven million SEK in the project, which also included replacements very old X-ray equipment.
3. Results from the development work at Mjo¨lby The long-term goals for the development work of this kind is to increase the efficiency of the referral procedure and radiology report handling, as well as the overall image handling procedure, both internally within the radiology department, hospital units, and externally between hospitals and other healthcare centres. This is expected to give new possibilities for co-operation and new organisational and hospital structural solutions to increase quality and efficiency in healthcare. The development work in Mjo¨lby is the first step in such future processes within O8 stergo¨tland county council. The results from this development work at the radiology department in Mjo¨lby, can be summarised in the following way, which in principle follows the direction of the patient and the image information flow through a radiology department: (1) Booking of patients and archive work: The booking function is unchanged, that is, the referring physician sends a request (on paper) for an appointment and the patient is given the day and time for examination and eventual preparation prescription (also on paper). The booking is registered in the RIS-system by the staff in Mjo¨lby and at the same time it is checked whether previous radiology images are in analogous (film) or in digital form. If the images are on film, they are fetched from the archive, as before. For digital images there is a newly-developed software programme, which automatically prefetches these images for transportation via the network to the relevant image workstation.
G. Karner, S. Olsson / Computer Methods and Programs in Biomedicine 57 (1998) 51–54
(2) Request and report handling: While waiting for a completed computerised referral and report system, the referral on paper is scanned as an image and digitally stored in the image archive, to be available at image diagnostic workstations. The radiology report is written on paper in a conventional way, and is sent in the ordinary mail system to the referring physician. However, the written report is also available in the RIS-system, and can be read directly by the referring physician if a RIS-terminal is available. In the end of 1997 a new system for handling requests and reports will be implemented. Requests will be sent from the computerised medical record via Intranet to the RIS system and the radiology report will be sent in the opposite direction. (3) Archive and other image handling: X-ray images on film are manually collected from the archive, and presented on a light box, to be compared with the newly taken digital images. The display of ‘old’ images already in digital format, for comparison reasons, will be on image workstations. The old analogue images are scanned for storage in the new digital archive in exceptional cases only. As long as the request note is received, report is sent, and stored on paper, the old X-ray archive is used for each examination. The major gain in effectiveness is expected when the request note and report handling become digital, and the conventional film archive can gradually be outphased. (4) Examination work: Ultrasound and fluoroscopy examinations are performed with digital image technique, and are usually already read at the time of the examination on the image workstation in the examination room. Other examinations made by radiology nurses (for example; skeleton, lungs, and kidneys) are performed with CR technology. (5) Diagnostic work: Since October 1994 every newly taken images at the department are in a digital format and read by use of image display workstations. The old darkroom has been converted into a computer room. The quality of the digital X-ray images is judged by the radiologists in Mjo¨lby, to be equal or better than corresponding previous old analogical images. A scientific study on image quality in this respect is reported
53
[3]. On the other hand, the diagnostic work with the handling of the digital images still takes some more time. This situation will most likely be balanced when the software for presentation of the images is completely developed. (6) Round activity: One of the advantages with X-ray rounds with the aid of digital images, is that the images can be manipulated (enlarged, contrast enhanced etc.), so that each participating physician on the round can utilise the image findings in a much better way than before. This has given an improved interest for the X-ray images in itself and the diagnostically findings amongst the referring physicians. The disadvantage with the digital rounds so far, is that there is a need for more time. A complete software programme product is still missing to be able to effectively prepare these rounds, which makes the process take a longer time. The final goal is in sight, though, which means that the round should be both quicker and qualitatively better than the old conventional film based round. (7) Teleradiology: Teleradiology as it is used at Mjo¨lby today, implies that images are sent to Motala when the radiologist is not on-duty in Mjo¨lby, consultations in unclear cases, and that images are sent when these are to be demonstrated to referring physicians in Motala or in Linko¨ping university hospital. Furthermore, teleradiology exists between Mjo¨lby and Mantorp primary healthcare centre. This is a project with the aim to evaluate possible advantages with a referring healthcare centre physician’s access to ‘his’ images even at a distance. The preliminary radiology report is presented both by the RIS-terminal in Mantorp, and as a voice message.
4. Technical specifications Archive: 198GByte ‘on-line’ capacity. magnet-optical discs a` 2,6 GByte per disc. Reversible compression 2,5-3 times. Workstation: Hewlett-Packard workstations, 1280x1024 pixels, 256 colours.
54
G. Karner, S. Olsson / Computer Methods and Programs in Biomedicine 57 (1998) 51–54
HP-UX Unix operative system. General radiology and ultrasound: CR-system with up to 2000× 2000 pixels, 10 bits (1024 grey-scale levels). Digital fluoroscopy with 1024×1024 pixels, 8 bits (256 grey-scale levels). Ultrasound with 720×720 pixels, 8 bits (256 grey-scale levels). Network: Standard Ethernet over TCP/IP with Ethernet exchange in the hub, that is 10 Mb s − 1 point to point. Teleradiology system: Irreversible compression (8 – 10 times of compression) over 2 Gb s − 1 network. Transmission time for a typical chest-image is about 10 s. Image standardisation: Dicom 3.0
5. Experience and discussions
time than expected to develop an effective and fast software for general image handling and for the diagnostic work. Therefore, this type of work was gradually divided with intermediate evaluations, which formed the basics for the continuous development work.During the project adequate information safety, confidentiality, integrity have been addressed. The subject is of current interest for other development projects and overlapping discussions are raised within the county council. It has been highly valuable that every single staff member at the radiology department in Mjo¨lby, from the start of the project, has been involved in the development work. This has given the staff patience and realistic expectations on the result. Throughout the project period, the staff members have had the opportunity to set off time to acquire knowledge and project participation. As a result, the competence of the staff has raised significantly. It is very important in such extensive development work to get support and feedback from different representatives within the county council itself, which has also been given.
6. Conclusion
In order to get a smoothly usable system with lack of approved computer communication standards, one of the major challenges of the project has been to reach an effective computer communication between the products form the different companies involved. The products involved in the development work were delivered by the following companies: Aloka (ultrasound) Radisoft, Sweden (RIS system) Fuji (CR-system) Hewlett Packard (image workstations) Philips (digital fluoroscopy) Sectra-Imtec, Sweden (digital image handling, archive, and teleradiology) Important drivers in this co-operative work with computer interfaces and communication, have been the companies SECTRA AB and O8 stgo¨tadata/Radisoft AB. One experience which was discovered early, was that it took a lot more .
The Mjo¨lby project has shown that technology now exists to transform from film to digital image handling in an X-ray department of this size. The quality of the digital images is judged to be as good or better than film. The staff has fully accepted the new way of working and does not want to go back to a film-based way of working.
References [1] S. Olsson, PACS and related developments in Sweden. NATO ASI Series, vol. F74, Picture Archiving and Communication Systems (PACS) in Medicine. Springer, Berlin, 1991. [2] S. Olsson, K Inamura, Diffusion of digital radiology modalities in the Nordic countries and Japan, Comput. Methods Programs Biomed. 43 (1994) 9 – 13. [3] A. Jonsson, S. Laurin, G. Karner et al., Spatial resolution requirements in digital radiography of scaphoid fractures. An ROC analysis. Acta Radiol., 1996.
Results and experience with four years of development work on a filmless department in Mjo¨lby health care centre Go¨ran Karner a,*, Silas Olsson b a
Radiology Department, Primary Healthcare Centre, Sma˚lands6a¨gen 24, S-595 30 Mjo¨lby, Sweden b Department of Health Economics, Spri, PO Box 70487, S-107 26 Stockholm, Sweden Accepted 3 February 1998
Abstract Since the end of 1994, the radiology department in Mjo¨lby has been running their activity without X-ray films. When the film developing machine at the department was discarded in April 1995, after six months of test-running of the new system, the film epoch was definitely abandoned. The practical experiences from working with digital images are all good. The background to this change lays in a four years development work, which has been supported financially by the O8 stergo¨tland County Council, Swedish National Board for Industrial and Technical Development (NUTEK), and a regional foundation for development of new ways to organise and perform work (Arbetslivsfonden). © 1998 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Radiology; Digital radiography; Teleradiology; Telemedicine; Evaluation
1. Background In 1971, development of a radiology information system (RIS) had already started in the O8 stergo¨tland county council, in close co-operation with O8 stgo¨tadata — a software company at the time owned by the County Council — and all the radiology departments in O8 stergo¨tland. At the end of the 1980’s, the time was right for the * Corresponding author. Tel.: + 46 141 42171; fax: + 46 141 42073; e-mail: [email protected]
fourth upgrading of the RIS-system, a work that started in 1989. In relation to the introduction of this updated RIS-system in Motala and Mjo¨lby, a co-ordinated function between teleradiology and RIS was tested. At about the same time, Swedish National Board for Industrial and Technical Developments, NUTEK, announced a call for proposals to a new R&D-programme called ‘Medical image and knowledge based systems’, with the aim to strengthen and further develop Swedish research and industrial activity within this sector. In the co-operation between the radiology depart-
0169-2607/98/$19.00 © 1998 Elsevier Science Ireland Ltd. All rights reserved. PII S0169-2607(98)00044-3
52
G. Karner, S. Olsson / Computer Methods and Programs in Biomedicine 57 (1998) 51–54
ment at Mjo¨lby and various central representatives within O8 stergo¨tlands county council, an application was drawn up for NUTEK in 1991, which granted the project 0.9 million SEK. The application was about a feasibility study to draw up requirements and specifications concerning ‘Digitalisation of smaller and medium-sized radiology departments’. The study was accomplished by the company SECTRA AB in Linko¨ping, Sweden, O8 stgo¨tadata (at present Radisoft AB, Sweden) in Linko¨ping, and the radiology department in Mjo¨lby, with the responsible radiologist as the project leader, throughout the whole project and the development work. No fully digital radiology departments existed at that time in Sweden [1,2]. The radiology department of Mjo¨lby is situated at the primary healthcare centre in the same town, but is organised as a satellite department to the radiology department in Motala, a medium sized town, also belonging to O8 stergo¨tland’s county council. One radiologist works in Mjo¨lby (parttime, 60%), together with four radiology nurses, and one radiology assistant (all part-time, 85%). The patient catching area for the radiology department in Mjo¨lby covers 35000 inhabitants, and is annually performing 7,000 X-ray examinations. 2. Working site programme Strengthened from preliminary results of the work with the requirements and specifications project, the county council submitted an application for grants to the regional foundation for development of new ways to organise and perform work (Arbetslivsfonden). Amongst other things, the aim with the application was to get development resources to: Turn the work with film into computer work (‘digital department’). Start up the work by replacing the manual image handling to simplify and increase the capacity of the work. Give the staff an increasing competence and altered duties. Development of computer programme for image handling to simplify and increase the capacity of the work.
Improved access of radiology images for referring physicians. Create confidence in digital image handling. Take part in a scientific evaluation of the diagnostic image quality on digital images. The regional foundation granted the radiology department in Mjo¨lby 4.1 million SEK in project funds in autumn of 1992. In addition, the O8 stergo¨tland county council has invested seven million SEK in the project, which also included replacements very old X-ray equipment.
3. Results from the development work at Mjo¨lby The long-term goals for the development work of this kind is to increase the efficiency of the referral procedure and radiology report handling, as well as the overall image handling procedure, both internally within the radiology department, hospital units, and externally between hospitals and other healthcare centres. This is expected to give new possibilities for co-operation and new organisational and hospital structural solutions to increase quality and efficiency in healthcare. The development work in Mjo¨lby is the first step in such future processes within O8 stergo¨tland county council. The results from this development work at the radiology department in Mjo¨lby, can be summarised in the following way, which in principle follows the direction of the patient and the image information flow through a radiology department: (1) Booking of patients and archive work: The booking function is unchanged, that is, the referring physician sends a request (on paper) for an appointment and the patient is given the day and time for examination and eventual preparation prescription (also on paper). The booking is registered in the RIS-system by the staff in Mjo¨lby and at the same time it is checked whether previous radiology images are in analogous (film) or in digital form. If the images are on film, they are fetched from the archive, as before. For digital images there is a newly-developed software programme, which automatically prefetches these images for transportation via the network to the relevant image workstation.
G. Karner, S. Olsson / Computer Methods and Programs in Biomedicine 57 (1998) 51–54
(2) Request and report handling: While waiting for a completed computerised referral and report system, the referral on paper is scanned as an image and digitally stored in the image archive, to be available at image diagnostic workstations. The radiology report is written on paper in a conventional way, and is sent in the ordinary mail system to the referring physician. However, the written report is also available in the RIS-system, and can be read directly by the referring physician if a RIS-terminal is available. In the end of 1997 a new system for handling requests and reports will be implemented. Requests will be sent from the computerised medical record via Intranet to the RIS system and the radiology report will be sent in the opposite direction. (3) Archive and other image handling: X-ray images on film are manually collected from the archive, and presented on a light box, to be compared with the newly taken digital images. The display of ‘old’ images already in digital format, for comparison reasons, will be on image workstations. The old analogue images are scanned for storage in the new digital archive in exceptional cases only. As long as the request note is received, report is sent, and stored on paper, the old X-ray archive is used for each examination. The major gain in effectiveness is expected when the request note and report handling become digital, and the conventional film archive can gradually be outphased. (4) Examination work: Ultrasound and fluoroscopy examinations are performed with digital image technique, and are usually already read at the time of the examination on the image workstation in the examination room. Other examinations made by radiology nurses (for example; skeleton, lungs, and kidneys) are performed with CR technology. (5) Diagnostic work: Since October 1994 every newly taken images at the department are in a digital format and read by use of image display workstations. The old darkroom has been converted into a computer room. The quality of the digital X-ray images is judged by the radiologists in Mjo¨lby, to be equal or better than corresponding previous old analogical images. A scientific study on image quality in this respect is reported
53
[3]. On the other hand, the diagnostic work with the handling of the digital images still takes some more time. This situation will most likely be balanced when the software for presentation of the images is completely developed. (6) Round activity: One of the advantages with X-ray rounds with the aid of digital images, is that the images can be manipulated (enlarged, contrast enhanced etc.), so that each participating physician on the round can utilise the image findings in a much better way than before. This has given an improved interest for the X-ray images in itself and the diagnostically findings amongst the referring physicians. The disadvantage with the digital rounds so far, is that there is a need for more time. A complete software programme product is still missing to be able to effectively prepare these rounds, which makes the process take a longer time. The final goal is in sight, though, which means that the round should be both quicker and qualitatively better than the old conventional film based round. (7) Teleradiology: Teleradiology as it is used at Mjo¨lby today, implies that images are sent to Motala when the radiologist is not on-duty in Mjo¨lby, consultations in unclear cases, and that images are sent when these are to be demonstrated to referring physicians in Motala or in Linko¨ping university hospital. Furthermore, teleradiology exists between Mjo¨lby and Mantorp primary healthcare centre. This is a project with the aim to evaluate possible advantages with a referring healthcare centre physician’s access to ‘his’ images even at a distance. The preliminary radiology report is presented both by the RIS-terminal in Mantorp, and as a voice message.
4. Technical specifications Archive: 198GByte ‘on-line’ capacity. magnet-optical discs a` 2,6 GByte per disc. Reversible compression 2,5-3 times. Workstation: Hewlett-Packard workstations, 1280x1024 pixels, 256 colours.
54
G. Karner, S. Olsson / Computer Methods and Programs in Biomedicine 57 (1998) 51–54
HP-UX Unix operative system. General radiology and ultrasound: CR-system with up to 2000× 2000 pixels, 10 bits (1024 grey-scale levels). Digital fluoroscopy with 1024×1024 pixels, 8 bits (256 grey-scale levels). Ultrasound with 720×720 pixels, 8 bits (256 grey-scale levels). Network: Standard Ethernet over TCP/IP with Ethernet exchange in the hub, that is 10 Mb s − 1 point to point. Teleradiology system: Irreversible compression (8 – 10 times of compression) over 2 Gb s − 1 network. Transmission time for a typical chest-image is about 10 s. Image standardisation: Dicom 3.0
5. Experience and discussions
time than expected to develop an effective and fast software for general image handling and for the diagnostic work. Therefore, this type of work was gradually divided with intermediate evaluations, which formed the basics for the continuous development work.During the project adequate information safety, confidentiality, integrity have been addressed. The subject is of current interest for other development projects and overlapping discussions are raised within the county council. It has been highly valuable that every single staff member at the radiology department in Mjo¨lby, from the start of the project, has been involved in the development work. This has given the staff patience and realistic expectations on the result. Throughout the project period, the staff members have had the opportunity to set off time to acquire knowledge and project participation. As a result, the competence of the staff has raised significantly. It is very important in such extensive development work to get support and feedback from different representatives within the county council itself, which has also been given.
6. Conclusion
In order to get a smoothly usable system with lack of approved computer communication standards, one of the major challenges of the project has been to reach an effective computer communication between the products form the different companies involved. The products involved in the development work were delivered by the following companies: Aloka (ultrasound) Radisoft, Sweden (RIS system) Fuji (CR-system) Hewlett Packard (image workstations) Philips (digital fluoroscopy) Sectra-Imtec, Sweden (digital image handling, archive, and teleradiology) Important drivers in this co-operative work with computer interfaces and communication, have been the companies SECTRA AB and O8 stgo¨tadata/Radisoft AB. One experience which was discovered early, was that it took a lot more .
The Mjo¨lby project has shown that technology now exists to transform from film to digital image handling in an X-ray department of this size. The quality of the digital images is judged to be as good or better than film. The staff has fully accepted the new way of working and does not want to go back to a film-based way of working.
References [1] S. Olsson, PACS and related developments in Sweden. NATO ASI Series, vol. F74, Picture Archiving and Communication Systems (PACS) in Medicine. Springer, Berlin, 1991. [2] S. Olsson, K Inamura, Diffusion of digital radiology modalities in the Nordic countries and Japan, Comput. Methods Programs Biomed. 43 (1994) 9 – 13. [3] A. Jonsson, S. Laurin, G. Karner et al., Spatial resolution requirements in digital radiography of scaphoid fractures. An ROC analysis. Acta Radiol., 1996.