PACS Club of Kuwait

When viruses attack ICU

2011-04-29T18:12:00.001+03:00

Intensive Care Units (ICU) are places in hospitals where people with special care are placed. Those people need continuous monitoring for there condition. These units are normally equipped with high tech patient monitor machines, ECGs, and ventilators.

Furthermore, ICU's normally keep higher standard of infection control to make them invulnerable to all kinds of infections due to the critical condition of it's patients.

e-Infection !

Last, week I was in Al-Amiri hospital, Kuwait. I was doing maintenance to a portable xray machine. There, I was struck with a view on all PC screens. Those PC's were running Critical Care Information system. In fact, all screens where showing a Mcfee Virus Alert. The list; as you see above, is showing multiple virus infections.

Even though ICU was equipped with high-tech patient monitors, ventilators and looked very clean and dis-infected, but it was; actually, infected with a special infections. These infection have no direct harm to the patient but they eventually do a harm !

How does a computer virus threatens life?

In these days, patient monitoring is not done at each bed. Each patient is monitored centrally by nurses & medical staff; i.e., at the nurse station. Thus, interruption in flow of clinical data between patient monitors and central monitoring system will definitely interrupt monitoring the vital signs of critically ill patient's .

Second; at critical care stations, physicians make electronic requests; i.e., for lab or imaging procedures. Virus infections can make those PC's slow or make them completely down by corrupting some files. In fact, delay in exam requests is definitely a life threatening .

Third, at critical care stations, physicians write there reports, notes or prescribe patient's medication. Virus threats on those stations; again, will delay the whole process at the ICU. Delay is not a good sign of a good ICU.

On the ground..

Frankly speaking, this ICU was not the only place in Ministry of Health where I have seen such virus attacks. Many places like neonatal ICUs, Radiology Departments, Cardiology, and Nuclear Medicine had the same issue.

In 2008, one year after world-wide attacks of a well know electronic warm(special viruses). the warm(or Trojan) with different names such as (DownaDop, Conficker, etc...) have hit most of ministry's information systems in a mater of a week. Moreover, xray and ultrasound machines were also hit by this warm specially those with MS-Windows XP were badly hit. Around 6 Xray machines went totally down due to network problems.

Finally, we have to admit that hospitals in Kuwait are in trouble ! In near Future we might see a crisis due to the fact that the no. of medical equipment getting connected using TCP/IP networks is exponentially growing.

Problem and Solution !

The problem is not actually the "virus attacks", virus attacks happen every day and everywhere, the problem is lack of network security , and maintaining that ! In fact, If you are connected to the outside world then you are at risk ! you don't have to be connected to the internet, allowing use of removable storage devices (i.e. USB sticks) is the biggest source of invulnerability.

The solution is not easy but affordable and better to start now than never.Effort to set standards for security in eHealth and for medical devices is going on. HIPAA is one example of such standards. HIPAA is a governmental act in USA to assure security and privacy of patient's health records. Some of these requirements are securing health records from viruses.

Moreover, and effort was taken by U.S department of veteran affairs to design a model for secure network of medical devices. See Excellent readings. Another effort was taken by Society of Hospital Information Mangament Systems (HiMSS) to encourage a medical device security disclosure like DICOM conformance statement. See Excellent Reading below.

In Kuwait, the gap is very huge. We should immediatly start some where. Niether we have IT team in hospital nor Biomedical Engineering departments have experience or a say in this.

Thus a very rough plan should be divided into three stages.

Stage 1. Putting IT security standards on our list of priorities.
Stage 2. Forming an independent IT support team in the hospital independent from medical device vendor. If MOH claims that they don't have enough resources, IT team doesn't have to be through local staff, IT can be outsourced just like electrical maintenance or waste Management .
Stage 3. To Include IT support, Network management , and network security in medical device RFP, and the service contract (service level agreement.)

Excellent Readings..

Big names make big mistakes

2011-03-26T01:01:00.003+03:00

Did you recently login to Q8PACS Blog ??
Did you notice the FDA IT recall list ??

Today, I have loged in to Q8PACS Blog and; as usual, I was checking FDA IT recall list.

This time I noticed some thing special in the list. This time in that list we had products from all BIG names (see image on top)

This observation can bring many lessons to our imaging community. Some of these lessons are:

Big names can also make mistakes ..
Some times their mistakes are as big as their name.

PACS recalls: wrong measurement.
Majority of PACS Recalls are due to wrong measurnment by medical software. Those wrong measurment will definitely affect a diagnosis or a treatment plan. It's time to start QC program for PACS Workstations.

PACS is a medical devices ..
Medical IT software are medical devices that are governed by medical device regulations. If you don't have those regulations.. make them !t are governed by medical device regulations.

Majority recalls are class 2.
Class 2 recalls are due to deficts which can have potential to cause serious injuries.

Take the effort and watch recalls.
Take the effort to improve safety of your patients by watching FDA recalls.

Share your thoughts with us by writting a comment !

Virtual Conferences..

2011-02-05T12:06:00.003+03:00

"PACS In Age of Change.." was the title of the first virtual conference by Auntminnie.com. The event was held online on November 17, 2010 at 11 a.m. USA Eastern Time.

This was my second time to attend a conference. My first chance was during SIIM 2009.

At that time I have logged-in to website. Logging in was much easier than reaching the Charlotte Convention center during SIIM2009. In Charlotte, I had to pay for car parking lot .. i got ticket on first day :).. and I was lost in down town Charlotte .. but this time loggin in was in a minute (of course I had to give my kids some candy to keep them away from me) !!

After logging in was the menu page, which is similar to SIIM2009 lobby floor. From there I had the choice to go to different sections of the event (i.e, lounge, auditorium, helpdesk, exhibit hall, etc..)

Thereafter, I wanted to catch the first talk by my favorite speaker: Eliot Siegel Chief of Imaging services at University of Maryland Medical Center and Professor; Vice Chair, University of Maryland School of Medicine Department of Diagnostic Radiology. The title of his talk was "Redesigning Your Radiology Department to Save Body and Mind"

Mr. Siegel's talk was about design of radiology reading rooms and design elements which insures proper reading of digital images and improve productivity in service. He started with design of reading room in old days (analogue) and from there he compared to reading rooms in digital era.

Dr. Siegel pin-pointed at several issues; i.e, effect of ambient light on reading productivity, Room temperature, integration with information system, acoustics (i.e, noise due to MR machine)

Affect of ambient light on fatigue

Effect of monitor brightness on reading time

Later I have attended the exhibit hall where I found medical software/hardware vendors. See below. In the exhibit hall I had the chance to chat with representatives of those vendors specially McKesson and Barco. McKesson is a very well known Healthcare, and Imaging IT vendor in NorthAmerica. Barco is top manufacturer of medical grade monitors. Barco representative gave his view on Q8PACS case study about monitors in Kuwait.

Exhibit Hall

Chatting at the exhibit hall.

Later, I decided to take a virtual beverage; so, I had to visit the lounge. At the lounge I met many participants who were chatting like real lounge. I exchanged my views about the virtual conference and about the talks..

Chatting with other participants at the lounge

My overall impression was great about this event and hope that Auntminnie will repeat this experience again.

This event was organized by Auntminnie.com and virtual service provided by InXpo.com

This experience was very good that we in Kuwait should think about organizing such event which (I'm sure) saves a lot of money which normally goes for the venue and Catering :( .. Hope we can see Kuwait Imaging Informatics events in virtual world on 2012.

Happy new year !! Many hands...

2011-01-01T11:04:00.000+03:00

PACS Club members during seminar in Dubai 2008
Suad, Iman, xxx, Haifa, Saud, Zaheer, xxx, Mutairi, Al-Seyeed, Ossama, Hashir, AbdulMuqeet, Hamad, Al-Eidan, Herman, Bader, xxx

If we get together,

We can do the impossible !!

If we stick together,

No body can break our unity !!

If we dream together,

Our dream can become true !!

If we think together,

Our imagination becomes reality !!

If we pray together,

Allah accepts from one to all !!

If we put hands together,

We can lift as much weigh as many hands are there !!

If we focus together,

All power will go into one direction !!

If we do "PACS" together,

Our imaging systems will have high "utilization rates" !!

If we grasp above together,

We all will have a "Happy new year" !!

PACS Group of Kuwait 1st Meeting

2010-12-29T07:00:00.001+03:00

PACS Professionals training. Courtesy of Q8PACS (2008)

" Finally, an official group
for PACS Admins is formed..
It's a place were PACS
Admins can speak out."; PACS Admin said.

On Dec.27th 2010 the first meeting of the PACS group of Kuwait was held at Mubarak Hospital. The group is the official committee formed by Radiology Council. Dr. Salwa AlKanderi head of radiology council announced establishment of this group to re-organize the operation of PACS in Radiology departments and to hear from PACS admins. PACS Group of Kuwait is lead by Dr. Salwa Haidar, a pediatric radiologist at Mubarak hospital and consists of at least one member from each radiology department in MOH hospitals.

In their first meeting, two posts were selected. Saud AlSaif; Senior PACS Admin at Amiri hospital was announced as deputy of the group and Abeer Hajiya; Senior PACS admin at Mubarak hospital at Mubrak Hospital was announced as Group officer.

In that meeting, members introduced themselves to each other and shared some of the problems they are facing in their daily work.

The discussion about problems was lengthy which shows the amount of issue they are facing. These problems ranged from issues like financial benefits to technical difficulties.For example, mobile phone bill which they have to pay from their own pocket and technical issues like patient image exchange using CD and difficulties referrals are facing to view those images. Moreover, during that meeting a member of the group brought up a technical issue they are currently facing in their hospital which stunned every body ! That was an issue of a huge image loss in their archive. That hospital lost approximately 12000 images from their Short-term storage and more from their Tape-Library due to tape warn out !!

The meeting was concluded by Dr. Salwa by promising every body to work hard to pass their needs and voices to the radiology council which will eventually take the required action.

Should you have any suggestion (or best wishes) to the PACS Group of Kuwait ? please write them down in below form.

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Contest Winner Nov. 2010

2010-12-03T17:57:00.017+03:00

THE WINNER of last month Dr. Salwa Hayder. Pediatric Radiologist , MubarakHospital. _________________________ *Contest award: 160GB USB HDD. Mubarak* Hospital (~800 bed hospital) is undergoing it’s third generation PACS. In the third time, radiology department realized that they cannot depend on vendor in setting their PACS/RIS requirements since they suffered a lot win their previous PACS Archive got full. They decided to help the vendor by putting their requirement in the form of an RFP. Even though this RFP contained fatal mistakes, but it was certainly better than leaving every thing up to the vendor. Their RFP writing process included PACS Storage calculation with help of their PACS Administrator Mr. Sadiq bin Hussein and Mrs. Abeer Hajiya.	َ Online contest Nov.2010 ..
	Dear All, After Long time, announcement of the winner of last month’s online contest is here. She is Dr. Salwa M. Hayder who is known for her care to patient and to her career. Quality at work was one of her motivation to fight for the best. On behalf of Q8PACS we send her our best wishes and hope that she can bring her qualities to people around her. · *Interviewing the winner* How do you find the contest in general ? Dr. Salwa: Very interesting and challenging. How hard was the contest questions ? Dr. Salwa: I believe it was hard especially it asked for some details which is out of my specialty, mainly medical engineer will know it. Did you do little research to answer the contest questions ? Dr. Salwa: Yes Do you think that details about HL7 messages, Diagnostic Monitors or any other PACS/RIS option should be added to the Tender document (RFP) ? why ? Dr. Salwa: I think its better to cover all the details in the tender to make sure the system will work smooth with other hospital systems. Do hospitals in Kuwait verify if these requested options are delivered with PACS/RIS ? Dr. Salwa: I know that they mainly insist on having HL7 compatibility with no more details. Thank you · *Contest and Solutions* Q1. What is the “eSec Login” option is ? A1. “eSec” is abbreviation of eSecurity.. which is a security option which allows radiologists to login to Centricity RIS using a magnetic card, which obviously requires a card reader Hardware. Q2. List three HL7 messages usedcommonly in Kuwait? a. ADT .. Patient admission and registeration. b. ORM .. order messages c. ORU .. Observation result (report) References : HL7 Messages \| Corepoint Health Q3. List three requirements of Medical Diagnostic Monitors. A3. a. Spatial resolution (Mega Pixel) b. Contrast resolution (Bit/Pixel) c. Brightness (cd/m2) .. more .. References: Guidelines on the Specification of Diagnostic Display Devices Q8PACS Blog. http://q8pacs.blogspot.com
		This Month's .. Win 16GB/3G/Wifi	برعاية ..

Blog Bibliography .. Q8PACS Second Birthday

2010-11-24T08:50:00.002+03:00

Medical Imaging Informatics 2010 (click to enlarge)

Index of most (older to newer) Q8PACS Blogs since it's establishment two years back

Dubai PACS Seminar

10 things PACS Admin should not do "on Network"

Structured Reporting

Best Source for "Free" Imaging & PACS

Radiology Reading Room – Questions need an answer !

How to install/Configure KPACS (free PACS)

FDA Recall Database

"Your Needs" first step toward your PACS project

Calculating your PACS storage

Sad Story

From Diary of a PACS Engineer

Down, Not .. By Herman Oosterwijk

Radiology Ergonomics

PACS Census in Kuwait

PACS Certifications: The way to standardize the Industry

Q8PACS blog's 1st birthday

DICOM Interoperability at Q8PACS

Using Google Desktop to Create an Education-centric Search engine

PACS During Holidays

Microsoft Amalga RIS/PACS

Distributor Vs. Corporate

PACS in the Emergency Department interview with Dr. Anwar AL-Awadhi

PACS Contest June 2010

10 Things we learn from history of PACS

Online contest July 2010

في ذكرى الغزو .. أهمية المعلومات

Diagnostic Monitors - Case Study in Kuwait - Part I

Online Contest Nov.2010

"PACS Laws" by Dr. Dalai

2010-11-07T07:03:00.001+03:00

Dr. Dalai Blog Logo

Here is a great piece of "PACS" by Dr. Dalai .. a well known PACS professional and blogger. Dr. Dalai started blogging long time ago (~2005) criticizing current status of imaging informatics and vendor's role on this. Dr. Dalai writes his blogs on

(http://doctordalai.blogspot.com)
Even though Dr. Dalai writes long blogs, but I always enjoyed his writings. I choose one article he recently wrote on his blog which summarized his long experience .. Enjoy it ..

“ Over the years, certain trends and patterns in PACS and our relations with PACS vendors as well as Information Technology became clear. I’ve distilled these into the LAWS of PACS. I have revised this list over the years, as the landscape keeps changing. Here they are

PACS IS the radiology department.

PACS exists to improve patient care. Its users are the radiologists and radiologic technologists. The entire goal of the PACS team is to optimize PACS function for its users.

PACS should be the shared responsibility of the radiology and IT departments.

PACS should not get in your way.

Workflow is inversely proportional to the number of buttons on the PACS desktop.

PACS is not film.

The degree of understanding of Radiologist workflow is inversely proportional to the size of the PACS company.

Vendors work for us, not the other way around.

A true PACS guru is worth his/her weight in gold.

All software errors, including those within PACS code, can be repaired if the vendor is sufficiently motivated to do so.

If IT doesn’t like something, it will be termed a security risk.

The PACS needs to be operable by the least technically-savvy radiologist on staff.

Drive before you buy. Request for test environment for your new systems; i.e. Virtual machine of your servers, (Q8PACS Admin)

Q8PACS Contest Nov.2010

2010-11-01T22:58:00.001+03:00

>>> >>>

* Photo contest this time is a contest about a PACS Tender document!!

* Answer all three questions below and win 120Gb Q8PACS HDD.

Click Above to enlarge

Loading...

Deadline: Friday Nov. 12:00 AM (Midnight) ..
----------------------------------------------------

Diagnostic Monitors - Case Study in Kuwait - Part I

2010-09-04T05:10:00.006+03:00

Abstract
Kuwait is one of first countries in region to convert medical imaging into digital. Many digital archives were available in mid nineties and full RIS/PACS installations were seen in many places in late nineties. Most Radiography systems are either converted to digital or equipped with CR readers. In principle, Kuwait has one of longest experience in digital radiography. Reporting from films is getting less and less and more soft copies are being seen around Kuwait.

Even though this long time of digital implementation in imaging, Kuwait imaging centers lack Quality control procedure for digital imaging in general and digital monitors specifically. Quality control procedures are still done until the modality monitor or film printer (camera, processor). No action has been taken to extend this QC procedure further to the reporting workstation, where radiologists read their images.

In part I of this article, we start shedding light on status of medical grade monitors or so called diagnostic quality monitors and their existence in imaging departments.

Study

Visiting many hospitals in Kuwait, you will find that majority of diagnostic monitors are off-shelf commercial monitors used regularly in any home/office pc. In exception to few hospitals, imaging departments have mixed brands, dimensions, or resolutions.

In this study, we visited radiology department of a 600+ bed hospital with fairly large radiology department with ~15 modalities including two MDCT and ~20 radiology PACS Workstations. Furthermore, distribution system is integrated with this setup to facilitate referral inside the hospital. We found out that more than 70% off PACS workstations are equipped with off-shelf non-diagnostic monitors used to report different types of medical images like DR, CT, MRI, and sometimes mammography. See table below.

Printed Version

Monitor photo Click down to enlarge	Manufacture/Model URL	Specs.

	HP LE1901W	Resolution: 1440 x 900 Brightness: 250 cd/m² Contrast ratio: 1000:1 Official use: Business moitor

	NEC 1980SXi -BK	Resolution 1280 x 1024 Brightness 270 cd/m2 Contrast Ratio 500:1 Official use: Professional (non-medical)

	PACSMate MMC – 2201c	Resolution 1600 x 1200 Color depth 16.7M colors Brightness (cd/m2) 300 Contrast Ratio 800:1(typical) Official use: Clinical Review (non-diagnostic)

	ViewSonic VP2030b	Resolution 1600x1200 Contrast Ratio 1000:1 (typ) Brightness 300 cd/m2 (typ) Official Use: applications and multimedia (non-medical)

	Samsung 206BW	Resolution 1680 x 1050 Contrast Ratio 1000:1 Brightness 300 cd/m2 Official use: Multimedia (non-medical)

	Barco MFGD3220D	Resolution 2048 x 1536(3MP) Contrast Ratio 600:1 Brightness 500 cd/m² Official use: Medical Diagnostic.

Conclusion
Many hospitals in Kuwait are using off-shelf monitors to diagnose different types of digital images. In part II, we will discuss international standards and requirements for monitors used in medical diagnosis.

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في ذكرى الغزو .. أهمية المعلومات

2010-08-10T17:23:00.006+03:00

English Version (By Google)

محطة أم العيش للإتصالات بعد 2-8-1990 : عدسة طارق مال الله

في الثاني من شهر أغسطس عام 1990 تعرضت الكويت لاجتياح من قبل النظام السابق في العراق حيث سيطر جيش هذا النظام على جميع الأراضي الكويتية خلال أيام معدودة وأعلن عن إقامة حكومة مؤقتة لفترة بسيطة أعلن بعدها ضم الكويت لجمهورية العراق. لقي هذا الأمر استنكاراً شديدا من قبل المجتمع الدولي ومقاومة مسلحة داخل الكويت وتشكيل قوات تحالف دولية لتحرير الكويت من هذا الإحتلال.

خلال تلك الفترة توقفت معضم خدمات الدولة لغياب حكومة شرعية على أرض الكويت ، سوى بعض الخدمات الرئيسية كالصحة والماء والكهرباء التي عانت الأمرين خلال تلك الفترة إلا أن صمود مجموعة من المواطنين والمقيمين حال دون توقف هذه الخدمات الرئيسية. فلم تتوقف مستشفيات الكويت عن خدماتها حتى في أحلك الظروف ورغم ما تعرض لها كثير من العاملين فيها من تهديد ، ولم تتوقف محطات الكهرباء عن العمل إلا بعد أن بدءت العمليات العسكرية لتحرير الكويت.

وهاهو العام العشرين لذكرى هذه الحادثة الأليمة مرت علينا في الأسبوع الفائت ولا أتمنى أنت تعود من تلك الذكرى إلى الإستفادة من عظاتها .. فهل من مدكر ؟

الهيئة العامة للمعلومات المدنية

تأسست هذه الهيئة المستقلة في العام 1985 ومهمتها تكوين قاعدة مركزية للمعلومات الأساسية لكل قاطن على أرض هذا البلد من مواطن أو مقيم بحيث يعطى لكل شخص رقم فريد (لايتكرر) يكون هذا الرقم هو المرجع الأساسي لهذا الشخص وهو مايسمى بالرقم المدني.

في أولى أيام الإحتلال ، قام مجموعة من العاملين في هذه المؤسسة فوراً بحمل شرائط التخزين المغناطيسي والتي تحمل هذه المعلومات المدنية إلى خارج الكويت حماية لها من العبث الذي تكرر في مؤسسات وطنية أخرى.

وبالفعل فلقد استرجعت هذه الشرائط مباشرة بعد التحرير ، ولولاها لعاودت الكويت بإتشاء قاعدة البيانات من الجذور ولتكبدت الكثير من الخسائر ولربما تأخرت عمليات إعادة الأعمار لضياع أغلب السجلات في كثير من وزارات الدولة وهيئاتها.

وهنا تتضح لنا أهمية المعلومات و قيمتها لتوفير الخدمات الأساسية لأي بلد بل وحتى في الاستشراف والتخطيط للمستقبل الذي لايتم إلا بوجود بيانات وإحصائيات كافية تمكننا من بناء نموذج نستقرء منه الأرقام ويعرفنا حاجاتنا المستقبلية.

وكذلك فإن تجربة الغزو المريرة لابد أنها علمتنا الكثيرعن أنظمةالأرشفة الإلكترونية ، لا سيما في أوقات الحروب أو حتى الكوارث الطبيعية .. علمتنا أن الأنظمة الالكترونية تسهل عملية نقل المعلومات من مكان لآخر .. بل إنه وفي أيامنا هذه فإن بيانات أنظمة المعلومات متوفرة في أكثر من موقع في وقت واحد فلا حاجة لنا لنقل نسخها الإحتياطية إلى مكان آمن يدوياً !

في مثل هذه الذكرى نقدم هذه التوصيات

إقرار قانون لحماية المعلومات لأهميتها وقميتها في التطوير وفي تقديم خدمات طبية أساسية ، وبالطبع يجب أن يشمل ذلك القانون مدة قصوى لحماية المعلومات (Retention Policy)
التخطيط لميكنة أنظمة المعلومات الطبية وربطها والإستفادة منها لصالح جودة الرعاية الطبية.
العمل على تشجيع العمالة الوطنية في مجال التكنولوجية الطبية عموما وفي مجال المعلومات الطبية خصوصا لتحقيق الأمن الوطني في هذه المجالات.
أن تقوم الحكومة بحماية سوق العمل في هذا القطاع من الإحتكار والغش من ناحية و إقرار نظام شامل لضمان الجودة والكفاءة في هذه المجال الحيوي.

قراءات إضافية

إعادة النظر بالمعلومات المدنية ، إبراهيم بهبهاني ، جريدة القبس 25/01/2010
مبنى مركز نظم المعلومات الجديد سينقل الصحة إلى نظام الميكنة ، جريدة الوطن 3/8/2010

10 Things we learn from history of PACS

2010-07-16T15:23:00.016+03:00

Source: http://www.pacshistory.com

Buying new technology doesn’t always help.
It might even make things worse! Big brand PACS without proper study of requirements is useless.
Speed Is Not The Only Criteria..
People thought that starting imaging in digital environment will speed up the process (which happened); however, people never though that demand will grow for imaging procedures.
Electronic systems Are No Magic!
Historically, imaging departments had their own policy & procedure in the manual workflow. After introduction of PACS people though that IT will automatically do this for them. Unfortunately we still need those policies. We still need human intervention.
Learning from mistakes
Through out two+ decades of PACS we have seen many incidents of PACS disasters and data loss. Did we take preventive action against those failures?!
Imaging IT is way behind !
History has shown us that PACS is way behind consumer IT. It’s time to bring IT staff inside the imaging department specially when considering the era of open-source solutions. However, those IT staff should be trained to appreciate medical services. (See also Eyes Wide Open, Herman Oosterwijk, 2010)
Evolution is part of our human nature... PACS is the same !
Evolution of PACS has shown us that radiologists gave up many things. For example, number of viewing heads (monitors) which have gone down (see DRC movie).
That means that radiologist who were trained on some hanging protocol can adapt to new ones. This message is both for vendors and for radiologist who should adopt new technology based on evidence not habits.
USER & VENDOR Marriage.
When you sign agreement with your PACS vendor make sure that your agreement is written and is inclusive.. It’s like your marriage.. Both parties should be clear.. Marriage certificate should be issued.. It’s a long term relationship.. In worst case scenarios: divorce is their.. But it’s painful.. in PACS/RIS terms, You will require the most painful process which is DATA MIGRATION..
Radiologists are doctors in the first place?
Some radiologists are loosing their insights and imagination. Through out history of imaging goal was to acquire best image quality for human anatomy of physiology to help diagnosing with bare eyes. Now days, a new direction is coming up .. Computer aided detection, virtual reality (i.e. volume rendering, virtual colonoscopy, etc..). Radiologists should maintain their role as physicians not as image interpreters only .. some one will take that role soon !!
PACS in the enterprise.
PACS historically was a XRAY, CT, MRI. Today we see multimodality PACS not only as the archive destination but as reporting stations as well. Tomorrow, vendor-neutral PACS will be hub for all healthcare imaging. PACS is getting more attention. I don’t thing we will have more territorially PACS..
Interconnectivity in PACS is key.
Through out history of technology, vendors started their innovations independently in some lab some where on earth. However, most current breakthroughs are not those standing alone. For inter-connectivity between different technologies we need standards such as TCP/IP, Bluetooth, IrDa, DICOM and HL7. Giving up those standards will not happen and should continue to spread. Thus, those standards have to be part of our Techs education.

PACS Club of Kuwait: 10 Things we learn from histgreat free widgetsWidgetboxMore info

Further Readings

· Early RFP (Year 1990): MDIS RFP

· PACS History Project: http://www.pacshistory.org

PACS in the Emergency Department

2010-03-26T13:30:00.005+03:00

PACS in the Emergency Department...
- An interview By Hussein AlSayiegh

Dr. Anwar AL-Awadhi

anwar.alawadhi@q8health.org

· PACS in the Emergency Department is a crucial tool.

· PACS in ER provides speed, accuracy, availability, cost effective health care access, management, delivery and quality improvement.

· Generally; X- Rays in the trauma slots can be obtained within 20-30min from request time.

· PACS: is moving towards, and should be more user-friendly.

A crucial tool in the ER.

PACS in the Emergency Department is a crucial tool in the daily practices of an Emergency Physicians. "Time = Tissue". Tissues could be heart, brain or skeletal muscles and so on in Emergency Medicine. Thus, PACS in the last few years has shifted the speed of availability of the studies, accuracy, and the reduction in costs on the long run, for imaging in the ED. Patient walk in to the ED, gets evaluated by and EM physician, decision is made on what radiological studies to be performed. The patient is then sent immediately to the X-Ray, CT, MRI or Nuclear Medicine Department. Results get uploaded to the radiologist screen whether in the hospital or off the medical campus, and then he/she will view, dictate and upload their results in PACS so the ED physician could view them on the spot. This led to more accurate and swift access to imaging and their results, which in turn has lead to the improvement in the quality of patient treatment and care.

PACS lead to more accurate swift access to images and results in ER.

Do you make requests for imaging procedures electronically?

Yes, but if the system goes down, then it is back to paper requests.

Plan (B) if eReq. Is down, paper requests are ready.

How do you get notified if your patient images are available and ready for you to read from PACS?

Only if there are significant abnormalities, like bleeding, pneumothorax (air in the lungs) and so on, the Radiologist calls over the phone to the ER or pages the physician over head and documents in PACS the name and title of the ER physician who has received the abnormal results so as the date & time too.

In significant cases, ER physician is contacted on the phone and is noted on PACS.

How is the PACS setup in the emergency room?

Some ERs had the mobile viewers and others that I've worked at, had the Viewing PCs. Both off which worked as well. Actually, The viewer PC lasted longer and was easier to be maintained.

Viewing desktop PCs lasted longer than mobile viewers and were easier to be maintained.

Is your viewing PCs having medical quality monitors?

So and so. Most are Dell, Siemens, Philips and General Electric. Dell predominates and I think it is one of the best and most user friendly monitors.

Diagnostic quality monitors are available in the ER.

Do you often use processing tools on your viewer? What are you still missing from that?

Yes all have been used, so as comparing old and new pictures on side to side screens. Organ windows are used too, like bone window lung window and so on. Some has the 3-D recon, which is the new state of the art imaging, but some don't have it.

In ER, physicians use preset windows levels

In ER, you can find 3D recon. Workstations.

What is the expected time until image ready in ER (i.e., for Trauma cases)?

Depends on how many traumas are received and how critically their conditions are, which will lead to how many tests are needed to be done and uploaded to PACS. In general the X-Rays in the trauma slots are within 20-30 min and other images like CTs are within 60-90mins to get the final diagnosis.

Expected time for CT images are within 60-90mins from request time.

What is the effect on patient's safety if images from PACS where delayed?

Delayed images might lead to the mixing of results with other patients and ultimately some patients might receive the wrong treatment. Some times EM physicians have to look and interpret the results themselves without waiting for the final report from the radiologist, so they use the ones already uploaded in PACS or hard copies if available.

Some patients might receive wrong treatment due to the delays in the delivery of images into PACS.

How the delay in the upload of images, might lead to the mix up in patients ultimate care?

Delayed images might compromise patients safety when, for example:

1. A patient might have an image before for hip or knee reduction for dislocation in the ER, and another image post reduction. When there is a delay, the ER Physician might have to go back to repeat the procedure if some of the images were uploaded as post reduction time, but in fact were the pre-reduction ones.

2. Injection of a contrast to rule out J-tube or G-tube leaks in the ER. Images pre and post contrast injection are taken, but the inaccurate timing and sequence of taking those images might lead to the non confirmation and/or the inaccurate interpretation of whether there is a leak or not.

3. Bowel perforation. STAT (immediate) orders in the ER are placed in the computer, but the requests that are being printed in the radiology department might be performed few hours later due to miscommunications or other technical issues, which in turns might lead to the delay in treatment, quality of care and ultimately; the patient disposition in the ER. Those delays can be avoided by better communication methods between the ordering the performing departments and staff.

Examples issues leading to patient safety concerns.

· Mixing pre and post condition images.

· Delayed Images can pose life threat.

As an ER physician, what are the difficulties you are facing with PACS?

1. PACS should be more user-friendly, i.e. can search a patient through their names, medical records, Civil I.D or other identifiable data as much as possible and not to restrict the search to one or two identifiable.

2. Images should be easily uploaded to the radiologist screens both at the medical campus and at their offices.

3. Online access, so when physicians are not at the medical center, they could login and follow up their patients from a remote access point.

4. Improve the security of those data.

5. Innovation in the security and the confidentiality of the retrieved images when used for medical conferences and meetings. NO patient identifiable data could be allocated. This can be done by removing the name, I.D and other identifiable data, so the meant to be used images protect the confidentiality of the patients and his/her records.

Difficulties,

· No search flexibility.

· No access for ER from home.

· Not enough data security.

Distributor Vs. Corporate

2010-03-13T02:03:00.003+03:00

*Jose Manuel Segadaes* SIEMENS Healthcare, South Africa	Distributor Vs. Corporate

Working for dealers I just wanted to express my views on how different it is to work for a dealer compared to a corporate company in the medical field. Through out my career as a service engineer in the medical field and having worked on a large variety of medical equipment, I have predominantly worked for dealers. At present I work for a corporate company. I have experienced both worlds and let me say the dealer companies have a lot to learn.		There is a lot to learn within a dealer organization.
Service issues within dealers organizations It's not acceptable that some dealers do not have a minimum stock of spare parts. Without spare parts stock the work of the engineer is increasingly more complicated and stressful. Not to mention the fact that it takes so much longer to service a unit due to the fact that it takes so long to import a spare part and also the image of the company is at stake. I understand that the financial resources of a dealer company are so much more reduced than a corporate company but it's up to senior management to manage wisely, streamline and improve work procedures to try to make the company more flexible and profitable.		· Dealers keep minimum stock of spare parts. · Management in dealer organization should improve procedures.
What if you work for a dealer? Dealer company management should draw up an employees work responsibilities and not treat the respective employee as a "jack of all trades". You do have to be more flexible working for a dealer but don't let them take advantage of you as you will land up executing tasks which have nothing to do with you and that eventually will affect the quality of the work that you actually were recruited to do.		If you work for a dealer, you will land up executing tasks which have nothing to do with your work
Missing Organization!! Dealer organisations should strive to be more organised and plan more on a medium/long term basis rather than just think on the present. Also, dealer organisations tend to be more corrupt. It is important that dealer senior management have strong community and business values as well as a long term vision of the organisation. These values and visions should in turn be communicated and taught to the respective employees. Your career growth in a dealer is rather limited.		Dealer organisations should be more organised.
On the contrary Corporate organisations on the other hand are not as flexible. There is normally a large hierarchy structure which has to be followed before certain things can be done. This can be frustrating. However, their business vision, community and employee values are very strong. Working for a corporate company you have more space and more options to grow in your career path.		Although the large hierarchy of a corporate is frustrating they usually have community and employee values.

Microsoft Amalga RIS/PACS

2010-02-17T05:39:00.007+03:00

Amalga RIS/PACS will be the new member of Microsoft Amalga. Amalga family members include Amalga HIS, Amalga Life Sciences, and Amalga Unified Intelligence System. Another healthcare solution from Microsoft is the Microsoft HealthVault.

Even though Microsoft has always been a pure IT solutions company. Microsoft is relatively new to this field, but that doesn't realy mean a bad thing. Inovation always comes as new !

Recently, news said that Microsoft is finally come up with the PACS/RIS through the Amalga PACS/RIS. Frankly speaking, Microsoft has shaped the way IT solutions outreach to many people and organizations with their verity IT solutions including their MS-Windows OS. So, will Amalga PACS/RIS change the future of Imaging informatics too?

Amalga HIS: Image enabled technology

I have divided my anticipation to the future of this product as positive and negative, advantages and disadvantages to under line such product of such key player in IT industry.

I have put some of these points in humorous way, but that doesn’t mean that Microsoft is a clown! Staytoon and watch for this product !!

“ What will happen when Amalga PACS/RIS is released? ”

Positives

· PACS/RIS will be everywhere.
Small hospitals off course will get a hacked copy. Just don’t run the genuinity check utility if you have the auto-update running!

· PACS/RIS administration will be piece of cake (easy).

Authentication using active directory, alerts using process monitors, statistics using excel templates,

· PACS/RIS will be easily customizable.
Field boxes, check boxes, drop down menus, and macros.. all possible using Visual Basic for Applications (VBA).

· Every thing can be done by drag and drop.
To reject an image just drop it to the Recycle Bin icon and then you can always change your mind and restore it back.

· Integration with other Microsoft products.
Lots of smart tags, Web Based using IIS v.7.5, teaching archive using Sharepoint server.

· DB migration is a piece of cake using MS-SQL 2008 migration tools.
Just match the field on the UI and click the “GO” Button.

· Need help for sophisticated problems?
Just login to http://msdn.microsoft.com.

· Doctors will be able to do tele-radiology through NetMeeting or Ms-Messenger.
With emoticons off course.

· You will always blame one company for any problem in the system. Thank you Vin. !!

since OS, DB, and Application are from one provider.

· First level technical support will be done through a help desk in Banglore, India.
If that doesn’t help a service engineer from a service partner will visit the site in just 72 hours.

· You can download your frequent service patches from http://update.amalga.com

Negatives

· A beta version will be released free of charge and price for the official release will be 50% less than competitor’s.

· At the day of the official release, hospital imaging IT personnel will stand in long lines to get their copy.

· First Service Patch (SP1) will be released only one week from the release day.

· Hospitals have to do a lot of System Reboot.

· If problem persists, just format and reload your PACS/RIS.. What about the database ? Don’t worry you will get easy DB recovery tools !

· malware (virus) programmers will target the new product and lots of them will be coded to replace medical images with personal photos like those of The Simpson’s cartoon characters…

PACS During Holidays

2009-12-08T20:21:00.005+03:00

Medical Imaging 24x7 service

Healthcare is one of many services which run around the clock specially at emergency rooms where patient is in high need of medical intervention on the spot.

Medical imaging is not an exclusion! In fact, requests for imaging procedures for emergency patients is very frequent due to the fast and the non-invasive nature of some imaging procedures like CT scans, ultrasonography, and even general x-rays which existed in emergency rooms for decades.

High end procedures like PETCT, MR, and SPECT scans are done as well for some emergency patients. For that reason, imaging departments in any general hospital are on service for 24x7 including national holidays.

During holidays and non-working hours, imaging departments usually provide services by assigning technicians on shifts and physicians on call trying to help emergency patients to save their lives and to prevent further medical complications.

Absence of PACS admins

Now and after transforming most of imaging services to digital, those services are in hands of a new technology called PACS/RIS. If that system is down, or out then the whole department is usually on hot plate. Due to lack of clear policies and weak technology implementation, PACS/RIS operation is almost impossible without an administrator. In fact, running PACS/RIS without an administrator at any time means threatening lives of many patients.

There are many examples were administrator interference is needed. One example is merging or rejecting wrong images which require administrative access rights to the system. In fact, wrong patient information is; in many times, a serious threat to patient's safety. See FDA similar reported event . The role of PACS admin cannot be substituted by any one.

One more example of tasks assigned to PACS admins, is the follow up of consistent backup handling. It's beyond changing the backup tape, it's about consistency. Backup logs should be verified for a successful backup job. Thus, role of PACS admin is continuum.

PACS Admins 24x7

Now and after knowing that PACS admin's job is continuous, that doesn't mean that a PACS admin should be available in the hospital all the time! Yes, a PACS admin should be available in the hospital at least during working hours where regular appointments are scheduled. However, PACS admin should be available on call 24x7 just like any other IT service. In fact, many Internet technologues can help in providing remote support from outside hospital without imposing any threat to data security.
Thus, PACS administration has to be treated according to the field of information technology standards in both payment scale and team organization to co-op with the demand for the PACS admins.

PACS admin team restructuring

Moreover, to be able to adopt a new PACS team organizational structure and payment scale, a job description for this post has to be defined. In fact, the best resource I have came across about forming PACS team and defining job description accordingly is a document written by Herman Oosterwijk and Janet Skinner from OTech Inc. and Skinner Associates (PACS Admin and IIP Resource Guide 2008, PDF Format). In last guide, authors discussed development, training, career tracks, job Descriptions, titles, salary of PACS professionals and more.

Recommendations

To solve the issue of absense of PACS admins during PACS operation hours I will recomend the following actions.

1. PACS (imaging IT) Team should be formed with proper team members in terms of quality, quantity and good work environment to cover the operation hours (24x7).

2. PACS admins should be on call during after working hours and during holidays with proper job dispatching and compensation system.

3. PACS admins should have access to hospital network using secure VPN connections to help reaching the system everywhere at any time.

4. For smooth operation with minimum down time, service level agreement (SLA) should include an explicit agreement for support during "after working hours" and public holidays.

5. Service agreement should assure 24x7 monitoring of log traps (logs send to vendor's support team) which is the only way to assure optimal down time.

6. Call management system has to be implemented to help PACS administration team managing this heavy job. This system will provide PACS team with ability to schedule jobs and organize support efforts.

Conclusion

Above discussion is not inclusive. It's actually a second call for a dialogue within Kuwait imaging community. That dialogue was already started before in the early days of Q8PACS by Mr. Ahmed Al-Mutairi (former senior PACS admin at AlSabah hospital, Kuwait) and was presented earlier to the Radiology & Nuclear Medicine council at that time.

This dialogue will be neccessary to start reform in PACS operations and thus in leveraging medical imaging services in Kuwait.

I think this is the time to start the dialogue Again!!

Using Google Desktop to Create an Education-centric Search Engine by Integrating MIRC and RIS*

2009-11-27T15:15:00.015+03:00

*Award Winning RSNA project

Author List: M. Kashif | Abdul Muqeet | Nabile M. Safdar | Khan Mohammad Siddiqu

Keywords: MIRC, MIRTH, XHTML, Google desktop, web user interface

	Background One of the limitations in current radiology systems is the inability to collectively search important educational cases. By combining teaching files in local MIRC, patient textual report in RIS and images in PACS, we report on the development of an integrated search engine that can perform keyword based searching in an education-centric manner. This project is an extension to last year’s award-winning informatics exhibit. We used a free open source software, Mirth (http://www.mirthproject.org/) as a middleware, to convert XML-based MIRC teaching files and HL7-based RIS reports to standard XHTML files. Google desktop was used to index XHTML files. Using a scripting language, 1) a function was created to launch the PACS viewer and 2) a web user interface was created to perform searching based on combination of customizable parameters.

	Evaluation
	Our resulting implementation provides an easy way to perform simple keyword based searching both in MIRC and RIS simultaneously. Radiologists have found the search engine extremely useful and a faster way of retrieving important clinical cases in a teaching environment. Although the search engine is proficient in facilitating educational needs, a few limitations were identified, such as data redundancy, manual scheduled updates and inability to perform search around particular context. Implementation of such searching logic requires minimal technical knowledge and can be easily implemented as a fresh installation or as an add-on to previously installed search engine.

	Discussion
	Implementing a combined MIRC and RIS search engine can be achieved by using freely available and open source tools to overcome current limitations of radiology systems. Creating an independent search engine also provides an opportunity to further enable the searching feature in electronic health records.

	Conclusion
	A combined searching system can provide an important tool with which radiologists can retrieve desired educational information from heterogeneous information resources. Such tools can be implemented to search through any HL7 or XML based information system repository.

DICOM Interoperability at Q8PACS meeting

2009-11-17T19:01:00.009+03:00

Links ..
1. First meeting on YouTube .. Sorry for bad quality !!
2. DICOM operability Presentation
3. KPACS Session

-----

On Nov. 7,2009 Q8PACS first meeting was held at AlSabah hospital training center. At 10:15 am the meeting started with a selected topic entitled "Introduction to DICOM interoperability" presented by Hussein AlSayiegh.
During this session, general concepts about DICOM were introduced. For example, DICOM services, DICOM SOPs, and DICOM conformance statment.
The three essential parameters needed to start DICOM communication were discussed. They are the IP address/or hostname, port no., Application Entity (AET). furthermore, practical tips and best practices of PACS managment were introdcued. A Modality Intgeration Form V1.01 (HTML, DOC) was presented. This form is ment to help PACS admin to make the modality integration easy by submitting PACS/RIS info to the new modality engineer and should make it easy for the PACS vendor's engineer to configure the new modality.

Discussion about the future of the club was held. The club decided that the main goal of forming this club is Educational !! By elivating level of PACS admins and other PACS/RIS users we can improve quality of services of the imaging departments. "By sharing experience we can avoid a lot of mistakes in the future"; Q8PACS member added. Finally , Q8PACS aims to set standards which will help in bringing our mission.

On Nov. 14,2009, the postponed practical session was held at 10:00 AM. The session was fantastic, where members installed and configured a free DICOM workstation called KPACS.
members had a chance to go through the nice features like DICOM Send/Reciece, DICOM query/retrieve, DICOM tag edit, and DICOM offline media (CD burning).

Finally, members have agreed to form an educational committe to establish a curriculim which can meet their goals.

After that meeting, members seemed very proud of their selves and for making this meeting to happpen.

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Q8PACS blog's 1st Birthday

2009-11-02T23:01:00.016+03:00

October 31st was the first birthday of the Q8PACS blog. One year back, Q8PACS Admin wrote the first blog post there .."Dubai PACS Seminar" .. This was when 16 PACS admins from Kuwait attended a seminar which introduced them to many concepts like DICOM, HL7, DICOM troubleshooting and Monitors QC.

This blog was a natural evolution from another service done by Q8PACS. This was the Q8PACS Google Group (email group). The blog was intended to help out others using a great but free tool. This idea came to me in moments when I was thinking how great is internet ? How huge was my benefit from Internet ?

This was when I though that I should pay back "internet" and my community. Regardless of how much we know about any thing ! We; for sure, know many things that many & many other people don't know .. How ?? Our experience about PACS with all surrounding environment is truly unique !!

How many PACS admins in this area work in orthopedic hospitals ? Few ..
How many PACS admins in this area work on vendor "x" PACS system ? Not so many ..
How many PACS admins have experienced data loss (God Forbid) ? Very Few ..
How many PACS admins have experienced PACS upgrades ? Not so many ..
How many PACS Admins have experienced selecting PACS without explaining their needs to vendor ? happens ONLY in KUWAIT!!
How many PACS admins have the "BAD" experience of integrating two PACS systems without having idea why they need so ? a couple only..

So, with all of these individualistic experiences we can add a lot to the humanity !! By communicating together about our experience, we can help others not to fall into our problems !!!

Q8PACS blog in Figures

Today, Q8PACS blog is ranked No.1 on Google when you search in any combination of "PACS","RIS" and "Kuwait"..
Q8PACS is No.1 Google search result for "how to configure kpacs?"
Q8PACS is No.1 Google search result for "Calculating PACS storage"
A total of 15 articles posted on the Q8PACS blog.
2190 visitors to the Q8PACS blogspot.

Q8PACS future on the internet..

Q8PACS currently has 3 online services..

1. Q8PACS blog (http://q8pacs.blogspot.com)

2. Google Group (http://groups.google.com/group/q8pacs)

3. Google DOCS (http://docs.google.com) where all members have access to a library of documents and resources.

In near future, "Q8PACS.ORG" will see the light ... The website for the PACS club of Kuwait will be launced.. with many nices features & services .. BUT .. This will never happen unless we all contribute some time & effort.

Until that moment, please contribute to this effort by giving ideas thoughts in following questionnaire to forecast future of Q8PACS electronic services.

How do you rate Q8PACS blog? *
Excellent
Very Good
Good
Not good enough
Poor

Top reason to give above rating ?

Can you suggest Ideas for the new Website? *

Your name ? (Optional)

PACS Certifications: The way to standardize the industry

2009-10-16T02:00:00.011+03:00

By Hussein Al-Sayiegh

PACS Club of Kuwait - Q8PACS

Little History..

PACS Admin start

PACS has started two decades ago to overcome many difficulties with film archiving issues driven by legal obligations. Since that time, choosing a PACS admin was a challenge. The appointment of PACS admin from radiography domain was a common practice. Just like appointing a dark room technician, PACS admin was chosen among other radiographers. They often chose a computer skilled, and an active young person to be able to run around.

PACS Admin and IT personnel

Later, when PACS started growing and the no. of modalities connected became larger, imaging departments started hiring IT technical support people to take care of IT issues. The IT person will be side-to-side to a clinical PACS admin who plays classical role like merging patients, searching for ray images and so on.

PACS Admin Outsourcing

Some other institutes, decided to outsource this position to a PACS vendor. This was to overcome delay caused by late response to technical problem. They did this by hiring resident PACS admin from vendor’s side to assure fast response to technical difficulties.

Need for PACS certification

1. Indefinite Qualifications and job duties.

Until today most hospitals and imaging centers lack information about qualifications and technical background of their future PACS admin. They probably don’t even know the full job description of the PACS admin which is often confused with the job of the vendor’s PACS engineer.

2. Standardizing Qualifications

One more reason to push for PACS certifications is to standardize this job. Thus, when hospitals start looking for a PACS admin they will look for any person with certain qualifications. However, if you cannot find a standard qualification then it will be too hard to find some one with all needed qualifications and experience.

With implementation of PACS certifications people looking to work in PACS will know their career direction and areas where they need to develop themselves in.

Certifying Organizations

For that reason, some organizations concerned with medical imaging started to pursue a bundle of certifications to standardize the job and to help in evaluating qualifications of the PACS professional.

A. PACS Administrators Registry and Certification Association (PARCA)

http://www.pacsadmin.org/

* PARCA

B. The American Board of Imaging Informatics (ABII)

The Society for Imaging Informatics in Medicine (SIIM), previously SCAR.

http://www.scarnet.org/

http://www.abii.org/

* CIIP: Certified Imaging Informatics Professional (CIIP)

Diversion

If you are convinced that you should get certified, or your PACS admin should be certified. Then, another question comes, which of above certification programs which should adopt: PARCA or CIIP ?

My answer is, pick which ever is more convenient for your facility. CIIP offers one exam only while PARCA offers three levels on five exams. CIIP is affiliated with the American Registery of Radioloic Technologists (ARRT) while PARCA is not. PARCA certification exams can be done anywhere at any time on the internet while CIIP exam is done in selected testing centers in the US. PARCA is working on preparing PACS certifications for PACS engineers for the same reason of certifying the PACS administrators.

Currently, both certifications are concentrating on Radiology only. However, PARCA is working on including parts from Nuclear Medicine and Cardiology since two of PARCA’s board members are from those disciplines.

For further readings, read the following article written by Herman Oosterwiij president of OTech Imaing entitle as PACS Administrator Certification: CIIP or PARCA.

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Q8PACS Census 2010

2009-08-29T12:44:00.011+03:00

"Census" is a tool to evaluate some current position of a phenomena and another great tool to forecast future of the same phenomena within a region.

Unfortunately, PACS/RIS installations in Kuwait were neither done based on info. nor based on a clear plan.

Moreover, lack of intercommunication in MOH resulted that many hospitals in Kuwait has more than one PACS/RIS. In fact, there is a one hospital in Kuwait which has Four PACS systems.

"There is a one hospital in Kuwait which has Four PACS systems"

For this reason, Q8PACS is calling for PACS/RIS census for all Public and Private hospitals in Kuwait and calling for your kind support by participating in below questionnaire.

Fig.1 shows prelimenary results of Kuwait PACS/RIS census 2009 showing total no. of PACS, RIS in Kuwait for Radiology, Nuclear Medicine, Cardiology specialties (e.g. echo, interventional, etc..).

Preliminary results show that Kuwait have 16 PACS installations, and 14 RIS installations. Among 16 PACS installation 3 installations only are in private hospitals while others are all in public ones.

" Kuwait have 16 PACS installations, Only 3 of which are in private hospitals "

This Census "Q8PACS Census 2010" will run on three phases. Phase(I) will count the existing PACS/RIS systems, phase(II) will conduct censuing for PACS/RIS setup(i.e, Storage capacity, Network speed, etc..) while phase(III) will count the PACS vacancies.

Again, this census will help in evaluating our current position and will help in assessing our position in the future.

If you have trouble in reading/filling questionnaire below. Please following the link below

http://spreadsheets.google.com/viewform?hl=en&formkey=dFNRRGU5SEs1ajZEQjFyaVR1RDRmNVE6MA..

Radiology Ergonomics

2009-08-21T20:05:00.015+03:00

By Teresa Quirante (RT) (R.M.) Email. tquirante@techno-aide.com http://www. techno-aide.com

Ergonomics is derived from two Greek words: ergon, meaning work, and nomoi, meaning natural laws, to create a word that means the science of work and a person’s relationship to that work. Simply put, ergonomics is the science of work and it becomes useful in radiology when it successfully creates a more comfortable and efficient environment that maximizes overall productivity and efficiency. When work is performed in awkward postures or with excessive effort, fatigue and discomfort can result. Under these conditions, muscles, tendons, ligaments, nerves and blood vessels can be damaged.		Ergonomics is the science of work and people’s relationship with work. Ergonomics design maximizes work productivity and efficiency.

Injury Risk Radiologists are at a much higher risk of developing musculoskeletal disorders (MSDs) than any other medical profession, according to Dr. Mansi Saksena, a radiologist at Massachusetts General Hospital. Many of us tend to think about ergonomics as simply an office problem and have rarely thought about it as being a problem in the radiology department. As hospitals morph from analog to digital, and the PACS environment increasingly comes into play, radiologists and technologists are complaining of eyestrain and neck, back and wrist pain because the reading environment has changed during this transition. PACS has virtually eliminated the need to manually hang films on viewboxes thus changing the regular work routines of radiologists and staff. Before, there was physical activity within the reading room and now the environment has become less physical, more static, and increasingly more image intensive. Nearly all radiologists are faced with ergonomic challenges as digital technology sweeps through imaging centers across the country.		“Radiologists are at a much higher risk of musculoskeletal disorders (MSDs) than any other medical profession “

How Ergonomic design helps ? Ergonomic planning is moving to the forefront to protect the radiologists and other staff from irreversible injuries. As more and new physical demands are put on radiologists, we must be focused on their health and creating ergonomic reading environments or lose productive hours as a result. Radiologists cannot sit in one place all day performing repetitive tasks without becoming fatigued. Physical fatigue leads to mental fatigue, and mental fatigue increases the potential for interpretive error.		“MSD’s often result when these devices are placed too high or too low or too near the user for extended periods of time”

Design Elements There is a need for the incorporation of several basic elements to build the optimal work environment for visual interpretation and high order mental activity. These elements include: The viewing angle between the head/neck and the image being reviewed; Proper support for the lower arms and wrists. Maintaining a 90-degree relationship of the lower and upper arm; A chair that supports the buttocks and the entire spinal column, including the head and neck, without creating any pressure points. Proper seat height, allowing the feet to rest firmly on the floor or a support. · Elimination of extraneous noise/interruption; and Proper ambient light levels for the output of the monitors being used.

Adjustability is a key consideration in reducing fatigue and decreasing opportunities for injury. Because the best scenario includes having the radiologist or technologist spending part of his or her time standing and part sitting, the ability to adjust the reading site up and down is important. Desk with electronic height adjustments can easily accommodate the needs of radiologist of varying heights. Proper ergonomics applies to each working component being adjustable to the needs of every member of the staff. An interesting challenge in most hospital and clinic reading rooms is the wide variety and quantity of radiologists that “float” between the PACS workstations. The goal is to have an ergonomic environment that will easily accommodate each user’s height requirement and needs.

Seating is often a misunderstood work tool. It is the one item that comes into contact with the human body and is of utmost importance. Choosing the correct ergonomic chair that provides back and arm support adjustments for multiple users is critical to the overall success of the ergonomic work environment. Monitor positioning and keyboard adjustability are also important factors in providing this ergonomic environment. MSD’s often result when these devices are placed too high or too low or too near the user for extended periods of time. If the reading area has not been set up with ergonomics in mind, the radiologists, technologists and others will suffer in varying ways.

Facts & Figures The Journal of the American College of Radiology published a report in August of 2008 reporting that 58% of the radiologists had repetitive stress injury symptoms. A survey of 107 faculty, fellow and residents supported the notion that repetitive stress is a real issue among those working in a PACS environment. The survey went on to show that an ergonomic environment can greatly improve repetitive stress injury symptoms. 70% of respondents in the survey reported system improvement with ergonomic chairs as did 80% of those who received ergonomic workstations and 80% who underwent ergonomic training.		“58% of the radiologists had repetitive stress injury symptoms 80% of those who received ergonomic workstations reported improvement with ergonomic”

Future of Ergonomics in Hospitals With increasing pressures on healthcare, effective ergonomics within hospitals and imaging centers will become increasingly important. The basic concept of ergonomics is that work should fit the worker rather than making the worker adjust to his or her work. Tailoring workstations to match individual characteristics is easy to do with Ergonomic Desks and PACS workstations that are designed for the radiology environment. For anyone touching the radiology and imaging industry, smart ergonomic planning in the radiology interpretive environment is a good and economic investment.

Down, Not Out

2009-07-28T22:11:00.005+03:00

Don’t wait until your facility’s PACS is on the fritz to consider implementing adequate backup policies and procedures. Plan ahead to head off disaster.

By Herman Oosterwijk*, OTech Inc.

As picture archiving and communication systems have become more widespread, so has dependence on this technology. Administrators who are newer to PACS may not realize the breadth of their facility’s dependency until the system shuts down—a far cry from the best-case scenario of being forewarned and forearmed.

Causes of a shutdown can be multifold. Cabling issues such as a cut line typically are the top cause of network downtime. A server may also overload—for example, someone performing a wide-open query for “Mr. Smith’s images” may create a zillion matches, crashing the database. A technologist may become frustrated with a slow response time, hit the return key 20 times and send the application into a loop. Or perhaps the system is unexpectedly shut down by a software bug.

But a facility’s dependency on high-end technology needn’t be feared; it merely requires proper management. That management includes a reliable, well-tested and relatively mature system; an architecture that provides proper redundancy and backup; and last but hardly least, a proper set of policies and procedures.

Even a highly reliable system with ample redundancy remains vulnerable if the backup procedures aren’t followed. A recent reader’s survey from the OTech e-newsletter, a bimonthly PACS publication, found that only 30 percent of health care institutions have a complete set of PACS policies and procedures in place, 44 percent have a partial set and 26 percent have none. One can imagine the frantic activity of that 26 percent when an ER trauma patient undergoes a computed tomography scan and PACS can’t provide the radiologist with images.

Implementing PACS policies and procedures isn’t rocket science. If they’re in place, surprises shouldn’t occur, patient care can continue and staff won’t need to scramble.

Downtime concerns
Downtime procedures are a relatively small—albeit critical—portion of the overall set of PACS policies and procedures. Sections also deal with data integrity, i.e., how to fix “broken studies” that end up in the PACS without proper identification or the correct relationship to the imaging order. Security-related procedures deal with authentication, screen savers, audit trails and other patient privacy requirements. Included are procedures for importing and exporting images from CDs, proper document scanning, etc. A facility would typically have 40 or 50 different policies and procedures dealing with all the PACS aspects.

Downtime can be scheduled or unscheduled. There is also the disaster recovery procedure in the event of a major catastrophe such as fire, flood or other disasters. While some institutions are down for more than a day, downtime typically lasts from five minutes to eight hours, with an average of about an hour. This doesn’t seem long, but it’s unacceptable when patients are involved.

Typically, scheduled downtime is used for implementing patches or major software upgrades. Most institutions have learned the hard way that they should have a test system in place that can store images for about one-three days and is preconfigured at each modality. The technologist knows to select this test sever as a destination, and the radiologist knows to look for his images on this test source.

As soon as the system is back online, the system administrator will move the images from the test server to the production server. Obviously, the radiologist won’t have access to prior studies while the PACS is running on the test server—but if the scheduled downtime is set to occur during a period of low activity, it should be manageable.

The procedure for nonscheduled downtime is similar to the scheduled downtime procedure. A different strategy would be taken, depending on what’s down. If the PACS is down, one could print a film (assuming a printer is available), burn a CD and carry it to the radiologist, who can use his workstation offline. If the network is down, a network or cable switch could be applied that allows for a second network connection. Some institutions store copies of the images on a separate Web server: If the main PACS is down, physicians can log onto any personal computer and still see the images.

Basic downtime procedures
While the downtime procedure often depends on a facility’s architecture and provisions, the following basic procedures should be in place:

Backup procedures. Who does the backup and how often? Depending on the risk level one will accept—and the imaging volume—a backup interval could range from hourly to daily for the database and daily to weekly for the images. Remember: Typically, the images also are available for about a week at the disk on the local modality.

Downtime procedure for modality. This typically consists of a procedure to deal with the worklist being unavailable and one for the PACS store-destination to be unavailable. A solid procedure for lacking worklist capabilities is critical because manual data entry can impact PACS data integrity.

Infrastructure downtime.These procedures deal with power, network, AC or electronic medical record/health information service outages.

PACS downtime procedures. A good policy will cover all possible scenarios (PACS workstations down, hospital network down, HIS/RIS down, single modality down, Web server down, etc.).

Scheduled downtime.This includes the mechanism of user notification.

Unscheduled downtime. Know how to report it, the steps to take and the escalation policy over time.

Disaster recovery procedure. This covers the restoration procedures for the database server and image server.

Proper PACS policies and procedures are essential but hardly impossible to create or implement. Rather than reinvent the wheel, use templates and samples from existing PACS policies and procedure manuals. That way, downtime is just another fact of life that can be managed in a professional manner with minimal impact on patient care.

-----------------------------------------

* Herman Oosterwijk is president of OTech Inc., a PACS training and publication company based in Aubrey, Texas. He publishes a PACS policy manual containing softcopy templates to generate the policies and procedures needed to optimally run a PACS system.

**

From Diary of a PACS Engineer

2009-07-19T02:17:00.006+03:00

Dear Q8PACS Members,

My Name is Mr. Q8PACS Engineer. I have been working in Kuwait as Service Engineer in the field of Medical Imaging for many years. I supported Modality as well as PACS system.

Working in Kuwait is enriching experience for me. In Kuwait, I have had the opportunity to learn and work on latest technology.

In general, customers (Kuwaitis and non-Kuwaitis) are heart-strong. If they like and accept somebody, they will overlook his weaknesses. This sometimes reduces professionalism at workplace. Although, end users (Radiographers, Radiologists, PACS admins, RIS admins) are talented and hard working in general, they do not get enough recognition from management.

During my career, I experienced a high level acceptance and respect once I proved myself. Sometimes they even protected me when I do some mistakes.

Frankly speaking, I have noticed some flaws in the system which can be easily removed. In fact, the system in Kuwait spends too much on showoff and cares less for substance.

Often, end users have no say in selection of their equipment, and systems. Their knowledge and experience is not utilized in this process. As a result of this, vendors are selling what they want and not what customers wanted. Actually, neither lower nor middle management have enough power in purchasing.

They do not even have their independent budget. For example, I have seen some Chairman of imaging depts. buying stationary (for dept use) from their own pocket!

Fortunately, I have seen lot of young people taking important positions throughout MOH. They are dynamic, practical, result oriented. They have deep desire for change in the system. I wish them success and I wish Kuwait a brighter future.

Thanks,
Q8PACS Engineer

Sad Story ..

2009-05-19T00:42:00.006+03:00

Figure 1: CT Scan showing ruptured aortic aneurysm

A 63-year-old man who had been complaining for 2 weeks of “aching” in his lower abdomen was referred by his family physician to the radiology department of a hospital for CT of the abdomen and pelvis.

Two days after the CT examination, the physician telephoned a secretary in the radiology department, stating that he had not received a report of the CT. The secretary replied that she would investigate the matter and forward a report to him. Four days later, a nurse at the physician’s office again telephoned the radiology department to complain that a report of the CT examination still had not been received.

There is no evidence that anyone in the radiology department followed up on these telephone calls. Eight days after the CT examination, the patient experienced acute onset of excruciating pain in the lower abdomen and back. The patient was rushed to the emergency department of the hospital, where he was found to be profoundly hypotensive and tachycardic. Sonography was ordered and disclosed a 7-cm-diameter dissecting aneurysm of the abdominal aorta.

The patient underwent emergency surgery, which revealed a ruptured abdominal aortic aneurysm. Surgical repair was attempted, but the patient died on the operating room table.

Questionnaire : Please answer questions below and then submit !

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Based on article
John J. Smith and Leonard Berlin "PACSand the Loss of Patient Examination Records", Malpractice Issues in Radiology, American Journal of Roentgenology, 2001

To Download full articlehttp://www.ajronline.org/cgi/reprint/176/6/1381.pdf

Calculating your PACS storage capacity

2009-05-13T20:57:00.005+03:00

I came through a nice table in a presentation from SIIM (society of Imaging Informatics in Medicine) which was showing typical image size and typical full study size for different digital images of different modalities in Radiology. See Table above.
This table will help in estimating the needed PACS storage. From your calculation of No. of exams/day, you can estimate the amount of storage you consume daily and then multiply this by the typical size of each study you will then get the your daily storage consumption (just like the calculation of film consumption in the old days.)
For example, if your department makes 15 CT SCAN cases a day, and by assuming that your study makes 1000 slices per study then each study will comsume around 1GB (assuming your CT is a new one with 1024x1024 image matrix).

Thus, 15 CT cases = 15 GB (per day)
15 GB/day = 15 x (30 working days) = 450 GB / Month
450 GB/Month = 450 x 12 (months a year) = 5400 GB = 5.27 TB

Thus, CT SCAN machine doing 15 cases/day will need a storage of ~ 5 27 TB/year.

Note. PACS admin should anticipate the department growth when using this calculation to estimate the PACS storage needed.

"Your Needs" first step toward your PACS project

2009-04-20T16:00:00.001+03:00

Last time...

We discussed lifecycle of PACS projects. Study, Design, Execution. We saw that first two phases usually are implemented by a PACS consultant where third phase is done at last by a vendor.

I don't know my needs !

This is actually a normal case in many projects when healthcare provider doesn't have enough experience. In fact, PACS is limited by IT and storage solution of current technology. Thus, if healthcare provider is not up to date with latest and most effective technology then they may endup with unstable, or outdated technology.

Consultancy Services

In that case, people will hire another body to verify and find there needs. The body who will study your needs is called a "Consultant". There are; infact, many consultants for PACS around the world. For list of consultants for PACS and related field you can refer to
SIIM consultant list, or auntminnie.com PACS Consulting.

Hiring a consultant is too expensive..

Yes !! This is a fact. Consultancy services can cost about 10 to 15% percent of project cost ... a full implementation of PACS can cost up to 1/2 million KD. So, consultancy (study & design) can cost up to 75,000 KD.

Thus, some hospitals will do the study phase themselves. They will study there needs like archive capacity, and fetching throughput to save the expensive cost of hiring a consultant. If hospital decides to do this, they; actually, need to understand their needs first !

Understanding Your needs

It starts with understanding your needs. Very simple: Input and output, it is about the income and outcome of such system. You may never be an IT expert but you can still make the right decision. Keen on the understanding of your needs !

Your pacs vendor may keen on some state of art technology used in his system, but what if non of this works! You can always go back to internet societies to review some technology or some brand name, but there will be no one better than you in understanding your needs..

Put Needs in Writing

Good ! You have been giving thoughts and thoughts about your needs and your work throughput. Later, you started telling your choice vendor about your thoughts and you started negotiating price and might be give up on some parts of your system for the sake of budget limitations. At the end, project accomplished, system starts and then you discover that this wasn't your expectation. The system doesn't meet your requirements and the worst thing that can happen that after few years you find out that your storage archive is FULL !

The big mistake you have done was that you never put your requirements in paper. Your contract was missing the important stuff.

Honostly, in many cases contract was explicit about some requirment; however, all requirement were written in technology specific terms. For example, amount of storage in Tera bytes of storage, type of storage used, servers and H.W used, and no. of client licenses.
In fact, you should state your archive capacity only if you know how much space in Terabytes your center will consume. This is an easy calculation if you study your needs in terms of No. Modalities, Compression rate and etc. Other wise, leave this job to the other party. Of course this will cost you a lot, but I think this is a good solution until we all have a better experience and better sense for our needs.

Request for proposal (RFP)

Now, you decided to call all PACS vendors to submit their offer to supply you with PACS. The invitation letter should; in fact, contain your basic requirments. Those requirments will be your evaluation criteria to decided wich PACS you will buy. The document which will contain your initial requirments is called "Request For Proposal (RFP)" or some times it's called Terms Of Reference (TOR). Down, you can see example of two RFP templates.

1. Georgetown University Medical Center PACS/RIS RFP

2. RFP from David Clunie Website

RFP can have many requirments apart from the system; like, training requirments and integeration services. Project schedule and total period have to be stated there.

Moreover, RFP can have finanical requirments as well. Financial requirments can be some thing like your budget range, your payment policy, and contract penalties.

If you have optional requirments which you think it's good to have but not sure if this will fit in your budget then you should state them as OPTIONAL requirments. Then, you can;first , evaluate (score) all mandatory requirments and later the optional requirments.

Afterwards, vendor can put his/her proposal and then you can score each proposal since all proposals are written based on your requriments

In Summary..

PACS is a full automation solution for imaging departments. Thus, knowing your workflow, and your requirments will lead to a successful PACS implementation. However, not knowing your detailed requirments like storage capacity doesn't mean that you cannot get good PACS. You can still do that by hiring a consultant to do the job or asking vendor to adopt any new requirment which comes in the future. In either way, your requirments should be written in official documents such as RFP. The RFP lists all certain requriments you decided (or consultant decided). RFP gives good way to evaluate different vendor proposal.

Previous Articles..

1. PACS Project lifecycle
2. DICOM SOP
3. DICOM Definition and basic setup

FDA Recall Database

2009-03-07T10:27:00.001+03:00

Key Words
FDA - U.S Food and Drug Association.
CDRH - Center for Devices and Radiological Health
CDRH Recall Database - This database contains a list of classified medical device recalls since November 1, 2002

What is a "RECALL" ?
A recall is an action taken to address a problem with a medical device that violates FDA law. Recalls occur when a medical device is defective, when it could be a risk to health, or when it is both defective and a risk to health.

URL for CDRH Database Search engine
http://www.accessdata.fda.gov/scrIpts/cdrh/cfdocs/cfRES/res.cfm

What Can you find in CDRH Database.

You can find recalls for many Medical imaging and medical systems. For example, PACS, MRI, US, FLuroscopy, etc...
you will be able to see Reason for Recall, Action taken, Class of Recall.
i.e, Recall for GE centricity RA1000 http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfRES/res.cfm?ID=70808

Class of Recall

Class I	High risk
Class II	Less serious risk
Class III	Low risk

Examples of PACS Recalls

New Search

Export to Excel Help

Product Name

	Recall Class

	Date Posted

	Recalling Firm

Philips Healthcare Informatics iSite PACS (Picture Archiving and Communications System), version 3....

Sep-18-2008

Philips Healthcare Informatics, Inc.

WEB1000 Versions 3.1, 4.1 and 5.1, Picture Archiving and Communications systems (PACs), used in the ...

Sep-11-2008

AGFA Corp.

IMPAX® 4.1, IMPAX ® 4.5, IMPAX ® 5.0, IMPAX ® 5.1 IMPAX ® 5.2, IMPAX ® 6.0, IMPAX ® 6.2; Picture Arc...

Sep-11-2008

AGFA Corp.

Impax® 6.x Clients including: 6.3 all versions below 6.3.1 SU5, 6.2 all versions below 6.2.1 SU14 an...

Sep-04-2008

AGFA Corp.

GE Centricity PACS RA1000 Workstation; for diagnostic image analysis. GE Healthcare Integrated IT So...

Sep-02-2008

GE Healthcare Integrated IT Solutions

Philips Medical Systems iSite PACS (Picture Archiving and Communications Systems) version 4.1.17.0 -...

Aug-16-2008

Philips Healthcare Informatics, Inc.

Philips Medical Systems iSite PACS (Picture Archiving and Communications Systems) version 3.6.28.0 -...

Aug-16-2008

Philips Healthcare Informatics, Inc.

Impax 4.5, Impax 5.0, Impax 5.2 and Impax 5.2x Picture Archiving Systems (PACs) with integrated Vox...

Jul-02-2008

AGFA Corp.

iSite PACS image management system; Picture Archiving and Communications System; Radiology software ...

May-08-2008

Philips Healthcare Informatics, Inc.

GE Centricity PACS RA1000 Workstation; for diagnostic image analysis. GE Healthcare Integrated IT So...

May-01-2008

GE Healthcare Integrated IT Solutions

See all the ways you can stay connected to friends and family

PACS Club of Kuwait

When viruses attack ICU

On the ground..

Problem and Solution !

Stage 1. Putting IT security standards on our list of priorities.

Stage 2. Forming an independent IT support team in the hospital independent from medical device vendor. If MOH claims that they don't have enough resources, IT team doesn't have to be through local staff, IT can be outsourced just like electrical maintenance or waste Management .

Stage 3. To Include IT support, Network management , and network security in medical device RFP, and the service contract (service level agreement.)

Excellent Readings..

Big names make big mistakes

Virtual Conferences..

Happy new year !! Many hands...

PACS Group of Kuwait 1st Meeting

Contest Winner Nov. 2010

Blog Bibliography .. Q8PACS Second Birthday

"PACS Laws" by Dr. Dalai

Q8PACS Contest Nov.2010

Diagnostic Monitors - Case Study in Kuwait - Part I

في ذكرى الغزو .. أهمية المعلومات

10 Things we learn from history of PACS

PACS in the Emergency Department

Distributor Vs. Corporate

Microsoft Amalga RIS/PACS

PACS During Holidays

Using Google Desktop to Create an Education-centric Search Engine by Integrating MIRC and RIS*

DICOM Interoperability at Q8PACS meeting

Q8PACS blog's 1st Birthday

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PACS Certifications: The way to standardize the industry

Q8PACS Census 2010

Radiology Ergonomics

Down, Not Out

From Diary of a PACS Engineer

Sad Story ..

Calculating your PACS storage capacity

"Your Needs" first step toward your PACS project

FDA Recall Database

PACS Club of Kuwait

When viruses attack ICU

On the ground..

Problem and Solution !

Stage 1. Putting IT security standards on our list of priorities.

Stage 2. Forming an independent IT support team in the hospital independent from medical device vendor. If MOH claims that they don't have enough resources, IT team doesn't have to be through local staff, IT can be outsourced just like electrical maintenance or waste Management .

Stage 3. To Include IT support, Network management , and network security in medical device RFP, and the service contract (service level agreement.)

Excellent Readings..

Big names make big mistakes

Virtual Conferences..

Happy new year !! Many hands...

PACS Group of Kuwait 1st Meeting

Contest Winner Nov. 2010

Blog Bibliography .. Q8PACS Second Birthday

"PACS Laws" by Dr. Dalai

Q8PACS Contest Nov.2010

Diagnostic Monitors - Case Study in Kuwait - Part I

في ذكرى الغزو .. أهمية المعلومات

10 Things we learn from history of PACS

PACS in the Emergency Department

Distributor Vs. Corporate

Microsoft Amalga RIS/PACS

PACS During Holidays

Using Google Desktop to Create an Education-centric Search Engine by Integrating MIRC and RIS*

DICOM Interoperability at Q8PACS meeting

Q8PACS blog's 1st Birthday

How do you rate Q8PACS blog? * Excellent Very Good Good Not good enough PoorTop reason to give above rating ?Can you suggest Ideas for the new Website? *Your name ? (Optional)

How do you rate Q8PACS blog? * Excellent Very Good Good Not good enough PoorTop reason to give above rating ?Can you suggest Ideas for the new Website? *Your name ? (Optional)

PACS Certifications: The way to standardize the industry

Q8PACS Census 2010

Radiology Ergonomics

Down, Not Out

From Diary of a PACS Engineer

Sad Story ..

Calculating your PACS storage capacity

"Your Needs" first step toward your PACS project

FDA Recall Database

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