Images in Scope

South Eastern Sydney Illawarra Area Health Service

Abstract

Before this initiative the SESIH SHN Picture Archiving and Communication System (PACS) provided immediate access to radiology images and reports across the entire network. Concurrently the Wollongong Hospital Gastroenterology Department produced endoscopy images only as a hard-copy colour photograph stored in the patient’s notes. There was no existing methodology to display the scope images alongside the relevant report.

This limited access to endoscopy images meant clinicians were unable to collaborate patient care effectively and accurately in multidisciplinary planning meetings.

This paper describes the process of research, testing and implementation to enable gastroenterology images to be integrated into PACS. 100% of specialist medical teams can now compare endoscopy images alongside other associated radiology images from any SESIH hospital enhancing patient diagnosis and treatment.

Aim

To provide immediate access for clinicians to gastroenterology images and reports via PACS to 100% of SHN clinicians within 12 months.

Nature of the Problem

Prior to April 2008, gastroenterology images were available only as a colour photograph stored in the patient’s medical records. Accordingly there was reduced access of patient information due to the hard copy system.

PACS already allowed access to radiology images across the SESIH enterprise and could possibly provide a mechanism to include endoscopy images using its existing distribution framework. 

A Society of Imaging Informatics in Medicine (SIIM) conference highlighting future trends of health information systems described how “scoped” images could be made available to enterprise clinicians.  This initiated research into how this could be achieved for gastroenterology images within our health service.

Extent of the Problem

It was identified that there was no immediate access of gastroenterology images for the clinicians who were treating the patients and hard copy images were only available at the patient’s bedside. These were often misplaced so medical collaboration of information was difficult.

Once discharged the records were filed so outpatient access for the general practitioner delegated with the continuum of care was also difficult.

Integrating the endoscope images to PACS would provide a solution to this dilemma however several technical hurdles needed to be cleared:

1. Patient safety had to be maintained by ensuring the correct demographic information was applied to each image.
2. The endoscopy camera produces images in jpeg format. This format is unknown to PACS and therefore needed to be converted (to DICOM).
3. The system required a simple workflow so that the Gastroenterologist’s diagnostic and procedural ability was not hampered.

Strategic Importance

This project relates directly to the NSW Health strategic directions Category 5 by:

• Integrating existing health information systems
• Creating a component of the patient electronic health record for clinicians
• Improving the effectiveness of the existing gastroenterology workflow
• Improved management of patient data allowing increased access of information

It is believed that the Wollongong hospital PACS is the first hospital in Australia to integrate these scope images.

The NSW Department of Health Greater Metropolitan Clinical Taskforce (GMCT) is keen for us to demonstrate a proven methodology with expansion to other NSW facilities in mind.

Planning and Implementing Solutions

The implementation of this project involved many stages from the initial research, proving the methodology, securing funding, putting the development team in place, getting managerial assent to proceed, trouble shooting, testing, training and final implementation. What follows is a brief outline of this process.

SIIM paper demonstrates scope images sent to PACS.  PACS Administrator researches various ways to integrate scope images to existing PACS.  Tested several software and hardware solutions.  Proved that scope images could be formatted to suit PACS.  Worked with the endoscopy camera vendor (Olympus) engineer to explore further integration workflows.  First scope images sent to PACS.  Workflow at this stage was considered cumbersome for gastroenterologists.  Possible risk of incorrect patient labelling of images if more than one patient on the endoscopy schedule.  Endosoft solution discovered at Digestive Disease Week by Dr Shehan Abey (Gastroenterologist).  Conference meeting with English vendor to assess product capabilities.  Endosoft selected as suitable for project.  Lee Floro (Operations Director, SESAIMI) approves expansion of PACS services to include gastroenterology images and reports.  Funding secured.  Server hardware installed and configured in PACS server room.  Endosoft engineer(Michael Mulcahy) relocates from London to Wollongong  (Sept. 2007) to implement integrated solution to PACS.  Trial phase includes work by GE Healthcare (Singapore) integration team and Endosoft software development team in London.  Test environment created.  Message interfacing problems.  Communication issues between Australian, Singapore and London due to time zone differentials.  Patient worklist created. This improves patient safety by ensuring all images are labelled correctly.  Tested image sent to PACS.  Implementation and staff training.  Go live 9th May 2008.  Success! Images and report are concurrently displayed in PACS.
	JPEG images sent to PACS. Patient demographics have been associated.
	Images from Olympus CV180 endoscope camera.  Patient details are associated.
	Image labelling function demonstrated.

Workflow Example

	Patient is entered to Radiology Information System at recption.
	Gastroenterologist selects patient from worklist.
	Colonoscopy procedure performed.
	Image is captured by pressing button on endoscope
	Image automatically sent to computer workstation.
	Report is created and images annotated prior to sending to PACS.

Outcomes and Evaluation

All Colonoscopy, Gastroscopy and ERCP procedural images are now available on PACS. A “pioneering” methodology such as this makes quantitative comparisons difficult however several outcomes are certain:

1. Gastroenterology images are now available immediately to ALL clinicians across the entire SESIH.
2. The gastroenterology image can now be viewed alongside the associated report.
3. Collaboration between the multidisciplinary teams making important decisions of patient treatment planning is now easier as gastroenterology images are directly displayed. Previously a gastroenterologist would be required to verbally describe findings.
4. Teaching is enhanced. Gastrointestinal tumour margins can be visualised and findings discussed in association with CT scans and pathology images.
5. Gastroenterology workflow is more efficient. Images are archived automatically. There is no manual filing of images.
6. Images are labelled with patient information automatically. Previously a patient label was stuck on the images manually. This reduces medico-legal risk and more closely aligns with the DOH correct patient, procedure, site policy.
7. Endoscopy is now integrated to PACS alongside CT, MRI and other modalities. The PACS includes many monitoring tools which can now be used for endoscopy.

Sustaining Change

The PACS Administrator maintains the interfacing between the GE Healthcare PACS and Endosoft server.

Ongoing maintenance and ‘helpdesk’ style support is offered by the Endosoft support desk to ensure ongoing efficiency of the workflow in the Endoscopy unit.

The GE Healthcare PACS has built in failover strategies so that even in the event of a PACS outage the images and reports can be sent to a stand-alone backup system.

A backup copy of all images from PACS is stored in a separate building so a complete disaster strategy exists.

Future Scope 

• Wollongong
  • The next phase will include dynamic images from pill-camera studies
  • Currently researching ways to include bronchoscopy, arthroscopy, laparoscopy, urology and even pathology images
• SESIH 
  • There are other PACS at other facilities throughout SESIH and the opportunity exists to utilise these existing frameworks in a similar fashion to our ‘achievement’ at Wollongong hospital.
• NSW
  • The GE Healthcare PACS will be implemented to the other major metropolitan hospitals in NSW. As such our integration is easily transferable to these sites
  • Digitising and storing scope images is an essential part of the NSW strategy for an Electronic Health Record (EHR)

Acknowledgements

Lee Floro – Director Operations South Eastern Sydney Illawarra Medical Imaging (SESIAMI)
Dr Shehan Abey – Gastroenterologist TWH Endoscopy Unit
Michael Mulcahy – Endosoft Applications engineer
K.Muthu  - GE Healthcare integration engineer
Zohair Hussein - HL7 programming specialist Endosoft

References

SIIM 2007 Presentations:

• Image Management beyond Radiology, Gary J. Wendt, MD, MBA, University of Wisconsin-Madison
• Image Workflow beyond Radiology, Paul J. Chang, MD, University of Chicago Pritzker School of Medicine
• Advanced Integration Strategies beyond DICOM and IHE, Paul J. Chang, MD, University of Chicago Pritzker School of Medicine
• Integrated Gastrointestinal Imaging and Therapy, Roy Soetikno, MD, Tonya Kaltenbach, MD, Kenneth Binmoeller, MD, Shai Friedland, MD, and
  Thomas Burdon, MD.

Contact

This project was entered in the 2008 NSW Health Awards, Make Smart Choices about the Costs and Benefits of Health Services category.