Rapid Reporting – Improving image and information management with IMPAX at the NUH Trust

Located in the East Midlands of England, the Nottingham University Hospital (NUH) NHS Trust is the UK’s fourth largest acute Trust, providing acute hospital services to a local population of over 650,000 and specialist services to a wider area of over two million people. As a major teaching centre, the Trust is closely linked to a number of leading academic institutions, maintaining a reputation for research excellence in a range of disciplines, including MR imaging, neurology, oncology, clinical haematology, diabetes and urology. The volume of patients arriving daily to the Trust’s two main facilities, The Queen’s Medical Centre (QMC) and Nottingham City Hospital (NCH), also means the Trust operates one of the busiest radiology and imaging departments in the UK, performing more than half a million imaging procedures annually.

In 2006, as part of Connecting for Health (CfH), the UK's National Health Service (NHS) long-term programme to deliver integrated care record services to all UK hospitals, Agfa's IMPAX PACS system was installed at the Nottingham Trust to improve imaging-based planning, interpretation and results distribution across the organization. The programme was selected by Accenture, a global technology services consulting and outsourcing company, which has helped to manage the installation of PACS systems in more than 30 Trusts, comprising more than 75 hospitals across the UK. Even among these, however, the installation of IMPAX at the NUH was an ambitious project that was achieved in a remarkably short period, enabling the Trust to quickly gain the advantages of one of the world's most popular PACS systems.

Dr. John Somers, Consultant Radiologist and Clinical Lead at Nottingham who oversaw the installation of IMPAX explained, 'The scale of the implementation process was incredible. IMPAX was installed in almost every hospital ward and department through a single Trust wide roll-out that took less then three months to complete. The magnitude of the project is perhaps best illustrated when you consider that the system had to be deployed to approximately 3,500 users simultaneously, 650 of whom would use the full, integrated radiology reporting equipment and the rest a web-based version of the system that makes PACS fully accessible anywhere in the hospital on a standard PC. We went live Trust-wide in June of this year in what has become known as the PACS 'big bang' at Nottingham. The speed with which this was achieved is a credit to the CfH programme and our software provider [Agfa].'

A PACS system that adapts to users

The concept of PACS is not new and the use of these systems for the efficient management, display and storage of radiographic images has been steadily increasing globally for more than a decade. Yet many healthcare organisations have been hesitant to adopt their use due to the steep learning curves and complex workflows of previous packages. The new IMPAX system from Agfa Healthcare, however, is a generational leap forward in the field of PACS and data management, having been specifically designed to meet the needs and daily routines of both imaging specialists and casual users alike. The software features, data presentation and workflow tools automatically adapt to meet any specific need so that users can work the way want to, with the information and tools they need to optimise their daily routines.

As Dr. Somers continues, 'Our radiologists adapted to IMPAX fairly rapidly, largely because of the system's intuitive worklists and other tools such as the display wizards, teaching files and multi-planar reconstruction ability. The rapid deployment and short learning curve of IMPAX then created noticeable improvements in daily workflows across the radiology department. Reporting times came way down, enabling the number of cases processed daily to significantly increase. This really is the crux of what we were looking to achieve, as the number one challenge in virtually every radiology department is simply the volume of cases they must regularly cope with.'

In addition to managing the capture and storage of images, PACS systems enable hospital staff to rapidly access patient image files from anywhere in an organisation. This eliminates the problems of lost files and misplaced images and allows staff to allocate their time to their core duties, rather than spending it moving from one ward to the next to find CT scans and X-rays. Not only does this provide a more comfortable working environment for doctors and nurses, it can also help to reduce patient waiting times and accelerate discharges.

'Basically, ones' physical location no longer matters,' adds Dr. Somers. 'Previously, for example, if we wanted a patient's CT or fluoroscopy images, we would have to go down to the CT department, get onto one of their workstations and perhaps even run off a printed image, which of course would require later filing. Now user can access these same images instantly from any part of the enterprise. We can then manipulate and window them for on-screen comparisons to other images, add digital annotations, or perform any of a host of new operations with them. Not only does this help us to better analyse information and images from various sources, it has led to a fairly sizable time savings for our radiologists, who might sometimes have to travel the five miles between sites to conduct a day's reports. The same has been true for other user groups, such as neuroradiology and nuclear medicine, which both used to be kept separate from other radiology files. At times, this could be irritating for users requiring images from these departments as it meant that patients' records were split into two or three separate files located in different areas of the hospital, each with their own associated administrative paperwork.'

Improvements in communication and the integration of imaging data also supported the merging of the Nottingham Trusts two primary sites, the QMN and the NCH, enabling their two radiology departments to function as a single entity. 'The merger took place mid-way through the installation of IMPAX. At first we thought this might cause some problems with IT, but in fact the system ended up facilitating and streamlining the fusion of the various imaging departments. Without the PACS system in place, there is no way that we could have achieved the level of integration that has already occurred - from a radiological perspective, we would have to have remained functionally separate.'

A paradigm shift in image analysis

The images available with IMPAX are extremely versatile and transportable, making them ideally suited for modern applications in a range of fields including teleradiology and telepathology. These images enable users and clinical teams to work with greater efficiency and perform tasks in ways that would have previously been impossible. Dr. Somers explains one such example at the Nottingham Trust where IMPAX is helping oncology teams to better communicate and treat patients.

'Our primary users are, of course, the radiologists and other imaging specialists. But the system itself is really quite universal - surgeons, paediatricians, neurologists, oncologists and many others have all stopped using film. In fact, one of the areas in which IMPAX really shines is in multiplenary meetings. These sessions, which are most commonly performed for oncology cases, can involve professionals from a variety of fields, including pathologists, oncologists, radiologists, surgeons and nurses - all of whom will be in some way involved in diagnosis and treatment planning. In the past, before you could even begin these meetings you would first have to track down all the films involved in a given case, which could each be located in various departments throughout the hospital. You would then have to gather everyone around a single viewing box and discuss tiny images, such as CT scans or X-rays, which created artificial bottlenecks in these meetings as everyone would have to individually look at these small images in sequence. Now with the web-enabled IMPAX you project the images on-screen, while users can direct the meeting from a workstation and point out key diagnostic features that can be clearly seen by everyone. You can then perform manipulation operations, such as changing window widths and levels on chest X-rays, which may seem simple, but are fundamentals that provide a noticeable improvement to the way we work and that we didn't have before. This has also been a boon to our teaching, which can use the same large or multi-screen approach to show medical students, nurses and other trainees, what's going on in each case.'

To maximise the use of bandwidth and IT resources, IMPAX uses Agfa's Websurge technology, which self-adapts to send only the pixel data required for the resolution of the monitor that the image is being displayed on. For those who choose to view the image magnified or at full resolution, full pixel data will be sent. Wavelet compression can also be applied at the modality level to reduce the effect of low-bandwidth environments. This can be particularly useful for high resolution applications such as those found in orthopaedic departments.

As described to by Dr. Somers 'During to the installation of the Agfa kit, there was some resistance to the idea of implementing a PACS system among the orthopaedic groups. At the time, they felt that a dedicated orthopaedic programme would have been better suited to their needs and there were some concerns that the resolution of the new system wouldn't be sufficient for the diagnosis of small fractures. These fears were not borne out, however, as the orthopaedic groups quickly found that the resolution achieved with the IMPAX workstations is more than capable of meeting their needs. They've also been among those who have really taken advantage of the templating systems included with IMPAX and the ability to access images from a distance while on-call so that they don't have to come in when it's not absolutely necessary.'

The bottom line

With the ability to save time for virtually everyone connected to diagnostic and treatment pathways involving pictures and images, IMPAX has in a short time changed the daily operations of the NUH staff, removing much of their administrative burden. 'It used to be that at any one time, there would be two or three doctors and nurses in the radiology wards looking for images. Now they're accessing images from where they need them, working with less paper and generally being able to process a higher volume of cases daily. Although our patients might not be acutely aware of the changes this has made to their hospital visits, the staff certainly are. The impact of how much our staff have come to enjoy working it was recently highlighted to our IT director when one of our orthopaedic consultants, who was initially one of those who was quite reticent to work with a PACS system, came to them and said: 'Listen, you know this IMPAX kit… it's really quite good isn't it?'