March 2015Edition 18

Healthcare transformation, we’ll take you...

24 BOGOTA, COLOMBIA Delivering faster patient care with the DX-D Retrofit18 ExECuTIvE REpORT, uK

Delivering state-of-the-art PACS refresh to the National Health Service in England

8 MAhATMA GhAndI MIssIOn, AuRAnGABAd, IndIAHow DR is playing a key role in advancing Asian healthcare standards 22 WALdKRAnKEnhAus sT. MARIEn, ERLAnGEn,

GERMAny Under the Microscope: Image quality and dose values study

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The future of radiology

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The role of the radiologist is evolving fast, with communication and teamwork at the heart of successful patient care.

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The Agfa HealthCare editorial team would like to thank all those who contributed to this publication. Agfa, the Agfa rhombus, DX, HEXAGONE, HYDMEDIA, IMPAX, MUSICA and ORBIS are trademarks of Agfa-Gevaert N.V., Belgium, or its affiliates. All other trademarks are held by their respective owners and are used for editorial purposes with no intention of infringement. All information contained herein is intended for guidance purposes only. Characteristics of the products and services can be changed at any time without notice. Agfa HealthCare strives to ensure all information is accurate but shall not be responsible for typographical errors. © 2015 Agfa HealthCare NV All rights reserved Published by Agfa HealthCare NV B-2640 Mortsel – Belgium

Patient care is definitely a team effort, and every member’s contribution is crucial. But it is clear that the role of the radiologist is evolving fast within the team, supported by both healthcare IT and diagnostic imaging technologies and solutions.

Let’s take a look at the future of radiology, and what the radiologist can bring to the table. Communication, quality, collaboration, tools, efficiency… Individually each of these directly impacts patient care and outcomes; together they form a new paradigm for radiology and beyond.

We know, for example, that patients themselves are playing a bigger part in their own care. The more they understand, the larger their contribution to their own outcome. The radiologist has a unique “view” of the patient; sharing this perspective creates ever-greater value for patients and colleagues alike.

Hospital IT is giving the radiologist a platform for this intercommunication, and for acting as the heart of collaboration for the entire care continuum. Departmental and regional data management solutions are opening the way for radiologists to move beyond the traditional interpretive role, and into a more central, enabling role – one in which they deliver actionable insight.

The radiologist is also at the center of some of the most important issues in long-term patient health outcomes, such as the need to control and monitor imaging radiation dose. Starting from neonatal care, the radiologist has a responsibility to find ways to provide the best image quality at the lowest possible dose.

Finally, the radiologist is also facing the same need for cost efficiency and accountability as other healthcare team players. “Value over volume” is the new watchword, but care quality cannot suffer! In a patient-centric healthcare model, where “customized care” is being offered, the radiologist must and will find ways to keep costs down and care quality up.

We invite you to read the articles we have prepared for you here. Happy reading!

4 In profIle. Prof. Winfried A. Willinek outlines present and future radiology challenges

8 Dr plays a key role In aDvancIng asIan healthcare stanDarDs. The healthcare challenges of serving an economically challenged population in Aurangabad, India

12 agfa healthcare’s fast forwarD Dr UpgraDe program - Loma Linda University Medical Center, USA on why the upgrade pays for itself

14 a long-term It strategy sUpports qUalIty InformatIon anD care. How Agfa HealthCare solutions are helping meet program and regulatory requirements at Jacques Lacarin hospital in Vichy, France

18 DelIverIng state-of-the-art pacs refresh to the natIonal health servIce In englanD. Executive Report on Agfa HealthCare’s 7 year IMPAX contract

22 UnDer the mIcroscope. Image quality and dose values study from Erlangen, Germany

24 faster patIent care – the DX-D Retrofit in action in Bogota, Colombia

28 In small Doses. Prof. Dr Maria-Helena Smet of University Hospital, University of Leuven, Belgium, on dose reduction in premature babies and neonatal patients

32 warsaw’s olDest raDIology co-operatIve goes DIgItal. Witold Zawadowski Cooperative of Radiology Specialists on its drive to go digital.

34 an archIvIng lIfelIne for ch emIle DUrkheIm. How HYDMEDIA offers a lifeline to French hospital ‘drowing in paper’.

36 plannIng to DelIver fUtUre sUccess. Thomas Health, USA, on its managed services agreement

38 Investment In moDalItIes followeD by Investment In It InfrastrUctUre. How RIS/PACS is helping Porz Hospital, Germany, position itself on Cologne’s hospital market

Front Cover: Communication, quality, collaboration, tools, efficiency; together they form a new paradigm for radiology and beyond.

March 2015Edition 18

Healthcare transformation, we’ll take you...

The future of radiology In a patient-centered healthcare model, radiologists are ever-stronger players in the care team

Marc De Fré Director Marketing Communications

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Prof. Willinek, where do you see current developments in radiological imaging?

The trend is moving away from static individual images toward collated image data sets, for example data gained from multiparametric imaging with the option of quantifying the pathological processes, or from moving images (“4D”) that allow dynamic visualization of the kinetics of pathological changes. Today, in oncology, not only are statements about tumor size required, but also information gathered non-invasively, including that concerning a tumor’s metabolic activity or malignancy. For instance, surgeons would like to see in front of them in 3D not only the liver they are going to operate on – to help in planning the operation, includingcolored display of the liver segments, vessels and metastases – but alsodata about the size and volume of the remaining parenchyma, and about the function. This means evidence of liver damage or fat content/fibrosis. When treatment is being monitored, increasingly we need functional information about the residual tumor and its vitality. Based on these radiological data, it is possible to plan the best courses of treatment or treatment options. In this process, I see my colleagues and myself more and more in a pioneering position. Radiology should play a crucial role not only in reaching a diagnosis, but also in treatment management and the selection of patients. Ultimately this is based on standardized, structured findings that allow comparisons and can document the success of the treatment.

One major example of the growing requirements placed on radiology is the rising importance of genetic analysis of cancers with a view to immunological approaches to treatment. Previously the role of radiology was to provide image-guided histological diagnosis of a lesion. Today it is important to document the changes in tumor genetics during treatment.

This requires numerous sequential biopsies over time. And here we find the foundation for the paradigm shift with individualized therapies – for example, moving away from classical chemotherapy to a combination of chemotherapy and immunotherapy, possibly also alternating with locoregional and local ablative radiological treatments.

In what period of time will this paradigm shift take place?

I think we will see treatments with biologicals becoming more established within the next five years – in combination with new developments in device-based medicine.

Can you give us an example?

With high intensity focused ultrasound, HIFU for short, we do not yet know the areas where it will become a routine clinical procedure in the future. In our Radiology Department in Bonn we have the first device in the German-speaking region that can offer treatment based purely on ultrasound. Initial results are encouraging, especially in the treatment of acute cancers with a poor prognosis, such as pancreatic cancer. The possibility of using HIFU in local and focal therapy opens up many more fields of application. Fibroids already constitute one established indication. In the future I can see additional applications, for example the prostate, but also soft tissue sarcomas or brain tumors.

Therefore, in tumor boards, radiology should promote all innovative treatment options for consideration alongside the others. Here functional information about the tumor is important for correctly categorizing the course of the disease under treatment. Radiology has the task of ensuring that findings are classified correctly and that decisions made on this basis serve the well-being of the patient (and especially to avoid overtreatment). It is not only the quality and standardization of the diagnostic process, but also the marking of crucial lesions over time, which make it possible to demonstrate the images and findings to an interdisciplinary conference.

Have these developments any impacts on the organization of radiological departments and institutes?

Sure. To improve our handling of the constantly increasing amount of data and complexity of the imaging, more than anything else we have to have the appropriate personnel, but we also have to work in networks. This may require bringing in several departments together in some cases. Furthermore, the number of interdisciplinary meetings in certification processes is rising all the time.

Radiology is an interdisciplinary field and is, therefore, in contact with other departments through its staff. For instance, in Bonn we have more than 60 meetings a week. This demands that radiology has very good time management and convincing research and image demonstration, so that clinically relevant findings from many patients can be presented within a short space of time.

Not even a Ferrari will get you to your destination without a driver Radiology is an interdisciplinary field influenced by virtually all medical innovations. This naturally applies to imaging and image-guided interventions just as much as to diagnostics and data management. We spoke to Prof. Winfried A. Willinek and asked him about present and future challenges.

I think we will see treatments with biologicals becoming more established within the next five years – in combination with new

developments in device-based medicine.

In profileProf. Winfried A. Willinek • Managing Senior Physician and Deputy Director of the Department of Radiology, University Hospital Bonn, Germany, currently working as Chairman, Department of Radiology, Neuroradiology, Sonography and Nuclear Medicine, Trier, Germany

Bonn, Germany

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How will image data management systems have to change?

PACS must adjust very rapidly to the changing demands. I have already mentioned the continually growing amounts of data. First, that brings challenges in archiving, and second, challenges in diagnostics. You only have to think of a patient from the emergency center after a car accident who is given a full-body 3D CT scan in multiple trauma diagnostic work-up. Here an intelligent and powerful program is needed to quickly reach a reliable diagnosis and valid findings.

What requirements does a PACS have to satisfy in particular, to support you in your work?

Alongside quality for compiling the findings, I attach special importance to demonstration of images. This reflects radiology’s self-confidence as a provider of information on the one hand, and on the other the interdisciplinary cooperation that will become even more important in the future; for instance working together with pathology, radiotherapy, oncology and surgery to arrive at the best possible treatment decisions.

The IT solutions are important here: to save time and emphasize relevant findings, we need simple tools for presenting complex data. When preparing to demonstrate findings, but especially for recommending a treatment and assessing the success of treatment, it is important to have direct access to all the patient’s clinical data. The faster and more effectively the image management systems provide the information, the more able radiologists will be to meet the constantly increasing requirements.

Radiologists influence patient care during examination, diagnostic work-up and image-guided interventions. Aren’t they turning more and more into treatment managers?

That is true, but I would not call them that. Actually they actively intervene far too often in the workflows to be considered “treatment managers” – whether it’s with locoregional or local-ablative image-guided therapies. Even if they adopt a central position in the treatment process, they always seek interaction with other specialist departments – and the better this works, the better it is for the patient.For radiology it is essential to continue to follow the developments occurring in technology so that new roles will always emerge for the therapeutic pathways. I see one of our most pressing tasks in defining – alongside the clinical pathways – relevant imaging pathways that ensure we undertake rapid, effective imaging procedures, but only those that are necessary or expedient. At the end of the process it must be possible to get the patients onto the best lines of treatment for them. That necessitates high quality in diagnostic imaging and image processing.

What conditions are needed for this to happen?

Best of all would be to realize this in a central radiology department. It would be advantageous to have the imaging – meaning all modalities – in a single department. In my opinion this structure is the only way to implement the imaging pathways. At the end of the day this can be more cost-effective for the hospital and better for the individual patients, because it enables even more immediate and targeted diagnostic work-up and treatment.

Moving away from technology, how important is the personnel in this?

The staff are the most important factor. If you own a Ferrari but have no one to drive it, you’re not going to reach your destination. It is therefore essential to invest in personnel. Staff members must be continuously given support and training, first in relation to the technology, and second in relation to the human and clinical challenges.

In this process, the chief radiologist has an important role as a person who thinks ahead and acts as an intermediary. But as far as I understand, that only works when they keep their eyes firmly on everyday practice. Of course they have to perform their management duties, but the clinical pathways harbor potential and knowledge that they need for optimizing the organizational structure.

Prof. Willinek, to finish off, let’s take a look into a crystal ball. Where do you see radiology in 2020?

Oh, even famous people have been mightily mistaken when looking into a crystal ball. But I’ll have a go. Radiology must and will always find new ways to maintain its key role in diagnostics and treatment. Examples of this would be standardization, networking, image fusion, multiparametric imaging and the quantification of pathways in the body. Furthermore, hybrid procedures will become more significant, just like minimally invasive therapies (including HIFU).

I think that personalized diagnostics and treatment will be part of the standard in 2020. I also think that what I have now formulated as a wish for image management systems (for instance integration of analytical software) will already be reality by that time. Radiology IT will require software solutions to be even more mobile, connected and integrative, so that they form the solid basis for further technical developments in innovative diagnostic and treatment procedures.

Are these types of work and services already reflected in billing?

Unfortunately they are not yet included to a sufficient extent in the billing systems, that’s true. But that absolutely has to change, because radiology requires high staffing levels and a lot of time if it is to provide high quality diagnostic work-up – including when services are provided by clinics outside the institute – and to hold meetings with properly qualified staff members. The preparation frequently includes examination and archiving of the patient’s prior images from medical practices or other hospitals. In the case of cancer patients, for example, during the tumor board’s preparation for the Center for Integrated Oncology (CIO) Köln Bonn. I often make a detailed study of the progression over two or three years. Without this preparation and knowledge, I can’t take part in the discussions to identify suitable treatment options. We focus on the patient, and any piece of information can be decisive for him or her.

What do the new challenges in radiology now mean for providers of IT solutions?

We are increasingly moving away from purely modality-guided solutions where we examine, assess and process images, towards comprehensive, network-based solutions from a single supplier. IT providers have to integrate assessment, analysis (like the quantification mechanisms I mentioned) and archiving. In addition, demonstration must be simple and we must be able to find index lesions that are then archived and are at the focus for periods of years when the patients come for check-ups.

An archive of this kind is not least a prerequisite for complex clinical studies that our radiology department here at the Study Center Bonn has a hand in designing. IT companies can be incredibly helpful in this if they allow simplification of the assessment and archiving processes and of data handling, but at the same time make it possible to integrate complex pathways in image analysis by means of standardized reporting templates.

What can you do to support the IT professional?

Also act professionally when it comes to IT. My experience is that the supporting systems and data management always work in departments that have specialists looking after the systems. Otherwise, our five-year success story since introducing PACS would not have been possible.

Several years ago my boss, Professor Schild, brought in Dr Wolfgang Block to fill the new post of Head of Radiology IT in our department. He takes care of all IT issues and is an important contact person both for the whole hospital and for the employees in radiology. On the one hand, he translates the special needs of radiology and ensures the smooth implementation of internal processes, while on the other he is responsible for integrating and networking the radiological systems, such as PACS, with those of the University Hospital. As a specialist he leads a whole team of employees: at this point the “clinically active” members of staff wish to express their heartfelt thanks to Dr Block and his team!

Radiology must and will always find new ways to maintain its key role in diagnostics and treatment. Prof. Winfried A. Willinek

Bonn, Germany

At the time of interview, Prof. Winfried A. Willinek, was Managing Senior Physician and Deputy Director of the Department of Radiology at the University Hospital Bonn, Germany. He has since taken up a new position in Trier, Germany.

Prof. Dr med. Winfried A. Willinek, MD ChairmanDepartment of Radiology, Neuroradiology, Sonography and Nuclear Medicine (Imaging Center) Krankenhaus der Barmherzigen Brüder Trier, Nordallee1, 54292 Trier, Germany

“Our Imaging Center is a place of interdisciplinary cooperation between radiologists, internists, nuclear physicians, surgeons, EDP specialists, physicists and economists – which means people from many fields work together. Medical technical assistants, medical assistants and secretarial staff are responsible for the organization and medical technical services.”Prof. Willinek

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The 1000 bed Mahatma Gandhi Mission Hospital (MGM) serves a local population of six million people drawn from the 12 districts of Maharashtra. When it was founded by the Mahatma Ghandi Mission Trust in 1990, it was with two key objectives: to provide the highest quality healthcare to the local population and to deliver advanced standards of teaching to its future generation of healthcare providers through its Bachelor of Medicine and Bachelor of Surgery and Postgraduate Courses (MD/MS/PG Diploma).

However, in an economically challenged region where money is scarce and 40% of the population is below the poverty line, the challenges posed by these two aims are ones not often seen in more developed regions.

We chose the DR 400 because it offers a complete, scalable DR solution that is able to grow and develop as our requirements change.

Dr Pravin SuryawanshiDeputy Dean, Chief Executive Officer, Professor and Head, Department of Surgery and Chief Endoscopist, Advanced Laparoscopic and Hepato Pancreatico Biliary Surgeon

“Meeting both of our stated objectives can, therefore, be very difficult, and, as we are a completely self-financing trust, we have to look continually for ways to generate new funds.”

And the way the hospital is meeting this challenge is to ensure it is using all of its facilities to maximum benefit by developing its technological capabilities, the reputation of the specialties offered by the medical centre and hospital, and by taking on outsourced contracts from government and the corporate sector to provide access to services they do not provide themselves.

Dr Suryawanshi explains, “We became an Agfa HealthCare customer about five years ago, through the installation of the CR 30-X with DRYSTAR 5500 and DRYSTAR AXYS, and were very satisfied with our solution. More recently, we became the first hospital in Asia to install the DR 400.

“We chose the DR 400 because it offers a complete, scalable DR solution that is able to grow and develop as our requirements change. This was of critical importance to us because to be able to promote ourselves to the corporate sector to attract the funding we need, we have to continually upgrade our infrastructure and services to deliver the most advanced medical capabilities.”

Education a key component to successful adoption

The drive for technological advantage does, however, pose its own additional challenges, as Dr Suryawanshi explains. “For our patients, many of whom are poorly educated, they simply accept what we provide and it doesn’t matter what technologies we use. However, for

DR plays a key role in advancing Asian healthcare standards Dr Pravin Suryawanshi, of the Mahatma Ghandi Memorial Hospital (MGM) in Aurangabad, Maharashtra, east of Mumbai, talks about the healthcare challenges of serving an economically challenged population and how DR is playing a vital part in preparing the next generation of doctors

Says Dr Suryawanshi, Deputy Dean, Chief Executive Officer, Professor and Head, Department of Surgery and Chief Endoscopist, Advanced Laparoscopic and Hepato Pancreatico Biliary Surgeon, “We serve a diverse range of patients. Many are drawn from local communities where healthcare has traditionally been scarce. These patients will often present with issues such as dysentery or other water-borne diseases, like hepatitis. In addition, because we are one of the fastest growing industrial areas in our region, there is also a transient labour force that is being drawn into the city to find work. This means we are also faced with industrial accidents, road traffic accidents, fractures, etc.

“As a result, our X-ray patient numbers have increased from around 100 people per day two years ago to around 160 a day now, and we expect the rate of increase to continue at a similar pace over the next few years.”

Taking a creative approach to the financial challenges

Dr Suryawanshi continues: “Because the local population is so poor, they can afford to pay only a fraction of what it costs to actually treat them, and we are charging just 10% of the costs that other facilities in the region are charging for the same care. However, although we are catering to the poorest class in the community, we still want to provide them with the very best quality healthcare. In addition, as a teaching facility, we remain committed to providing our students with exposure to the best technology and facilities and to offering them the best learning experiences.

“Another challenge is that we wanted to shorten the time per X-ray; aiming to achieve around 120 X-rays out of the 160 we do each day in just four hours.

Aurangabad, India

Dr Pravin Suryawanshi

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many of the established healthcare providers, they have found it challenging to accept digital imaging. They are used to seeing, and in many cases still want to see, images on film, so there continues to be an educational process with some of our colleagues.”

Dr Suryawanshi recognizes that, for some, acceptance of digital imaging will take time, but he is passionate that the medical school graduates, which now number 150 graduates and 80 post graduate students a year, are experienced and comfortable with the very latest digital technologies. He says, “We are one of the very few medical colleges in our state to have super specialty courses like plastic surgery, cardiology, urology, pediatrics, radiology and nephrology and were recently given A+ Accreditation from the National Assessment and Accreditation council – a very prestigious accreditation. Providing students with access to leading technologies and capabilities, such as those offered by the DR 400, is pivotal to that achievement.”

By 2020, MGM Institute of Health Sciences, of which MGM is part, aims to be a top-ranking Centre of Excellence in Medical Education and Research. To achieve this, Dr Suryawanshi sees MGM’s continued association with Agfa HealthCare as a key element.

“We have enjoyed excellent advise and immense support from Agfa HealthCare over the last five years. As we move forward, and the gap between what our patients can afford to pay and what we need to recoup to finance ongoing technological developments continues to be difficult, being able to reduce running costs by maximizing efficiencies and having complete confidence in our choice of solutions will be critical.”

DR 400 • Flexible configurations and options for most needs

• Floor-mounted for cost-effective and easy installation and use

• Best-of-breed solid components, offering reliability and maximum uptime

• Can be equipped with CR and DR technology

• DR systems can be combined/integrated with Agfa HealthCare CR systems for even greater versatility

Innovations in healthcare IT and diagnostic imaging technologies and solutions fundamentally changing how we deliver the patient experience.

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We have enjoyed excellent advise and immense support from Agfa HealthCare over the last five years.

Dr Pravin Suryawanshi

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Loma Linda University Medical Center’s upgrade to DR pays for itself with Agfa HealthCare’s Fast Forward DR Upgrade Program

X-rays are one of the most frequently used technologies within the radiology department of any hospital. X-ray has become a staple technology for the diagnosis of many conditions due to its non-invasive ability to easily and quickly view internal injuries. However, technological developments have seen it progress from film developed with chemicals, to computed radiography (CR) using an imaging plate processed through a special laser scanner or image viewed on a computer, to direct radiography (DR), considered to be the most advanced radiography technology available today.

Today the benefits of DR are widely known; however, many hospitals are challenged to find cost effective ways to upgrade their legacy radiation technologies. This was the situation at Loma Linda University Medical Center located in Loma Linda, CA. LLUMC is part of a non-profit health system of six hospitals with 1,076 licensed beds available for patient care. It is the only level one regional trauma center for Inyo, Mono, Riverside, and San Bernardino counties. In addition to providing renowned patient care, including neonatal care, LLUMC operates some of the largest clinical programs in the United States. Each year the institution discharges more than 43,500 inpatients and serves roughly 725,000 outpatients.

The diagnostic radiology department of LLUMC conducts an average of 500 diagnostic exams for roughly 1,600 images per day. It was clear that transitioning from CR to DR would have significant positive impact on patient care. However, without the availability of sufficient capital to fund this transition, moving to DR did not appear to be a current possibility, but instead it would need to be a future goal. The radiology department was left with the challenge of trying to find a way to implement a DR upgrade that they knew would save the hospital vast amounts of money in the long-run without the availability of a large up-front capital investment to purchase and install the new equipment.

The answer came in the form of Agfa HealthCare’s Fast Forward DR Upgrade Program.

Loma Linda, California, USA

Unique cost structure makes DR upgrade possible

It made it possible for LLUMC to proactively upgrade its X-ray technologies to DR despite its lack of immediate capital to pay for the upgrade. The program features a unique cost structure in which LLUMC pays fixed monthly payments over a 60-month period in lieu of dedicating a large amount of capital to the upgrade immediately.

“What made the DR upgrade a no-brainer for us was the marginal cost increase in monthly payments for the adoption of significantly superior DR technology as compared to what we were paying previously for ongoing maintenance of our CR technologies,” said Roland Rhynus, CRA, Executive Director of Radiology. “The minor cost increase has resulted in major realizations in staff efficiency, patient comfort and satisfaction, time savings and X-ray image quality. ”The main benefit of the Fast Forward DR Upgrade Program is to obtain the latest and most advanced DR X-ray technologies in a cost effective manner. The bonus is that the program also includes a service maintenance agreement (SMA) for ongoing maintenance support and a Damage Assistance Program (DAsP), which provides insurance for the costly DR plates as part of the monthly payment. Mike Haman, Enterprise Director Imaging Informatics commented: “These are expenses that a hospital would normally pay for on top of the purchase and installation costs of new equipment. Having them included in the cost of the program makes the upgrade especially cost effective.”

Upgrading existing CR technologies instead of replacing

Agfa HealthCare’s DX-D Retrofit is the heart of the upgrade program. The DX-D Retrofit provides healthcare facilities using analog or CR technology an efficient upgrade to the benefits of DR without replacing their existing X-ray equipment. By maximizing the use of existing equipment while simplifying installation, DX-D Retrofit provides an easy and affordable way to implement direct digital image capture in the X-ray room that can then be shared and accessed within the EHR. This vendor-neutral upgrade solution provides DR workflow and image quality for a fraction of the price of a complete system and handles many applications throughout multiple hospital departments.

Real benefits of DR upgrade at LLUMC

Streamlined workflow and time savings. Although typically it only takes a few minutes to develop a CR X-ray cassette, collective processing time becomes substantial when it is multiplied by the hundreds of X-rays LLUMC conducts every day. The automatic digital downloading of images with DR technology, combined with faster exams, has saved the radiology staff significant time, which also translates into cost savings at the hospital.

Better image quality and radiation dose reduction. Agfa HealthCare’s patented MUSICA image processing software is utilized with the entire DR product line and was automatically installed with all of LLUMC’s DR technologies. MUSICA brings multi-scaled image processing to a new level by showing exquisite detail in low noise images that allows radiologists at LLUMC to consistently capture high-quality images at lower radiation dose when the needle-based detector option is used. Images processed with DR technologies using MUSICA show more detail. This allows radiologists to modify their techniques by increasing the kilovoltage (kVp) and decreasing the milliampere seconds (mAs), thus lowering the effective radiation dose. With Agfa HealthCare’s DR systems using the needle-based detector option, the radiation exposure to the patient can be reduced by at least one third without any noticeable difference in image quality. DR technologies are able to produce quality images at a lower exposure index (EI) than is needed to achieve the same quality image with CR technologies. A quality image can be achieved even though the EI may indicate that the technique selected is “underexposing”. MUSICA allows the contrast and brightness of an image to be adjusted directly after it has been taken. This allows an image with a lower EI taken with DR to be as diagnostic as one with an EI within mid-range taken with CR.

Optimized patient comfort and care. Patient engagement, comfort, and satisfaction at LLUMC have greatly increased as a result of the upgrade to Dr Agfa HealthCare’s DR technologies allow the technologist to view the X-ray image seconds after the exposure is made while still with the patient. This allows the technologist to immediately verify that a high quality radiograph is obtained and any necessary adjustments can be made quickly if an additional image is required. If any additional views or modifications are

What made the DR upgrade a no-brainer for us was the marginal cost increase in monthly payments for the adoption of significantly superior DR technology as compared to what we were paying previously for ongoing maintenance of our CR technologies

Roland Rhynus, CRA, Executive Director of Radiology

DR Advantages: By the Numbers

67more exams per day for increased productivity

time savings on average, per exam

minutes

%

8.16

more patients

more per

gain by reducing the number of technologists required per exam from two to one

( F u l l - t i m e E q u i v a l e n t )100 FTE%

9 per day

3,285year

needed, the patient is able to stay in their current position while the image is retaken, as the DR image plate does not have to be replaced after each exposure, as is required with CR plates. Furthermore, no matter where the body part of interest is placed on the DR detector, the image is automatically centered after the exposure is made. This is especially beneficial when imaging the small extremities of pediatric patients that are positioned on the edges or corners of the detector.

“For bed-ridden trauma patients and children in particular, the ability to immediately review an image and retake it right then and there, if necessary, is a huge positive. To force a bed-ridden trauma patient in pain or an active child to redo the entire X-ray process can be very difficult. We’re now able to avoid those unnecessary and uncomfortable image retakes. We’re also able to take action immediately if the X-ray image indicates further medical procedures are needed,” said Aimee Gallegos, R.T. Interim Manager Children’s Hospital Radiology.

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HYDMEDIA integrates with both ORBISand HEXAGONE. Plus, the flexibility of theparameterization and the powerful searchengine were critical decision factors.

Patrice James

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For many years, the Centre Hospitalier Jacques Lacarin de Vichy (CH Vichy) and Agfa HealthCare have collaborated in creating an IT infrastructure that will support the hospital’s development program. Agfa HealthCare IT solutions – from the HEXAGONE* hospital information system (HIS), to the ORBIS* clinical information system (CIS), through the IMPAX radiology information system/picture archiving and communication system (RIS/PACS) and now the upcoming adoption of the HYDMEDIA** enterprise content management solution – are helping it to achieve its long-term goals for patient care and management.

“My vision for our hospital IT infrastructure is to have a solution that covers almost all the major, computerized functions at the enterprise level – from administration (especially everything regarding the patient), to managing our financial and economic resources, through to human resources,” says Patrice James, Director of Information Systems for CH Vichy. “And of course we need a strong medical IT part – including all medical AND nursing information.”

Partnering to solve the real needs of real hospitals

For fifteen years, CH Vichy has been a pilot site for the HEXAGONE HIS, working in close partnership with Agfa HealthCare and its development team. With the HIS up and running, the hospital turned towards eliminating the information silos that existed throughout the enterprise. “We were already implementing our clinical information in the 1990s,” explains Patrice James. “But computerizing the patient files was done individually by department or service. That’s the problem ORBIS has been solving for us, decompartmentalizing each activity within our hospital, and bringing everything together to create a true medicalized information system.” CH Vichy now has a number of ORBIS functionalities and modules, including the patient record (diagnosesand procedures), medical information, PMSI (the French medicalized information system program), prescriptions, medication workflow and supply management, canteen management, office/administration and business intelligence.

Rolling out ORBIS, step by step

The first ORBIS modules to be implemented were the patient record (diagnoses and procedures) and the office/administration module. During these initial installations, the Agfa HealthCare team supported the CH Vichy implementation team. But for the rest of themodules the Vichy team was able to act autonomously, explains Patrice James. “We set up an internal ORBIS implementation team consisting of three IT professionals and a nursing manager, who

knows the functioning of the services much better than the IT staff!Including a ‘field expert’ in the implementation team has been a big factor in our success. For example, when we implemented the administration/office functionalities, we brought in a secretary to provide that insight.

We continue to do this for each new module, such as the operating theater and emergency department.” Patrice James highlights that one of the most important success factors has been bringing together into a single activity the IT services and the department ofmedical information, finance and patient management. “This collaboration allows us to optimize the interface with the healthcare professionals and to focus the discussions on the real optimization issues for our HIS.” The roll-out process for each ORBIS functionality or module is essentially the same. First, the team selects a ‘pilot site’ within the hospital. “We have found that a unit with around 15 beds is generally a good size for the pilot,” comments Patrice James. Once the pilot site is going well, the module is launched department by department. However, the length of time it takes to implement a module can vary a lot, explains Patrice James.

“The functionality for inputting diagnoses and procedures was implemented across the hospital in 15 days. The administration/office module was completed in two months. On the other hand, the medication circuit is very complex: we are talking about the prescription by the doctor, then the verification by the pharmacist and finally the administration of the medication by the nurse. So that module took over a year to fully implement. You have to be a bit flexible with the timing: ensuring a good quality of implementation is the most important thing.”

Vichy, France

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At the Jacques Lacarin hospital in Vichy,a long-term IT strategy supports quality information and quality care Agfa HealthCare’s IT solutions come together to help the hospital meet its development program and regulatory requirements

Our relationship with Agfa HealthCare allows us to take advantage of the opportunities from technical evolutions, to anticipate things, and ultimately to expand our vision of the future of healthcare IT.

Patrice James,Director of Information Systems

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HEXAGONE hospitalinformation system

• Patient administration management

• Financial management

• Human resources management

ORBIS clinicalinformation system• Provides access to shared patient record and administrative data anywhere, anytime

• Allows better patient management and security

• Improves collaboration between healthcare professionals

• Reduces the risk of administrative errors, and increases administrative productivity

HYDMEDIA enterprise content management solution• Facilitates information sharing through integration with ORBIS and the HIS

• Negates the need for paper and fi lm-based documentation

• Reduces physical archiving space

• Speeds information retrieval times

• Reduces costs and increases productivity

• Improves disaster recovery capabilities

Solutions that help improve patient care CH Vichy has now been using ORBIS for five years, and the biggest changes for Patrice James are in the traceability and the quality of information.

“It’s not just about productivity, although we do see gains in terms of administration and secretarial work. For example, structured documents, such as release letters that automatically include the patient’s history, obviously save time and effort, and reduce the risk of error.

“But the big benefits are more qualitative: better patient management and security, which lead to better care. Take the medication circuit, which completely secures the management of the patient’s medication. That’s key! Having access to all the relevant information about the patient in real time also improves patient care. Finally, being able to see the entire history when a patient comes to the hospital, for example to the emergency department, allows the physicians to make informed decisions about e.g. which exams need to be performed, potentially allowing us to eliminate repeated exams.”

CH Vichy will be putting the ‘final ORBIS brick’ in place later this year, comments Patrice James: the module for the nursing record will be piloted in September, with the full implementation expected in October/November.

Towards the paperless future

Now, CH Vichy is taking its next step in digitization, with its project to eliminate paper documentation. “The challenges we faced had to do with how to manage the ever-growing archive, how to access files once they were archived and how long it would take to access them. We did an evaluation, based on archiving and accessing documents from external consultations only, and found it would require six medical administration staff (full-time equivalents) doing only that all day long. So we looked around at available solutions. HYDMEDIA could best integrate with our IT infrastructure: it integrates with both ORBIS and HEXAGONE. Plus, the flexibility of the parameterization and the powerful search engine were critical decision factors. We began the project mid-2013, and had our first implementation meeting in the first quarter of 2014.”

In any case, it is clear that this won’t be the last technological evolution for CH Vichy. Already, the hospital is collaborating with Agfa HealthCare to develop further improvements to its solutions. “We’re working on a pilot for a touchscreen tablet for ORBIS canteen management which will put all patient information at the fingertips of the dieticians, during consultations. It’s a very interesting way to use new technology, and it highlights to me how our relationship with Agfa HealthCare allows us to take advantage of the opportunities from technical evolutions, to anticipate things, and ultimately to expand our vision of the future of healthcare IT in our hospital.”

Medical information was not circulating between departments. ORBIS has been solving that for us, step by step: decompartmentalizing

each activity within our hospital, and bringing everything together to create a medicalized information system.

Patrice James

Vichy, France

* HEXAGONE and ORBIS are not available in Canada and the U.S.** HYDMEDIA is not available in the U.S.

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North East

EastMidlands

110IMPAX servers

2regions

14months

1,135workstations

100hospitals

30Trusts

Agfa HealthCare awarded 7 year IMPAX contract

Picture Archiving and Communication Systems (PACS) are installed in over 160 National Health Service acute trusts in England. Most of these NHS hospitals received systems to enable them to capture and store digital diagnostic images as part of the health service IT modernisation program, called the National Programme for IT (NPfIT). The NPfIT, which originated a decade ago, sought to develop the NHS national IT infrastructure for delivering electronic patient record services across NHS England. As part of the NPfIT, PACS was to be deployed to enable the digital storage and retrieval of patient related images. Five different regions were established throughout England and contracts were awarded to Local Service Providers (LSPs) to deliver the solutions. With Accenture as the LSP, Agfa HealthCare won contracts to deliver IMPAX, its fully integrated digital information and management PACS solution, to 30 Trusts across two LSP regions – the North East and East Midlands. The roll out of PACS is often considered to be one of the few big successes of the NPfIT.

Delivering state-of-the-art PACS refresh to 100 hospitals in just 14 months 30 NHS Trusts across the North East and East Midlands regions in the UK to implement IMPAX

Executive Report

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Departmental and regional data management solutions are opening the way for radiologists to move beyond the traditional

interpretive role, into one in which they deliver actionable insight.

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SUCCESS FACTORS

As part of the original National Programme for IT (NPfIT), Agfa HealthCare delivered IMPAX to 20% of NHS England through: • Clear program parameters. Ensured no “program scope creep” throughout the upgrade program, although the project team’s success did ultimately result in its scope being expanded. • Utilization of technical expertise. Ensured replacement of live clinical systems minimized impact to patients. • Technological knowledge. Enabled the creation of a solution suitable for all sizes of hospitals. • Technical expertise. Facilitated problem solving without impact on live service. • Strong relationship management, as well as its understanding and empathy of each Trust’s desire for an individual solution, was key to convincing customers of the value of the IMPAX solution. • Comprehensive training program, incorporating a training center to train the PACS users, provided understanding of the advanced functionality provided by the new version of IMPAX. • Added value to customers by upgrading all customer Trusts to IMPAX 6.5.2 within the allocated budget. • Delivered a complex project on time and on budget. A cross functional project board meant strong financial control, key decisions taken effectively/ quickly, a clear line of escalation management and a strong team spirit through the challenges. • Strong financial management controlled costs and provided effective governance of all aspects of the program. • Resource management. Agfa HealthCare was responsible for both its own team of professional as well as external teams. • Effective logistical management. Despite unanticipated supply challenges, Agfa HealthCare effectively managed large volumes of equipment from source to supply. • Team commitment delivered most aggressive upgrade program ever. The success of the project team resulted in the program scope being expanded into running other projects.

The future Under the UK National Health Service Supply Chain framework customers benefit from a more flexible and bespoke imaging IT solution. New components such as image exchange, integration of clinical applications, 3D and support for digital tomosynthesis can be added to existing services to ensure unique imaging requirements are met.Having upgraded both the IMPAX software solution and the PACS hardware of all its program clients, Agfa HealthCare believes its Trusts are now well placed for the next wave of Agfa HealthCare technology.

Full details of the project and its outcomes can be found at www.agfahealthcare.com

Agfa HealthCare’sInvolvement

6 EXECUTIVE REPORT IMPAX

PROGRAM BENEFITSDelivered 99.98% PACS availability in 2013

During the life of the program and the subsequent upgrade, Agfa HealthCare’s IMPAX solution:

Halved the number of open incidents in 2013 Delivered a new, more stable and functional platform and reduced service failures due to the upgrade to IMPAX 6.5.2

Reduced service outage and penalties Reduced service failures as a result of unsupported and obsolete equipment Prepared customers for new future technologies such as Enterprise Imaging for Radiology

Delivered 75% average satisfaction score across our 26 PACS Trusts (as at early 2013)

Agfa HealthCare’s involvement in this large scale complex project delivered:

KEY STATISTICS

Less than 9 minutes’

unplanned downtime per Trust per month

in 2013

75% reduction

in overall service failures since

2009

A change success of 98.5% during 2013

8 years’ experience

serving NHS customers with our fully managed service,

delivered to stringent and high performing

service levels

Key Statistics

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Under the microscope Study of image quality and dose values for thorax images with the DX-D 300 and MUSICA 3 by PD Dr Karina Hofmann-Preiss, Institute of Imaging Diagnostics and Therapy (BDT), Erlangen

Scope of study

A total of 354 patients participated in the study, with an age range of 17 to 94 (Fig. 1). Examinations were carried out on 190 male patients and 164 female patients. In 74 cases only PA images were taken and in 280 cases two-plane images. The exposure parameters were 117 kV for PA, 125 kV for lateral X-rays with automatic exposure, anti-scatter grid r = 8:1, f0 = 180 cm, 52 L/cm.

The dose area products of all examinations were calculated in cGy x cm2 and the effective dose for the individual X-ray was estimated from this using the conversion factor (0.002). The BMI was calculated for 275 patients from this collective and was between 18 and 44 (Fig. 2).

Initial results

For both the PA and lateral images, the dose area products for all BMI values were clearly below the current German dose reference value of 16 cGy x cm2 or 55 cGy x cm2 for lateral images. The average dose area product for PA images in this collective was 6.44 cGy x cm2 and for lateral images was 16.01 cGy x cm2 (Figs. 3 and 4). The average effective dose for a PA thorax X-ray in the collective was 0.013 mSv and for a two-plane X-ray was 0.046 mSv.

The lowest dose area product with a BMI of 18 was 3.1 for PA and 5.02 cGy x cm2 for lateral. In this case the effective dose for the complete examination was 0.016 mSv. The maximum dose area product for a PA image was 14.7 cGy x cm2, and correspondingly the dose area product for a lateral image in this case was 36.3 cGy x cm2. Here the effective dose was 0.1 mSv for the complete examination.

The image quality was assessed in line with the quality requirements of the guidelines published by the Bundesärztekammer on quality assurance in diagnostic radiology.

Conclusion

Even at a very high BMI there were no limitations on the representation of characteristic features, important details or critical structures.

Both the retrocardiac lung and the mediastinal structures can be well assessed even with very overweight patients (Fig. 5 and 6).

In particular, the retrocardiac lunge and the mediastinal structures were easier to assess in an intra-individual comparison between MUSICA² and MUSICA 3.

Sources:German Federal Office for Radiation Protection; Announcement of updated diagnostic reference values for diagnostic and interventional X-ray examinations, 07.22.2010

Bundesärztekammer; Guidelines on quality assurance in diagnostic radiology – Quality criteria for diagnostic X-ray examinations, 11.23.2007

Erlangen, Germany

Dr Karina Hofmann-Preiss Institute of Diagnostic and Therapeutic Imaging

Fig. 1: Age distribution for thorax images Fig. 2 distribution of BMI in the collective Fig. 3 dose area product for thorax (pA)

Fig. 4 dose area product for thorax (LAT) Fig. 5: BMI: 18, dAp pA 3.1 cGy x cm2effective dose including lateral image: 0.01 msv

Fig. 6: BMI: 43.8, dAp pA 14.7 cGy x cm2effective dose including lateral image: 0.1 msv

cGy x cm2

Average 6,44 cGy x cm2

diagnostic reference value - Germany 16 cGy x cm2

cGy x cm2

Average 16,01 cGy x cm2

diagnostic reference value - Germany 55 cGy x cm2

1 plane

2 plane

Agfa HealthCare’s DX-D 300 digital U-arm system has been in use at the Waldkrankenhaus St. Marien healthcare center since May 2013. Radiologist Dr Karina Hofmann-Preiss and her team attach great importance to patient comfort and high image quality as well as the minimization of radiation exposure. For Dr Hofmann-Preiss, the DX-D 300 kills two birds with one stone. “We get higher-quality and more diagnostically meaningful images with a lower radiation dose.” The high image quality of the DX-D 300 was achieved primarily by the cesium iodide detector and the MUSICA image processing software. In fall 2013 it was still unclear what dose reduction the radiologists at the Institute of Imaging Diagnostics and Therapy (BDT) would ultimately be able to achieve during individual examinations, as some assessments of the individual examinations still remained to be carried out. At that time it was estimated that the dose could be reduced by at least 15% compared with the previously used imaging plate systems.

In May 2014, the DX-D 300 was equipped with MUSICA 3, the next, further optimized generation of the image processing software. To collect reliable information about the dose and image quality with MUSICA 3, thorax X-rays were evaluated for a period of five weeks after the software was installed.

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As one of the longest-standing departments of the University Hospital San Ignacio in Colombia, the radiology and diagnostic imaging department is committed to offering patients fast and top-quality imaging. But with its high patient throughput, the department faced regular backlog for carrying out exams, and patient wait times were growing too long.

The University Hospital San Ignacio was founded in 1942 in Bogotá, Colombia as a hospital and a research center for doctors and students. It is one of the most important hospital centers in Colombia, and one of the most respected in Latin America.

In 2013 the hospital decided to update its imaging equipment, in order to speed up its diagnostic imaging services. With Agfa HealthCare’s DX-D Retrofit solutions, as well as a DX-M computed radiography (CR) system for mammography and more, the department was able to achieve its goals, while maximizing the value of its existing imaging investment and enhancing image quality.

Competitive testing reveals advantages

The radiology and diagnostic imaging department provides a wide range of services, from conventional radiology, through ultrasound and scanning, to nuclear medicine, and MRI. Two years ago, the department carried out a competitive evaluation of the digital radiography offers of multiple vendors. The objective was to find a solution that would support it in achieving its overall goal of offering faster diagnostic service to patients and doctors alike. Over several weeks, systems from different manufacturers were tested for speed of image acquisition. Based on the results, the radiology department chose to implement two DX-D Retrofit solutions with DX-D 10G digital detectors and the DX-M CR system with needle detectors.

With DX-D Retrofit, healthcare facilities using either analog or computed radiography (CR) can upgrade to the benefits of direct radiography (DR), without replacing their existing equipment. The non-invasive, connection-only installation is quick and easy.The DX-M, for mammography and general radiography, combines excellent image quality with high throughput, delivered by a unique five cassette drop-and-go buffer, and a very fast preview.

Faster emergency unit workflow

Two DX-D Retrofit systems were installed in the hospital’s emergency department. According to Dr Luis Felipe Uriza, Head Director of Radiology, “The emergency unit handles a large number of patients, carrying out around 200 exams each day. Before, we would get patient queues for imaging, which affects care quality. We added another person to register data, but the backlogs continued.

“With our previous equipment, each exam took five minutes; now, with the DX-D Retrofit, an exam is complete in just one minute. When you multiply that time savings by 200 daily exams, the improvement is considerable.” The time saved means faster workflow and quicker patient treatment, which is especially important in a busy emergency department.

Bogota, Columbia

Retrofit DR brings faster patient care for busy radiology and diagnostic imaging unit With two Agfa HealthCare DX-D Retrofit solutions and the DX-M CR system, the University Hospital San Ignacio is improving image quality and reducing exam times.

With our previous equipment, each exam took five minutes; now, with the DX-D Retrofit, an exam is complete in just one minute. When you multiply that time saving by 200 daily exams, the improvement is considerable.

Dr Luis Felipe Uriza Carrasco,Head Director of Radiology

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Bogota, Columbia

High-quality mammograms, quickly The hospital also installed a DX-M with needle detectors, which is used for mammograms and other radiography exams. “The tests carried out with the DX-M show that it provides notable advantages in terms of time, productivity and image quality, and again has allowed us to optimize patient care,” Dr Uriza notes. Furthermore, the DX-M fulfilled a fundamental requirement by easily integrating with the radiology department’s existing systems. “We absolutely needed a solution that was compatible with our existing systems from different manufacturers, and the DX-M delivered,” continues Dr Uriza.

Smooth implementation

“The installation of the Agfa HealthCare solutions was simple and took little time. The integration with our existing equipment went fine,” says Dr Uriza. “One difficulty with temperature was handled quickly by the Agfa HealthCare services team,” he says. “Given the complexity of the systems used in radiology, incidents sometimes occur and must be resolved as soon as possible.”

Since the implementation, the hospital carried out a time and movement study of the Agfa HealthCare solutions. “Our study showed that they are cost-effective and reduced our patient wait times. Image quality also improved significantly.”

Constant technical innovation

Dr Uriza has experienced the evolution of diagnostic images first-hand. With the arrival of digital systems, radiology and diagnostic imaging departments have experienced a host of advantages, he says: “Image acquisition time is shortened, the workflow is better controlled, and productivity, security and delivery of patient care are improved.” The implementation of the DX-D Retrofit and DX-M systems is only the start for the University Hospital San Ignacio. In fact, the radiology unit is planning to update its mammography equipment soon and to implement a new RIS/PACS. “We are in a process of constant technological innovation, which fits with the motto of the founders of the hospital: ‘Science and technology with social projection’.” A process that Agfa HealthCare looks forward to supporting.

Our time and movement study showed that the Agfa HealthCare solutions are cost-effective

and reduced our patient wait times. Image quality also improved significantly.

DX-M with needle detectors• For digital mammography and general radiography

• State-of-the-art image quality, with potential dose reduction when using Cesium Bromide needle-based imaging plates

• Intelligent MUSICA image processing

• Choice of needle-based imaging plates and standard phosphor plates

• Drop-and-go cassette buffer

• Broad range of applications

DX-D Retrofit• All the workflow and image quality benefits of direct radiography

• Maximizes your existing imaging investment

• Easy installation, quickly up and running

• Choice of Cesium Iodide (CsI) or Gadolinium Oxy-Sulphide (GOS) detector conversion screens

• Potential dose reduction when using Csl detectors

• Specially-tuned MUSICA software, for gold-standard image processing, and NX workstation for smoother workflow

• Connectivity to PACS, HIS/RIS and imagers

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Image quality has two aspects: physical qualityand clinical image quality. Physical quality is easier tomeasure. But the clinical image quality is more personal,based on the viewer’s preferences and needs.

Prof. Dr Maria-Helena Smet

To visit UZ Leuven’s new, state-of-the-art Neonatal Intensive Care Unit (NICU), you have to go through special measures, from careful hand and arm washing, to wearing gloves and removing rings, to wearing a gown over your clothes. But these are just a few of the precautions to protect the delicate patients, who face elevated health risks in several areas.

Other actions taken for patient safety are not so visible, yet are just asimportant, including the ongoing efforts of UZ Leuven’s pediatric radiology department to reduce to the minimum the amount of radiation neonates (as well as other pediatric patients) receive. Prof. Dr Maria-Helena Smet, a Pediatric Radiologist at UZ Leuven,and her colleagues are spearheading efforts and research into dose reduction and image quality optimization. Along with a multi-disciplinary team, including Agfa HealthCare, she is carrying outthe testing of CR and DR modalities to determine which allows the greatest dose reduction while still offering the image quality needed for the specialty. She sat down to explain the research, and why dose reduction is so important in pediatric radiology.

How is neonatal and pediatric radiology different from imaging for adults?

Imaging is absolutely crucial for many of our NICU patients, who can have a broad range of pathologies, including the positioning and checking of catheters. One baby can require multiple images during a stay here, and may need additional images in the future.

But the imaging can be quite challenging. Between premature babiesand other neonates you can have a huge size and weight difference: anything from an extremely premature baby weighing only 500 grams, to a full-term baby that can weigh from 2500 to 4000grams. And each individual patient will change and evolve over time, rapidly and significantly. The chest of a grown man, for instance, will be essentially the same at 20 years, 30 years, 40 years… and theradiation dose will remain the same. This is not at all the case in pediatric imaging! And the smaller the patient, the moresignificant the changes.

With this smaller size, the structures being imaged are also smaller, as are the catheters. Some of the structures have a high contrast and some have very low contrast. And here in the NICU, we are often dealing with a broad range of pathologies that can be visible in the images. It’s a very mixed population.

What’s more, their cells are still developing and dividing. DNA repairafter radiation is difficult and hence these patients are more

susceptible than adults to stochastic effects, such as radiation inducedcancer. Radiation effects are known to appear a long time after theimaging process. The probability of a stochastic effect is proportionate to the dose, but the severity is independent of absorbed dose. And it may occur without a threshold level of dose.

Finally, we must remember that radiation risks are cumulative throughout the patient’s life. And while we are very pleased that our NICU and other pediatric patients have ever-greater life expectancies, there is also thus more time for carcinogenic effects to appear.So we must find ways to lower radiation dose without impacting thequality of the imaging. We have achieved a lot in this area over the 30 years I have been practicing medicine, and I believe there are still dose reductions to be found. In this neonatal environment,

our Agfa HealthCare DX-D 100 has been ideal. We got this mobile wireless DR solution in early 2014. It has proven very convenient, very smooth in operation, with a short turning circle that is ideal for the individual patient rooms in the new department. The detector fits into the incubator, and we can switch off the batteries when not in use, so battery life is longer. And of course the image quality is very good. In all, it fits right in.

In this context, what does image quality mean to you?

In neonatal and pediatric imaging, the term image quality relates to whether an image allows me, in a clinical situation, to answer the clinician’s question. If I can, then the image quality is good or good enough. So image quality isn’t really something tangible but certainly has important consequences. And as we follow the ALARA (As LowAs Reasonably Achievable) principle for dose, image quality can even vary for a specific image, depending on what we need it for. An image that is not the ‘highest’ quality can in a certain case be perfectly suitable for our needs, allowing us to use a lower dose. On the otherhand, there are radiologists who prefer to always have ‘very high quality’ for every image. This attitude does not fit the ALARA principle.

Image quality thus has two aspects: physical quality and clinical imagequality. Physical quality is easier to measure: DQE, MTF, SNR, CNR…But the clinical image quality is more subjective, based on the viewer’spreferences and needs. So, despite the physical quality parameters, the radiologist may say: “No, I don’t like it, the image quality is not what I want or need.” How should we measure that perceived quality? One can make a visual grading analysis, look at statistics, etc., but it’s difficult to test on very young patients. We have tested whether we can

Leuven, Belgium

In small doses Reducing dose to improve the long-term health and safety of premature babies and neonatal patients with Prof. Dr Maria-Helena Smet, Pediatric Radiologist in the Department of Radiology at University Hospitals Leuven (UZ Leuven) and Associate Professor at the Faculty of Medicine, University of Leuven (KU Leuven), Belgium

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Ultimately, quality communication, images and technology will deliver the balance of image quality versus controlled

costs that healthcare demands in the 21st century.

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use the physical quality parameters to predict the clinical perception of image quality. In other words, is there a definable, measurable relationship between them? We found that in the present case, the physical measurements largely predicted the perceived clinical image quality. There is an additional complication with digital imaging because the clinician is aware when dose is too low, but not when dose is too high. Low dose results in image noise but high dose just gives you very nice images, which can lead to something called ‘dose creep’ – slowly increasing dose to have ever ‘better’ images, when in fact images acquired at a lower dose would be sufficient to perform the clinical task. We need to eliminate this. Of course, you can’t push dose reduction too far either. Sometimes it is a question of trial and error.

What tools help you to control and reduce dose?

First of all, we try to take only images that are necessary. For example, we might do an en face spine image but not a profile image, which increases lumbar dose, because we often have enough information from the first image. Post processing is very important.I worked with Agfa HealthCare to adaptthe second-generation MUSICA imageprocessing software for neonatal use,and now I am working with them on thenext generation, MUSICA 3. As I said,with these very small children you canhave small structures with high or lowcontrast. MUSICA offers a proper balancebetween the contrasts, with a betterpreservation of low contrast details nextto high contrast structures. You also needa very stable image processing to ensurestandardized images.

Collimation is key, too. Consideran adult chest versus an infant chest.If the technician increases the field by1 cm on top and bottom, this makeslittle difference for the adult. But for theinfant, the proportional increase is huge!This can account for as much as 70% ofthe radiation dose.

We have to keep track of the doseeach patient has received. For our fixedimaging modalities, we have integratedsoftware that automatically records thetechnician, the dose, the parameters andthe patient. So that information becomes part of the patient’s file. For our DX-D 100,we do the calculations ourselves, but wewill add the software soon.

How are you carrying outthe modality testing?

We have been testing three Agfa HealthCare detector systems: a CR system using powder phosphor, a CR needlebased phosphor system and a DR needlebased phosphor system. Our goal is to find the optimal parameter settings – the right mAs, the right kV, the right filtration – to allow us to use the lowest acceptable dose for diagnosis.

The testing is quite complex, and we have already acquired a total of 66 phantom images. These images were scored with image quality criteria during three sessions, with every session taking about an hour. As a next step, we performed a comparative scoring test. I work on this in between my clinical responsibilities, and I see it as a necessary and logical part of my job. This makes my job very busy, yet rewarding interms of scientific insights and qualityimprovement.

We do have some preliminary results. For example, our results indicate that we may be able to reduce dose with the fine needle phosphor detector compared to the general powder phosphor detector, while still generating acceptable image quality. But we still have a lot of testing to do. For example, we need to subdivide the effect of filtration on image quality.

What’s key here is that, like in so much of patient care today, a multi-disciplinary approach will get the best results. To findways to reduce dose, we can’t work inisolation, nor can manufacturers. So ourteam includes radiologists, clinicians, technicians, engineers, physicists, themanufacturer of the system – evenstatisticians! We need them all, and wekeep in regular contact – that’s the bestframework for this type of testing.

While the awareness of the importanceof dose reduction has increased in thepast years, it has always been an issue.In fact, it was one of the reasons I wasattracted to the specialty of pediatricradiology 30 years ago. And we havemade a lot of progress, thanks to betterparameter settings, digital detectors,better training… Here at UZ Leuven,we already use a quite low dose. The highimage quality we get from the needlebasedCR and DR indicates that there isstill further room to reduce dose. In othertypes of imaging, we see for example thatthe speed of CT is increasing, allowingless sedation or anesthesia, and greaterthroughput. I would also like to seegreater availability and increased speed inMRIs – with small children, speed is key!

We have to always remember – thesmallest patients are also the mostsensitive. We must find the balancebetween quality and dose.

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scanning speed and tissue-organ differentiation. Our requirements also included enhanced imaging quality and system reliability,” Mr. Wiśniewski explains.

A DX-S CR system with needle imaging plates (NIP) replaced the CR 75-X CR system, while a DX-G CR system with NIP and a DX-D 300 DR system replaced the CR 30-X systems. The DX-S is a high-throughput, decentralized digitizer with state-of-the-art image quality; the DX-G next-generation system unites excellent image quality with a drop-and-go buffer-based workflow and enables a potential reduction in patient dose; and the DX-D 300 DR room offers top-of-the-line technology, a single detector and a fully-motorized positioner, yet requires limited space. The major benefit of DR is that it is even faster than CR. If necessary, retakes can be performed immediately; there is no need to replace the cassette.

The clinic also upgraded the gold-standard second-generation MUSICA image processing software to the next-generation MUSICA3. Fully automatic and exam-independent, MUSICA provides consistently high image quality across CR and DR solutions. The next-generation MUSICA3 includes new technology improvements such as no window level adjustment requirement, high level of details in the mediastinum and true representation of implants with clear bone interfaces, allowing confident and comfortable reading. “We decided to upgrade our software systems to improve diagnostic capabilities. The MUSICA3 software is exceptional in recognizing soft lung tissue, while we still prefer MUSICA2 for viewing bone tissue,” says Mr. Wiśniewski.

A smooth introduction of advanced DR room

According to Mr. Wiśniewski, the introduction of the new direct radiography technology took place without difficulty at the Cooperative of Radiology Specialists. “Implementation was carried out fairly smoothly. It is quite easy to get acquainted with the system’s operation, as well as to its everyday use.”

The only major hiccup came in implementing the new MUSICA software, due to a fault in the dominant operating system at the time. This caused problems when opening the image CDs given to patients. “Agfa HealthCare continued to provide us support, for both hardware and software, throughout this process, and most issues have been resolved,” Mr. Wiśniewski comments.

The benefits of next-generation digital radiography

Upgrading to advanced digital radiography solutions proved a significant change for the clinic, and offered some specific benefits. “The new systems improve comfort and quality of work,” describes Mr. Wiśniewski. “Importantly, we also see improved differentiation of tissue-organ systems – between the chest, ribs and lungs, the joints and bones, tendons and muscles.”

In addition, digital radiography has increased the clinic’s overall efficiency and workflow speed, in part due to the simplified image storage and archiving system. “It is obvious – faster imaging, with no chemicals and associated costs, means a faster workflow, plus greater efficiency, easier quality control and enhanced image analysis.”

The potential patient radiation dose reduction is another important factor, and a great benefit for patients. “Using Cesium Bromide needle-based imaging plates with our CR solutions, and Cesium Iodide detectors with our DX-D 300 equipment, along with MUSICA image processing in the NX system, helps us reduce radiation dose for the patient without impacting the quality of the images,” Mr. Wiśniewski explains. Greater clarity also means fewer rejected images and thus fewer retakes, again resulting in smaller doses of radiation for patients.

He also praises Agfa HealthCare’s excellent suppot for both technical and user issues.

The Spółdzielnia Pracy Specjalistów Rentgenologów im. prof Witolda Zawadowskiego w Warszawie (Witold Zawadowski Cooperative of Radiology Specialists in Warsaw) is the oldest diagnostic cooperative in Warsaw. Over its 50+ year history, it has undergone many ‘facelifts’ to stay up-to-date and to continue to provide top radiology services to its community. In fact, for many years the clinic has been ranked among the top three medical facilities in Warsaw.

Its medical team consists of 190 staff, including 17 professors, seven associate professors and 75 doctors of medical science. All in all, the cooperative performs about 37,800 radiology exams annually.

Over the years, the Cooperative has relied on Agfa HealthCare’s radiography solutions and software. Implementing several generations of solutions – from the CR 30-X to the DX-D 300 –, it has moved not only from analog to digital, but also from computed radiography (CR) to direct digital radiography (DR).

Jacek Wiśniewski, a member of the Board and radiological protection inspector of the Cooperative, explains how Agfa HealthCare’s solutions have supported the Cooperative in its continuous journey to “modernization”. The shift from analog to digital has been the most fundamental change the cooperative has undergone in recent years, and included streamlining image processing and archiving, says Mr. Wiśniewski.

Specialized services to meet patient needs

The Cooperative of Radiology Specialists in Warsaw began in 1956 as a purely diagnostic clinic that over time expanded its range of services to adapt to the needs of patients. In the 1990s, the clinic became widely known for its specialist consultations and medical advice, as well as care for minor procedures. It expanded to two locations then added a third in 2001, in a modern facility in the south of the city.

“Services include the full range of diagnostic X-rays, analysis and ultrasounds,” explains Jacek Wiśniewski. “We specialize in general radiology, mammography with tomosynthesis, tomography, dental radiology and cone beam computed tomography (CBCT).”

In 2006, the cooperative celebrated its 50th anniversary. While this was a landmark in its history, it was also an indicator that the Cooperative needed to modernize to remain a top-ranked facility. So in 2007, the Cooperative acquired several CR 30-X systems, followed the next year by a CR 75-X, enabling time savings and easy archiving.

High-quality images in seconds and state-of-the-art image processing

A few years later, in 2012, the Cooperative took another big step forward. When deciding to replace its older systems, there were several factors the Board took into consideration. “We wanted improved

Warsaw’s oldest radiology cooperative goes digital Cooperative of Radiology Specialists gets thoroughly modern with Agfa HealthCare’s newest line of digital radiography solutions and software.

Using Cesium Bromide needle-based imaging plates with our CR solutions, and Cesium Iodide detectors with our DX-D 300 equipment, along with MUSICA image processing in the NX system, helps us reduce radiation dose for the patient without impacting the quality of the images. Jacek Wiśniewski, Member of the Board and Radiological Protection Inspector

Warsaw, Poland

DX-D 300 DR room• Cesium Iodide DR detector technology offers potential for significant patient dose reduction

• Universal, flexible and affordable modality combines a single detector and a fully motorized positioner

• DICOM connectivity to PACS, HIS/RIS and imagers

• Floor mounting and compact size for an ideal fit

• A quick and easy way to go Direct Digital

MUSICA3 image processing software• Excellent image quality, maximum ease of use and optimum output of images every time, regardless of collimation, body part or patient position

• Better viewing of difficult areas:

• Balanced presentation of both soft tissue and overlapping bone structures

• Visualization of subtle details in the abdomen

• True representation of implants with clear bone interfaces

• High level of detail in the mediastinum

• Sharp trabecular and cortical bone

ThERE 3534 ThERE

An archiving lifeline for CHEmile Durkheim, in Epinal, France HYDMEDIA offers lifeline to hospital ‘drowning in paper’, with a robust digital archive that centralizes electronic information storage, saving time, space and resources.

Like most hospitals today, the Centre Hospitalier Emile Durkheim in Epinal, France faces a growing challenge: how to manage an ever-increasing volume of documents – both digital and paper. As Dr Gérard Mougenot, of the Medical Information Department (DIM), explains: “This volume isn’t multiplying, it’s expanding exponentially. The paper uses a lot of resources, in time, money and space. The digital information needs to be centralized, and easy to access.” It’s a challenge that CH Emile Durkheim is taking head-on. Having implemented ORBIS* as its clinical information system (CIS) in 2010, the hospital is now adding the HYDMEDIA** enterprise content management solution to help achieve the goal of an efficient and secure solution that will help it to eliminate paper, while integrating with the existing electronic document-producing systems.

“More and more, data and information are digital from the source, from the beginning,” continues Dr Mougenot. “So it seems natural to move in that direction. But we have a long way to go. At CH Emile Durkheim, we currently produce around 300 linear meters of paper documents each year. Each meter equals about 3,500 pieces of paper. So our annual production is somewhere around a million pieces of paper a year! All that has to be managed, handled and stored.”

The hospital also has multiple systems that produce digital documentation, including ORBIS and the HEXAGONE* hospital information system (HIS) installed in 1998, as well as many medical software programs. In addition, the hospital broke ground in June 2014 for the construction of its ‘new hospital’, which will replace its principle site on Avenue Schuman. “At the new hospital, all information production will be computerized, and it will be as paper-free as possible,” Dr Mougenot explains. HYDMEDIA will be part of achieving that.

Epinal, France

Immediate, easy access to archived files

The Centre Hospitalier Intercommunal Emile Durkheim is a departmental hospital serving a region with a population of around 265,000. Born out of the merging of the Centre Hospitalier Jean Monnet d’Epinal and the Centre Hospitalier Intercommunal of Golbey, it now has three sites. The main site in Epinal counts around310 beds for hospitalized patients, while the site in Golbey focuses on longer-term and follow-up care, and the Maison de Santé Saint Jean offers external consultations in a broad range of services.

It was the Maison de Santé Saint Jean that was selected by the hospital to be the site of the internal ‘pilot’ for implementing HYDMEDIA. “We chose the allergology department at Saint Jean because it is a rather specialized service, meaning that its patient files generally aren’t needed by most other departments. So a pilot involving those files wouldn’t impact the rest of the hospital,” says Dr Mougenot. The hospital decided to digitize the files of all new and returning patients to the allergology department. “There isn’t much point to digitizing the files of patients who don’t return. We have now digitized the files of all patients who have been to the department in the last year. We already are seeing a big difference for the secretarial staff, who were drowning in papers and paper files before!”

For other users, including doctors and nurses, the differences are also striking. “For all these patients, the nurses no longer have to track down the paper files; instead, they go directly to HYDMEDIA or ORBIS. And the doctors can immediately access the patient’s old files, too, for example during a consultation, which impacts how they deliver patient care.

“With the pilot so well implemented, the hospital has begun the process of launching HYDMEDIA in other services. Dermatology, which like allergology is a rather small service, was next, and will be followed by the blood transfusion files. “Blood transfusion archives are maintained separately, as they are liable to different regulations: for example, they need to be kept for 30 years instead of 10,” comments Dr Mougenot.

“Being able to access them immediately when a patient returns for a transfusion is critical. This is a step that will impact the entire hospital, and require all the doctors and nurses to learn to use HYDMEDIA: this will be completed by the end of the year.” Currently, around 30 people – doctors, nurses and secretarial staff – are working with HYDMEDIA. When it has been fully implemented in the hospital, around 1,000 staff will use it.

Integration with ORBIS: see everything with just a click

An important advantage of the HYDMEDIA solution for CH Emile Durkheim is its close and easy integration with other Agfa HealthCare solutions, especially ORBIS. “We’ve been working with Agfa HealthCare for a long time; we are a ‘good’ customer,” smiles Dr Mougenot. “Their solutions are helping us to achieve our goal of maximizing our digitization. Beyond ORBIS, all of the medical software programs will directly send medical information to HYDMEDIA. This has already been implemented for the emergency module and the blood transfusion module; in the short-term, we will be adding reports from ophthalmology and radiotherapy, for example.”

“ORBIS and HYDMEDIA are complementary,” he continues. “From

ORBIS, users can see everything in a click: including images in the picture archiving and communication system (PACS) and archived documents in HYDMEDIA.”

“We have to be able to work like that, to see everything in one domain and one way. With ORBIS and HYDMEDIA, a doctor in service B who needs to see what happened to a patient 3 months ago in service A will not only find the information immediately, but will see it presented in the same, familiar way his own service uses. So communication and transparency are enhanced.”

Dr Mougenot concludes: “Introducing information systems is of course quite complicated, but you very quickly appreciate the advantages! Integrating the HYDMEDIA enterprise content management solution with our ORBIS will not only help us solve the issue of space and resources for storing documentation, but it will save time and effort for everyone – doctors, nurses and secretarial staff – and make their jobs easier. And that means they can give more time to their core responsibility: patient care.”

The nurses no longer have to track down the paper files; instead, they go directly to HYDMEDIA. And the doctors can immediately access the patient’s old files, which will have a big impact on how they deliver patient care. Dr GERARD MOUGENOT, Medical Information Department

HYDMEDIA enterprise content management solution• Facilitates information sharing through integration with ORBIS and the HIS

• Negates the need for paper and film-based documentation

• Reduces physical archiving space

• Speeds information retrieval times

• Reduces costs and increases productivity

• Improves disaster recovery capabilities

ORBIS HIS/CIS system• Provides access to shared patient record and administrative data anywhere, anytime

• Allows better patient management and security

• Improves collaboration between healthcare professionals

• Reduces the risk of administrative errors, and increases administrative productivity

* HEXAGONE and ORBIS are not available in Canada and the U.S.** HYDMEDIA is not available in the U.S.

ThERE 3736 ThERE

In deciding to upgrade its solutions, Thomas Health System was clear that it was not just its own radiologists that it needed to service, but the referring physicians who also have access to the hospital’s data, as Teresa Simmons, System Director of Medical Imaging, explains. “At least 60% of our imaging is outpatient based. Part of the managed services agreement was the purchase of the Agfa HealthCare XERO® Viewer which is the zero footprint viewer capable of working with IMPAX. It provides us with a scaled down version of the client to offer our referring physicians.”

Bill adds, “Before, a lot of physicians who have gone out and purchased Apple iPAD® mobile digital devices or similar solutions other than Microsoft products found that their new purchase was not compatible with what they were trying to access. Now, with XERO Viewer that has all changed, and the new version of IMPAX will also run on Microsoft Windows® 7 and 8 operating systems.” That increased compatibility will become increasing important if, as Bill believes, “our outpatient volume will continue to grow because everyone is trying to limit the hospitalization of patients to control their costs.”

Cohesive teamwork essential to successful upgrade

And the test of a successful upgrade? Well that, Teresa says, is not simply specifying the solution but ensuring that when it goes live it is as seamless as possible. “With a busy emergency room, doctors’ offices and our own radiology team needing consistent access to images, we really couldn’t afford to have the system down. As a backup, we ensured that while the upgrade was taking place, they could access images up to two months old via a temporary system.”

Says Bill, “For the RIS, we upgraded our tests system and spent a large amount of time testing and validating the function of the system. When we did the upgrade, we did it in the middle of the night, and Agfa HealthCare brought in resources both for that night and for the next couple of days to ensure any issues were dealt with quickly. For the PACS upgrade, we brought the servers up after Agfa HealthCare had done a lot of the configuration remotely and again the team was onsite both during and after go live.”

In situations such as this, Bill says, having a good working relationship is a key element to success. “I have seen plenty of situations where installs or upgrades have spiralled out of control because of lack of understanding by one party of what the other party is seeking to achieve; or a lack of understanding about what is possible. Having Agfa HealthCare involved from the beginning gave us the confidence that everyone knew what was expected. We also knew from past experience that should anything require addressing, that Agfa HealthCare’s support teams are responsive and resolve issues quickly.”

“We are in a very competitive market. To remain relevant, we must maintain the most advanced technology and deliver the highest quality service. Like most other hospitals, finances remain a challenge; more patients are being seen with less reimbursement,” says Brian Ulery, VP of Ancillary Services.

Every investment delivers a direct patient benefit

“Healthcare is a very expensive industry. So much so that anything we do now has to be put under the microscope. Every investment has to have a direct benefit on patient care. We are continually driving for more efficiency and cost savings, so making the right choice in terms of solutions and their providers has never been more important.”

When Thomas Memorial and St. Francis joined forces in 2007 to create Thomas Health System, the priority was to develop a PACS and RIS solution that enables the two sites to share data from within medical imaging. “We started small,” explains Bill Lucas, Senior PACS Administrator. “Initially, our driving desire was to get a PACS system up and running. We also needed to install a RIS system at Thomas Memorial as we didn’t have one at the time. St. Francis was brought up on PACS in 2007. Over the following years we have extended our portfolio to include DX-S® CR solutions and IMPAX® for Mammo, as well as more recently IMPAX CV for our cardiology unit, which will complete its upgrade in the first quarter of 2015. We have no immediate plans to replace the DX-S CR solutions as the image quality is outstanding because of the cesium detectors and MUSICA® image processing and they are well-thought of by the radiology team.”

Agfa HealthCare advice provided inside knowledge of future solutions

Bill continues, “However, as with any solution, there does come a time when hardware becomes outdated and solutions need to be upgraded, and that is a process we have been through extensively over the past few months.

We knew that our hardware was getting to the end of its life and, while the Agfa HealthCare solution – IMPAX 6.3 – was very stable, we recognized that the later version, IMPAX 6.5.5, offered additional functionality, so we started to investigate the upgrade. We had long and detailed discussions with Agfa HealthCare about where we wanted to go as a hospital and they were able to provide guidance as to what our options were – not simply now, but also with regard to technology that was going to be coming through in the future.

“They came up with a road map that allowed us to bring up the elements we wanted in the time frame we needed but to do it in an economical way that fit the hospital's overall plan. It was a cooperative effort but Agfa HealthCare had a tremendous amount of input into it.

Four year Managed Services Agreement manages costs and mitigates the risk of technology obsolescence “Ultimately, we chose to make all the upgrades through a four year Managed Services Agreement. It enables us to know our costs over the next four years and as part of the agreement, it also means that Agfa HealthCare guarantees to leave us with the most up-to-date versions of their applications at end of the life of the agreement.”

Planning to deliver future success Community hospital Thomas Health System’s upgrade of its PACS solutions and a four year Managed Services Agreement is ensuring its competitive position amongst peer hospitals in Charleston, West Virginia.

We are in a very competitive market. To remain relevant, we must maintain the most advanced technology and deliver the highest

quality service. Brian Ulery,

VP of Ancillary Services

Charleston, West Virginia, USA

Having Agfa HealthCare involved from

the beginning gave us the confidence that

everyone knew what was expected.

Bill Lucas,Senior PACS Administrator

As to the benefits so far, Bill says that, “having PACS moved to a virtual platform allows us to do hardware maintenance without bringing the system down and we can move the virtual machines around from one solution to the other. The additional functionality that comes with the 6.5 client means that the radiologists are very happy and the RIS system is delivering faster running on new hardware so workflow has benefitted.”

Know your objective and stick to your plan

And the advice Teresa would give to other hospitals considering upgrading? “It’s very important to know what you want and what the benefits are that you are trying to deliver. Having a clear plan for the next four years, understanding all of the projects rather than simply focusing on what you need right now means that you won’t have to keep amending the managed services agreement. You will enjoy detailed knowledge of your costs and always having the most current version of your applications means that you can be confident of remaining at the forefront of your competitive market.”

Teresa simmons, system director of Medical Imaging

Bill Lucas,senior pACs Administrator

ThERE 3938 ThERE ThERE 39

Investment in modalities followed by investment in the IT infrastructure RIS/PACS helps Porz Hospital position itself on Cologne’s hospital market

However, it was not a requirement that a monolithic HIS/RIS/PACS solution should emerge at the end. “The decision in favor of IMPAX and ORBIS* RIS from Agfa HealthCare was made independently of the established ORBIS HIS (hospital information system) that is used in the hospital,” Claus explains. “We are convinced that the solutions installed in April 2014 provide the ideal support for our workflows.”

Enhanced hospital performance

“The new systems, especially PACS, really do represent a huge step forward for us,” says Dr Bansmann, also satisfied with the choice. He illustrates the hospital’s performance with an example: “This morning, after a long weekend, there were 500 X-ray examinations waiting to be assessed. Things that used to take days are now completed in a matter of hours.” The benefits of the new RIS/PACS are particularly noticeable during weekends and shifts in emergency: “At present an MTRA (medical technical radiology assistant) is responsible for the pathways in the institute. Before we had the digitized system, she had the job of receiving the requests and passing them on manually, sticking labels on the X-ray sleeves, loading the films, entering patient data once again at the modality, and then carrying out the examination.

Today it is much simpler. The request arrives at the modality electronically via the RIS, with all the necessary parameters. The patient can go as soon as the pictures have been taken. For us this really amounts to a revolution.”

Porz Hospital clocks up around 45,000 X-ray images every year, along with 6,000 CT scans, 6,000 MRI scans, and 15,000 ultrasound examinations. This is pretty impressive for a hospital with 443 beds. Nonetheless, the managing director and the chief radiologist would like to increase the proportion of outpatient examinations.“However, to do this we will have to position ourselves as a powerful, competent health service provider,” says Sigurd Claus. Radiology stands out because it involves complex specialized examinations requiring high levels of investment. “We made these investments during recent years, but at the same time we neglected the infrastructure,” notes Dr Bansmann self-critically. “We have to catch up here so that we can match the other high-performing departments in the hospital.”

External communication via PACS

The installation of RIS/PACS proves its value in the hospital on a daily basis, for instance during the interdisciplinary case discussions. “The figure has increased continually over recent years, just as their significance in everyday clinical work has done. We have 15 X-ray discussions per week. Before digitization we had to spend more than 40 hours on preparing and holding them, but today we only need about half that because the preparation time alone has definitely come down by a good ten hours,” Dr Bansmann calculates.But the chief radiologist is not only concerned with providing

services within the hospital. His institute is also a provider of consulting services to other facilities. “PACS makes it much easier to manage prior images or those from other organizations; the large number of CDs and DVDs we had before used to massively slow down our processes.”

In the future all communication with the referring doctors and partner hospitals will be via IMPAX/web.Access. “This means that we can dispatch DICOM studies quickly with SSL encryption via a secure connection, and the doctor can view them in any browser – without having to install anything or spend a lot of time on it. They will only need an individually created access code, and will authenticate themselves via a security prompt using the patient’s date of birth,” is how Dr Bansmann explains the procedure. “That is simple and saves a huge amount of time.”

PACS supports training for specialists

But Porz Hospital is carving out a new position in more than patient care – again with the aid of IMPAX. “We are founding an academy for cardioradiology to offer training for specialists. This will not be possible without an electronic educational archive, in our case the Teaching File Archive. It holds records of examinations that have been anonymized and indexed with keywords, and we can link them with the diagnoses and make them available for visiting physicians to study. That is a fantastic possibility for us,” the chief radiologist says with delight.

But even with the large number of projects, he does not lose sight of his original task, that is, managing the Institute for Diagnostic and Interventional Radiology. This is no easy job in times of scarcer resources, shorter hospital stays and a generally difficult financial framework. “I always have to work out our performance on the basis of reliable figures. With RIS I can now compile a range of up-to-date statistics. I look at separate monthly performance figures for each modality, referring physician and so on, and if necessary I can take remedial action,” is Dr Bansmann’s description of the advantages of the information system.

Oriented to solutions and success

What ultimately appears so simple – the successful introduction of an integrated RIS/PACS – demanded a vast amount of commitment and discipline from all those involved. “This kind of project is not something you can realize just as a sideline,” Dieter Bock points out. “Here I need a strong team with the necessary freedoms, and a flexible industry partner. Despite nine change requests in the course of the project, Agfa HealthCare has consistently kept to the deadlines and always worked in a way that was oriented to solutions. You could feel that the company was doing everything it could to bring this project also to a successful conclusion.”

Cologne, Germany

38 ThERE

The city of Cologne is blessed with a large number of hospitals, and there are many more hospitals in nearby places such as Aachen, Düsseldorf and Bonn. This creates some challenges for the institutions. “And they do not get any smaller if you are located on the 'wrong bank' in the city of Cologne,” notes Sigurd Claus, Managing Director of Porz Hospital, referring to the eastern side of the River Rhine. His general hospital is therefore concentrating on certain specific fields. “Over recent years we have been quite successful at focusing on our cardiology and rheumatology,” Claus says. In Cologne the treatment available for rheumatology patients is somewhat sparse – a situation that is no different in the rest of Germany. To position itself appropriately in this field, the hospital needs a proficient radiology department that serves as a provider to the other departments. “We have built this up over time,” explains Chief Radiologist Dr Paul Martin Bansmann.

One key area is non-invasive cardiac diagnostics. The institute has the most advanced modalities, such as currently the fastest computed tomography (CT) scanner and two powerful magnetic resonance imaging (MRI) scanners. “So you can see that the investments have flowed into imaging. But as a result, although we have made quantum leaps in technology, we have loaded ourselves up with a huge volume of data that we have to archive properly according to the law,” says Dr Bansmann, describing the consequences of this development. “In the end this could no longer be done on CDs or DVDs.” Now help is at hand from a digital information system for radiology.

New generation, new technology

Managing Director Claus realized the right time had come when a new senior physician arrived, ringing in a new generation to head the institute. “Dr Bansmann and I put our heads together and considered what form future progress should take to make sure that the infrastructure would ultimately be suitable for the equipment,” Claus says. The chief radiologist adds, “Right from the outset it was clear we were looking for a system that was going to be used for more than just radiology. Our goal was to improve processes throughout the hospital.”To this end, Porz Hospital brought in Delphimed as an experienced advisor. The firm’s engineers Wolfgang von Schretter and Dieter Bock started working with the hospital at the end of 2012 to analyze the processes and workflows and identify the demands that clinicians place on radiology. This culminated in a detailed plan for digitizing the institute with a radiology information system (RIS) and a digital picture archiving and communication system (PACS).

“Both systems should come from the same provider, to enable us to take full advantage of an integrated solution,” says Bock.

* ORBIS is not available in the US and Canada

Things that used to take days are now completed in a matter of hours.

Dr Paul Martin Bansmann,Chief Radiologist

We are convinced that the solutions installed provide the ideal

support for our workflows.

Sigurd Claus, Porz Hospital

Sigurd Claus, Porz Hospital

www.agfahealthcare.com

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