Academic PACS: It’s Not Elementary, Watson

In the late 1990s, Yale School of Medicine, New haven, Connecticut, implemented its first PACS. James Brink, MD, chair of the department of radiology and professor of diagnostic radiology, recalls how radiologists initially adapted to the brave new digital world: “It took some of the more senior radiologists a while to get used to using a cine display,” he says. “There’s no difference in the way we read anymore, but when we first got PACS, some of our radiologists continued to use a tile display on the workstation so they could read the images the same way they’d been done on film.”

Yale’s radiology department is on its second PACS, having switched to the Synapse platform from FUJIFILM Medical Systems USA in the early 2000s, and the technology plays an important role in both teaching and research for the 50-radiologist institution. Brink explains that ready access to prior studies for comparison is critical in instructing trainees in the rigors of good clinical work. “I always marvel at how much better our access to comparison exams is with PACS than without,” he says.

“Access to prior studies is important for accurate results. It’s good clinical care to take that Sherlock Holmes approach to every case: You have to look for clues, and PACS allows you to find more clues, more quickly.”

-James Brink, MD, chair
Yale School of Medicine

In an academic institution, the ability to identify and catalog teaching cases for trainees is critical. Yale’s PACS includes a flexible DICOM export tool that makes it easier to link to an electronic teaching file, Brink notes, and FUJIFILM is in the process of developing a conferencing tool to assist in radiologist training. Though the department reads about 415,000 exams annually, Brink explains that cases for teaching must fit specific criteria. He says, “They have to show the findings of interest quite clearly. If they’re about anatomy, they need to show that quite clearly; for pathology, same thing. We know from being medical educators the topics and issues that are poorly understood or illustrated and need to be highlighted.”

One of the goals of training residents to use PACS is to teach them how to read a cine display, “showing how one can follow structures longitudinally, as well as in three dimensions,” Brink says. PACS also enables radiologists to proctor their trainees better, overreading resident’s studies to provide feedback, using a process that Brink says “was much more laborious” on film.

Another priority in the academic setting is clinical research, which PACS facilitates by allowing radiologists to make and store specific measurements. “That’s of enormous value, especially when you think about having to do all that with a grease pencil and ruler,” Brink says. “The ability to do and store quantitative image measurements is the biggest benefit of PACS for clinical research.”

Of course, throughout all of this, the pressure is on to remain as clinically productive as possible; this, Brink explains, was the reason that Yale switched to a Web-based PACS platform in the early 2000s. “The biggest feature that really drove that purchase was the Web-based nature of the product—being able to view images from any location and from any source,” he says. “That was quite unique back then, and it remains the number-one benefit of Synapse: You can access it from anywhere in the world with a computer and a secure connection.” The ability to share images rapidly and easily has enabled Yale to preserve a higher degree of subspecialization, Brink says, while integrated critical-results management and voice recognition improve turnaround time.

In the future, Brink hopes for a couple of PACS innovations that would make the practice of academic radiology easier. “Having really robust teaching files built into PACS is really important,” he says, “and the other thing I see on the horizon is automated comparison of studies with clinical modeling, a program that would deform the organs in an image to look today the way they did a year ago and then compute the difference.”

In the meantime, however, Brink is pleased to see the new, more computer-savvy generation of radiologists picking up the use of PACS in no time. “This generation of residents is more fluent and more likely to use all the various PACS tools,” he says. “I find myself asking them for advice when I’m struggling.”