Toward True Globalization: The Air Force and PACS

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Sharing images across any health care enterprise represents a challenge, but doing so across the Pacific Rim was the dilemma faced in 2003 by the US Air Force. Taking up this challenge were Lt Col Grant Tibbetts, MD, now radiology consultant to the surgeon general, and Tom Lewis, the director of the Air Force PACS Office. “The largest hospital in the area was at Elmendorf Air Force Base in Alaska,” Lewis recalls, “so at the time, we had to fly radiologists from there to Japan or Korea when they were needed. Solo radiologists within the Western Pacific needed support when they went on vacation or were out of pocket for various other reasons. That’s what led us into trying to get a PACS solution that would allow a global enterprise view and sharing of the workload.”

At that time, the Air Force had implemented PACS at numerous sites around the country, some of which were set up to communicate with smaller sites using a hub-and-spoke approach designed to create efficiencies in staffing. In the Pacific, out of nine imaging sites, there were radiologists at four, with strategic realities often leading to staff reduction at smaller sites. During radiologist absences, these were each supported by the only site that had more than one radiologist: Elmendorf Air Force Base.

The Elmendorf PACS was several years old and difficult to support by 2003, Tibbetts says, and its continued operation was viewed as an increasing risk. Meanwhile, other sites in the Pacific were in the queue to get their first PACS. “The Air Force had a few projects on the books, spread out over a few years for budgetary reasons, that would have brought PACS to those sites that didn’t have it,” Tibbetts says. “I needed to get Elmendorf moved forward in priority, and combining the projects was a way to do this. Better, our idea to implement an enterprise-wide PACS across the Pacific not only saved us a lot of money, but also offered us the opportunity to connect our sites in a way that the Department of Defense (DoD) never had before.”

Unique Needs

Ten proposals for new PACS were initially received, but Tibbetts, Lewis, and their team of clinical, IT, PACS, and administrative consultants soon truncated that list. “We quickly whittled down to two capable vendors,” Tibbetts says. “The others simply weren’t ready to meet our security requirements, and were less eager to embark on a challenging project spread across 65 million square miles of water, nine sites, and three countries.”

The first obstacle faced by any vendor to the Air Force is the DoD’s stringent security requirements. FUJIFILM Medical Systems USA, Stamford, Conn, worked with the Air Force to qualify their Synapse PACS platform for the project, becoming the second qualified vendor on the Air Force network. Both vendors continue to be important partners today, Tibbetts says, and several other vendors have approached security testing favorably in recent years.

After security, another requirement of the prospective Pacific PACS was access to relevant prior studies across the enterprise. “We were attracted by the ability to serve these up in a compressed format,” Tibbetts says. “The final two PACS vendors we considered both offered selectable wavelet compression. We knew that might be very beneficial for what we were trying to do in a sometimes bandwidth-constrained environment.” Tibbetts later went on to write supporting policy allowing for and establishing limits on compression use in DoD for primary interpretation.

Tibbetts and Lewis wanted a user interface that was intuitive, and one with which the Air Force’s IT professionals could become quickly familiar—“for better or worse,” Tibbetts says. “Windows is not the be-all, end-all for everyone, but it’s simple and immediately familiar to most, quickly giving you basic functionality with little training. We really liked the fact that the clinicians’ interface was the same, too. At the time, Synapse was one of few products offering this. Today, almost all PACS systems mirror most of the radiologist’s interfaces, providing the same look and feel for their clinician counterparts.”

Finally, the team knew that it needed the ability to build a worklist that could be shared across all nine sites—another uncommon characteristic of PACS platforms at the time. “If I was covering a site other than my own, I could bring it up in a combined worklist, or open up another instance of Synapse, which thicker clients didn’t allow,” Tibbetts says. “This functionality