- The document discusses the imaging solutions at Máxima Medisch Centrum, including two PACS systems (PACS One for radiology and PACS Two for other specialties), and efforts to standardize and integrate imaging across the hospital. - Over 40,000 procedures have been performed using PACS Two to store and distribute images from modalities in various specialties like cardiology, endoscopy, and photography. - However, having two separate PACS vendors has created issues, and fully integrating images and reporting within the hospital systems remains a work in progress. The goals are to record more specialized imaging types like hemodynamic waves, have one unified PACS, and greater regional and standards-based inter

1. Martijn Schasfoort
business manager Medical and Information Technology
22 april 2009
m.schasfoort@mmc.nl

2.  Máxima Medisch Centrum
 Vision
 Methods
 Solution
 Results and wishes

4. Princess Máxima Royal family
Veldhoven Eindhoven
58.000 m2 45.000 m2
Profile: acute / specialized Profile: short stay / planned / elective

5. ● Medical specialists: 230
● Medical specialism’s: 28 (common)
● Employees: about 3,500
● Beds: 836
● Admissions: about 23,600
● Outpatients: about 416,000
● Day care admissions: about 20,000
● Visits to the emergency department: about 44,500
● foundation Top-Clinical hospitals Holland
(20 of 100 hospitals, no university hospitals)
● Workstations (fat client): 2000 numbers of 2007
● Workstations (thin client) : 400 (Citrix, Softgrid, Powerfuse)
● Mobile workstations : 120 (COW’s, laptops)
● Servers : 300
● Printers : 500 (incl. receipt printers) HIS : Chipsoft EZIS v.4.10
● IP telephones : 800 (Nortel) LIS : Philips Labosys
● Wireless IP telephones : 800 (Nortel) RIS : Agfa Quadrat
● Wireless Access Points : 650 (Cisco) MIS: Centrasys
● Wired network active ports : about 10.000 (Cisco)

6. Department Medical and Information Technology
is an integration of departments IT and Medical
Technology
clinical and IT technicians clinical and IT engineers 2 x clinical physicist
1 x IT architect
2 x safety and policy
continuity implementation idea

8. HIS

Cardiology
Obstetrics
OR
EHR Ophthalmology
Urology
Plastic surgery
Orthopedics …….
Dermatology
Dental X-Ray

9. EHR
•Formal data
•Contains no images
•(can contain text)
Image Text
PDMS-DS
PACS
•Informal data
Images available via links Laboratory
•No images
with EHR or PDMS/DS
Radiology Outside the Radiology

10. Standardized central storage and distribution
of all medical images using the network
infrastructure of the hospital and
standard (central / hospital) IT components
- standard hardware (Intel-based / HP)
- standard operating system (Windows XP, Server)
- standard software (Microsoft Office)
- standard applications (PACS, PDMS, HIS)
- standard storage (NAS)
- hospital network

11.  One PACS hospital wide
 Use of international accepted communication standards
(HL7, DICOM)
 All medical images in DICOM
◦ ECG, endoscopy, ultrasound, radiology, photography
 Patient demographics available at the source
 All images available for all physicians (requirements)
 Integration in hospital applications
 Reporting in HIS

13.  Interest in hospital wide image management started in 1999
 Solution for endoscopy (image/video) not availible on Dutch market
 Search for open and transparant software
 PACS implementation Radiology department in 2002
 Radiology PACS vendor was not interested in endoscopy
 First contact in 2002 with Visus TT GmbH

14.  Started 2003 testing with JiveX in Operation Rooms (orthopedics)
◦ Testing central software and DICOM-izer software
◦ Changes to software
 Implementation JiveX hospital started 2004
 Used “bottom-up” approach
◦ At first no integration with EHR and HIS, because EHR and HIS functionality was not
available
◦ In 2008 integration started in HIS and EHR
 Implementation by internal project team

15. PACS Three Outside hospital
PACS Two Outside Radiology
PACS One
Radiology

16. 2 MRI (1 and 1,5T Philips – 3T in 2010)
1 mobile MRI (1,5T Philips)
1 CT (Philips)
2 multislice CT (Philips MX8000)
2 digital mammography (Hologic Selenia)
6 Ultrasound (ATL, Aloka, Toshiba)
2 angio (Philips)
7 Bucky (Philips, 4 new Siemens)
1 digital thorax (Hologic)
4 DSI (Philips)
4 mobile DSI (Ziehm)
3 mobile CR (Shimadzu)
- Storage in PACS from Agfa
- Use of department planning system (RIS)
- Total procedures : 200.000 per year
- Total capacity (cmpr.) : 2,3 TB per year
- EHR integration (reports RIS and PACS-WEB)

17. 9 Cardiac and vascular ultrasound (Philips, ATL)
15 Obstetrics and gynecology ultrasound (Kretz, ATL, Aloka, Toshiba)
1 Cardiac digital angio (Philips)
1 Cardiac MRI (Philips i.c.w. Radiology)
1 Digital ECG’s (Mortara) (this year increase to 4)
10 endoscopic solutions (gastro, lung, urology)
16 endoscopic solutions (OR)
7 digital photography (derma, ophthalmology, plastic surgery, dialysis)
1 dental digital x-ray (Oldelft)

19. PACS URL / HL7
Two
HL7
non Radiology HIS / EHR
Radiology
HL7
RIS
URL / HL7
PACS
One

20. PACS One
- Keep solution for Radiology
PACS Two
- Storage in PACS from Visus
- Use of HL7-query and worklist-generator
Use of HIS planning system planned 2009
- Total procedures : 25.000 per year
- Total capacity : 2 TB per year
- EHR integration (URL-link images)
- All image flavors in DICOM
- Video’s in DICOM

21. Workflow DICOM modalities
PACS Two
• Query or worklist available on modality
• Acquisition of images on the modality
• Selection of relevant images on the modality
• Images are sent to the Server
• Accession number is generated by the Server
• Configured images flavors are generated
• Notification to the HIS
• Review images with high, medium or low end viewer,
reporting in the HIS/EHR

22. Mortara ELI 350 ECG recorder (rest ECG)
Mortara M-gate (DICOM gateway)
possibility of integration in JiveX Review Client
DICOM ECG in JiveX Review Client (#1680)

23. Canon CF 60 UV
OIS Winstation 1400
Dell workstation
ophthalmology

24. Workflow non-DICOM modalities
PACS Two
• Query or worklist available on the DICOM-izer application
• Acquisition of images on the DICOM-izer application
• Selection of relevant images on the DICOM-izer application
• Images are sent to the Server
• Images are deleted from the DICOM-izer application
• Accession number is generated by the Server
• Configured images flavors are generated
• Notification to the HIS
• Review images with high, medium or
low end viewer, reporting in the HIS/EHR

25. Gastroenterology
Olympus CV160
VISUS JiveX AMG/AV 1165
Sumicom (industrial PC)
IDS Falcon PCI framegrabber

26. Lungdisease
Olympus CV240
VISUS JiveX AMG/AV 1165
Sumicom (industrial PC)
IDS Falcon PCI framegrabber

27. Gastroenterology
Pentax EPK-i (gastro, colon)
NDS Radiance SC-SX19-A1511
VISUS JiveX AMG/AV 1189
Sumicom (industrial PC)
IDS Falcon PCI framegrabber
 HD: IDS Eagle framegrabber

28. Cardiology
Philips / ATL HDI 5000
VISUS JiveX AMG/AV 1165
HP DC 7100 SFF
IDS Falcon PCI framegrabber

29. Gynaecology
WISAP endoscopic tower
VISUS JiveX AMG/AV 1165
Onyx 175 Medical Panel PC
IDS Falcon PCI framegrabber

30. Orthopedics
Smith&Nephew 350 3-ccd
VISUS JiveX AMG/AV 1165
Onyx 175 Medical Panel PC
IDS Falcon PCI framegrabber

31. Neonatal Intensive Care
Plastic Surgery
Dermatology
Dialysis
Canon 350D / 400D digital camera
Canon EFS 60mm macro-lens
Sigma EM-140DG macro-flash
VISUS JiveX AMG/AV 1189
Installed on standard hospital workstation

32. Workflow MR/CR
• Patient planned in radiology workflow
• Procedure finished
• Transfer from “PACS One” to “PACS Two”
• Workflow cardiology (one viewer)
• Workflow pediatric physicians (one viewer)
• Review images with high, medium or low end viewer,
reporting in the HIS/EHR

34.  It works…
 All images in DICOM
 Total 40.000 procedures till now
 All images available for physicians
 Integration in EHR (link to images)
 Reporting in HIS/EHR for “PACS Two”
BUT,
 Two PACS vendors
 PACS One is Agfa
 PACS Two is Visus

35.  Functionality versus politics and emotion
 Acceptance of physicians of provided solution
 Introduction too much technology driven
 No expectation management
 Vendor rigidness by integration issues
 No cooperation althought functionality available

36.  Hemodynamic waveforms in DICOM
◦ Lungfunction results, cardiac stress test
 Full integration in HIS and EHR
 One PACS (it is possible)
 Dutch citizens service number
 Comply to IHE compliance
 ……

37.  Hemodynamic waveforms in DICOM
 Recording full OR-procedures
 Full integration in HIS/EHR
 Regional PACS
And….
 One PACS