15+ Years Healthcare Experience Digital Radiology Expert

Contact Details
Cell Phone: 250-507-4343
Victoria , BC
Canada
moniefeied@gmail.com
or
moniefeied@yahoo.com
15 years healthcare specialist experience and practice
management consulting. Utilizing extensive industry
experience within medical equipments, IT healthcare
(PACS/RIS/CIS & CVIS), pharma, biotech, clinical
research and healthcare to execute and implement
certain process as well as methodology into diverse
operational roles at all organizational levels. Prince2
Certified.

Components and workflow of a Digital Radiology Department
 Understanding the components of a digital radiology department helps us visualize
the way each of the components interact, and how the different people, machines,
and components work together to help us provide quality healthcare. The following
diagrams demonstrate how information and images flow through the different areas
of a hospital. Each hospital may have different tools and programs to perform these
functions, but the way the components interact is essentially the same.
 In the diagrams, the components above the gray line deal with the demographic
information and orders for a patient. The components below the gray line deal with
the images and reports that are associated with a patient. The Electronic Health
Record (EHR) spans the entire length of the diagram to show that throughout a
patient's visit to the hospital, the EHR is continuously being updated with new
information.
 Information gathered in the hospital workflow flows in both directions. For example,
information gathered by the modality is passed to the Picture Archive and
Communication System (PACS), as well as to the Radiology Information System
(RIS).

The Electronic Health Record (EHR) is a record of all medical data about a patient,
in electronic form.
The data in the EHR is composed of images and reports gathered during a patient's treatment.
It also includes up-to-date results, clinical information, and reminders that prevent the
unnecessary duplication of radiological and laboratory exams. In some enterprises, family
doctors can access this information.
The goal of the EHR is to integrate all of
this patient information into one system
, but often the health records can be
found in many different systems in the
hospital, such as the Hospital Information
System, (HIS), Radiology Information

Hospital Information Systems (HIS) may be comprised of an EHR component, a patient
Registration component and an order/scheduling component. The HIS is responsible for
ordering patient examinations among all healthcare organization departments. They typically
send an order to a departmental information system that contains high-level diagnostic
requests. The details of these requests are completed and sometimes changed by the
departmental information system. HIS systems are typically interested in the status of orders
that were placed along with the final results of an order (reports).
Admission, Discharge, and Transfer (ADT):
Admission, Discharge, and Transfer (ADT) systems are responsible
for Patient Administration. ADT systems are generally built into or
are a part of the HIS. ADT information systems are
responsible for maintaining the following data:
• Patient demographics (patient identifier, name, sex, date of
birth, weight, height, etc.)
• Patient visits to the healthcare organization
• Admissions, discharges, or transfers of the patient
• Patient location

The radiology department uses the Radiology Information System (RIS) to:
•Manage patient visits to radiology
•Schedule and track diagnostic procedures
•Store diagnosis and results
•Send billable items to billing systems
The RIS conveys scheduled procedures to modalities via a worklist. This worklist allows the
Technologist to simply select a patient and procedure at the modality. Once the procedure is
completed, all of the patient demographics are automatically included with the resulting
images.

Modalities are responsible for acquiring various types of images that are later reviewed by
Radiologists for diagnostic purposes. Most modern acquisition modalities are digital.
They query departmental information systems for scheduled procedures to be completed.
Captured images are sent digitally to PACs systems. Types of modalities include X-Ray,
Computed Tomography (CT), Ultrasound, and MRI Scanners.
Picture Archive and Communication System (PACS)
The PACS stores, transmits, displays, and prints medical images. Radiologists, cardiologists
and clinicians use the PACS Display Station to view and report studies. The PACS Server
manages and shares information related to study attributes, system configuration, user
accounts, study markup, and Annotation of studies. It collects, organizes, and manages all
patient and study demographic data.

Reporting
The radiologist reviews a study and creates the report that accompanies the study. The report can be
generated in a variety of ways:
•Hand written
•Dictated onto tape
•Dictated into voice recognition software
Reports are then converted into a document either by a transcriptionist or by voice recognition
software. Voice recognition software displays the spoken words on a computer screen that the
radiologist can see during dictation. Reports are typically stored long-term in the RIS.
Web
Images and reports are also available through a Web-based interface. Physicians can view studies and
reports on standard web browsers such as Netscape Navigator or Microsoft Internet Explorer from any
location. This is intended for use in clinical review and referral of medical images and not for official
diagnosis.
An additional web component may be attached to the HIS that allows physicians to view electronic
patient records, and any images that may be associated with that patient.

The proliferation of information technology (IT) and other high technologies into medical imaging
and
diagnostic equipment in the last decade has resulted in the evolution of powerful new devices in the
field of diagnostics and interventional radiology. The information generated and carried by these
images is crucial to the treatment in radiology, cardiology, neurology, oncology, gynecology &
obstetrics, orthopedics, surgery and pulmonary medicine. These new developments have helped in
the early detection and treatment of diseases and significantly improved patient care. Such typical
Network is illustrated in the next slides .
can be broken down into five broad sub-categories:
1. Modalities that capture or generate the images
2. Picture Archiving and Communications Systems (PACS) that store the generated images and
make them available to the physicians and nurses for diagnosis and treatment
3. Radiology Information Systems (RIS) and Hospital Information Systems (HIS) that monitor and
manage the work flow of radiology departments and entire hospitals, all the way from the patient
check-in, to scheduling and billing, to generating electronic medical records and management
Reporting.
4. Computed Radiography (CR) that helps convert films to digital images on cassettes or Digital
Radiography (DR) that provides cassette-less digital images.
5. Laser printers that print films when required and other peripherals.
Physical Infrastructure for Medical Imaging and Diagnostic

Modalities are high tech medical imaging systems including Computed Tomography (CT), Magnetic
Resonance Imaging (MRI), Positron Emission Tomography (PET), Ultrasound (US), and Electro-
Cardiogram (ECG). They get connected to a PACS and to RIS/HIS through Local Area Networks
(LANs) or Wide Area Networks (WANs). Newer, modern hospitals have even started to deploy
Wireless Local Area Networks (WLANs). PACS may have there own Storage Area Networks (SANs) or
Network Attached Storage (NAS) and the RIS and HIS may be made of several clusters of servers and
a number of workstations distributed in different departments of the hospitals. Because of their
numerous benefits combined with the enormous pressure on the hospitals to improve quality of care,
reduce errors, comply with International regulations like HIPAA, and simultaneously cut cost, adoption
of all these technologies is inevitable, converting the traditional hospital into a “digital enterprise”.
The backbone of this new digital hospital is a network made up of different modalities, PACS and
RIS/HIS, CR/DR, printers and peripherals. This highly complex network and its components has to
comply with relevant standards like Digital Imaging and Communications in Medicine (DICOM), Health
Language Seven (HL7), Underwriters Laboratory (UL), Federal Communications Commission (FCC),
National Electrical Code (NEC), and other applicable local and national codes such as BS7671:2001
(U.K.), NFC15-100 (France), and VDE (Germany), as well as international such as CEI IEC 60364. This
imposes a huge challenge to the IT and the facilities manager to provide the right Network-Critical
Physical Infrastructure (NCPI). NCPI is the foundation upon which the critical equipment, systems and
networks reside, but is often ignored. It has to be reliable, scalable, highly available, and manageable. It
consists of:

1. Power systems such as UPS, power distribution units (PDUs), isolation transformers, and
generators to provide uninterrupted, conditioned, clean power to the critical loads
2. Precision cooling systems that provide optimal environment by regulating temperature and humidity
3. Racks that house the critical network equipment like servers, switches, routers, and gateways
4. Physical Security and fire protection systems
5. Cabling to interconnect equipment
6. Management systems to monitor and manage these systems, locally as well as remotely to ensure
their satisfactory operation 7x24x365
7. Services to design, deliver, install, commission, operate and maintain these systems
Special attention should be given to the hospital wiring closets which allow networking of the modalities
to PACS and RIS/HIS as well as other workstations and peripherals within the hospital premises. It is
these backbone closets that support this complex hospital network carrying critical data, voice and
video, keeping the network up and running.

PACS make it possible to electronically store, manage, distribute and view images. Fundamentally,
these systems are a network of all image acquisition devices, display workstations and storage systems.
They are made up of a broad range of technologies that enable digital radiology and digital hospitals that
will eventually be capable of tele-radiology, tele-medicine and tele-surgery. In the last decade, PACS have
become more complex, encompassing systems that digitally acquire, convert, interpret, transmit and store
medical images. It is growing at a significant pace and is expected to completely transform the legacy
hospitals into digital enterprises. Diagnostic images will be available anytime, anywhere with little or no
human intervention, making their distribution faster, easier and more reliable. Because of its numerous
benefits, adoption of this technology is inevitable.
The core of the PACS is made up of high availability RAID storage and server clusters running Windows,
Unix, Linux or a propriety operating system. These RAID storage and server clusters are housed in racks
in a computer / data room or data center environment. Typically they draw less then 10 kVA, single phase
AC power at 120V, 208V or 230VAC. Very large systems may draw three phase power.
PACS need to be available on demand to the nurse, physician, clinician or specialist surgeon, providing
latest imaging data of the patient under treatment. It needs to be highly available, 7x24x365 and there is
little tolerance to downtime. Since the RAID drives and server clusters are confined to rack enclosures,
handling their heat dissipation within the racks often becomes a bigger challenge.

• PACS should be protected with an N+1 redundant UPS system. This N+1 UPS system not only
protects the hardware but also protects the software from malfunctioning and gracefully shuts down
and reboots the operating system if needed, thereby preventing a hard crash. The N+1 redundancy
of the UPS system mirrors the redundancy of the RAID storage drives and server clusters which
are at the core of the PACS, providing high availability. For smaller, simpler systems, a basic UPS
can be provided.
• Often times, additional receptacles are needed for plugging in all required devices. Rack based
power distribution units (PDUs) should be used to provide additional outlets. PDUs that can
measure and display current, which can help prevent accidental overloading and shut down of the
PACS are recommended. PDUs that allow remote outlet control via the web are desirable as they
can help reboot a hung server or a storage drive efficiently.
• At a minimum, surge suppression should be provided for LCD/CRT based passive view-stations.
For PC based active workstations running software applications, UPS protection with graceful shut
down and reboot capabilities is highly recommended.
• The PACS storage and servers should be housed in secured, lockable, rack enclosures. These
racks should be in a temperature controlled environment. The racks housing PACS storage and
servers are generally very dense physically and in terms of power consumption. The rack doors
should be perforated, allowing for maximum airflow. When power draw in the rack exceeds 2kW,
rack-based cool air distribution units should be provided so that the RAID drives and the servers in
the top portion of the rack do not get overheated and fail. For rack power densities approaching 6
to 8kW, rack-based hot air removal units should be considered. For power densities in excess of
8kW, self-contained high-density cooling systems should be used.

• A good management strategy involves the management of PACS servers, storage and their entire
NCPI including UPS, PDUs, batteries and their critical environment (temperature and humidity).
This will give early warning of any anomaly or impending disaster so that corrective actions can be
taken and prevent all avoidable shutdowns.

RIS and HIS are server based systems running special software that make it possible to store, monitor,
manage and distribute patient medical information. They help patients in scheduling appointments,
registration, and billing, and help hospitals in generating, maintaining and managing patient’s electronic
medical records as well as generate workflow, work-list, management reporting and variety of other
tasks.
These RIS and HIS are really becoming one large HIS and are integrated / networked with PACS as well
as various other modalities within the hospitals providing complete automation. By converting them into
“digital hospitals”, they can significantly improve patient-care, minimizing human errors, saving lives and
reducing costs.
RIS / HIS are the most important systems within the data center requiring longer runtime and higher
redundancy and availability then most other equipment. Since these systems are merging to form one big
HIS on which the entire hospital depends for normal functioning, their availability requirements are
generally 99.999% (five nines) or higher which translates to average unplanned downtime of 5 minutes
per year or less. Additionally these systems may be located in high rise buildings and attention should be
paid to the floor load (weight) handling capacity, elevator hauling capacity, door heights and widths to
ensure that the NCPI elements like UPS, batteries, and air-conditioning can be rolled in to their planned
positions.

Conclusion:
To ensure high availability and reliability to medical imaging and diagnostic equipment, including PACS,
RIS, HIS, modalities and their network, special attention must be paid to their Network-Critical Physical
infrastructure (NCPI). The biggest challenges are in terms of power, cooling, physical space,
management
and services. Providing UPS protection to all such devices protects the hardware, prevents the software
from unwarranted crashes and increases their availability significantly. Cooling is a special problem for
bigger floor mounted modalities, high density storage and servers for PACS as well as RIS / HIS and
hospital wiring closets. In some cases, a building’s HVAC system along with proper ducting, ventilation
and airflow may be sufficient. However in many situations, additional cooling in the form of precision air
conditioning is required. Companies like American Power Conversion have dedicated team of systems
engineers, power protection specialists and availability consultants who can help in doing assessments
and audits of Network-Critical Physical Infrastructure and provide detailed actionable reports on
improving overall system reliability and availability while minimizing the total cost of ownership.

Scheduled Study Workflow: The Systems View
At its simplest, a workflow is a sequence of events, initiated by a trigger
event*, such as when a study is scheduled. Messages must be transferred
to different information and imaging management systems in the hospital
based on these events. Understanding workflows allows you to optimize the
interactions between the systems in the hospital. You can also troubleshoot
problems when the workflow breaks down; for example, when a modality
does not receive the proper worklist.
The following topics outline a typical, simplified, workflow for a scheduled
study:
• Pre-Acquisition
• Acquisition
• Reporting
• Results Distribution
* The real-world health care event that initiates an exchange of messages, or a workflow. An event in the real world of
health care means data must flow among systems. For example, the trigger event “a patient is admitted" means data
about that patient must be sent to other systems.

A. Pre-Acquisition
The pre-acquisition phase begins when the patient visits his family physician
with a complaint and the physician determines that a radiological exam is
required. It ends when the order is scheduled with the Radiology Department.
1. Patient goes to his family physician:
The patient goes to his family physician
with a bad cough. The physician decides
to refer the patient to the local hospital for
a chest x-ray.
2. Receptionist calls the hospital to place
order :
The receptionist at the physician's office
places a call, or faxes or mails a requisition
to the hospital's Radiology Department to
reserve a time slot for the exam.
The receptionist in the Radiology Department
takes the order and enters it into the Radiology
Information System (RIS).
3. Radiology department schedules the
Order:
The order is placed and scheduled.
When the receptionist enters the order, the RIS
generates a study scheduled event. (It may also
generate a visit scheduled event.) The RIS then
sends this event to a connectivity system.
This connectivity system translates the
event from HL7, which the RIS speaks, to DICOM,
which the modality and the PACS speak.
Workflow Part Diagram

(The connectivity component can keep the study scheduled event for weeks until a preset time, or
horizon. When the horizon arrives, such as midnight the day before the study is scheduled, the
connectivity component sends the study scheduled event to the PACS. The PACS receives the event
and knows to prefetch all of the relevant priors for the patient. For example, if the patient had pneumonia
six months ago, the images from that old study are pulled out of long-term storage and placed in short-
term storage in preparation for the radiologist to read during the reporting phase.)
Integration Part Diagram

B. Acquisition
The acquisition phase begins when the
patient arrives at the hospital for the study
, including when the technologist "acquires“
the study images. It ends when the study is
sent to the PACS.
4. Patient arrives at the hospital:
On the day of his study, the patient arrives
at the hospital admitting desk. The
receptionist takes the patient's information
and enters it into the Hospital Information
System (HIS) to obtain a unique identifier
for that patient.
5. Patient arrives at the radiology department:
The patient proceeds to the radiology department
and reports to reception. The receptionist
registers the patient into the Radiology
Information System (RIS). The order for the
patient is filled and is assigned a unique
identifier to identify that study. The arrival status
of the patient signifies to the technologist that the
patient is in the waiting room and is ready to be
imaged.
6. Technologist takes the x-ray:
When the patient arrives at the modality for his
study, the technologist requests a worklist that
contains the patient information and the details
of the study to be performed. In this case, the
patient needs a x-ray of his chest. The
technologist takes the x-ray at the modality.
7. Technologist does a quality check:
The technologist performs a quality check on the
images, then forwards them to the PACS for
storage.
8. Images sent to PACS:
The PACS receives the images. The demographic
patient and study information maybe verified
against the HIS/RIS to ensure that the information
is correct prior to storage.

(The PACS verifies that the images received from the modality match a specific patient. This process is
called HIS verification. The PACS sends a query to the connectivity component that normally asks for a
patient based on the patient ID and accession number. If the connectivity component returns one patient, the
study is verified and stored. If more than one patient is returned, the study is marked as unverified and must
be verified manually, usually by the PACS administrator. Numerous fields relating to patient and study
information are also checked and updated if differences are found).
When the patient arrives at the modality,
the technologist requests a worklist that
contains the patient information and the
details of the study to be performed.
The modality worklist query is sent to the
connectivity component, which responds
with the most up-to-date patient and study
information that it has received from the
RIS. (The modality speaks DICOM, and
the RIS and HIS speak HL7, so the
connectivity component is required as
a translator.)

C. Reporting
The reporting phase occurs when the radiologist views the study images and
then reports the findings.
9. Radiologist dictates the report :
The flow of the reporting step can be slightly
different depending on the system used in the
hospital.
• Using a traditional voice dictation system,
the radiologist records his interpretation on tape.
The recorded interpretation is listened to and
transcribed by a transcriptionist into a report.
The report is then sent back to the radiologist for
approval. The report, along with the report status,
is sent to the Radiology Information System (RIS).
or
• Using a voice recognition system, the radiologist
dictates, edits, and approves the report.
The voice recognition system sends the report,
along with the report status, to the Radiology
Information System (RIS).
RIS sends interpretation transcribed, updated,
and approved events

(As the RIS receives the report from the dictation system or the voice recognition system, the RIS
sends interpretation transcribed, updated, and approved events to the connectivity component.
These events are sent to the PACS to update the study status. The report itself is stored on the RIS
, not the PACS.)

D. Results Distribution
The results distribution phase occurs after the radiologist has approved the
report, when the referring physician views the report and images.
10. Referring physician views the report and
Images:
The Radiology Department sends the family, or
referring, physician, a paper report to read.
Or the family physician views the report and
images over the Internet using a web browser.
The patient may also receive a printed copy of
his images to take to his family physician.
If the physician wants to see the images for the
study, the request goes to the PACS and the
images are downloaded and viewed in the web
browser. When the physician requests the
approved report, the request goes to the
connectivity component and the report is
retrieved from the RIS.
11. Follow-up appointment:
The patient returns to his family physician for
a follow-up appointment. The physician then
gives the diagnosis and treatment options to
the patient.

To conform with privacy and security standards, auditing provides the ability to recreate the actions of a particular
user or users, whether those users are people, external systems such as modality sources, or external systems
such as a HIS, RIS, PACS, or web viewer. The following events trigger an addition to the audit log:
• A user views the specific details, images or reports of a patient
• A user initiates a search that results in the display of Protected Health Information (PHI)
• A user views, adds, deletes, merges, prints, or modifies PHI
This audit information is saved and can be viewed to determine who has viewed a patient's PHI, or to provide the
audit information to the patient upon request.

15+ Years Healthcare Experience Digital Radiology Expert

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