PACS offers direct access to MSK specialists without alienating rads

Dr. Justin LaMont has jettisoned the grease pencil, protractor, and ruler that he used to plan his joint replacement procedures. The chief of orthopedic surgery at Tisch Hospital in New York City now does his presurgical templating digitally on the images sent to him via the hospital's PACS, instead of manually marking the hard-copy acetate sheet overlaid on the hard-copy film.

For LaMont, having PACS capability means that he can do more precise planning for hip and knee implants from start to finish: assessing implant size, guiding osteotomy around the implant area, and assessing congenital or post-traumatic bone deformity.

Unlike other specialties in which PACS integration has hit some roadblocks (radiation oncology is a prime example), orthopedists have embraced PACS enthusiastically.

"Adoption has been accelerating quickly" among orthopedists he knows, said LaMont, whose hospital is the larger of two facilities within the New York University (NYU) Medical Center. "Looking at my own practice here, within the period of two years since PACS rolled out here at NYU, it's already become a de facto standard. I've been piloting this in my own practice for about five months and, already, I'm finding it indispensable."

And PACS offers more than just the ability to micromanage surgical procedures. On a larger scale, orthopedic surgeons like LaMont who work in multicampus environments are extolling the benefits of image and data sharing, which PACS makes possible. With more healthcare facilities merging or forming partnerships, the need for virtual sharing of images and data has only grown. "In the old film world, it would have been a nightmare to try to practice efficiently across multiple sites," he said.

PACS is a natural fit with the practice patterns of orthopedic surgeons working in various clinical environments. Orthopedic specialists shared with what they like most about having PACS as part of their daily practice, and how the technology has actually cemented cordial relationships with their imaging colleagues.

Head-to-toe PACS

Orthopedists focusing primarily on joint replacements were the first to flock to PACS, but the preplanning capabilities of working digitally are rapidly drawing in others.

Dr. Peter Hoepfner, an assistant professor in the department of orthopedic surgery at Northwestern University's Feinberg School of Medicine in Chicago, specializes in hand and upper-extremities surgery.

"I use the PACS system all the time and like the ability to measure things digitally on the screen, with an electronic ruler, or measure angles very easily," said Hoepfner, who also practices at Northwestern Memorial Hospital. "With the small bones in the wrist, (you) frequently need to draw angles or take measurements, and that's so much easier with point-and-click technology, doing it digitally."

The ability to share images with fellow surgeons, radiologists, and other medical specialists is an incredibly important aspect of the PACS phenomenon, Hoepfner said. Since Northwestern Memorial went live with orthopedic PACS in 1999, workflow processes have been dramatically streamlined.

"We have a very sophisticated hospital, with the ability to pull up the images in the operating room," Hoepfner said. "And if you get a call from a resident in the middle of the night, you can access images from home. You can also share images with physicians who might be anywhere, or you yourself might be anywhere." The risk of film loss is also eliminated, he added.

Scott Grier, a director at Abrio Healthcare of Brentwood, TN, pointed out that the ability to share such images in real-time positively impacts patient care, especially in an emergency setting.

"Particularly when you're talking about traumatic injury, the (emergency department) docs are going to look at the imagery, make the call, and set the patient up for immediate treatment," explained Grier, who is based in Sarasota, FL.

Peace, love, and PACS

Orthopedists stress that PACS implementation in their practice environment has actually fostered more collegial relations between themselves and radiologists.

"If anything, we've found that having the information at hand when you need it and want it, and being able to communicate with colleagues, actually encourages even more communication," said Dr. Jonathan Schaffer, managing director of the eCleveland Clinic at the Cleveland Clinic Health System in Ohio. "And that's because the friction around getting the images is no longer there."

"We have musculoskeletal radiologists on campus, but if I'm not on campus, wouldn't it be nice to share an image through the PACS ... and get their opinion? And we're starting to have that capability. So anytime you facilitate that communication, whether it's real or virtual, it's a help," said Schaffer, who is also the program director for the clinic's Advanced Operative Technology Group.

The Cleveland Clinic system is striving for even broader PACS availability and use, according to Dr. Bradford Richmond, a musculoskeletal radiologist and an associate professor of radiology at the Cleveland Clinic Lerner College of Medicine.

"What we're doing here in e-radiology is that we're working with orthopedic surgeons all over the country," Richmond said. "We read images for orthopedic surgeons 24 hours a day, seven days a week, for orthopedists across the country. We have a main musculoskeletal group of 10 radiologists that takes care of the 100 orthopedic surgeons here; and in e-radiology, we've got a group of four radiologists that handles other Cleveland Clinic sites in Ohio and across the country." This remote access also has education value, Richmond added, with virtual conferences that include input from multispecialty physicians.

Of course, an issue that radiologists and their nonimaging counterparts wrangle over is who performs the imaging exams and interpretations. Would more orthopedic surgeons do some of their own interpretations if they had PACS within their own offices, complete with high-resolution workstations?

Yes, said Dr. Jay Mabrey, chief of the department of orthopaedics for the Baylor University Health System in Dallas, but PACS are expensive and "there's only one other surgeon in my office, and we lack the time and money to set up our own PACS," Mabrey added. "For some surgeons, even if they could have their own office-based PACS ... it would be too much of a hassle to operate and maintain it," especially for a small surgical practice, he said. For now, and probably into the future, the presence of PACS in the hospital facility environment will be sufficient for most surgeons, Mabrey said.

For IT executives working toward bringing their orthopedic specialists to PACS, the key is to make clinician access as broad as possible, said Timothy Zoph, vice president and chief information officer (CIO) at Northwestern Memorial.

"My advice to CIOs would be to provide broad-based image access through your Web-based solution, and selectively provide higher-resolution monitors throughout the facility, at least one per floor, to allow specialists who require diagnostic quality convenient access," he said.

By Mark Hagland contributing writer
October 18, 2007

Related Reading

Radiation oncology and PACS: ramping up for the digital age, August 9, 2007

MRI, CT prove their metal for imaging orthopedic hardware, May 4, 2007

Radiologists and surgeons fractured over vertebroplasty vs. kyphoplasty, November 18, 2003

Turf Wars in Radiology, Part V: Radiologists, orthopedists put best foot forward, October 1, 2002

Copyright © 2007

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