John Halamka's blog post shows the importance of having good administrative procedures to accompany the available standards and technology. Without these, the new technology and standards do not improve patient care as they should.
I noticed several administrative decisions that made his experience much worse and likely caused some confusion. They are not driven by standards or technology.
First, they apparently failed to explain the nature of the CD that he was given. He discusses the need for a vendor neutral format that can be used by any vendor. The CD that he was given was almost certainly exactly that. The DICOM media formats and IHE PDI profile are supported by over 100 different vendors. It is widely used and vendor neutral. But they apparently failed to explain this. I can understand the staff not explaining this, but it would have cost nothing to include an explanatory document on the CD itself.
Second, they only included a Windows viewing application. I can understand the need to make a selection. There are over 100 different DICOM viewers available for Windows, Mac OS, Linux, IOS (iPhone/iPad), and Android. It can be too burdensome to provide support for all the possibilities. But why didn't they include a document explaining that there are free, open source, and commercial viewers available for all these systems? I would point MacOS users to Osirix as a starting point, and give some google hints for the others.
Leaving patients with no documentation or hints about where to get a viewer is another administrative mistake. It would cost very little to explain the alternatives in the document describing the CD.
Third, why didn't he get the CD immediately? When I went to the vet I got a DICOM CD with my cat's X-rays immediately. It was just part of the end of visit process. There is no technical reason for a substantial delay or a 9-5 policy. All that's involved is transmitting the images to a system with a CD burner and burning the CDs. This should take tens of minutes at most. It will be less if the network and CD burner are fast. If this were part of the routine process, I would expect the burner to be finished before the patient is ready to leave. The IHE profiles specify the routine process for creating CDs and DVDs. There are more than 10 vendors offering IHE compliant CD creating products, and they all exchange data without problems.
It's an administrative policy decision that I don't understand to force patients to return later with some 9-5 limit on services.
Finally, there is some confusion about whether DICOM requires a PACS system.
Back when imaging was done on film, radiologists, dentist, veterinarians, and other imaging users had filing cabinets with specialized folders and labels to keep track of all the films. The organizing and managing of the film library was a necessary part of daily operations. It could consume a huge floor space and require a large staff.
With the move to digital images, this organizing and managing of images has shifted from film cabinets in huge rooms to image management software and disk drives. It's much smaller and faster than the film libraries, but it remains a necessary part of daily operations.
What DICOM has done is standardize the interface to this image management system. Radiologists call this system "PACS", but other groups like dentists and veterinarians often just call it their image management system. It is normal in a hospital to have a PACS from one vendor, with workstations and modalities from many other vendors. This works because DICOM has standardized the PACS interfaces. The IHE actor called the "Image Manager" is found in many IHE profiles is a PACS. The profiles specify both the DICOM interactions and the HL7 interactions for the common hospital activities.
It is possible to use DICOM without having a PACS system. There are small niche uses that do not need to organize and manage their images. These are not common, but they exist and do use DICOM. In most applications you need an image management system. PACS systems are used because the applications need an image management system, not because DICOM requires it. DICOM allows you to choose the image manager vendor independently from the other vendors and still expect everything to fit together and work.
The range of needs for image management is huge. Open source image managers like dcm4che co-exist with very large expensive commercial image managers. The users can decide how much they want to do by themselves and how much they purchase. The systems can be sized appropriately to the volume of imaging that they perform. As a proof of concept, we installed and ran dcm4che on an Android phone. I do not recommend using an Android phone as the PACS for any serious imaging operations, but it worked quite well for a small number of small images. Small research applications do not need to pay the cost of the large systems needed by large hospitals.
Disclosure, I work for a PACS vendor and am involved with dcm4che.
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