Introduction to two PACS ‘82 Panel Discussions edited by André J. Duerinckx, M.D., Ph.D.: “Equipment Manufacturers’ View on PACS” and “The Medical Community’s View on PACS”

THE FIRST INTERNATIONAL CONFERENCE AND WORKSHOP on Picture Archiving and Communications System (PACS) for Medical Applications in 1982 was the creation of Andre Duerinckx during his early years as a researcher at Philips Ultrasound Inc., in Santa Ana, California.1 At that time Dr. Duerinckx and Jim Pisa, the head of research and development at Philips Ultrasound, were exploring the concept of an Ultrasound Mini-PACS.1,2 To help design this early PACS concept Dr. Duerinckx called together experts from many fields for a meeting in beautiful Southern California in January 1982. Obviously the word “PACS” in radiology as we understand it today did not yet exist. The term was created by Dr Duerinckx prior to this first meeting in 1982 after many discussions with Sam Dwyer and others, and after rejecting many alternate names.3 Dr. Duerinckx has since moved on from being a medical physicist and engineer to become a diagnostic radiologist with residency training at the University of California at Los Angeles (UCLA) and fellowship training in cardiovascular magnetic resonance imaging at the University of California, San Francisco (UCSF). His first encounter with a clinical PACS was as a radiology resident. Later, as a faculty member at UCLA, he worked with the early PACS developed by H. K. Huang at UCLA. He went on to work through the very early stages of a commercial PACS development by a major vendor (AGFA) and witnessed firsthand the clinical impact and growing pains of commercial PACS technology while working at the West Los Angeles Veterans Affairs Medical Center (West LA VA), a UCLA-affiliated institution, from 1992 to 2000.4 With Dr. Edward Grant, Chief of Radiology at the West LA VA, and many other collaborators, an ambitious project was started to implement and link the PACS of all VA Medical Centers in Southern California via a fast network, including asynchronous transfer mode (ATM) links to selected sites.5,6,7,8 The impact on educational programs has been described.6,7 Extensive planning and cost analyses were needed to justify the PACS-based digital radiography services for a network of hospitals (like the Southern California Veterans Integrated Service Network).9,10 These new services were successfully implemented in the Southern California VA network in 2001. In June 2000 Dr. Duerinckx moved to Dallas, Texas, to become the Chief of Radiology at the VA Medical Center. There he uses a commercial PACS from a small vendor that does not have all of the refinements and updates available in the latest PACS from larger vendors. Communication between PACS at several VA hospitals in Texas is a key element in the delivery of patient care. Many of the concerns expressed by both the equipment manufacturers and the medical community during the panel discussions of the 1982 PACS workshop are still true today and were visionary, even though the technology has changed dramatically since. Access to fast computers, fast networks, and fast data transmission has improved, but the fundamental issues of how to integrate and standardize these technologies, and how to improve the workflow once the equipment is in place remain partially unresolved and not widely implemented, as shown in some of the more recent papers in this special issue of the Journal of Digital Imaging. One of the recurring topics during the equipment manufacturer discussion was the importance of standardization. Obviously 1982 was pre-DICOM (digital imaging and communications in medicine) standards. The standardization issues that were discussed in January 1982 were a reflection of the state of technology and the nonexistence of large clinical PACS. Many concepts proposed and discussed were linked to 1982 technology but have since resurfaced with 2002-2003 technology. One idea proposed in 1982 was the patient “image credit card” which would contain the full medical record including images and would be portable from location to location.2 It is interesting to look at the newest concept of image data portability offered 20 years later by many large PACS vendors in 2002-2003. The idea of the image credit card has basically resurfaced as the capability of burning a CD with image data embedded in such a way that it can be read on any computer system using any type of image format. Concerns in 1982 about the possibility that standards could be a deterrent to innovation in the PACS world have proved not to be true. In fact, DICOM standards have helped PACS development by demonstrating the importance of integrating all the pieces needed to make PACS into an integral, cost-effective, and universal patient care component. The medical community’s views on PACS expressed in 1982 reflect the fact that “filmless” PACS was a big unknown. The clinicians on the panel described how film-based radiology systems worked, why it would be important to get information on the workflow in radiology departments, and how that would help design PACS. Shortcomings of film-based radiology departments were described (misplaced films, film handling, film file room inadequacies, etc.). However, nobody at that time could yet consider futuristic concepts like redesigning workflow as a key to success when using a non-film-based PACS. People at that time also discussed the differences between film-based PACS versus a non-film-based PACS. Overall the 1982 workshop was a great stimulus to bring bright minds (industry, vendors, scientists, and clinicians) together to discuss this very important concept for today’s practice of clinical imaging. The ideas presented in 1982 are part of the foundation of the expansion of PACS worldwide in 2003 and beyond.