A good evaluation study requires a good baseline study. Significant amounts of effort were directed toward determining existing problems in radiology image management. The baseline study is useful in two ways: the definition of problems that digital technology should address and the evaluation of the effectiveness of digital solutions. 2.1 Clinical Perspective The clinical issues of image management can be viewed either from the perspective of the “core” radiology service or from that of the referring physician. The “core” functions of radiology are performing examinations, reviewing the resulting images, consulting, and generating and distributing reports. Poor performance of any task connected with these functions will lead to poor service. The hospital or referring physician must consider broader issues than those considered by the radiologist. Examples of such issues include the questions of what demands a physician makes on the radiologist and how such demands can be successfully addressed. Similarly, a physician may ask the radiologist if there is an imaging technique which can help in patient diagnosis. This dialogue defines the consultation phase—the two physicians talking is one of the most important interfaces between the radiology department and the rest of the hospital operations. After talking to the radiologist and deciding that a procedure needs to be done, the next step is to schedule the procedure, which involves the use of an HIS/RIS. This initiates the core radiology service (mentioned above), which starts when the radiologist performs the procedure. Next a diagnosis is made and reports are generated by a radiologist. The referring physician reviews the report and films and often speaks with the radiologist again, involving interaction both with people and the electronic systems. From a clinical perspective, there are several potential problems in the film-based environment which result in poor service. First, a delay may occur in scheduling an examination. Once an examination has been completed, several factors may delay or adversely affect the quality of the report. These include both delays in accessing either current films or older images and missing previous studies. Since a single sheet of film cannot be in two places at once, the availability of films currently in use is also problematic. This is potentially more important when multimodality comparisons are required. Finally, the current workload on a radiologist may affect report generation time. Delays in getting radiologic procedures and reports completed can result in delays in patient care, and, if the referring physicians become too frustrated by such delays, the radiologist’s professional role may be affected. Improvements in radiology service can have a positive impact in patient care which in turn makes the radiology service that much more effective. Non-problem A number of problem areas have been identified in our study. There is however an important non-problem area that may become an issue in the digital environment. The image quality in current systems has been perfected over the past century and it is not a problem in current film-based systems. Furthermore the medical/legal issues are well-defined in this environment. 2.2 Operational Perspective A number of problems exists in the operations of radiology service because the image media is film. A digital imaging network should be viewed as a device to solve significant film-based operational problems that impact radiology service. Unavailable Films During a baseline study at Georgetown University Hospital in 1987 we found that 9% of films were unavailable when requested. The reasons for this are that they may be in another department or signed out for multimodality correlation, used for educational and research activities, in transit, misfiled on shelves, misfiled in the wrong jacket, given away, or stolen. Some of these problems are virtually impossible to resolve (e.g., misfiling in the wrong jacket, given away) in a film-based service. Misuse of Resources Unavailable films cause a loss of productivity among radiologists, the clerical staff, the technical staff, and referring physicians and their staffs. Unavailable films also cause misuse of expendable supplies such as film and chemicals, and misuse of the equipment resources used in film duplication. Report Generation When a diagnosis requires a multimodality correlation study, reporting is often delayed due to difficulties in collecting related images from various imaging systems. This creates a delay between the completion of a procedure and reading. Space One solution to the problem of missing files is to duplicate film files, thereby increasing space requirements. Also, the report process is frequently hindered by the unavailability of films, so the match-up of reports and films is incomplete, forcing the duplication of files in many departments. Cost Conventional radiology department operating costs impacted by DINS are detailed in Table 2. These figures are based upon a 300 bed institution which does approximately 80,000 to 100,000 procedures per year. Table 2 Table 2. Archive Materials $460k-720k Labor $1680k-2400k Maintenance $600k-1000k Depreciation $1000k-1500k Space (opportunity) $50k-100k Total $3790k-6720k Acquisition costs for equipment in a conventional department, including film handling equipment, the file room, and silver recovery equipment, is approximately $900,000.

I MAGE MANAGEMENT and communication in medicine has made significant progress over the past 5 years in all major fronts: clinical, technological, and administrative. Technological development has been an integral part of medicine, and new imaging modalities have revolutionized diagnostic imaging and made significant impacts on the quality of patient care. These technological innovations, however, are creating an ever increasing amount of data to be presented to physicians and to be managed over a long period of time. The technical difficulties in the distribution and management of these complex diagnostic data are universal enough that there are no national boundaries. On the other hand, health care policy and professional practice of diagnostic imaging are different in different countries. The medical imaging sector of the computer application market is small compared to the rest of the computer industry. It is desirable for the medical community to be fully informed of technological advances so that medicine can take advantage of the technologies available in the large consumer and business markets. How, then, can the diagnostic imaging community implement image management and communication (IMAC) systems using international technology to meet the needs of many different clinical environment? The First International Conference on IMAC, which was organized in Washington, DC in June of 1989, was attended by 500 people representing 15countries. Experts and serious innovators from clinical, technological, and administrative disciplines participated in addressing wide ranging topics in IMAC. It also, for the first time, provided an opportunity to bring many international lMAC experts together for future collaboration. Since the first IMAC meeting, many new cooperative efforts and exchanges of ideas among the international participants have taken place. Especially for the large scale interna-

Image management and communication (IMAC) systems are automated and integrated systems that capture digital medical images and related patient information and transmit them electronically, display them for interpretation, and store them for future retrieval. The IMAC system concept includes images and relevant information from all clinical sources. The First International Conference on Image Management and Communication in Patient Care (IMAC 89) provides a forum for expert presentations, poster sessions, and discussion and debate among all attendees interested in the implementation and impact of IMAC systems. Plenary sessions provide an international perspective and explore the role of image-based information in patient care, approaches to improved IMAC systems, current technical barriers, quality of care issues, evaluation approaches, and scenarios for the future. Invited participants are from North America, Europe, Japan, Australia, and the WHO. Conference organizers are working with numerous professional organizations and representatives of meetings which focus on IMAC-related technology to complement, and not duplicate, the contribution of other groups.

T HE MANAGEMENT of the vast amount of medical images and information generated in contemporary clinical services is a growing problem. Solutions to the problem increasingly require the use of advanced computerbased technologies in data storage, image display and communication, and human engineering. The progress of individual technologies has been rapid. However, system integration and user acceptance have been slow in coming. As experience accumulates in the clinical application of image management and communication systems (IMACS), a critical assessment of their role in patient care and of their professional and economic impact is useful in developing the future strategies for scientists, users, and manufactur-

The Digital Imaging Network (DIN) Project is a collaborative project among numerous components of the Department of Defense, Public Health Service, Veterans Administration, industry, academia, and the MITRE Corporation. The project is evaluating prototype DIN systems (DINS) at Georgetown University (in collaboration with George Washington University) in Washington, DC, and at the University of Washington in Seattle, WA. Results of the project will be used to plan DINS for implementation in fixed and deployable military medical care facilities in the 1990's.

These transcripts were edited slightly for clarity. The presenters did not have an opportunity to review the text because of the press of publication. Although the verbatim transcripts are not accompanied by the slides and thus are somewhat difficult to follow, the thoughts of the individual presenters on many key issues warrant this publication.