• Increased efficiency
• Improved image quality
• Decreasing cost for digital imaging modalities
• Consolidation of the veterinary profession is leading to larger group veterinary practices with large national caseloads

Lessons from large veterinary practice implementations can be applied towards human medicine implementations.

PACS implementations for veterinary medicine include individual primary care clinics, academic teaching institutions or private, specialty hospitals that serve as secondary and tertiary referral centers, academic institutions that do clinical trials, and locations where animals are sold or used for sport. Animal imaging is a large market based on the fact that per US household, there are 3.5 horses, 2.5 birds, 2.2 cats, and 2.6 dogs, resulting in 1.7 veterinary visits per household .

• Detector sizes for radiograph acquisition
• Software processing packages
• Techniques that range widely between patients (i.e., imaging a Chihuahua versus a horse)
• Specific veterinary patient demographic information to be documented, as defined by DICOM (Digital Imaging and Communications in Medicine) veterinary extensions
• The workflow differs dramatically, depending on the practice setting, ranging from emergency medicine at the horse track, to a wellness exam in a small clinic of your pet, to imaging zoo and exotic animals
• Requirements for privacy and security of the clinical information differ widely:
  • Large, corporate practices have to comply with the Payment Card Industry (PCI) security standards
  • Physical security at a race track
  • Low security requirements at an individually owned and operated veterinary hospital

1. Requirements:

• Exam mix/specialties: Veterinary PACS vendors exist due to the differences and modifications required of existing PACS system for human imaging. Many veterinary practices are focused on general practice and primary care and most of the exams are radiographs and ultrasounds. Veterinary specialists, such as cardiologists, surgeons, neurologist, and others are most often connected to veterinary teaching hospitals or large, private practice referral hospitals which utilize more advanced imaging modalities such as CT, MRI, endoscopy, fluoroscopy, and nuclear medicine. The number of exams varies widely. For example, for a pre-purchase exam of a horse, typically all of its joints are examined with three views, resulting in more than 32 images. This type of exam is typically performed using DR technology in less than 15 minutes and requires separate hanging protocols.
• Teleradiology: Most exams are performed in the primary veterinary practice, with interpretation performed by the veterinarian on-site. Veterinary radiologists or other specialists are used more in a consultant role, especially in an emergency, when a second opinion is needed. A radiologist might need to read cases from a variety of PACS vendors, which is similar to the requirements for human emergency medicine Nighthawk services.
• DICOM requirements: The DICOM protocol can be used as-is for exchanging images, work lists, and any other DICOM objects. The data formats have been expanded since 2006 to include extensions which are critical for a PACS system to function. These extensions are added as optional attributes to the DICOM header being part of “general modules,” so they can be applied not only to almost all DICOM SOP (Service Object Pair) Classes, and but also as optional extensions to some of the attributes to cover animals. It is imperative for a scheduling application to support and collect these attributes, and for a modality to retrieve them, forward them, and allow for potential modifications. For the archive and database, it is important to store and allow for queries to be supported. Workstations must also display these attributes. These extensions include:
  • An additional Patient ID field to support RFID and/or barcodes
  • Species field drawing from a species code list
  • Breed field, including potential breed registration organization information
  • Responsible person, role and organization to capture owner name
  • A field to indicate its neutered status

2. Preliminary Implementation results:

Banfield, The Pet Hospital includes a nationwide group of veterinary practices, with over 750 hospitals located in 46 states, with the majority located inside PetSmart stores. Nationally, Banfield hospital teams help over 110,00 pets per week (almost 6 million pet visits per year). Approximately 325 of those hospitals have DR modalities (while the rest are in the process of being converted from traditional film), and approximately 100 have ultrasound modalities. The over 2,500 veterinarians at Banfield, The Pet Hospital primarily see dogs and cats, but also see small mammals, birds, reptiles, and other species, for primary care and urgent care situations. Banfield is currently implementing a 3-phased project to upgrade from a proprietary, legacy telemedicine system to a DICOM-compliant, fully-integrated PACS system. The ultimate purpose of the project is to create a robust, extensible, cost effective PACS, internally hosted on an internal network to ensure Banfield control and security, and to enable record sharing, that provides for fast, reliable, and accurate telemedicine services based on images from radiology equipment that is stable, technically advanced, and well supported. Implementation of a PACS within a veterinary setting and within such a distributed model presents many challenges.

• DICOM-compliant modalities, PACS and RIS systems which support veterinary DICOM attributes are essential to match Banfield’s vision of “treating Pets like family.”
• The unique workflow of a veterinary hospital varies from workflow supported by many major commercial PACS systems. The Banfield hospital setting more closely approximates the setting of a human primary care physician’s office with radiograph capabilities than that of large hospitals or dedicated imaging centers.
• Banfield’s large number of modalities and locations in such a wide distribution across the country presents network, support, and user education challenges.

Banfield is overcoming these challenges by implementing an open source PACS system, which can be modified to accommodate veterinary DICOM attributes and unique veterinary workflow. Distance challenges are overcome using remote workstation access and distance learning techniques. Banfield PACS national rollout is scheduled for December of 2009 and will provide many lessons that can be applied to other veterinary and human distributed PACS implementations.