An in-house software package called

An in-house software package called DICOMUploader (DIUP) was developed in order to include patient image data from CDs into our normal workflow. This software package was the result of improvement of an earlier version of the uploading procedure [13].

DIUP reads all DICOM files from a CD on any workstation in the hospital. After loading the CD, the patient name and the available series are displayed. The physician can choose the relevant series and push these to a file transfer protocol (ftp) server after providing the in-house patient ID and checking whether the selected data are correct. This forces the physician to check whether the patient is registered at our hospital, and if not, to register the patient first. Replacement of the patient ID with the in-house patient ID is performed during the transfer to the central ftp server. At the radiology department, the data are retrieved from the ftp archive and stored at the appropriate DICOM node. During the storage process, the information regarding a patient having external data is recorded. The uploaded images will be updated with patient identifiers from our institution’s radiology information system (RIS) by overwriting the original patient ID and accession number with the correct patient ID and accession number in the DICOM header. Image-related materials such as radiology reports or informed consents are obtained from other institutions via email or fax. These image-related materials were not stored in the system but delivered separately to the physicians. Later, the stored data are subsequently removed from the ftp site if the transfer is successfully finished. Using DIUP, physicians can also track whether their CD has already been stored into the DICOM node, thus avoiding resending the same CD over and over.

Besides data handling, DIUP also registers all actions and stores them in a database. This database can be used by the requester of the upload to check on progress or, in the case of this study, to analyse the usage of the software.

In this study we analysed the trend in the workload of CDs that were uploaded per month from August 2005 until December 2012 (89 months) by querying data recorded in the database of DIUP. Based on the results of these queries, the amount of storage required was calculated using an average size per image. The average image size was determined for each type of investigation (computed tomography [CT], magnetic resonance [MR], combined positron emission tomography [PET]/CT, etc.). Furthermore, there was an estimate on the cost involved in this whole process.

Moreover, a short written survey was sent to heads of departments, heads of laboratories, radiologists, PACS application administrators or information and communication technology (ICT) staff from 39 Dutch hospitals to determine the common practice for cross enterprise data sharing. We obtained contact details from secretaries of each individual radiology department and through our own network. We sent out a total of 39 requests to all 39 hospitals; therefore each hospital had one of their representatives to fill in the questionnaire.

The respondents were asked to fill out the survey online and a reminder was sent to all the respondents who had not yet returned a questionnaire. Eight questions were asked regarding the practice and future movement of respondent institutions towards image sharing and their current use of portable media to distribute medical images. The questions are listed below.

Does your institution share image data with other healthcare institutions?
Yes (Continue to question number 2)
No (Continue to question number 6)
Which method does your institution use for sharing such data?
CD/DVD (Continue to question number 3)
Other portable media (Continue to question number 6)
XDS (Continue to question number 7)
Other :
How many CD/DVD does your institution produce and send per week?
How many CD/DVD arrive at your institution per week?
Are incoming CDs/DVDs uploaded or saved into your own digital archive/PACS system?
Yes
No
Don’t know
Are you planning on moving to a network-based solution such as XDS?
Yes
No
Don’t know
If No, why not?
Remarks
The responds to the questionnaires were decoupled from the e-mail address of the participant and thus anonymised at the time of submission of the response.

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Results
DIUP results

A total of 33,982,404 images from 88,952 CDs have been stored into the PACS of our hospital over the 89-month period. The number of images transferred per year steadily increased since the first year of the use of DIUP (Fig. 1). In 2012, the system has transferred nearly 9 million images from multiple different modalities; most data stored originated from CT and MR; ultrasound (US) and computed radiography (CR) examinations were also commonly uploaded (Fig. 2).

Fig. 1
Fig. 1
Total images transferred using DIUP annually
Fig. 2
Fig. 2
Total images transferred using DIUP per modality and estimated file size in megabytes (CR computed radiography, CT computed tomography, MR magnetic resonance, US ultrasound, XA X-ray angiography and Other modalities including nuclear medicine, digital ...
The number of external CDs handled with this procedure increased over the 89 months period in steps from less than 600 CDs uploaded each month in the 1st year to an average of more than 1,300 CDs uploaded per month in the last year (Figs. 3 and ​and4).4). The yearly upload of CDs shows an annual increase of 1,500–2,000 CDs, with a current total of 18,000 CDs in 2012 (Fig. 5).

Fig. 3
Fig. 3
Number of CDs transferred in the first 12 months (August 2005 to July 2006)
Fig. 4
Fig. 4
Number of CDs transferred in 2012
Fig. 5
Fig. 5
Total number of CDs transferred using DIUP
Roughly, an average of 60 gigabytes (GB) of uncompressed images per month or 720 GB of uncompressed images per year were added into the PACS in the early stages of using DIUP. In 2012, the amount of images stored through the DIUP reached 360 GB uncompressed per month or an average of 4.2 terabyte (TB) uncompressed per year, which accounts for approximately 28 % of the total current storage per year on our PACS environment.

Other institutions

We conducted a survey in 39 Dutch hospitals to determine the extent of the use of portable media and whether there is a plan for moving into the latest technology. In total, 14 questionnaires were filled in online, each came from a different institution. This is a response rate of 36 %. All the completed questionnaires were included into the analysis, subject to quality criteria (i.e. no missing indicators and values).

Twelve out of 14 respondents stated that their hospital was still using CD/DVD as the method of data sharing, while three of them also used other alternative portable media to share data (Table 1). The use of network-based methods is still rare, shown by only one hospital that already implemented cross-enterprise document sharing (XDS), but also still utilise the CD/DVD method for image sharing. This mainly caused by the fact that not all other cooperating institutions are able to connect to the XDS environment.

Table 1
Table 1
Methods used by institutions for sharing data
The survey indicates that at least 60 CDs/DVDs arrive and 75 CDs/DVDs are produced every week in a hospital and reaches up to an arrival of 425 CDs and to a production of 200 CDs per week in a large university hospital (Fig. 6).

Fig. 6
Fig. 6
CD production and arrival in respondent’s institution each week
All hospitals currently using CD/DVD for data transfer uploaded the incoming images to their PACS. Almost all institutions stated that they are planning on moving into a network-based solution, such as XDS/XDS-I in the near future (Table 2).

Table 2
Table 2
Planning on moving to network based solution
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Discussion
The results presented in this study clearly show an enormous increase in the amount of data shared between healthcare institutions. The increased use of the upload of data from portable media into the hospital infrastructure shows that it is providing an important service to the hospital. However, although data sharing is beneficial in improvement of quality of patient care and should be done when needed, the amount of data shows that without a software tool as described above, the handling of the CDs with patient data will become virtually impossible.

Even though uploading images from CDs into PACS is likely to reduce the rate of repeat imaging in one institution [14], a centralised upload into PACS by the radiology department, as mainly implemented by most PACS vendors, is often leading to large stacks of CDs and very high workload. By providing a decentralised upload, the workload is divided over multiple departments. The time required to perform the CD handling will be approximately the same regardless of who does the upload. However, the time required with centralised upload to take care of internal shipping of the media and keeping track of the progress of the handling is saved when using decentralised upload.

An additional benefit of the decentralised upload is that the CD remains at the point of care, which means that in case of an emergency situation requiring access to the image data before upload process has finished, the image data remains available at the point of care by using the original CD/DVD.

Previous evaluation showed that the procedure developed at our institution using decentralised uploading of the data works very efficiently and allows easy access to the data [13]. This is indicated by the satisfaction from the respondents in the referred work where 63 % rated the procedure as excellent, compared with the manual procedure, while the rest marked the system as good. The growing use has shown a wide scale adoption of the method throughout the hospitals, thus suggesting a preferred procedure compared with reading directly from CD/DVD.

However, although the utility of our system with decentralised uploading is alrea