To evaluate a conventional radiology image management system, by investigating information accuracy, and information delivery. To discuss the customization of a picture archival and communication system (PACS), integrated radiology information system (RIS) and hospital information system (HIS) to a high volume emergency department (ED). Materials and Methods: Two data collection periods were completed. After the first data collection period, a change in work rules was implemented to improve the quality of data in the image headers. Data from the RIS, the ED information system, and the HIS as well as observed time motion data were collected for patients admitted to the ED. Data accuracy, patient waiting times, and radiology exam information delivery were compared. Results: The percentage of examinations scheduled in the RIS by the technologists increased from 0% (0 of 213) during the first period to 14% (44 of 317) during the second (p less than 0.001). The percentage of images missing identification numbers decreased from 36% (98 of 272) during the first data collection period to 10% (56 of 562) during the second period (p less than 0.001). Conclusions: Radiologic services in a high-volume ED, requiring rapid service, present important challenges to a PACS system. Strategies can be implemented to improve accuracy and completeness of the data in PACS image headers in such an environment.