evolution of teleradiology. elizabeth krupinski, phd
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Elizabeth A. Krupinski, PhDArizona Telemedicine
Program
Ovitt , et al.Intravenous angiography using digital video subtraction: x-ray imaging system.AJR 135(6):1141-4, 1980.
An x-ray imaging system, using digital subtraction techniques, has been developed. The system requires: (1) high output generation equipment; (2) an image intensif ier capable of receiving high output exposures, 1 mR (2.58 X 10(-7) C/kg) at the face of the intensif ier, without loss of either contrast or resolution; (3) a precision digital video camera; (4) processing computer with sufficient storage capacity; and (5) digital image storage. With this system it is possible to visualize the major arteries after intravenous contrast injection.
Capp et al.The digital radiology department of the future.Rad Clin N Am 23(2):349-55, 1985.
The boom in microelectronics, including cost-effectiveness, hasnow allowed us to consider the use of these objects to storedigital images. There remains much research, development, And clinical evaluation to be done in receptor technology. Further improvements in image processing, optical laser disk storage, & optical transmission and further commercial Development of display technology must take place. All of These developments are occurring simultaneously . Within 5 to 10 years, radiology departments wil l most l ikely be totallyelectronic, probably cost-effective, and, i t is hoped, morediagnostically accurate.
Oldest established TM application Well integrated in numerous settings Facil itated by co-evolution PACS Few to no reimbursement issues Only interventional radiology currently
less amenable to teleradiology applications
Litt le/no differences between teleradiology & on-site radiology
ACR-NEMA development DICOM Continual updates of DICOM Development of standards & practice
guidelines that explicit ly include teleradiology
http://medical.nema.org/ http://deckard.duhs.duke.edu/~samei/tg18.htm
Key is the human-computer interface
Series of observer performance studies designed to optimize the digital reading room environment
Performance metrics◦ Diagnostic accuracy (ROC)◦ Search eff iciency (eye position)
Human Visual System Modeling
Softcopy display parameters◦ Luminance◦ Calibration (tone scale)◦ Type of phosphor◦ CRT vs LCD◦ MTF◦ Viewing angle◦ Number of displays◦ Ambient l ighting◦ Compression◦ Role of color
P45 P104
Spatial & contrast resolut ion l imitations require radiologists to search images. The UVF is about 2.5 deg radius. Probabil i ty of target detection fal ls off as a function of target eccentricity from axis of gaze.
Total viewing time shorter Time to first hit shorter Total t ime on lesion shorter Fewer returns to lesion Total path length shorter Overall = more EFFICIENT
TaskTask
ExperienceExperience
Med StudentResidentPathologist
Display & InterfaceDisplay & Interface
20% fixations fell outside diagnostic image
Hospital/MC Clinics Mobile van◦ Mammo
Dedicated◦ PET cl inic◦ THH◦ UASA
Public Health Battlef ield Hand-held
Medical Imaging Consultants -> ? ◦Data acquisit ion & archiving
RadWorks (GE) -> Siemens/Fuji◦ Viewing station
35% of department’s reading volume 25% department’s income ◦Reading only & reading + archiving◦ $/case & $/set volume
68% sites using AHSC hub for TM services use TR service
TR typically 1 s t service requested◦ 79% of sites with TR use only TR◦ 21% started with TR & added
services TR specialty with most volume
Time from mammography to consult with oncologist ~ 28 days◦ Screening mammography◦Diagnostic mammography◦ Biopsy◦ Pathology processing & report◦Oncology consultation
THIS IS TOO LONG!
Even Worse in RuralEven Worse in Rural
- DS3 (45 Mbps) backbone- ATM protocol
- T1 (1.5 Mbps) links- 65 direct link sites- ~ 85 with affiliated - NARBHA- DOC- IHS
- RT & SF applications- ~ 55 sub-specialties- Teleradiology core app.
Started in 2001 to rural sites 7/28 telerad sites send mammo Mostly use GE system Directly to TBC for reading Some archive some do not Contracts specify 30-45 min TAT > 26,000 telemammography
MammographySurgical
ConsultationBreast Care Biopsy
Rapid tissue processing
Virtual slide scanning
Laboratory report
Telemedicine
Clinic
Digital Mammography
(Teleradiology)
Telepathology
Cancer specialistTeleconsultation
UltraClinic Model
Milestone Medical Systems RHS-1-30 Milestone Medical Systems RHS-1-30 Vacuum HistoprocessorVacuum Histoprocessor
Quick Processing
DMetrixTM -40 Slide Scanner DMetrixTM -40 Slide Scanner SystemSystem
TelepathologyTelepathology
Lab Process MinutesGrossing 3Tissue Processing 58Embedding 13Cutting 10Stain/Dry/Coverslip 32Scanning (2 Slides) 13LM Interpretation 6Telepathology 14
Telepathology report sent S&F to oncologist
Oncologist connects RT videoconference to rural location
Discuss pathology results If necessary discuss treatment
options and plan of action
MI = prevention, detection, diagnosis, treatment & therapy
Acquisit ion & display technology continually changes
Clinician shortages are not easing Rapidly expanding types & number images◦ Multi-modality & fusion complimentary
information sources is becoming common◦ Anatomy & function gross & molecular levels◦ Merging specialt ies
(Quon et al. J Cl in Oncol; 2005; 23:1664-1673)
Clarke et al. Validation if Tumor Burden Measurements Using 3D Histopathology. In: Digital Mammography 2008. Springer-Verlag.
Image Display, Analysis & Processing are key l inks in the imaging chain
Need to present data to the cl inician in the most eff icient & informative manner
Taking into account perceptual & cognit ive capabil i t ies of human observer
Ultimate goal = facil i tate decision-making process & enhance patient care
Related goal = improve workflow & the reading environment
Stereo vs Tradit ional
- Az 0.85 to 0.94
-23% increase TPs
-105% increase calcs
- 46% decrease FPsGetty et al. Stereoscopic Digital Mammography: Improved Accuracy of Lesion Detection in Breast Cancer Screening.In: Digital Mammography 2008. Springer-Verlag.
50 DR chest images (PA) : 1/2 solitary pulmonary nodule verif ied CT; 1/2 nodule free
6 radiologists (3 sr residents, 3 board-cert if ied)
3MP Barco color medical-grade display (Barco Coronis MDCC-3120-DL) vs COTS color 2MP monitor (Dell 2405)
Calibrated (DICOM GSDF ) to luminance corresponding to backlight aging 1-year t ime ◦ Max Barco 500 cd/m 2 min 0.77 cd/m 2
◦ Max Dell COTS 342 cd/m 2 min 0.376 cd/m 2
0
0.2
0.4
0.6
0.8
1RO
C A
z
Read
er 1
Read
er 2
Read
er 3
Read
er 4
Read
er 5
Read
er 6
Mea
n
Medical Grade
COTS
F = 4.1496, p = 0.0471Sensit ivity = 0.91 vs 0.86Specif icity = 0.93 vs 0.92
05
1015202530354045
Mea
n Vi
ewin
g Ti
me
(sec
)
Read
er 1
Read
er 2
Read
er 3
Read
er 4
Read
er 5
Read
er 6
Mea
n
Medical Grade
COTS
F = 3.38, p = 0.067
0
0.5
1
1.5
2
2.5
3
3.5
4
Mea
n Ti
me
Firs
t H
it (s
ec)
TP FN FP
COTS
Medical Grade
0
1
2
3
4
5
6
7
8
Cum
ulat
ive
Dw
ell (
sec)
TP FP FN TN
COTS
Medical Grade
No significant differences
TN significantly different
Firs t (Re feren ce ) Im ag e Or igin al sR GB Im ag e o n Displa y with S hif ted P r im ar ies
S-CIELAB Delta-E Image Map RMS Delta-E = 3.3997
200 400 600 800 1000
100
200
300
400
500
600
7005
10
15
20
25
30
35
40
Carpal tunnel syndrome Elbow & shoulder (cubital tunnel) Neck, back & shoulder strains Computer vision syndrome◦ Eye strain◦ Dry eyes◦ Glaucoma◦ Headaches◦ Corneal erosion and abrasions◦ Contact lens problems
Reader Fatigue
BLURRED VISION
Variable How long correlation How many correlation
Blurred vision R = 0.344 p = 0.0113 R = 0.422 p = 0.0015
Eyestrain R = 0.429 p = 0.0012 R = 0.475 p = 0.0003
Difficulty focus R = 0.384 p = 0.0042 R = 0.446 p = 0.0007
Headache R = 0.235 p = 0.0899 R = 0.432 p = 0.0011
Neck strain R = 0.384 p = 0.0042 R = 0.549 p < 0.0001
Shoulder strain R = 0.250 p = 0.0711 R = 0.469 p = 0.0003
Back strain R = 0.304 p = 0.0265 R = 0.424 p = 0.0014
General fatigue R = 0.471 p = 0.0003 R = 0.642 p < 0.0001
TR has made a signif icant impact on patient care over the past 20 years
Advances in technology wil l further change MI & interpretation of medical data by more clinicians
Costs can increase & decrease Optimizing observer accuracy while
maintaining eff iciency & comfort are crit ical to continued success
THANK YOU!
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