PACSPACS Outside Outside

RadiologyRadiologyDr Keith Foord

Consultant RadiologistEast Sussex Hospitals, UK

`basic’ web viewers used in many clinical settings

Radiology integration in the multi-disciplinaryworkplace

Enterprise wideMulti-speciality

PACS“In an Enterprise PACS Radiology images account for 30% or less

of image volume…. It quickly became clear that many images sources outside of radiology were not being captured, and if they were they were not available for

enterprise distribution, nor linked to the electronic patient record

Another problem related to workflow. There was no RIS entry – no accessionnumber and no entry on the DICOM MWL….. Perhaps the biggest problem with

expanding PACS is the lack of informatics standards in other departments. Some ophthalmology images are so proprietary that there is (essentially) no out

put.”

Gary Wendt U Wisconsin SCAR 2005

EnterprisePACS

“One of the things we believe is that a radiology PACS, by itself, will not provide an adequate return on investment.

The (enterprise) PACS must become part of the Electronic Patient Record to take advantage of electronic ordering, scheduling and reporting.

To accommodate this we add 1.5 to 2 TB of storage EACH MONTH”

Ramin Khorasani MD, Director of Information Management for Radiology, Brigham and Women’s Hospital, Boston

Q. Who works with images?Image producers

Image viewers – passive/learning

Image interpreters and reporters

Image interpreters / concurrent operators

Image users – planning

Image users – virtual endoscopy

Image users – real time guided therapy and surgery

A. Almost everyone, and if they don’t access to images would enrich their clinical lives

Image producers

The IT systems they use and how they record and manage images affects the remainder of the operation……

and many others

Scanned Images

Visual Light

and

Radiotherapy

Capturing non radiological, scanned in images(includes images of request forms if no Order-Entry system linked via an EPR)

Scanned images – TWAIN

High end Scanned images – ISIS

Both can be converted using DICOM Secondary capture and DICOM GWL via a PACSport computer.Pdf files can now be DICOM encapsulated

Capturing Visual Light Images

What is DICOM-VL?DICOM-Visible Light is an Supplement to integrate visible light images into DICOM

Microscopy, endoscopy and digital photography.

In particular, DICOM-VL specifies how to store preparation procedures and image-acquisition conditions in the image headers. It allows other ‘ologies’ to implement the DICOM standard, allowing their integration into EPRs

It is the first real visible light image standard and allows display of these images next to radiological images on a DICOM viewing station.

Part of the DICOM standard since 1999. DICOM minutes show struggle to obtain interest or expertise from medical VL companies,

but better recently and DICOM MPEG2 Video soon (?now)

Pathology PACS…a rather special case!

“Glass slides must be scanned at at least 400x

Generates up to 6 GB per slide

Scanning a single slide can take up to 20 mins, but developments are expected to reduce this to 1 minute.

Compression of 15:1 can be applied, but will still generate 134 GB per day – 3 TB per monthThis will require 350 TB storage over 10 years”

Kai Saeger, Charite Institute of Pathology, Berlin CARS2003

“In the last few years, dynamic telepathology has been the only real digital application that has been able to transmit wide areas of microscopic preparations Dynamic telepathology is a real-time technology system. Only a few systems are able to store and create a database of the transmitted cases e.g. Bliss by BacusLabs. http://www.bacuslabs.com//.

A WebSlide can be created either in uncompressed .bmp format or in .jpg format.

These systems are very expensive because they work by means of a robotic microscope, and the software for image viewing and interaction is often sophisticated and only available with the purchase of apparatus. A WebSlide can be created either in uncompressed .bmp format or in .jpg format”

Francesco Alfredo Zito1, Franco Marzullo1, Diego D'Errico1, Cesare Salvatore1, Rosanna Digirolamo1, Angela Labriola1 and Antonio Pellecchia2

1 Division of Pathology2 Division of Digestive Endoscopy, National Cancer Institute, Bari, Italy

Each of these slides from one pathological specimen must be Scanned (BacusLabs system)

This is a 3 2 mm image of an endoscopic gastric biopsy.

The 7200 5200 pixel image was digitized at an objective magnification of 20.

A total of 20 still pictures are required to generate a large image of 85 MB in TIFF format, which is then compressed into a 9 MB Quick Time VR file.

The entire digitization process takes 60 min. The quality of the movie is related to the quality of initial images

Quicktime virtual reality technology in light microscopy to support medical education in pathologyFrancesco Alfredo Zito1, Franco Marzullo1, Diego D'Errico1, Cesare Salvatore1, Rosanna Digirolamo1, Angela Labriola1 and Antonio Pellecchia21Division of Pathology2Division of Digestive Endoscopy, National Cancer Institute, Bari, Italy

Image viewers – passive/learners

PET-CT SPECT-CT

Bachuslabs.com

Agfa Web 1000

As most viewers are not specialists need skilled interpretive reports with images.Means must have coherent IT systems to input these with no error. Related images – and their reports should be linked together

Potential for systemsfragmentation if needto maximise integrationnot recognised by differentproject groups.

A corporate knowledgedeficit / lateral thinkingissue

Image interpreters and reporters

• A & B scan Ultrasound• Corneal Topography• Automated field analysers• Optical Coherence Tomography (OCT)

Reminder….

“Perhaps the biggest problem with expanding PACS is the lack of informatics standards in other departments.

Some ophthalmology images are so proprietary that there is (essentially) no out put.” Gary Wendt U Wisconsin SCAR 2005

Image interpreters and concurrent operators. Use old images to plan, but dynamic image users in operation, recording new images - still and short video clips to be added to patient file

Image users – planning

3D CT images –help with Orthoreconstruction

CTA – diagnosticstudy prior to IRangioplasty of ext.iliac artery

DICOM RT is the the extension of the DICOM 3.0 standard which handles the Radiotherapy modality. It was developed to extend the current DICOM 3.0 standard to include the RT modality, rather than produce a completely new standard

Seven new objects define the RT modalityDICOM-RT is not a separate standard - it is an extension, defining 7 new objects:- RT image- RT dose- RT structure set- RT plan- RT treatment record (beam session, brachy session, summary). Beams are defined with a system of "control points

RT ImageIncludes all the normal RT images, DRRs, portal images, simulator images and radiogramsRT DoseThe total dose distributions from the planning system; dose matrix, dose points, isodose curves and dose volume histograms.RT Structure SetPatient related structures identified from diagnostic data, CT, virtual simulations and treatment planning systems.RT PlanThis is the geometric and dosimetric data for course of external beam treatment or brachy-therapy.RT Treatment Record Records all the treatment session data.

Radiotherapy Planning

“Virtual endoscopy focuses on the virtual representation of minimally invasive procedures for training, planning, and diagnosis without an actual invasive intervention.

In the past few years, virtual endoscopy modes have been transferred from research systems in virtually every commercial medical imaging software, but with a varying quality and exibility.

It is based on a 3D scan of the respective body region. Examples for these scans are CT (Computed Tomography) scans, MRI (Magnet Resonance Imaging) scans of the abdominal area, the heart, the head, the lungs, or rotational angiography of blood vessels in various body parts. Based on the resulting volumetric data, the organs of interest are visualized and inspected from interior (.endo.) viewpoints.”

Virtual Endoscopy in Research and Clinical PracticeDirk Bartz, Visual Computing for Medicine Group, University of TübingenEurographics 2003

The video images need embedding in PACS…this video is 36 kBytes

Image users – virtual endoscopy

Virtual Endoscopy in Research and Clinical PracticeDirk Bartz, Visual Computing for Medicine Group, University of TübingenEurographics 2003

Planning endoscopic neurosurgery

The lung tumour is not visibleon virtual bronchoscopy, butthe site for a trans-bronchial biopsy is mapped in green

More VIRTUAL ENDOSCOPY

These VE images should be available in the VL endoscopy suitevia enterprise PACS

Image users – real time guided therapy and surgery

midturbvirtendosc.jpg

GE Medical Systems

Sinus surgery.The cross lines showThe position of the probeon the correspondingCT in x,y and z axes

Digital OR Images

 

                                      

                           Smith and Nephew website :UPMC Southside Hospital

BrainLAB AG

HEAD-MOUNTED DISPLAYS AND AUGMENTED REALITY Visual interfaces—like haptic interfaces—are used to immerse participants in a virtual environment. These displays range from conventional desktop screens to head-mounted displays, depending on the degree of reality required.

Head-mounted displays consist of goggles that afford a stereoscopic view of the computer-generated environment. A sense of motion is created by continuously updating the visual input with positional information derived from the participant's head movements. Collected by a tracking system connected to the display, this information is fed back to the computer controlling the graphics.                                                

Microvision's display system uses anatomical, biochemical, and physiological images and other data to guide surgeons through procedures.                       

The computer assisted approach allowed a smaller, exactly placed craniotomy primarily in MCA aneurysms. 3D presentation of the aneurysms and the adjacent arteries in correct orientation facilitated identification and dissection the aneurysms. Current navigation systems are not precise enough to allow “blind” aneurysm clipping by placing a real clip on the virtual aneurysm neck.

Minim Invasive Neurosurg 2003; 46: 269-277

R.  Schmid-Elsaesser1, A.  Muacevic1, M.  Holtmannspötter2, E.  Uhl1, H.-J.  Steiger1

Neuronavigation Based on CT Angiography for Surgery of Intracranial Aneurysms: Primary Experience with Unruptured Aneurysms

Vectorvision’s FDAApproval to market2004

Most recent p

apers suggest navigatio

nal accuracy of these systems to within 1 – 1.5 mm

Most recent p

apers suggest navigatio

nal accuracy of these systems to within 1 – 1.5 mm

They are not yet accuarte enough to perfo

rm say aneurysm clipping with

out skilled

They are not yet accuarte enough to perfo

rm say aneurysm clipping with

out skilled

surgical final m

anouevres

surgical final m

anouevres

Incorporated into the report are captured images of key findings (which can be exploded to full screen presentation), structured diagnosis information, recorded video and audio, the ability to sort findings by anatomy or priority, to view prior findings associated with the corresponding patient and hyperlinks to related information.

      

DICOM SR – is an ‘envelope’, but within this useful structure is available.

It allows linkage to other DICOM objects, including between associated radiological and other images and waveforms. CAD outputs can be in SR format.

User decides how much structure to use and controls with templates the type of content, if it is mandatory or optional and modes of expression

Structured reporting

DICOM Structured Reporting", Dr. David A. Clunie, ISBN 0-9701369-0-0

PointDx

Dilemma– products from many different vendors

– hardware & software incompatibility

Goal– prevent being vendor dependent

- consumer locked into specific products

– component interoperability “plug and play”

– seamless integration with “other” IT

John A. Carrino, M.D.

Assistant Professor of Radiology

Information Management Group

Jefferson Health System

ISSUES for Enterprise PACS

• Image data set size – MDCT/Pathology

• Image storage volumes• Networking• Integration

• RIS becomes IIS within EPR, but preferably an integrated RIS becomes IIS within EPR, but preferably an integrated component of the EPRcomponent of the EPR

• Image and data Protocols• Lack of protocol standards and expertise with some

vendors• DICOM & IHE• Corporate awareness and lateral thinking

Quite clearly if we do not all eat and think together

Enterprise wide PACS may be a very long time coming

“Perhaps the biggest problem with expanding PACS is the lack of informatics standards in other departments.”Gary Wendt U Wisconsin SCAR 2005

Vendors of all medical imaging equipment, not just in radiology, must be brought into the IHE and DICOM fraternities. We need to educate hospital operators and image users in all clinical specialities not to buy bespoke IT solutions. Keith Foord Conquest Hospital UK CARS 2005

CfH looking to integrate other ‘ologies’ within 2 to 4 years