RADIOLOGY & ITRADIOLOGY & ITMerger or Collision ?Merger or Collision ?

David P. Mayer, MD,MS,FACRDavid P. Mayer, MD,MS,FACRClinical Professor of RadiologyClinical Professor of Radiology

Drexel University College of MedicineDrexel University College of Medicine

RADIOLOGY & ITRADIOLOGY & ITOUTLINEOUTLINE

What is Radiology? What is Radiology? Connectivity & Image Connectivity & Image

ManagementManagement Alphabet Soup: DICOM;PACS Alphabet Soup: DICOM;PACS

and IHE et al.and IHE et al. The Future of IT & RadiologyThe Future of IT & Radiology SummarySummary

Diagnostic RadiologyDiagnostic RadiologyRe-Defined:Re-Defined: The use of various The use of various

imaging tools to examine the bodyimaging tools to examine the body

in order to guide patient treatmentin order to guide patient treatment

There is an There is an information chaininformation chain that that connects the patient and referring connects the patient and referring Doctor to the Radiology Department Doctor to the Radiology Department which responds with useful diagnosticwhich responds with useful diagnosticinformationinformation

““Radiology is an applied IT field”Radiology is an applied IT field”

Email & Fax

Diagnosis?

rDigital Image:

A Dx Puzzle

Results

““You’ve got You’ve got Questions,Questions,We’ve got answers!”We’ve got answers!”

Radiology: “Information Steps”Radiology: “Information Steps”

The Radiologist Works HERE!

Imaging Tools:Imaging Tools:CT Scanning (CAT Scan)CT Scanning (CAT Scan)MRI (Magnetic Resonance Imaging)MRI (Magnetic Resonance Imaging)UltrasoundUltrasoundAngiography & InterventionalAngiography & InterventionalX-ray & FluoroscopyX-ray & FluoroscopyMammography & etc. Mammography & etc.

Ultrasound

CT Scanning MRI

Diagnostic Radiology: IT IssuesDiagnostic Radiology: IT Issues

Imaging Challenges:Imaging Challenges:Xs Digital Data (225K Cases/yr=3Tb/yr)Xs Digital Data (225K Cases/yr=3Tb/yr)Future = Video Display (Film is “dead”)Future = Video Display (Film is “dead”)Digital transmission via Inter and IntraNetDigital transmission via Inter and IntraNetDisseminated Access is RequiredDisseminated Access is RequiredDemandsDemands Xs Bandwidth; Redundancy; 3-5 Xs Bandwidth; Redundancy; 3-5 Megapixel Display @ >500:1 contrast; Long Megapixel Display @ >500:1 contrast; Long term Image & Data Archival; Rapid Access term Image & Data Archival; Rapid Access with report info & Demographics; with report info & Demographics; Standardized format- i.e. DICOM; Image Standardized format- i.e. DICOM; Image Manipulation tools; etc.Manipulation tools; etc.

Computer DataComputer Data

ByteByte == 8 bits or 256 shades of gray8 bits or 256 shades of gray

KilobyteKilobyte == 1024 Bytes1024 Bytes

Megabyte =Megabyte = 1024 Kbytes (KB)1024 Kbytes (KB)

GigabyteGigabyte = = 1024 Mbytes (MB)1024 Mbytes (MB)

TerabyteTerabyte = = 1024 Gbytes (GB)1024 Gbytes (GB)

Average Average Word processing DocWord processing Doc < 100KB < 100KB

Average Average (Digital) Radiology Exam(Digital) Radiology Exam =25MB =25MB

SingleSingle Digital X-Ray = Digital X-Ray = 10 MB10 MB

Network StandardsNetwork Standards

PACS data loads are PACS data loads are hugehuge

Requires high speed/high capacity Requires high speed/high capacity networknetwork

@ 100 – 1000Mb/sec@ 100 – 1000Mb/sec

MHSMHS data volume/year ~ data volume/year ~ 3TBytes/yr3TBytes/yr

Data Multiplication:Data Multiplication: exams move exams move many times across the networkmany times across the network

Diagnostic Radiology: IT IssuesDiagnostic Radiology: IT Issues

Read-to-write ratioRead-to-write ratio:: In healthcare because many different In healthcare because many different medical professionals repeatedly access the same data. medical professionals repeatedly access the same data.

Data lifecycle:Data lifecycle: Process by which you can move data from online Process by which you can move data from online storage, to near online, to tape, to archive—is specific to storage, to near online, to tape, to archive—is specific to healthcare. healthcare. RRecall dataecall data: Captured years earlier & Accessed very quickly.: Captured years earlier & Accessed very quickly.

Disparate data:Disparate data: Generated, captured, and stored in different Generated, captured, and stored in different locations & different applications, with different Dx modalities. locations & different applications, with different Dx modalities.

Requirement:Requirement: Link the images with the patient's chart, pharmacy Link the images with the patient's chart, pharmacy records, billing information, etc..records, billing information, etc..

Health Insurance Portability and Accountability Act Health Insurance Portability and Accountability Act (HIPAA):(HIPAA): 1.1. Providers must communicate information between different Providers must communicate information between different

stakeholders in the system including doctors, stakeholders in the system including doctors, hospitals, insurance companies, and the Federal hospitals, insurance companies, and the Federal

governmentgovernment2.2. Information Information mustmust be secure at every step in the process. be secure at every step in the process.

Diagnostic RadiologyDiagnostic RadiologyPACS:PACS: “Picture Archival & “Picture Archival & Communication System”Communication System”

DICOM:DICOM: A Digital Communication A Digital Communication Standard between DiagnosticStandard between Diagnostic

Modalities & PACSModalities & PACS

IHE:IHE: “Integrating the Healthcare “Integrating the Healthcare

Enterprise”Enterprise”

““Radiology is an applied IT field”Radiology is an applied IT field”

PACSPACS & Diagnostic Radiology & Diagnostic RadiologyPACSPACS:: “Picture Archival & “Picture Archival & Communication System”Communication System”Provides a means to Provides a means to move, display move, display and store imagesand store images generated by generated by radiology or other hospital depts.radiology or other hospital depts.Radiology Radiology “product”:“product”: The The interpretationinterpretation of an image of an imageInterpretations Interpretations MUSTMUST be timely! be timely!

PACSPACS““Any image, anywhere, Any image, anywhere,

anytime – and fast”anytime – and fast”Northwestern Memorial Hospital, Northwestern Memorial Hospital,

Chicago, IllinoisChicago, Illinois

PACSPACSKey Components:Key Components: Modality InterfacesModality Interfaces Network BackboneNetwork Backbone Database Management Database Management

SystemSystem Image Management SystemImage Management System Long term ArchiveLong term Archive DiagnosticDiagnostic Workstations Workstations Clinical WorkstationsClinical Workstations Web server Access to Web server Access to

imagesimages

PACSPACSAdvantages:Advantages: Redundant Archives; Cost savings: Film, Redundant Archives; Cost savings: Film, Chemicals, Storage Space; Manpower, & Time !!!Chemicals, Storage Space; Manpower, & Time !!!PotentialPotential Increased productivity Increased productivity

Reduced Turnaround timeReduced Turnaround timeReduced Retakes & Lost FilmsReduced Retakes & Lost FilmsEasier consultation & Stat reportingEasier consultation & Stat reporting

Disadvantages:Disadvantages: Large Capital $ outlay; Requires new Large Capital $ outlay; Requires new work paradigm; Clinician cooperation?; Reinvestment work paradigm; Clinician cooperation?; Reinvestment are requiredare required

Cultural shift:Cultural shift: Age and Medical Specialty Age and Medical Specialty dependentdependent

PACS: PACS: 2006-72006-7

Hospitals w/o PACS:Hospitals w/o PACS:The question shifts from “if” to “when”The question shifts from “if” to “when”

Approx. 50% of US HospitalsApprox. 50% of US HospitalsHospitals w/ PACS:Hospitals w/ PACS:Upgraded systems: Upgraded systems:

IHE Networking IHE Networking Upgraded data handling capabilitiesUpgraded data handling capabilitiesUpgraded computers & monitors to Upgraded computers & monitors to

LCD’sLCD’s

PACS: PACS: 2006-72006-7

Upgraded systems:Upgraded systems:

99.99% Network & PACS Uptime99.99% Network & PACS Uptime::

Redundancy; “self healing”Redundancy; “self healing”

99% uptime = 1 failed day/100d99% uptime = 1 failed day/100d

RequirementsRequirements::

HL7; DICOM; IHE standardsHL7; DICOM; IHE standards

HIS+RIS+PACS: HIS+RIS+PACS:

““seamless” & “bidirectional”seamless” & “bidirectional”

Modality “worklist” (MWL) etc.Modality “worklist” (MWL) etc.

Wireless systems??Wireless systems??

PACS: PACS: 2006-72006-7

Upgraded systems:Upgraded systems:

PACS is “Not just for Radiology”:PACS is “Not just for Radiology”:

Cardiology & PathologyCardiology & Pathology E.M.A. E.M.A.

[“-ologies” : common data storage][“-ologies” : common data storage]

Data Storage requirements:Data Storage requirements:e.g. MD-CT: 64+ slices; Digital Mammo;e.g. MD-CT: 64+ slices; Digital Mammo;

ultrasound video clips; High res. MRI;ultrasound video clips; High res. MRI;

FasterFaster Spinning media archive access Spinning media archive access

3D renderings3D renderings

PACS: PACS: 2006-72006-7

PACS: PACS: 2006-72006-7

Upgraded systems:Upgraded systems:

““Off the shelf” hardwareOff the shelf” hardware

““Software only” solutionsSoftware only” solutions

Mergers:Mergers:

Images with Voice Recognition Images with Voice Recognition generated reportsgenerated reports

Hospital-wide Image & DataHospital-wide Image & Data

Clinical Data w/ ImagesClinical Data w/ Images

Surgical templates w/ imagesSurgical templates w/ images

Healthcare IT IssuesHealthcare IT IssuesIT Government Oversight:IT Government Oversight:

HIPAA: HIPAA: Audit trails requiredAudit trails requiredFDAFDAState & Local Health RegulationsState & Local Health Regulations

HIPAA:HIPAA:1. 1. Electronic Data format standards:Electronic Data format standards:2. 2. Privacy:Privacy: Integrity & Confidentiality of Integrity & Confidentiality of patient info. patient info. Flexibility vs. privacyFlexibility vs. privacy3. 3. Security:Security: Storage, Transmission and Storage, Transmission and Display Data protection. Display Data protection.

*PHI (Protected Health Information) *PHI (Protected Health Information) requires User Authentication requires User Authentication*Every data access must be logged*Every data access must be logged*Secure Storage & Transmission*Secure Storage & Transmission

PACS: PACS: 2006-72006-7

Upgraded systems:Upgraded systems:

HIPAA Compliant security systemsHIPAA Compliant security systems

Site requirements:Site requirements:

PACS administratorPACS administrator

Voice recognition AdministratorVoice recognition Administrator

Teamwork:Teamwork:

Healthcare IT DilemmaHealthcare IT DilemmaSecuring clinical Information systemsSecuring clinical Information systems

““CIA Triad”:CIA Triad”: ConfidentialityConfidentiality; ; IntegrityIntegrity & & AvailabilityAvailability

Confidentiality:Confidentiality: Staff & Pt. Data must be Staff & Pt. Data must be protectedprotected

IntegrityIntegrity:: Correct & Complete data; Correct & Complete data; Legal & HIPAA: sanctionsLegal & HIPAA: sanctions

Availability:Availability: Timely and secure access; Timely and secure access; Mission criticality: 24/7/365Mission criticality: 24/7/365

Tradeoff:Tradeoff:

Protected Info. vs. Ease-of-useProtected Info. vs. Ease-of-use

HIPAA – Its Impact on RadiologyHIPAA – Its Impact on Radiology

Cost estimates: $2B-43BCost estimates: $2B-43B

Security for Radiology Reports & ImagesSecurity for Radiology Reports & Images

Digital environment: Digital environment:

Authentication: “Who are you” ? Authentication: “Who are you” ?

Encryption: “Encode the data”Encryption: “Encode the data”

Access: “Need to know” basisAccess: “Need to know” basis

DICOMDICOM (Digital Image Communication in Medicine):(Digital Image Communication in Medicine):A A standard forstandard for imageimage communication in the communication in the medical field, that is supported by most medical field, that is supported by most vendors of digital imaging devices (CT, vendors of digital imaging devices (CT, MR, MR, digital X-Ray, ultrasound, etc.). digital X-Ray, ultrasound, etc.).

DICOMDICOM standard includes a detailed description standard includes a detailed description of the of the patient information withpatient information with the imagesthe images and and the way the images are sent the way the images are sent

between different devices:between different devices: e.g. between a CT scanner and a PACS e.g. between a CT scanner and a PACS

(Picture Archival and Communication System)(Picture Archival and Communication System)

DICOM 3DICOM 3 (Current level):(Current level):

ACR & NEMAACR & NEMA: Formed joint committee : Formed joint committee to develop Digital Imaging to develop Digital Imaging standardsstandards

Other participating organizationsOther participating organizations: : IEEE, HL7, ANSI, JIRA, etc.IEEE, HL7, ANSI, JIRA, etc.

Allows Gateway to HL7, wwwAllows Gateway to HL7, www

HIS/RIS – PACS Communication:HIS/RIS – PACS Communication: Optimal: Bidirectional interface Optimal: Bidirectional interface between HIS/RIS & PACSbetween HIS/RIS & PACS Minimizes data entry errorsMinimizes data entry errors

Est. 15% of medical data entries have errors !!!Est. 15% of medical data entries have errors !!! Faster reporting and image availabilityFaster reporting and image availability Pre-fetching of old reports & examsPre-fetching of old reports & exams Modality Work List: Data Modality Work List: Data Scanner Scanner

DICOMDICOMNote:Note:

Gary Wendt, MD

“

”

i.e. The devil is in the details !

DICOM DICOM http://medical.nema.org/http://medical.nema.org/

Many Capabilities are included under the Many Capabilities are included under the “DICOM” name “DICOM” name [e.g. [e.g. 1212 DICOM “Classes”] DICOM “Classes”]DICOM Verification Service Class DICOM Verification Service Class DICOM Storage Service Class DICOM Storage Service Class DICOM Query/Retrieve Service Class DICOM Query/Retrieve Service Class DICOM Study Content Notification Service Class DICOM Study Content Notification Service Class DICOM Patient Management Service Class DICOM Patient Management Service Class DICOM Study Management Service Class DICOM Study Management Service Class DICOM Results Management Service Class DICOM Results Management Service Class DICOM Print Management Service Class DICOM Print Management Service Class DICOM Media Storage Service Class DICOM Media Storage Service Class DICOM Storage Commitment Service Class DICOM Storage Commitment Service Class DICOM Basic Worklist Management Service Class DICOM Basic Worklist Management Service Class DICOM Queue Management Service ClassDICOM Queue Management Service Class

RISRISRRadiology adiology IInformation nformation SSystemystem

1.1. Patient registration order entryPatient registration order entry

2.2. Data analysisData analysis

3.3. Management reportingManagement reporting

4.4. Scheduling & Billing dataScheduling & Billing data5.5. Exam & Patient tracking Exam & Patient tracking (incl. Mammo)(incl. Mammo)

6.6. TranscriptionTranscription

7.7. Integration: IHE; HIPAA; PACSIntegration: IHE; HIPAA; PACS

RISRISRRadiology adiology IInformation nformation SSystemystem

8. Patient info merges w/ Images:8. Patient info merges w/ Images:

Allergies; lab values & HxAllergies; lab values & Hx

9.9. Internet linkageInternet linkage

10.10. Mammography: Mammography: (Unfunded federal (Unfunded federal mandate)mandate) MQSA Regulations MQSA Regulations

DICOMDICOMNote:Note: All new imaging modalities (e.g. CT, All new imaging modalities (e.g. CT, Ultrasound, MRI, Digital X-Ray etc.) are Ultrasound, MRI, Digital X-Ray etc.) are availableavailable with DICOM compatibility with DICOM compatibilityOlder imaging equipment Older imaging equipment require ($$$)require ($$$) upgrades or interfaces to the DICOM std.upgrades or interfaces to the DICOM std.There are numerous “levels” or There are numerous “levels” or ““classesclasses” to DICOM compatibility” to DICOM compatibilityDICOM DICOM continuescontinues to evolve to evolve IHE IHE

What is IHE?What is IHE?"Integrating the Healthcare Enterprise" (IHE), "Integrating the Healthcare Enterprise" (IHE), is a multi-year initiative, sponsored by the is a multi-year initiative, sponsored by the Radiological Society of North America (RSNA) Radiological Society of North America (RSNA) and the Healthcare Information and and the Healthcare Information and Management Systems Society (HIMSS), whose Management Systems Society (HIMSS), whose single purpose is to bring together medical single purpose is to bring together medical equipment and information products from equipment and information products from different manufacturers for different manufacturers for developing an developing an efficient and seamless workflow between efficient and seamless workflow between multiple products from multiple vendors multiple products from multiple vendors while improving the clinical and while improving the clinical and economic efficiencies of hospital-wide economic efficiencies of hospital-wide connectivityconnectivity..

Note that the IHE is not a Note that the IHE is not a Standards organization. The IHE Standards organization. The IHE uses existinguses existing standardsstandards, such as , such as DICOM and HL-7, for developing DICOM and HL-7, for developing workflow solutions for the workflow solutions for the healthcare enterprisehealthcare enterprise

PartnersPartners Supporting organizations providing Supporting organizations providing

expertise, technology and guidanceexpertise, technology and guidance• American College of PhysiciansAmerican College of Physicians• Centers for Disease Control & PreventionCenters for Disease Control & Prevention• CDISCCDISC• Duke University Medical CenterDuke University Medical Center• Food & Drug AdministrationFood & Drug Administration• OASISOASIS• Massachusetts Medical SocietyMassachusetts Medical Society• National Institute for Standards & TechnologyNational Institute for Standards & Technology• UC David, Medical InformaticsUC David, Medical Informatics

ParticipantsParticipants

IHEIntegrating the Healthcare Enterprise

• Multi-year initiative• Creates framework for seamless passage of

health information• Provides framework for implementing

relevant standards: e.g. “Connectathon”• 1998: RSNA & HIMSS provides leadership• Drives the adoption of standards to address

specific clinical needs• Does NOT create new standards• Ensures higher level of practical

interoperability• Clinical Domain Expansion: Cardiology,

Medication Mgnt. And Clinical Engineering

Brokered Claim; Registry DiscoveryBrokered Claim; Registry DiscoveryFor patient chart and Tumor Registry; CCR back to PCPFor patient chart and Tumor Registry; CCR back to PCP

PCP

From Continuity of Care scenarioFrom Continuity of Care scenarioImaging Integration, Tumor Reporting, Claims ProcessingImaging Integration, Tumor Reporting, Claims Processing

Surgery

Server

EMR

Hospital

Repository

Pathology

Dictation

Tumor Registry

Registry

eForms

Broker

Broker

Payer

Workstation

ImagingRIS

EMREMR

eFormseForms

EMREMR

EMREMR

Secure Secure transporttransport

TransforTransformm

ImagingImaging

DictationDictationLabLab

ImagingImaging

Virtual EHRVirtual EHR

Virtual EHRVirtual EHR

Tumor Tumor Registry/repositoryRegistry/repository

PCPPCP

HospitHospitalal

Continuity of Care (Continuity of Care (e.g.e.g. TumorsTumors))Imaging Integration, Tumor Reporting, Claims ProcessingImaging Integration, Tumor Reporting, Claims Processing

HighlightsHighlightsFirsts:Firsts: Annotated Electro-cardiogram, submissionsAnnotated Electro-cardiogram, submissions CDA College of American Pathology tumor report, CDA College of American Pathology tumor report, CDA Continuity of Care Record (CCR)CDA Continuity of Care Record (CCR) Clinical Document Architecture Release 2 (ballot draft)Clinical Document Architecture Release 2 (ballot draft) DistributedDistributed, standards-based decision support, standards-based decision support Document-based HIPAA Document-based HIPAA claims attachmentsclaims attachments End-to-end, standards-based electronic clinical End-to-end, standards-based electronic clinical

trial data submissiontrial data submission End-user Authentication profileEnd-user Authentication profile Hyperlink between electronic document and Hyperlink between electronic document and

PACS imagePACS image Nationally Notifiable Disease reportNationally Notifiable Disease report Open-source metadata registry for ubiquitous Open-source metadata registry for ubiquitous

access to distributed informationaccess to distributed information Patient Information Patient Information Cross-reference profileCross-reference profile Patient Synchronized ApplicationsPatient Synchronized Applications Retrieve Information for DisplayRetrieve Information for Display profile profile Re-useRe-use of electronic clinical documents to support a of electronic clinical documents to support a

claimclaim Structured Product LabelingStructured Product Labeling Third-party brokered claims attachmentsThird-party brokered claims attachments Version 3/CDA TemplatesVersion 3/CDA Templates

The HL7-IHE Demo…The HL7-IHE Demo…

Creates the future of Creates the future of machinemachine interoperability through interoperability through humanhuman interoperabilityinteroperability• We identify barriers to Interoperability We identify barriers to Interoperability

andand• And we engineer breakthroughs.And we engineer breakthroughs.

IHE INTEGRATION PROFILES

Scheduled Workflow :Scheduled Workflow : flow of information for flow of information for the key steps (registration, ordering, the key steps (registration, ordering, scheduling, acquisition, distribution and scheduling, acquisition, distribution and storage) storage)

Patient Information ReconciliationPatient Information Reconciliation method for method for reconciliation of information for unidentified or reconciliation of information for unidentified or mistakenly identified patients mistakenly identified patients

Consistent Presentation of ImagesConsistent Presentation of Images ensures a ensures a consistent view of images and annotations consistent view of images and annotations across different displays and media across different displays and media

Presentation of Grouped ProceduresPresentation of Grouped Procedures management of images for multiple procedures management of images for multiple procedures in a single acquisition step (e.g. spiral CT: in a single acquisition step (e.g. spiral CT: chest & abdomen) chest & abdomen)

Access to Radiology InformationAccess to Radiology Information mechanism for mechanism for sharing radiological images and information sharing radiological images and information across department boundaries across department boundaries

IHE Components (1)

Key Image NoteKey Image Note addition of textual notes and addition of textual notes and pointers to key images in a series pointers to key images in a series

Simple Image and Numeric ReportsSimple Image and Numeric Reports standard standard way of creating, managing, storing and viewing way of creating, managing, storing and viewing reports that include images, text and reports that include images, text and numerical values numerical values

Charge PostingCharge Posting information about procedures information about procedures available to billing systems allows consistent available to billing systems allows consistent and timely billing of technical and professional and timely billing of technical and professional charges charges

Basic SecurityBasic Security establishes enterprise-wide establishes enterprise-wide security infrastructure for meeting privacy security infrastructure for meeting privacy requirements (such as HIPAA) requirements (such as HIPAA)

Post-processing WorkflowPost-processing Workflow supports workflow supports workflow steps such as Computer-Aided Detection (CAD), steps such as Computer-Aided Detection (CAD), Imaging Processing, and Image ReconstructionImaging Processing, and Image Reconstruction

IHE Components (2)

TeleradiologyTeleradiologyTeleradiology programs allow the sending Teleradiology programs allow the sending of pictures between different stations in of pictures between different stations in

different locations. different locations. MR Image from the brain

TeleradiologyTeleradiologyTeleradiology programs allow the sending Teleradiology programs allow the sending of pictures between different stations in of pictures between different stations in

different locations.different locations.

CT

MRIX-Ray

Productivity in Radiology:Productivity in Radiology: Why?Why?

Procedure volume increasing by 3.5-5%/yrProcedure volume increasing by 3.5-5%/yr

Supply of radiologists increasing by 2%/yrSupply of radiologists increasing by 2%/yr

Between 1995 - 2000Between 1995 - 2000

MRI Exams increased by 19%:MRI Exams increased by 19%:

CT Exams increased by 10%:CT Exams increased by 10%:

Case complexity & Slices: Case complexity & Slices: 64 slice CT !!!64 slice CT !!!

Clinical expectations are also increasing !!Clinical expectations are also increasing !!

Diagnostic RadiologyDiagnostic Radiology

SUMMARY: SUMMARY: The Future of MedicineThe Future of Medicine

Digital based image acquisition, Digital based image acquisition, interpretation and distribution interpretation and distribution Continued integration of imaging Continued integration of imaging with demographic & clinical datawith demographic & clinical data

Computer Assisted Diagnosis (CAD):Computer Assisted Diagnosis (CAD):

[the real “Tricorder”][the real “Tricorder”]

Diagnostic RadiologyDiagnostic RadiologySUMMARY: SUMMARY: The Future of MedicineThe Future of Medicine

Computer Assisted Diagnosis (CAD):Computer Assisted Diagnosis (CAD):

[the [the firstfirst real “Tricorder”??] real “Tricorder”??]

Working CAD systems:Mammography

Clinical Trials:CT Scanning: ChestChest X-Rays

The Tricorder Site, 2001, www.tricorder.cjb.net 

Office: 610-237-4353Pager: 888-966-9716dpmradx@earthlink.net

Questions ????