The UK PACS and Teleradiology Group

(Special Interest Group of Royal College of Radiologists)

Autumn 2009 Meeting

Focus: PACS and RIS – part of open standards based EPR

PACS & Open Standards EPRPACS & Open Standards EPR

Robin Breslin

Commercial Manager

Medical Systems UK

PACS Integration

• Why we need it

• Why standards are so important

• How PACS fits in

• How PACS fits in as these standards evolve

PACS Integration

• Integration is an old old subject.

• In the old days – Integration meant

“Please can you attach my CR with some wires so I can save my images somewhere?”

• Then it became

“Can I see my images alongside other modalities?”

• Then

“Please can I have a fully integrated care record system?”

DO NOT TOUCHANY OF THESE WIRES

DO NOT TOUCHANY OF THESE WIRES

• Easy to get lost in the detail and lose sight of our real objectives

• So let’s remind ourselves of why we do integration

PACS Integration

• The reason for integration has not changed

• It’s all about context

Name: A. N

Autre

DOB 08/09/

1965

• Films in a packet

• Name and ID (label)

• Filed in library

• Digital Images

• Name and ID (tag)

• Filed in a Database

Why?

Why do we do this?To present meaningful and useful information

Clinical user• Images/Exams, clearly identified

(with certainty)• A clinical context (requests, reports, priors)

Clerical user• Clearly identified images/exams• Meaningful context

– how to manage the data– date/time, type of exam, status

(eg. is it reported yet?)

Common Framework

We need a common framework• So different suppliers can agree ..• So different user entities can agree ..

.. so we all can agree ..• What data is to be captured • How it is identified• How it interrelates• How it is to be communicated

• As I was preparing this presentation

• searching the web for information

Why?

Why do we do this?To present meaningful and useful information

Clinical user• Images/Exams, clearly identified

(with certainty)• A clinical context (requests, reports, priors)

Clerical user• Clearly identified images/exams• Meaningful context about how to

manage the data(date/time, type of exam, status– eg. is it reported?)

• This is where I started

• But I see this is not going to be useful

• So I click on something that looks more use

• My own knowledge confirms I’m on the righttrack

Server world of Wikipedia

Server world of IHE

Simple experiencefor the user

Server world of Wikipedia

Server world of IHE

Very simplified view

Some important things that make this happen

• A common way to interpret and display the informationBrowser

• A common way to describe the informationhttp / xml

• A copy of the link ‘registered’ in the world of Wikipediaintegration

The web is a complex world

We know that it’s more complicated than this

• Many kinds of objects

• Many ways to deliver them

• Many ways to display/hear them

And the Medical world.

The Medical world is not an “uncontrolled environment of content” (like the web)

• Disparate systems to synchronise

• Complex objects to display• Existing integration tools and

standards• But overall – we should be

aiming at finding an open way to share this information“A web like experience”

IHE is providing help

• A standardised way to describe data

• A communication framework

• HL7, DICOM .. Now extended to XDS

Exchange data between medical imaging systems

Exchange data between medical

information systems

XML description & set of methods for interchange of all

medical data

Using XML is in line with many major web services software developments.

Including CfH

SOAP, WSDL, HTTP, OMGCORBA, DCOM, Java/RMI,

• I am not going to focus on the technical aspects

– You’ll get plenty of that today

– And I’m not an expert

• XDS gives the possibility to include PACS as part of a wider ‘web based’ Electronic Medical Record

http://en.wikipedia.org/wiki/Web_Serviceis a fantastic source for web services information

Special Cases For PACS

• Some special aspects of Medical (Radiology) based imaging need to be considered(This is in addition to the contextualising of the data)

1. That the image data objects are large

2. That the displayed image needs to be of clinically suitable quality (of course this can vary)

3. That existing repositories (PACS’s) exist

XDS-I & PACS

1. & 3.Large Images/ExamsRe-use existing PACS’s)

• Images not copied to Repository

• Reference to images placed in Registry

• Images retrieved directly from PACS

XDSRegistry

XDSRepository

PACS

PACS

XDS-I & PACS

2. Image Quality• Able to deliver images rendered

to appropriate quality– JPEG– DICOM

• XDS image transfer notcomplete yet– but an existing DICOM extension call WADOis used

“WADO = Web Access to DICOM persistent Objects

(this is just an HTTP encapsulation of DICOM)”

XDSRegistry

XDSRepository

WADOweb service

Summing up so far

• We have looked at existing integration tools - DICOM and HL7

• Seen how encapsulating this web services extends the capability of these tools

• Imposing a web based approach onto existing standardsWhich I think is a natural approach– in line with most user’s experienceof computers.

Summing up so far

This gives us the ability to

• Develop web like EPR’s

• Use existing tools to include existing systems (like PACS).

.. And I am very familiar with this approach ..

Fujifilm Synapse PACSSimplified Architecture

• Database Reference to DICOM & compressed image objects

• Web Services delivery mechanism

• XML linkage and layout of image objects enhances functionality

• Specialised plug-in for image rendering/display embedded in Browser

PACS Integration

• Looked at PACS Integration in “one dimension”From Data Source to Integrated incorporation in a medical record

Data Source

Delivery

• What about Integrated tools for workflow?“Time Based Integrated behaviours”

Patient Booking Report Delivery

PACS Integration & Workflow

• Normally integrated workflows are managed between systems

– RIS, PACS, PAS, VR

• Like a set of runners “passing the baton”

• Easiest to show in a couple of examples

Workflow example Request & Acquire an Exam

Exams Scheduledin RIS

Placeholder Reservedin PACS

Exam Performedat modality

Images Importedinto PACS

Reporting Worklistis prepared

DICOM Worklist

HL7

DICOM Store

Synapse

Imaging Devices

Instantaneous Systems

Communication

ExaminationPerformedand Stored

Exams available for reporting as soon as they are completed.

Place holder reservedin VR database

RIS

Master Patient IndexProvide Patient ID

HL7

Voice Recognition

Workflow example Report an Exam

Report Stored

Reporting SessionReporting Worklist

is prepared

Desktop Integration

RIS

Voice Recognition

Synapse

Imaging Devices

Voice RecognitionDictations

HL7

Report TextGenerated

Exam Reported

HL7

Exam Images &Report Available

HL7

Reporting Session: VR seen writing text as spoken in real time. VR & PACS

working as one application

Text report, and exam status updated within seconds

All images and reports available to all authorised users within seconds of

reporting

Desktop Integration

• Remember that easy move between web pages?

• An example of integrated behaviour on a user’s computer desktop

• Two Client Server Applications working in a coordinated way

RIS PACSHL7

PACSClient

RISClient

Client/ServerRelationship

Desktop Integration

Example;

• RIS & PACS databases are aligned

• In RIS & PACS clients you can see

– Same patient

– Same exams

• But how to coordinate their activity?

RIS PACSHL7

PACSClient

RISClient

Desktop Integration

• Historically there have been several methods for this kind of integration.

1. Direct programmed communication RIS PACSHL7

PACSClient

RISClient

Desktop Integration

• Historically there have been several attempts at this kind of integration.

1. Direct programmed communication

2. Shared Memory Objectseg. COM, CCOW ..

RIS PACSHL7

PACSClient

RISClient

The Voice/PACS example shown uses a shared

ActiveX software component.

Desktop Integration

• Historically there have been several attempts at this kind of integration.

1. Direct programmed communication

2. Shared Memory Objectseg. COM, CCOW ..

3. url reference

RIS PACSHL7

PACSClient

RISClient

Desktop Integration

Difficult to work with;

• Require actual modification of the client applications

• Any changes require re-modification of clients

• .. And all the software release and testing that goes along with that.

Cumbersome and expensive to maintain

RIS PACSHL7

PACSClient

RISClient

Browser

WebServices

Desktop Integration & XDS

• XDS allows more functionality to come from the Server“Migration of control” from client to server”

• Thinning out the client

• Reducing links to really just links

• Allowing modifications to the links in the Server

RIS PACSHL7

PACSPages

RISPages

Summing Up

• Started talking about showing images in context

• Described an evolution towards web services

• Now the important note of my presentation …

In my web example

• I looked for XDS information

• I decided my first search was not useful ->

• I made a choice to look at a better detailed page

• I used my knowledge to inform affirm my right choice ->

Server world of Wikipedia

Server world of IHE

Simple experience

for the user

• As more integrated information becomes available

• We have to be careful not to switch off our brains

• Continue to play an active role in steering our way through the information

Server world of Wikipedia

Server world of IHE

Simple experience

for the user

Further items

No time to discuss …• Access rights & Roles of users• Information Governance• Speed of response• Image quality and image interpretation• The CfH solutions and the role of CfH

But 15 minutes is not longAnd these will be discussed elsewhere today