Data Management Solution for Large-Volume Computed Tomography in an Existing Picture Archiving and Communication System (PACS)

Multidetector row computed tomography (MDCT) creates massive amounts of data, which can overload a picture archiving and communication system (PACS). To solve this problem, we designed a new data storage and image interpretation system in an existing PACS. Two MDCT image datasets, a thick- and a thin-section dataset, and a single-detector CT thick-section dataset were reconstructed. The thin-section dataset was archived in existing PACS disk space reserved for temporary storage, and the system overwrote the source data to preserve available disk space. The thick-section datasets were archived permanently. Multiplanar reformation (MPR) images were reconstructed from the stored thin-section datasets on the PACS workstation. In regular interpretations by eight radiologists during the same week, the volume of images and the times taken for interpretation of thick-section images with (246 CT examinations) or without (170 CT examinations) thin-section images were recorded, and the diagnostic usefulness of the thin-section images was evaluated. Thin-section datasets and MPR images were used in 79% and 18% of cases, respectively. The radiologists’ assessments of this system were useful, though the volume of images and times taken to archive, retrieve, and interpret thick-section images together with thin-section images were significantly greater than the times taken without thin-section images. The limitations were compensated for by the usefulness of thin-section images. This data storage and image interpretation system improves the storage and availability of the thin-section datasets of MDCT and can prevent overloading problems in an existing PACS for the moment.Key words: CT, MDCT, PACS, computer applications     

The Effect of Wireless LAN-Based PACS Device for Portable Imaging Modalities

The aim of this study was to develop wireless Picture Archiving and Communication System (PACS) device and to analyze its effect on image transfer from portable imaging modalities to the main PACS server. Using a laptop computer equipped with wireless local area network (LAN), the authors developed a wireless PACS device with DICOM modality worklist and DICOM storage server modules. This laptop computer could be easily fixed to portable imaging modalities such as ultrasound machines. From May to August 2007, 112 portable examinations were evaluated. Of these, 62 were done with wireless LAN-based PACS device, and 50 were done without wireless PACS device. To evaluate the impact of the wireless LAN-based PACS device on productivity and workflow, we analyzed the mean time delay and standard deviations (SD) both in cases where wireless LAN-based PACS device was used and in cases where it was not used. Statistical analysis was performed using a t test. The mean time interval from image acquisition to storage in the main PACS when the wireless LAN-based PACS device was used was 342.4 s (5 min and 42.4 s, SD = 509.2 s). When the wireless PACS was not used, the mean time interval was 2,305.5 s (38 min and 25.5 s, SD = 1,371.8 s). The mean time interval was statistically different between the two groups (t test, p < 0.001). The wireless LAN-based PACS device could help in reducing the storage intervals of images obtained by portable machines and in promoting effective and rapid treatment of patients who have undergone portable imaging examinations.     

The Role of Key Image Notes in CT Imaging Study Interpretation

The objective of the study was to investigate the clinical effects of CT key image notes (KIN) in the interpretation of a CT image study. All experiments were approved by the ethics committee of the local district. Six experienced radiologists were equally divided into routine reporting (RR) group and KIN reporting (KIN) group. CT scans of each 100 consecutive cases before and after using KIN technique were randomly selected, and the reports were made by group RR and KIN, respectively. All the reports were again reviewed 3 months later by both groups. All the results with using or not using KIN were interpreted and reinterpreted after 3 months by six clinicians, who were experienced in picture archiving and communication system (PACS) applications and were equally divided into the clinical routine report group and the clinical KIN report group, respectively. The results were statistically analyzed; the time used in making a report, the re-reading time 3 months later, and the consistency of imaging interpretation were determined and compared between groups. After using KIN technique, the time used in making a report was significantly increased (8.77 ± 5.27 vs. 10.53 ± 5.71 min, P < 0.05), the re-reading time was decreased (5.23 ± 2.54 vs. 4.99 ± 1.70 min, P < 0.05), the clinical interpretation and reinterpretation time after 3 months were decreased, and the consistency of the interpretation, reinterpretation between different doctors in different time was markedly improved (P < 0.01). CT report with KIN technique in PACS can significantly improve the consistency of the interpretation and efficiency in routine clinical work.     

PET/CT Fusion Viewing Software for Use with Picture Archiving and Communication Systems

We developed positron emission tomography (PET)/computed tomography (CT) viewing software (PETviewer) that can display co-registered PET and CT images obtained by PET/CT and stored on picture archiving and communication systems (PACS). PETviewer has tools for presetting windows for CT display; control bars for PET window level; zoom, pan, and pseudo-color functions; and allows the user to draw a rectangular region of interest (ROI) for standardized uptake value (SUV) measurement. SUV was calculated using PET DICOM header information and the pixel intensity in PETviewer. Reconstructed datasets of PET/CT and maximum intensity projection (MIP) of the PET images were transferred and archived in PACS. Phantom experiments were performed to evaluate the validity of image fusion. PET/CT images were displayed on an independent window in PACS. Transaxial PET images were reformatted as sagittal and coronal PET images, which were displayed with the corresponding CT and PET/CT fusion images with adjustable color and transparency. Transaxial, sagittal, and coronal PET images corresponding to the location of the cursor were shown using cine display of MIP images. All images were displayed in PETviewer within 20 s on a personal computer for PACS, which was equipped with a P4, 1.3-GHz CPU, and 512 Mb of RAM. We could measure maximum and mean SUV in a ROI using PETviewer. Transaxial fused images of patients and phantoms showed excellent registration and fusion of PET and CT images in the X and Y directions. PETviewer provided very useful clinical tools for assessing PET/CT images on PACS and should assist in maximizing the benefits derived from PET/CT imaging.     

Use of a Dedicated Server to Perform Coronal and Sagittal Reformations in Trauma Examinations

The purpose of this study was to evaluate the impact of implementing an automated process for generating coronal and sagittal reformatted images on radiologist workflow. When performing trauma-related CT examinations of the cervical, thoracic, and lumbar spine at our institution, technologists manually generate coronal and sagittal reconstructions at the scanner console and send these images to a picture archiving and communication system (PACS) for interpretation by radiologists and clinical viewing. Although certain PACS, thin-client three-dimensional systems, and CT scanners are capable of automatically generating reconstructed or reformatted images, the systems at our institution do not support this functionality. We have recently integrated a dedicated server that is capable of automatically generating multiplanar reformatted (MPR) images from source thin-section axial images and sending these images to PACS without requiring technologist input. This dedicated server was used to generate coronal and sagittal MPRs for trauma-related spine studies in parallel with technologist-generated coronal and sagittal reconstructions. When comparing the two methods, using the dedicated server to automatically generate reformations resulted in substantial time savings for the radiologist compared to technologist-generated reconstructions. Additionally, a survey of interpreting radiologists indicated that a significant majority preferred to view the automatically generated MPRs on PACS compared to the thin-client system, considered the image quality to be good or excellent, and believed that viewing MPRs increased diagnostic accuracy and confidence. It is expected that this automated process will significantly improve radiologist workflow with respect to image interpretation time and report turnaround time.     

System Integration and DICOM Image Creation for PET-MR Fusion

This article demonstrates a gateway system for converting image fusion results to digital imaging and communication in medicine (DICOM) objects. For the purpose of standardization and integration, we have followed the guidelines of the Integrated Healthcare Enterprise technical framework and developed a DICOM gateway. The gateway system combines data from hospital information system, image fusion results, and the information generated itself to constitute new DICOM objects. All the mandatory tags defined in standard DICOM object were generated in the gateway system. The gateway system will generate two series of SOP instances of each PET-MR fusion result; SOP (Service Object Pair) one for the reconstructed magnetic resonance (MR) images and the other for position emission tomography (PET) images. The size, resolution, spatial coordinates, and number of frames are the same in both series of SOP instances. Every new generated MR image exactly fits with one of the reconstructed PET images. Those DICOM images are stored to the picture archiving and communication system (PACS) server by means of standard DICOM protocols. When those images are retrieved and viewed by standard DICOM viewing systems, both images can be viewed at the same anatomy location. This system is useful for precise diagnosis and therapy.     

Summation or Axial Slab Average Intensity Projection of Abdominal Thin-section CT Datasets: Can They Substitute for the Primary Reconstruction from Raw Projection Data?

We hypothesized that that the summation or axial slab average intensity projection (AIP) techniques can substitute for the primary reconstruction (PR) from a raw projection data for abdominal applications. To compare with PR datasets (5-mm thick, 20% overlap) in 150 abdominal studies, corresponding summation and AIP datasets were calculated from 2-mm thick images (50% overlap). The root-mean-square error between PR and summation images was significantly greater than that between PR and AIP images (9.55 [median] vs. 7.12, p < 0.0001, Wilcoxon signed-ranks test). Four radiologists independently compared 2,000 test images (PR [as control], summation, or AIP) and their corresponding PR images to prove that the identicalness of summation or AIP images to PR images was not 1% less than the assessed identicalness of PR images to themselves (Wald-type test for clustered matched-pair data in a non-inferiority design). For each reader, both summation and AIP images were not inferior to PR images in terms of being rated identical to PR (p < 0.05). Although summation and AIP techniques produce images that differ from PR images, these differences are not easily perceived by radiologists. Thus, the summation or AIP techniques can substitute for PR for the primary interpretation of abdominal CT.     

DICOM Modality Worklist: An essential component in a PACS environment

The development and acceptance of the digital communication in medicine (DICOM) standard has become a basic requirement for the implementation of electronic imaging in radiology. DICOM is now evolving to provide a standard for electronic communication between radiology and other parts of the hospital enterprise. In a completely integrated filmless radiology department, there are 3 core computer systems, the picture archiving and communication system (PACS), the hospital or radiology information system (HIS, RIS), and the acquisition modality. Ideally, each would have bidirectional communication with the other 2 systems. At a minimum, a PACS must be able to receive and acknowledge receipt of image and demographic data from the modalities. Similarly, the modalities must be able to send images and demographic data to the PACS. Now that basic DICOM communication protocols for query or retrieval, storage, and print classes have become established through both conformance statements and intervendor testing, there has been an increase in interest in enhancing the functionality of communication between the 3 computers. Historically, demographic data passed to the PACS have been generated manually at the modality despite the existence of the same data on the HIS or RIS. In more current sophisticated implementations, acquisition modalities are able to receive patient and study-related data from the HIS or RIS. DICOM Modality Worklist is the missing electronic link that transfers this critical information between the acquisition modalities and the HIS or RIS. This report describes the concepts, issues, and impact of DICOM Modality Worklist implementation in a PACS environment.     

A Filmless Radiology Teaching Conference System for Pertinent Displaying and Image Searching

To solve the problems of image displays in filmless radiology conferences for the purpose of teaching, we made an experimental design of a conference system with dual 50-in. plasma monitors for displaying larger images and a shared folder containing shortcuts to images for quick display during conferences on the desktop of each client computer in a picture archival and communication system. The image quality of the monitors was evaluated using the TG18-QC test pattern. The display time of images was measured in 20 cases when the shared folder was used and when it was not. Monitor screen size and image quality, operability, display time of images, and overall impression given by the system were evaluated subjectively by five radiologists. Although the image quality of the monitor was not as high as that of the high-resolution monitors used for diagnostic radiology, its performance was good enough for teaching. The average display time using the shared folder (2.6 ± 0.39 s) was significantly shorter than without it (16.9 ± 5.04 s; p = 2.85 × 10⁻⁶). Despite the need for certain improvements in monitor size and in the operability of the system, the radiologists considered the system suitable for radiology teaching conferences. We believe that this system is useful for institutions that intend to introduce a filmless system for filmless radiology teaching conferences.     

General Consumer Communication Tools for Improved Image Management and Communication in Medicine

We elected to explore new technologies emerging on the general consumer market that can improve and facilitate image and data communication in medical and clinical environment. These new technologies developed for communication and storage of data can improve the user convenience and facilitate the communication and transport of images and related data beyond the usual limits and restrictions of a traditional picture archiving and communication systems (PACS) network. We specifically tested and implemented three new technologies provided on Apple computer platforms. (1) We adopted the iPod, a MP3 portable player with a hard disk storage, to easily and quickly move large number of DICOM images. (2) We adopted iChat, a videoconference and instant-messaging software, to transmit DICOM images in real time to a distant computer for conferencing teleradiology. (3) Finally, we developed a direct secure interface to use the iDisk service, a file-sharing service based on the WebDAV technology, to send and share DICOM files between distant computers. These three technologies were integrated in a new open-source image navigation and display software called OsiriX allowing for manipulation and communication of multimodality and multidimensional DICOM image data sets. This software is freely available as an open-source project at . Our experience showed that the implementation of these technologies allowed us to significantly enhance the existing PACS with valuable new features without any additional investment or the need for complex extensions of our infrastructure. The added features such as teleradiology, secure and convenient image and data communication, and the use of external data storage services open the gate to a much broader extension of our imaging infrastructure to the outside world.     

Freehand Liver Volumetry by Using an Electromagnetic Pen Tablet: Accuracy, Precision, and Rapidity

The purpose of this study is to assess the accuracy, precision, and rapidity of liver volumes calculated by using a freehand electromagnetic pen tablet contourtracing method as compared with the volumes calculated by using the standard optical mouse contourtracing method. The imaging data used as input for accuracy and precision testing were computed by software developed in our institution. This computer software can generate models of solid organs and allows both standard mouse-based and electromagnetic pen-driven segmentation (number of data sets, n = 70). The images used as input for rapidity testing was partly computed by modeling software (n = 70) and partly selected from contrast-enhanced computed tomography (CT) examinations (n = 12). Mean volumes and time required to perform the segmentation, along with standard deviation and range values with both techniques, were calculated. Student's t test was used to assess significance regarding mean volumes and time calculated by using both segmentation techniques on phantom and CT data sets. P value was also calculated. The mean volume difference was significantly lower with the use of the freehand electromagnetic pen as compared with the optical mouse (0.2% vs. 1.8%; P < .001). The mean segmentation time per patient was significantly shorter with the use of the freehand electromagnetic pen contourtracing method (354.5 vs. 499.1 s on phantoms; 457.4 vs. 610.0 s on CT images; P < .001). Freehand electromagnetic pen-based volumetric technique represents a technologic advancement over manual mouse-based contourtracing because of the superior statistical accuracy and sensibly shorter time required. Further studies focused on intra- and interobserver variability of the technique need to be performed before its introduction in clinical application.     

Integration of Temporal Subtraction and Nodule Detection System for Digital Chest Radiographs into Picture Archiving and Communication System (PACS): Four-year Experience

Since May 2002, temporal subtraction and nodule detection systems for digital chest radiographs have been integrated into our hospital’s picture archiving and communication systems (PACS). Image data of digital chest radiographs were stored in PACS with the digital image and communication in medicine (DICOM) protocol. Temporal subtraction and nodule detection images were produced automatically in an exclusive server and delivered with current and previous images to the work stations. The problems that we faced and the solutions that we arrived at were analyzed. We encountered four major problems. The first problem, as a result of the storage of the original images’ data with the upside-down, reverse, or lying-down positioning on portable chest radiographs, was solved by postponing the original data storage for 30 min. The second problem, the variable matrix sizes of chest radiographs obtained with flat-panel detectors (FPDs), was solved by improving the computer algorithm to produce consistent temporal subtraction images. The third problem, the production of temporal subtraction images of low quality, could not be solved fundamentally when the original images were obtained with different modalities. The fourth problem, an excessive false-positive rate on the nodule detection system, was solved by adjusting this system to chest radiographs obtained in our hospital. Integration of the temporal subtraction and nodule detection system into our hospital’s PACS was customized successfully; this experience may be helpful to other hospitals.     

User Interface of a Teleradiology System for the MR Assessment of Multiple Sclerosis

The aim of this study was to assess the image display of a web-based teleradiology system that uses a common web browser and has no need of proprietary applets, plug-ins, or dedicated software for DICOM display. The teleradiology system (TS) is connected to the Internet by ADSL and to radiological modalities using the DICOM standard with TCP/IP. Images were displayed on a PC through Internet connection with the remote TS using a common web browser. MS lesion number and volume in T1- and T2-weighted images (T1w and T2w, respectively) of 30 brain MR studies were quantified using both the TS and a conventional software. Wilcoxon signed ranks test and intraclass correlation coefficient (ICC) were used to assess the variability and concordance between intra- and inter-observer and TS and conventional DICOM viewer, setting significance at p < 0.05. No significant differences in T1w and T2w volumes between the TS and the conventional software were found by either operator. The ICC results showed a high level of inter-operator agreement in volume estimation in T1w and T2w images using the two systems. Quantitative assessment of MS lesion volumes in T1w and T2w images with a user interface of a teleradiology system that allows the consultation by means of a common web browser, without the need for proprietary plug-ins, applets, or dedicated software for DICOM display showed no significant differences from, and almost complete agreement with, conventional DICOM viewers.     

一种符合医学数字影像与通讯标准的医学影像管理系统的设计

医学影像的存储与传输在数字化医疗快速发展的今天占据着非常重要的地位。为了实现医学数字影像与通讯（DICOM）医学影像在局域网上的传输和查询,本文设计了一个符合DICOM标准的医学影像管理系统。该系统能对DICOM格式文件进行解析,并在数据库中把DICOM影像文件与对应的病历信息进行关联存储,可以给医院影像科提供完全数字化的影像和数据。此研究工作不仅满足了医院影像中心对大量影像数据存储的需求,同时也促进了PACS系统的发展。     

A Mobile Phone Integrated Health Care Delivery System of Medical Images

With the growing computing capability of mobile phones, a handy mobile controller is developed for accessing the picture archiving and communication system (PACS) to enhance image management for clinicians with nearly no restriction in time and location using various wireless communication modes. The PACS is an integrated system for the distribution and archival of medical images that are acquired by different imaging modalities such as CT (computed tomography) scanners, CR (computed radiography) units, DR (digital radiography) units, US (ultrasonography) scanners, and MR (magnetic resonance) scanners. The mobile controller allows image management of the PACS including display, worklisting, query and retrieval of medical images in DICOM format. In this mobile system, a server program is developed in a PACS Web server which serves as an interface for client programs in the mobile phone and the enterprise PACS for image distribution in hospitals. The application processing is performed on the server side to reduce computational loading in the mobile device. The communication method of mobile phones can be adapted to multiple wireless environments in Hong Kong. This allows greater feasibility to accommodate the rapidly changing communication technology. No complicated computer hardware or software is necessary. Using a mobile phone embedded with the mobile controller client program, this system would serve as a tool for heath care and medical professionals to improve the efficiency of the health care services by speedy delivery of image information. This is particularly important in case of urgent consultation, and it allows health care workers better use of the time for patient care.     

Linking Whole-Slide Microscope Images with DICOM by Using JPEG2000 Interactive Protocol

The use of digitized histopathologic specimens (also known as whole-slide images (WSIs)) in clinical medicine requires compatibility with the Digital Imaging and Communications in Medicine (DICOM) standard. Unfortunately, WSIs usually exceed DICOM image object size limit, making it impossible to store and exchange them in a straightforward way. Moreover, transmitting the entire DICOM image for viewing is ineffective for WSIs. With the JPEG2000 Interactive Protocol (JPIP), WSIs can be linked with DICOM by transmitting image data over an auxiliary connection, apart from patient data. In this study, we explored the feasibility of using JPIP to link JPEG2000 WSIs with a DICOM-based Picture Archiving and Communications System (PACS). We first modified an open-source DICOM library by adding support for JPIP as described in the existing DICOM Supplement 106. Second, the modified library was used as a basis for a software package (JVSdicom), which provides a proof-of-concept for a DICOM client–server system that can transmit patient data, conventional DICOM imagery (e.g., radiological), and JPIP-linked JPEG2000 WSIs. The software package consists of a compression application (JVSdicom Compressor) for producing DICOM-compatible JPEG2000 WSIs, a DICOM PACS server application (JVSdicom Server), and a DICOM PACS client application (JVSdicom Workstation). JVSdicom is available for free from our Web site (), which also features a public JVSdicom Server, containing example X-ray images and histopathology WSIs of breast cancer cases. The software developed indicates that JPEG2000 and JPIP provide a well-working solution for linking WSIs with DICOM, requiring only minor modifications to current DICOM standard specification.     

Medical Image Resource Center–making electronic teaching files from PACS

A picture archive and communications system (PACS) is a rich source of images and data suitable for creating electronic teaching files (ETF). However, the potential for PACS to support nonclinical applications has not been fully realized: at present there is no mechanism for PACS to identify and store teaching files; neither is there a standardized method for sharing such teaching images. The Medical Image Resource Center (MIRC) is a new central image repository that defines standards for data exchange among different centers. We developed an ETF server that retrieves digital imaging and communication in medicine (DICOM) images from PACS, and enables users to create teaching files that conform to the new MIRC schema. We test-populated our ETF server with illustrative images from the clinical case load of the National Neuroscience Institute, Singapore. Together, PACS and MIRC have the potential to benefit radiology teaching and research.     

Automatic Segmentation of the Ribs, the Vertebral Column, and the Spinal Canal in Pediatric Computed Tomographic Images

We propose methods to perform automatic identification of the rib structure, the vertebral column, and the spinal canal in computed tomographic (CT) images of pediatric patients. The segmentation processes for the rib structure and the vertebral column are initiated using multilevel thresholding and the results are refined using morphological image processing techniques with features based on radiological and anatomical prior knowledge. The Hough transform for the detection of circles is applied to a cropped edge map that includes the thoracic vertebral structure. The centers of the detected circles are used to derive the information required for the opening-by-reconstruction algorithm used to segment the spinal canal. The methods were tested on 39 CT exams of 13 patients; the results of segmentation of the vertebral column and the spinal canal were assessed quantitatively and qualitatively by comparing with segmentation performed independently by a radiologist. Using 13 CT exams of six patients, including a total of 458 slices with the vertebra from different sections of the vertebral column, the average Hausdorff distance was determined to be 3.2 mm with a standard deviation (SD) of 2.4 mm; the average mean distance to the closest point (MDCP) was 0.7 mm with SD = 0.6 mm. Quantitative analysis was also performed for the segmented spinal canal with three CT exams of three patients, including 21 slices with the spinal canal from different sections of the vertebral column; the average Hausdorff distance was 1.6 mm with SD = 0.5 mm, and the average MDCP was 0.6 mm with SD = 0.1 mm.     

Influence of Image Metrics When Assessing Image Quality from a Test Object in Cardiac X-ray Systems

Modern fluoroscopic systems used for invasive cardiology typically acquire digital images in a 1,024 × 1,024 × 12 bits. These images are maintained in the original format while they remain on the imaging system itself. However, images are usually stored using a reduced 512 × 512 × 8-bits format. This paper presents a method for digital analysis of test objects images. The results obtained using image-intensifier and flat-detector systems are given for the original and reduced matrices. Images were acquired using a test object (TO) and a range of polymethyl methacrylate (PMMA) thicknesses from 4 to 28 cm. Adult patient protocols were evaluated for 16–28 cm of PMMA using the image-intensifier system. Pediatric protocols were evaluated for 4–16 cm of PMMA using the flat-detector system. The TO contains disks of various thicknesses to evaluate low contrast sensitivity and a bar pattern to evaluate high-contrast spatial resolution (HCSR). All available fluoroscopic and cine modes were evaluated. Entrance surface air kerma was also measured. Signal-to-noise ratio (SNR) was evaluated using regions of interest (ROI). HCSR was evaluated by comparing the statistical analysis of a ROI placed over the image of the bar pattern against a reference ROI. For both systems, an improvement of approximately 20% was observed for the SNR on the reduced matrices. However, the HCSR parameter was substantially lower in the reduced metrics. Cardiologists should consider the clinical influence of reduced spatial resolution when using the archived images.     

The Clinical Application of a PACS-Dependent 12-Lead ECG and Image Information System in E-Medicine and Telemedicine

This study presents a software technology to transform paper-based 12-lead electrocardiography (ECG) examination into (1) 12-lead ECG electronic diagnoses (e-diagnoses) and (2) mobile diagnoses (m-diagnoses) in emergency telemedicine. While Digital Imaging and Communications in Medicine (DICOM)-based images are commonly used in hospitals, the development of computerized 12-lead ECG is impeded by heterogeneous data formats of clinically used 12-lead ECG instrumentations, such as Standard Communications Protocol (SCP) ECG and Extensible Markup Language (XML) ECG. Additionally, there is no data link between clinically used 12-lead ECG instrumentations and mobile devices. To realize computerized 12-lead ECG examination procedures and ECG telemedicine, this study develops a DICOM-based 12-lead ECG information system capable of providing clinicians with medical images and waveform-based ECG diagnoses via Picture Archiving and Communication System (PACS). First, a waveform-based DICOM-ECG converter transforming clinically used SCP-ECG and XML-ECG to DICOM is applied to PACS for image- and waveform-based DICOM file manipulation. Second, a mobile Structured Query Language database communicating with PACS is installed in physicians’ mobile phones so that they can retrieve images and waveform-based ECG ubiquitously. Clinical evaluations of this system indicated the following. First, this developed PACS-dependent 12-lead ECG information system improves 12-lead ECG management and interoperability. Second, this system enables the remote physicians to perform ubiquitous 12-lead ECG and image diagnoses, which enhances the efficiency of emergency telemedicine. These findings prove the effectiveness and usefulness of the PACS-dependent 12-lead ECG information system, which can be easily adopted in telemedicine.