Computers in imaging and health care: Now and in the future

Early picture archiving and communication systems (PACS) were characterized by the use of very expensive hardware devices, cumbersome display stations, duplication of database content, lack of interfaces to other clinical information systems, and immaturity in their understanding of the folder manager concepts and workflow reengineering. They were implemented historically at large academic medical centers by biomedical engineers and imaging informaticists. PACS were nonstandard, home-grown projects with mixed clinical acceptance. However, they clearly showed the great potential for PACS and filmless medical imaging. Filmless radiology is a reality today. The advent of efficient softcopy display of images provides a means for dealing with the ever-increasing number of studies and number of images per study. Computer power has increased, and archival storage cost has decreased to the extent that the economics of PACS is justifiable with respect to film. Network bandwidths have increased to allow large studies of many megabytes to arrive at display stations within seconds of examination completion. PACS vendors have recognized the need for efficient workflow and have built systems with intelligence in the management of patient data. Close integration with the hospital information system (HIS)-radiology information system (RIS) is critical for system functionality. Successful implementation of PACS requires integration or interoperation with hospital and radiology information systems. Besides the economic advantages, secure rapid access to all clinical information on patients, including imaging studies, anytime and anywhere, enhances the quality of patient care, although it is difficult to quantify. Medical image management systems are maturing, providing access outside of the radiology department to images and clinical information throughout the hospital or the enterprise via the Internet. Small and medium-sized community hospitals, private practices, and outpatient centers in rural areas will begin realizing the benefits of PACS already realized by the large tertiary care academic medical centers and research institutions. Hand-held devices and the Worldwide Web are going to change the way people communicate and do business. The impact on health care will be huge, including radiology. Computer-aided diagnosis, decision support tools, virtual imaging, and guidance systems will transform our practice as value-added applications utilizing the technologies pushed by PACS development efforts. Outcomes data and the electronic medical record (EMR) will drive our interactions with referring physicians and we expect the radiologist to become the informaticist, a new version of the medical management consultant.     

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.     

The practical use and evaluation of picture archiving and communication system in the department of orthopaedic surgery

A picture archiving and communication system (PACS) was started in June 1989 in the outpatient clinic of the Department of Orthopaedic Surgery. Hokkaido University, Sapporo, Japan. The PACS system has several advantages: space savings for storage of images, safe custody and quick access to image data, simultaneous access to image data, the possibility of obtaining good quality data on utilization of images, and applications for medical education and resident training. However, this system has just begun, and several problems must still be solved. In this article, we describe our experiences with the PACS system in the outpatient clinic of the department of orthopaedic surgery.

     

The design and development of a physician-oriented PACS for the enhancement of e-hospital facilities

Recent advancements in modern medical diagnoses have required a huge increase of the use of equipment such as CT and ultrasound machines. Correspondingly, the storage and dissemination of these medical images have become an important issue to medical professionals. Unfortunately, management of these images has traditionally been slow and cumbersome. With the prevalence of the personal computer, however, along with increased network bandwidth, it is now possible to handle this information electronically as well as wirelessly. The Picture Archiving and Communication System (PACS) is at the forefront of this revolution. Yet, commercially available PACS software is generally prohibitively expensive for hospitals with limited financial resources. A dilemma among many hospitals is deciding how to acquire and implement the proper PACS system without unduly affecting the budget. In this paper, a full function, efficient, and economical PACS system is presented as a viable, non-compromising option for many small and medium-sized hospitals. This system, designed and developed mainly by the physicians and technicians of Puli Christian Hospital (PCH), with the assistance from academia, allows for customization to fit the needs of individual hospitals. This system can be used as the foundation of a hospital's health information infrastructure and to enhance e-hospital service.     

Developing a Multi-Institutional PACS Archive and Designing Processes to Manage the Shift from a Film to a Digital-Based Archive

The Quality Assurance Review Center (QARC) works to improve the standards of care in treating cancer by improving the quality of clinical trials medicine. QARC operates as a data management and review center providing quality assurance services for multiple external groups including cooperative groups and pharmaceutical companies. As the medical world migrates from analog film to digital files, QARC has developed an innovative and unique digital imaging management system to accommodate this trend. As QARC acquires electronic data from institutions across six continents, the system is continually developed to accommodate Digital Imaging and Communications in Medicine (DICOM) imaging originating from a wide variety of Picture Archival and Communications System (PACS) manufacturers, thus creating one of the largest and most diverse multi-institutional imaging archives in the cancer research community.     

Four-Year Enterprise PACS Support Trend Analysis

While health care facilities recognize the need for dedicated picture archiving and communication system (PACS) staff at the time of the initial implementation of PACS, they often do not plan accordingly for ongoing or increasing PACS support needs as a PACS matures. This article reviews trends in a health care system’s PACS support data over 4 years to show how PACS support needs evolve over time. PACS support items were logged and categorized over this period and were used by the health care system to become more proactive in system support and adjust staffing levels accordingly. This article details how PACS support needs change over the life of a PACS installation and can be used as a model for health care facilities planning for future PACS support needs.     

Clinical experience with a second-generation hospital-integrated picture archiving and communication system

In a previous report we described a second-generation hospital-integrated picture archiving and communication system (HI-PACS) developed in-house. This HI-PACS had four unique features not found in other PAC systems. In this report, we will share some of our clinical experiences pertaining to these features during the past 12 months. We first describe the usage characteristics of two 2,000-line workstations (WSs), one in the in-patient and the second in the out-patient neuroradiology reading area. These two WSs can access neuro-images from 10 computed tomographic and magnetic resonance scanners located at two medical centers through an asynchronous transfer mode network connection. The second unique feature of the system is an intensive care unit (ICU) server, which supports three WSs in the pediatric, medical surgery, and cardiac ICUs. The users’ experiences and requests for refinement of the WSs are given. Another feature is physician desk-top access of PACS data. The HI-PACS provides a server connected to more than 100 Macintosh users for direct access of PACS data from their offices. The server’s performance and user critiques are described. The last feature is a digital imaging and communication in medicine (DICOM) connection of the HI-PACS to a manufacturer’s ultrasound PACS module. The authors then outline the interfacing process and summarize some of the difficulties encountered. Developing an in-house PACS has many advantages but also some drawbacks. Based on experience, the authors have formulated three axioms as a guide for in-house PACS development.     

基于DICOM的医学影像设备接口设计与实现

医学影像存档与通讯系统(Picture Archiving and Communication Systems,PACS)是目前医院信息化建设的热点,医学数字成像和通信标准(Digital Imaging and Communication in Medicine,DICOM)是有关医学图像及其相关信息的数据编码及通讯的国际标准,支持DICOM标准是医学影像设备并入PACS网络的必要条件。为使目前尚不符合DICOM标准的影像设备有效并入PACS系统,必须为其添加DICOM接口。我们介绍了DICOM信息模型并实现了接口的软件系统,重点介绍了应用VisualC 编程实现DICOM服务中的C-STORE和DCM文件的读写功能。     

Picture Archiving and Communication Systems and related developments in Sweden

Large PACS (Picture Archiving and Communication Systems) installations do not yet exist in Sweden, but some hospitals have had experience with limited PACS activities. At present there are four mini PACS installations in radiology departments and about 12 teleradiology systems in use in Sweden. A couple of small Swedish enterprises work in the market segment of digital imaging including PACS and teleradiology, although the radiology market is dominated by the large international companies. Interest in PACS and teleradiology in Sweden has increased during the last few years, along with advancements in technology and international experience. However, radiology is organized very differently in the United States, Japan, Southern Europe, and Scandinavia. Because of this, PACS will be introduced in different ways, and experience with PACS gained in one health care system may differ from that gained from other health care systems. This article reviews the status of PACS and related developments in Sweden.     

Design and Implementation of Disaster Recovery and Business Continuity Solution for Radiology PACS

In the digital era of radiology, picture archiving and communication system (PACS) has a pivotal role in retrieving and storing the images. Integration of PACS with all the health care information systems e.g., health information system, radiology information system, and electronic medical record has greatly improved access to patient data at anytime and anywhere throughout the entire enterprise. In such an integrated setting, seamless operation depends critically on maintaining data integrity and continuous access for all. Any failure in hardware or software could interrupt the workflow or data and consequently, would risk serious impact to patient care. Thus, any large-scale PACS now have an indispensable requirement to include deployment of a disaster recovery plan to ensure secure sources of data. This paper presents our experience with designing and implementing a disaster recovery and business continuity plan. The selected architecture with two servers in each site (local and disaster recovery (DR) site) provides four different scenarios to continue running and maintain end user service. The implemented DR at University Hospitals Health System now permits continuous access to the PACS application and its contained images for radiologists, other clinicians, and patients alike.     

Interfacing aspects between the picture archiving communications systems,radiology information systems,and hospital information systems

Information relevant to radiological applications is commonly managed by several autonomous medical information systems including hospital information systems (HIS), radiological information systems (RIS), and picture archiving and communications systems (PACS). In this report, we explain the need to coordinate these systems and to provide some framework in which they can exchange information. In the first half of this report, we describe the integration of a PACS system into a hospital operation. Next, we present the interfacing methods between the HIS and the RIS, and between the RIS and the PACS. Two methods are further detailed for the communication between the RIS and the PACS (1) the triggered database to database transfer, and (2) the query protocol. The implementation of the first method successfully allows RIS reports, procedure and patient demographic information to be displayed at the request of the user along with the associated images at a PACS workstation. The query protocol allows a PACS to dynamically query RIS information. It will be eventually integrated into the design of a scientific multimedia distributed medical database system built on top of the HIS, the RIS, and the PACS.     

The future of PACS

How will the future of picture archiving and communication systems (PACS) look, and how will this future affect the practice of radiology? We are currently experiencing disruptive innovations that will force an architectural redesign, making the majority of today's commercial PACS obsolete as the field matures and expands to include imaging throughout the medical enterprise. The common architecture used for PACS cannot handle the massive amounts of data being generated by even current versions of computed tomography and magnetic resonance scanners. If a PACS cannot handle today's technology, what will happen as the field expands to encompass pathology imaging, cone-beam reconstruction, and multispectral imaging? The ability of these new technologies to enhance research and clinical care will be impaired if PACS architectures are not prepared to support them. In attempting a structured approach to predictions about the future of PACS, we offer projections about the technologies underlying PACS as well as the evolution of standards development and the changing needs of a broad range of medical imaging. Simplified models of the history of the PACS industry are mined for the assumptions they provide about future innovations and trends. The physicist frequently participates in or directs technical assessments for medical equipment, and many physicists have extended these activities to include imaging informatics. It is hoped that by applying these speculative but experienced-based predictions, the interested medical physicist will be better able to take the lead in setting information technology strategies that will help facilities not only prepare for the future but continue to enjoy the benefits of technological innovations without disruptive, expensive, and unexpected changes in architecture. A good PACS strategy can help accelerate the time required for innovations to go from the drawing board to clinical implementation.     

基于CORBA的医院信息系统与PACS的分布式集成研究

在实际医学应用中 ,医生需要及时获得病人的有关图像和文本记录信息。这些信息有助于医生进行病历诊断 ,临床试验和研究分析。但是这些信息分布零乱 ,并且位于不同的系统上 ,如图像管理和通信系统 (Picturearchiving and comm unication information systems,PACS) ,医院信息系统 (Hospital inform ation systems,HIS)等 ,这些系统使用不同的标准和协议 ,并且都不支持分布式操作 ,使系统间信息不能完全共享。为了实现各种医学系统间的分布式操作和信息的共享 ,本文结合当前流行的 WWW技术 ,利用分布式处理软件 (Common object requestbroker architecture,CORBA) ,提出了一种基于 WEB的 PACS和 HIS分布式集成方法 ,该方法将图像和文本信息系统及各种医学应用都看作是 CORBA组件对象 ,把对这些系统和应用的操作都当作是对应用对象的处理 ,利用面向对象的技术实现了对 PACS和 HIS系统的分布式集成和互操作 ,并且利用 WEB技术实现了信息的共享     

Content-based retrieval in picture archiving and communication systems

A COntent-Based Retrieval Architecture (COBRA) for picture archiving and communication systems (PACS) is introduced. COBRA improves the diagnosis, research, and training capabilities of PACS systems by adding retrieval by content features to those systems. COBRA is an open architecture based on widely used health care and technology standards. In addition to regular PACS components, COBRA includes additional components to handle representation, storage, and content-based similarity retrieval. Within COBRA, an anatomy classification algorithm is introduced to automatically classify PACS studies based on their anatomy. Such a classification allows the use of different segmentation and image-processing algorithms for different anatomies. COBRA uses primitive retrieval criteria such as color, texture, shape, and more complex criteria including object-based spatial relations and regions of interest. A prototype content-based retrieval system for MR brain images was developed to illustrate the concepts introduced in COBRA.     

PACS Bypass: A Semi-automated Routing Solution to Enable Filmless Operations When PACS Fails

In the filmless imaging department, an integrated imaging and reporting system is only as strong as its weakest link. An outage or downtime of a key segment, such as the Picture Archive Communications System (PACS), is a significant threat to efficient workflow, quality of image interpretation, ordering clinician's review, and ultimately patient care. A multidisciplinary team (including physicists, technologists, radiologists, operations, and IT) developed a backup system to provide business continuity (i.e., quality control, interpretation, reporting, and clinician access) during an extended outage of the main departmental PACS.     

R-PS一体化数字放射学科整合技术的研究

探讨了 R- PS一体化数字放射学科整合技术。通过对 RIS和 PACS的整合 ,使 R- PS中各个系统和各医学影像设备之间所有的数据信息交换都遵循 DICOM3.0标准并通过模块的接口和方法实现无缝连接。R- PS系统具有共享性、安全性、兼容性、实用性和操作简单等特点 ,可实现通信接口标准化、应用功能模块化和医学信息资源共享。     

医学图像三维可视化系统的构建

针对当前PACS的需要，利用可视化工具包VTK，设计和实现了一个能应用于PACS的三维可视化系统。该系统实现了医学图像的三维可视化与剖面显示功能，丰富了PACS的图像处理功能。     

Sharing patient care records over the World Wide Web

In order to obtain appropriate medical care, patients can be referred or transported from one hospital to another based on the capacity, capability and quality of medical care provided by hospitals. Therefore, enabling patient care records to be shared among hospitals is essential not only in delivering the quality of medical care services but also in saving medical expenses. Currently, most patient care records are paper-based and not well organized. Hence, they are usually incomplete and can hardly be accessed in time. The authors in this paper present methods to structure and represent patient care records, design mechanisms for interpreting and integrating the XML-based patient care records into the existing hospital information systems. More importantly, in our approach, each significant piece of medical record is associated with a tag based on the syntax and semantics of the XML. The XML-based medical records enable a computer to capture the meaning and structure of the document on the web. The authors have developed a unified referral information system in which patient care records can be shared among hospitals over the Internet. It can not only facilitate the referral process but also maintain the integrity of a patient's medical record from distributed hospitals. The workflow of the system basically follows the existing manual system and can easily be adapted. The working group on integration of municipal hospital information systems, Department of Health, Taipei City Government, has decided to adapt this system for referral practice among the municipal hospitals.     

Diagnostic imaging over the last 50 years: research and development in medical imaging science and technology

Over the last 50 years, diagnostic imaging has grown from a state of infancy to a high level of maturity. Many new imaging modalities have been developed. However, modern medical imaging includes not only image production but also image processing, computer-aided diagnosis (CAD), image recording and storage, and image transmission, most of which are included in a picture archiving and communication system (PACS). The content of this paper includes a short review of research and development in medical imaging science and technology, which covers (a) diagnostic imaging in the 1950s, (b) the importance of image quality and diagnostic performance, (c) MTF, Wiener spectrum, NEQ and DQE, (d) ROC analysis, (e) analogue imaging systems, (f) digital imaging systems, (g) image processing, (h) computer-aided diagnosis, (i) PACS, (j) 3D imaging and (k) future directions. Although some of the modalities are already very sophisticated, further improvements will be made in image quality for MRI, ultrasound and molecular imaging. The infrastructure of PACS is likely to be improved further in terms of its reliability, speed and capacity. However, CAD is currently still in its infancy, and is likely to be a subject of research for a long time.