Preparing medical students for a filmless environment: instruction on the preparation of electronic case presentations from PACS

RATIONALE AND OBJECTIVES: As the use of picture archiving and communication systems (PACS) expands and radiology departments become increasingly filmless, it will become increasingly necessary to teach physicians how to use PACS and download diagnostic images. The authors developed an instruction method in which medical students enrolled in a radiology clerkship were taught how to use the PACS, download digital images, and incorporate them into an electronic case presentation. The feasibility and potential benefits of this instructional method were studied prospectively. MATERIALS AND METHODS: Between June and October 1999, all 36 medical students enrolled in Harvard Medical School's core radiology clerkship at Massachusetts General Hospital, Boston, were required to give an electronic radiology case presentation with images downloaded from the departmental PACS. They were taught how to download images, edit them, and then import them into PowerPoint software. They were also given access to the hospital information system to obtain pertinent clinical information. At the formal presentations, the images were displayed with a liquid crystal display (LCD) projector. The students were surveyed on the Ist and last days of the clerkship regarding their learning experiences. RESULTS: Before the radiology clerkship, 81% of the students had never given an electronic presentation with computer and LCD projector, 83% had no PACS experience, and 56% had no PowerPoint experience. All students learned to prepare and deliver electronic presentations of radiologic cases downloaded from PACS. Their presentations were informative, innovative, and entertaining, and the images were well displayed. The students praised the instruction highly and thought their new skills would serve them well. CONCLUSION: Teaching medical students how to prepare and deliver electronic presentations of radiologic cases downloaded from PACS proved to be very feasible and well appreciated by the students.     

Shareware program for nuclear medicine and PET/CT PACS display and processing

OBJECTIVE: Many of the functions necessary for imaging and analyzing nuclear medicine studies are not available on radiology PACS. Over the past 20 years, we have developed a user-friendly, easily installed software package for nuclear medicine study analysis, display, Web access, and database storage and an integrated display for fused PET/CT. We are making this software available as free shareware that can be used without a license on any PC. The software package was developed as a cooperative effort between house and attending staff and our nuclear medicine programmer. Particular emphasis was put on making functions intuitive and user friendly. CONCLUSION: A shareware nuclear medicine PACS software package including a display for fused PET/CT studies has been developed, extensively clinically tested, and is freely available on the Internet.     

PACS and Web-based image distribution and display.

Picture archiving and communication system (PACS) delivers images to the display workstations mostly through digital image communication in medicine (DICOM) protocols in radiology departments, and there are lots of medical applications in healthcare community needing to access PACS images for different application purposes. In this paper, we first reviewed a hospital-integrated PACS image data flow and typical diagnostic display software architecture, and discussed some Web technologies and Web-based image application server architectures, as well as image accessing and viewing methods in these architectures. Then, we present one approach to develop component-based image display architecture and use image processing and display component to build a diagnostic display workstation, and also, give a method to integrate this component into Web-based image distribution server to enable users using Web browsers to access, view and manipulate PACS DICOM images as easy as with PACS display workstations. Finally, we test and evaluate the performance of image loading and displaying by using the diagnostic display workstation and the component-based Web display system, the experimental results show that the image distribution and display performance from the Web server to browser clients is similar with that of the image loading and displaying procedure of the diagnostic workstation as more browser clients accessing the Web server at same time. We also discuss the advantages and disadvantages of the Web-based image distribution and display in different medical applications.     

A comparison of the time required by radiologists for the preparation of clinico-radiological meetings when film and PACS are used

The hypothesis was that when a hospital-wide Picture Archive and Communications System (PACS) is used, preparation for clinico-radiological meetings is faster, and more images are available, than when a conventional film system is used. This paper reports a study which compared the preparation time by radiologists when film was used with the time for the same activity when a hospital-wide PACS was used at Hammersmith Hospital for the preparation of the respiratory medicine and hepato-biliary meetings. It was found that when PACS was used the time per patient to prepare for the respiratory medicine session was reduced by 11.1 min and that similarly, 16 min per patient was saved in the preparation of the hepato-biliary sessions. The number of images which were unavailable for the session was reduced when PACS was in operation, but this reduction was not shown to be statistically significant. The introduction of PACS at Hammersmith Hospital has significantly reduced the time spent by radiologists in preparing for the two clinico-radiological sessions studied and, if this is extended to the other numerous sessions held each week, contributes to a considerable saving of staff time within the radiology department. Received: 1 April 1999; Revised: 24 June 1999; Accepted: 9 August 1999     

Diagnostic image workstations for PACS

Image workstations will be the ‘window’ to the complex infrastructure of a PACS with its intertwined image modalities (image sources, image data bases and image processing devices) and data processing modalities (patient data bases, departmental and hospital information systems). They will serve for user-to-system dialogues, image display and local processing of data as well as images. Their hardware and software structures have to be optimized towards an efficient throughput and processing of image data.     

应用图像浏览软件构建简易医学影像存档与通讯系统的研究

目的论证利用数字影像与通信标准（Digital Imaging and Communications in Medicine,DICOM）图像浏览软件构建简易医学影像存档与通讯系统（picture archiving and communication systems,PACS）,实现医学影像全院性共享及远程会诊的方法及其可行性。方法利用医院现有的局域网、各个科室现有PC机,采用互联网上免费DICOM图像浏览软件,通过网络及软件设置,将具有DICOM接口并开放的影像设备（如CR、DR、CT、MRI、DSA、数字胃肠及具有网络接口的激光胶片相机等）与PC机连接。结果具有DICOM图像浏览软件的PC机实现实时传输、调阅影像图像,达到类PACS效果。同时可以利用互联网,实现远程会诊。结论利用DICOM图像浏览软件构建简易PACS系统方法简单、经济、实用,特别适合在各中小型医院。     

Evaluation of a PACS workstation for assessment of body CT studies

Conventional hardcopy images from 266 body CT studies were compared with those provided at a commercially available picture archiving communication system (PACS) workstation. Unprocessed PACS images were larger but otherwise precisely duplicated hardcopy images. The PACS images were evaluated before and after application of various image processing/display features. Approximately three-quarters of the cases were depicted equally well with PACS and hardcopy, but in one quarter of the cases, diagnostic features were judged to be shown more clearly at the PACS workstation. When PACS images were viewed first, change in diagnosis after subsequent hardcopy inspection was infrequent (confidence change: 4%; different findings: 2%). Conversely, when hardcopy images were viewed first, change in diagnosis after subsequent PACS inspection was more frequent (confidence change: 19%; different findings: 8%). Specialized image manipulation available on PACS was critical for its performance. Review of cases with new findings discovered during the second inspection showed the majority of them to be clinically significant, true-positives discovered by PACS. We conclude that PACS is a useful modality for interpretation of body CT images.     

In-house access to PACS images and related data through World Wide Web

The development of a hospital wide PACS is in progress at the University Hospital of Geneva and several archive modules are operational since 1992. This PACS is intended for wide distribution of images to clinical wards. As the PACS project and the number of archived images grow rapidly in the hospital, it was necessary to provide an easy, more widely accessible and convenient access to the PACS database for the clinicians in the different wards and clinical units of the hospital. An innovative solution has been developed using tools such as Netscape navigator and NCSA World Wide Web server as an alternative to conventional database query and retrieval software. These tools present the advantages of providing a user interface which is the same, independent of the platform being used (e.g. Mac, Windows, UNIX), and an easy integration of different types of documents (e.g. text, images). A strict access control has been added to this interface. It allows user identification and access rights checking, as defined by the in-house hospital information system, before allowing the navigation through patient data records.     

Software tools for interactive instruction in radiologic anatomy

RATIONALE AND OBJECTIVES: To promote active learning in an introductory Radiologic Anatomy course through the use of computer-based exercises. MATERIALS AND METHODS: DICOM datasets from our hospital PACS system were transferred to a networked cluster of desktop computers in a medical school classroom. Medical students in the Radiologic Anatomy course were divided into four small groups and assigned to work on a clinical case for 45 minutes. The groups used iPACS viewer software, a free DICOM viewer, to view images and annotate anatomic structures. The classroom instructor monitored and displayed each group's work sequentially on the master screen by running SynchronEyes, a software tool for controlling PC desktops remotely. RESULTS: Students were able to execute the assigned tasks using the iPACS software with minimal oversight or instruction. Course instructors displayed each group's work on the main display screen of the classroom as the students presented the rationale for their decisions. The interactive component of the course received high ratings from the students and overall course ratings were higher than in prior years when the course was given solely in lecture format. CONCLUSIONS: DICOM viewing software is an excellent tool for enabling students to learn radiologic anatomy from real-life clinical datasets. Interactive exercises performed in groups can be powerful tools for stimulating students to learn radiologic anatomy.     

The digital imaging workstation

Picture archiving and communication systems (PACS) are expected to convert film-based radiology into a computer-based digital environment, with associated cost savings and improved physician communication. The digital workstation will be used by physicians to display these "soft-copy" images; however, difficult technical challenges must be met for the workstation to compete successfully with the familiar viewbox. Issues relating to image perception and the impact on physicians' practice must be carefully considered. The spatial and contrast resolutions required vary according to imaging modality, type of procedure, and class of user. Rule-based software allows simple physician interaction and speeds image display. A consensus appears to be emerging concerning the requirements for the PACS workstation. Standards such as the American College of Radiology/National Electrical Manufacturers' Association Digital Imaging and Communication Standard are facilitating commercial applications. Yet much careful study is needed before PACS workstations will be fully integrated into radiology departments.     

Enterprise-wide PACS: beyond radiology, an architecture to manage all medical images

RATIONALE AND OBJECTIVES: Picture archiving and communication systems (PACS) have the vocation to manage all medical images acquired within the hospital. To address the various situations encountered in the imaging specialties, the traditional architecture used for the radiology department has to evolve. MATERIALS AND METHODS: We present our preliminarily results toward an enterprise-wide PACS intended to support all kind of image production in medicine, from biomolecular images to whole-body pictures. Our solution is based on an existing radiologic PACS system from which images are distributed through an electronic patient record to all care facilities. This platform is enriched with a flexible integration framework supporting digital image communication in medicine (DICOM) and DICOM-XML formats. In addition, a generic workflow engine highly customizable is used to drive work processes. RESULTS: Echocardiology; hematology; ear, nose, and throat; and dermatology, including wounds, follow-up is the first implemented extensions outside of radiology. CONCLUSION: We also propose a global strategy for further developments based on three possible architectures for an enterprise-wide PACS.     

Integration of radiology and hospital information systems (RIS, HIS) with PACS: requirements of the radiologist.

PACS development has now reached a stage where it can clearly be stated that the technology for storage, networking and display in a fully digital environment is available. This is reflected by an already large and rapidly increasing number of PACS installations in USA, Western Europe and Japan. Such installations consist of a great variety of information systems, more or less interconnected, like PACS, HIS, RIS and other departmental systems, differing in both hardware and software. Various data - even if they only concern one person - are stored in different systems distributed in the hospital. The integration of all digital systems into a functional unit is determined by the radiologist's need of quick access to all relevant information regardless where it is stored. The interconnection and functional integration of all digital systems in the hospital determine the clinical benefits of PACS. This paper (1) describes the radiologist's requirements concerning this integration, and (2) presents some realistic solutions such as the Siemens ISI (Information System Interface), and a mobile viewing station for the wards (visitBox).     

PACS图像显示器质量控制的初步研究

目的探讨放射科PACS系统中图像显示器的质量保证(QA)、质量控制(QC)问题。方法参考美国医学物理学会第18工作组(AAPMTG18)制定的测试图和质量评估标准,利用光度计、显示器校正软件,对3种型号的BARCOCRT灰阶显示器进行季度性定量检测。内容包括:DICOM灰阶标准显示函数校正、最高亮度和最低亮度检测、亮度均一性检测、显示器分辨率、几何失真校正。结果显示器的各项性能指标都符合AAPMTG18规范。放射科95%的医学图像依靠PACS显示器做出了诊断。结论PACS图像显示器的质量控制是确保数字化医疗环境优质性的重要措施。     

PACS系统的应用体会

目的：介绍我院影像医学存档与通讯系统（ＰＡＣＳ）应用的经验。材料与方法：将所有Ｂ超、ＣＴ、Ｘ线机和一台ＩＢＭ服务器、四台奔腾Ⅱ档次的工作站及惠普光盘塔连接成医学数字影像传输（ＤＩＣＯＭ）网络;ＤＩＣＯＭ服务器与各种图像浏览终端羞以太网络;通过ＨＵＢ连接成ＰＡＣＳ系统。结果：将常规放射图像的模拟信号通过数字转换器转换为数字信号后,与ＣＴ等数字成像系统的数字信号一并输入光盘塔,并进行诊断。将数字图像和诊断报告一起舆到医院各个图像浏览终端,使其可通过ＷＥＢ界面系统及咨询平台进行查询。ＰＡＣＳ投入使用２年来,效果良好。结论：ＰＡＣＳ的应用明显提高了放射科及相关科室的工作效率,方便了工作、教学、科研和会诊。     

IHE profiles applied to regional PACS

PACS has been widely adopted as an image storage solution that perfectly fits the radiology department workflow and that can be easily extended to other hospital departments. Integrations with other hospital systems, like the Radiology Information System, the Hospital Information System and the Electronic Patient Record are fully achieved but still challenging aims. PACS also creates the perfect environment for teleradiology and teleworking setups. One step further is the regional PACS concept where different hospitals or health care enterprises share the images in an integrated Electronic Patient Record. Among the different solutions available to share images between different hospitals IHE (Integrating the Healthcare Enterprise) organization presents the Cross Enterprise Document Sharing profile (XDS) which allows sharing images from different hospitals even if they have different PACS vendors. Adopting XDS has multiple advantages, images do not need to be duplicated in a central archive to be shared among the different healthcare enterprises, they only need to be indexed and published in a central document registry. In the XDS profile IHE defines the mechanisms to publish and index the images in the central document registry. It also defines the mechanisms that each hospital will use to retrieve those images regardless on the Hospital PACS they are stored.     

Construction of a common utilization system for medical images using a high-speed cable network

We constructed an Electronic Medical Record (EMR) and Picture Archiving and Communication System (PACS) in December 1999, and established a satellite clinic 5 km away from the core hospital in November 2001. Both medical doctors and patients were exchanged between the two institutes. Because it was necessary for both institutes to use the same medical information and medical images, we re-constructed both the PACS and EMR using high-speed cable network technology.     

The evolution of display technologies in PACS applications.

Picture archiving and communications systems (PACS) systems have been around for over a decade now. The most visible components in a PACS system are the PACS workstations. Most of the clinical users of PACS only interact with the display hardware/software pieces and never truly think about the archival and communications that occur behind the scenes. This paper discusses the evolution of PACS display technology in the past 16 yr, which can roughly be divided into three phases and will also discuss future emerging trends.     

Integration of multiple direct digital imaging sources in a picture archiving and communication system (PACS)

OBJECTIVES: The aim of this report was to describe a flexible picture archiving and communication system (PACS) able to handle and communicate digital image data from various radiography systems and other sources. METHODS: The radiographic image is acquired using the vendor's own software. Following image capture, a "request for update" message (appending a record to an Access database) activates our PACS engine, "DigiMerge". Images from sources with no patient-related organizing software, e.g. TWAIN-compatible scanners and digital cameras, are handled by a self-developed program, "MedCom-T". DigiMerge generates and maintains one database based on all manufacturers' databases (software: VixWin 2000, Digora for Windows, Dimaxis Pro, Sidexis, CDR DICOM for Windows, Trophy for Windows). This database contains patient information, image information and image path. The program "DigiView" searches a patient and displays patient and image data from the database generated by DigiMerge. With DigiView, images can be viewed at any workstation in the dental school, but only temporary changes can be made (contrast, brightness, etc.) and no image can be deleted. RESULTS: The PACS is currently installed on 86 workstations. Statistics collected by DigiMerge reveal that approximately 2000 new digital images are recorded each month, half of which are radiographs and the other half are clinical photographs. Statistics collected by DigiView reveal that 500-800 digital images are opened per week. CONCLUSIONS: The self-developed PACS is able to manage images from a range of digital modalities each providing its own image data format.     

Clinical experiences with computed radiography

Computed radiography (CR) based on photostimulable phosphor is currently the only feasible way for a radiological department to digitize the bulk of radiological data: the lung and skeletal examinations. Regarding the quality of images for diagnostic purposes, CR imaging is never inferior to a screen/film system (SF) and for several clinical entities CR is superior. Of the many processing possibilities of the image plate (IP) image, the unsharp masking or edge enhancement should be used at a minimum. Dose reduction with CR ranges from 15% to 95%; at our institution it is 37%. Softcopy reading of CR images is advantageous due to the many postprocessing and improved display facilities. Currently there is little use for a 4000 × 4000 (4 K) pixel imaging and display. All images (including mammograghy) can be read in 2 K without any loss of clinically important information. To include CR in a picture archive and communication system (PACS) is demanding because of the load of data that each CR image represents. Networks for image distribution are essential if digital imaging is to have any impact on patient treatment and hospital organization.     

Hanging protocol and viewers for a dental full picture [corrected] archiving and communication system (PACS) [corrected

OBJECTIVES: Study objectives were: to develop a hanging protocol for displaying digital transmission radiographic images of oral and maxillofacial regions using a dental DICOM (digital imaging and communication in medicine) viewer and a dental Web viewer; and to give information on a system that allows patients and health professionals to share image information. METHODS: For the hanging protocol, alphanumeric tags were defined and used in a DICOM modality worklist. These tags consisted of layout information to display images on monitors by the type of projection method and assignment information to display images of template for intraoral full-mouth survey that were numbered and slotted according to tooth position. Tooth code and algorithm for assignment of images for intraoral full-mouth survey were determined. Expanded correspondence for viewers was used for modalities without tags. Images could be edited by quality control system. An electronic medical record (EMR) system, a radiological information system (RIS) and a picture archiving and communication system (PACS) with servers, terminals and viewers were set up in a patient-centred hospital environment. RESULTS: Using the hanging protocol, the viewers displayed digital transmission radiographic images automatically on display areas on one or multiple monitors showing intraoral, panoramic and extraoral views produced during various examinations. The images were also displayed using the coupling function of EMR and RIS. Users can compare the images taken at various times more efficiently. CONCLUSION: The new system using a dental DICOM viewer and a dental Web viewer is the most advanced for examining oral and maxillofacial regions compared with medical viewers. Our local but clinically operational hanging protocol should be a good model for DICOM Working Group 22.