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1.  The use of Digital Imaging and Communications in Medicine (DICOM) in the integration of imaging into the electronic patient record at the Department of Veterans Affairs 
Journal of Digital Imaging  2000;13(Suppl 1):133-137.
The US Department of Veterans Affairs (VA) is using the Digital Imaging and Communications in Medicine (DICOM) standard to integrate image data objects from multiple systems for use across the health care enterprise. DICOM uses a structured representation of image data and a communication mechanism that allows the VA to easily acquire images from multiple sources and store them directly into the online patient record. The VA can obtain both radiology and nonradiology images using DICOM, and can display them on low-cost clinican’s color workstations throughout the medical center. High-resolution gray-scale diagnostic-quality multimonitor workstations with specialized viewing software can be used for reading radiology images. The VA’s DICOM capabilities can interface six different commercial picture archiving and communication systems (PACS) and more than 20 different image acquisition modalities. The VA is advancing its use of DICOM beyond radiology. New color imaging applications for gastrointestinal endoscopy and ophthalmology using DICOM are under development. These are the first DICOM offerings for the vendors, who are planning to support the recently passed DICOM Visible Light and Structured Reporting service classes. Implementing these in VistA is a challenge because of the different workflow and software support for these disciplines within the VA hospital information system (HIS) environment.
doi:10.1007/BF03167644
PMCID: PMC3453236  PMID: 10847382
2.  Borderless Teleradiology with CHILI 
Teleradiology is one of the most evolved areas of telemedicine, but one of the basic problems which remains unsolved concerns system compatibility. The DICOM (Digital Imaging and Communications in Medicine) standard is a prerequisite, but it is not sufficient in all aspects. Examples of other currently open issues are security and cooperative work in synchronous teleconferences. Users without a DICOM radiological workstation would benefit from the ability to join a teleradiology network without any special tools. Drawbacks of many teleradiology systems are that they are monolithic in their software design and cannot be adapted to the actual user's environment. Existing radiological systems currently cannot be extended with additional software components. Consequently, every new application usually needs a new workstation with a different look and feel, which must be connected and integrated into the existing infrastructure.
This paper introduces the second generation teleradiology system CHILI. The system has been designed to match both the teleradiology requirements of the American College of Radiology (ACR), and the functionality and usability needs of the users. The experiences of software developers and teleradiology users who participated in the first years of the clinical use of CHILI's predecessor MEDICUS have been integrated into a new design. The system has been designed as a component-based architecture. The most powerful communication protocol for data exchange and teleconferencing is the CHILI protocol, which includes a strong data security concept. The system offers, in addition to its own secure protocol, several different communication methods: DICOM, classic e-mail, Remote Copy functions (RCP), File Transfer Protocol (FTP), the internet protocols HTTP (HyperText Transfer Protocol) and HTTPS (HyperText Transfer Protocol Secure),and CD-ROMs for off-line communication. These transfer methods allow the user to send images to nearly anyone with a computer and a network. The drawbacks of the non-CHILI protocols are that teleconferences are not possible, and that the user must take reasonable precautions for data privacy and security.
The CHILI PlugIn mechanism enables the users or third parties to extend the system capabilities by adding powerful image postprocessing functions or interfaces to other information systems. Suitable PlugIns can be either existing programs, or dedicated applications programmed with interfaces to the CHILI components. The developer may freely choose programming languages and interface toolkits.
The CHILI architecture is a powerful and flexible environment for Picture Archiving and Communications Systems (PACS)and teleradiology. More than 40 systems are currently running in clinical routine in Germany. More than 300,000 images have been distributed among the communication partners in the last two years. Feedback and suggestions from the users influenced the system architecture by a great extent. The proposed and implemented system has been optimized to be as platform independent, open, and secure as possible.
doi:10.2196/jmir.1.2.e8
PMCID: PMC1761707  PMID: 11720917
Teleradiology; Telemedicine; Remote Consultation; Diagnostic Imaging; Computer-Assisted Image Interpretation; PACS; Middleware; TLS; Security; Plugin; Visualization
3.  Enterprise-scale image distribution with a Web PACS 
Journal of Digital Imaging  1998;11(Suppl 1):12-17.
The integration of images with existing and new health care information systems poses a number of challenges in a multi-facility network: image distribution to clinicians; making DICOM image headers consistent across information systems; and integration of teleradiology into PACS. A novel, Web-based enterprise PACS architecture introduced at Massachusetts General Hospital provides a solution. Four AMICAS Web/Intranet Image Servers were installed as the default DICOM destination of 10 digital modalities. A fifth AMICAS receives teleradiology studies via the Internet. Each AMICAS includes: a Java-based interface to the IDXrad radiology information system (RIS), a DICOM autorouter to tape-library archives and to the Agfa PACS, a wavelet image compressor/decompressor that preserves compatibility with DICOM workstations, a Web server to distribute images throughout the enterprise, and an extensible interface which permits links between other HIS and AMICAS. Using wavelet compression and Internet standards as its native formats, AMICAS creates a bridge to the DICOM networks of remote imaging centers via the Internet. This teleradiology capability is integrated into the DICOM network and the PACS thereby eliminating the need for special teleradiology workstations. AMICAS has been installed at MGH since March of 1997. During that time, it has been a reliable component of the evolving digital image distribution system. As a result, the recently renovated neurosurgical ICU will be filmless and use only AMICAS workstations for mission-critical patient care.
doi:10.1007/BF03168249
PMCID: PMC3453358  PMID: 9735424
4.  Integration, acceptance testing, and clinical operation of the Medical Information, Communication and Archive System, phase II 
Journal of Digital Imaging  1999;12(Suppl 1):144-147.
The Medical Information, Communication and Archive System (MICAS) is a multivendor incremental approach to picture archiving and communications system (PACS). It is a multimodality integrated image management system that is seamlessly integrated with the radiology information system (RIS). Phase II enhancements of MICAS include a permanent archive, automated workflow, study caches, Microsoft (Redmond, WA) Windows NT diagnostic workstations with all components adhering to Digital Information Communications in Medicine (DICOM) standards. MICAS is designed as an enterprise-wide PACS to provide images and reports throughout the Strong Health healthcare network. Phase II includes the addition of a Cemax-Icon (Fremont, CA) archive, PACS broker (Mitra, Waterloo, Canada), an interface (IDX PACSlink, Burlington, VT) to the RIS (IDXrad) plus the conversion of the UNIX-based redundant array of inexpensive disks (RAID) 5 temporary archives in phase I to NT-based RAID 0 DICOM modality-specific study caches (ImageLabs, Bedford, MA). The phase I acquisition engines and workflow management software was uninstalled and the Cemax archive manager (AM) assumed these functions. The existing ImageLabs UNIX-based viewing software was enhanced and converted to an NT-based DICOM viewer. Installation of phase II hardware and software and integration with existing components began in July 1998. Phase II of MICAS demonstrates that a multivendor open-system incremental approach to PACS is feasible, cost-effective, and has significant advantages over a single-vendor implementation.
doi:10.1007/BF03168784
PMCID: PMC3452915  PMID: 10342195
5.  Toward Clinically Relevant Standardization of Image Quality 
Journal of Digital Imaging  2004;17(4):271-278.
In recent years, notable progress has been made on standardization of medical image presentations in the definition and implementation of the Digital Imaging and Communications in Medicine (DICOM) Grayscale Standard Display Function (GSDF). In parallel, the American Association of Physicists in Medicine (AAPM) Task Group 18 has provided much needed guidelines and tools for visual and quantitative assessment of medical display quality. In spite of these advances, however, there are still notable gaps in the effectiveness of DICOM GSDF to assure consistent and high-quality display of medical images. In additions the degree of correlation between display technical data and diagnostic usability and performance of displays remains unclear. This article proposes three specific steps that DICOM, AAPM, and ACR may collectively take to bridge the gap between technical performance and clinical use: (1) DICOM does not provide means and acceptance criteria to evaluate the conformance of a display device to GSDF or to address other image quality characteristics. DICOM can expand beyond luminance response, extending the measurable, quantifiable elements of TG18 such as reflection and resolution. (2) In a large picture archiving and communication system (PACS) installation, it is critical to continually track the appropriate use and performance of multiple display devices. DICOM may help with this task by adding a Device Service Class to the standard to provide for communication and control of image quality parameters between applications and devices, (3) The question of clinical significance of image quality metrics has rarely been addressed by prior efforts. In cooperation with AAPM, the American College of Radiology (ACR), and the Society for Computer Applications in Radiology (SCAR), DICOM may help to initiate research that will determine the clinical consequence of variations in image quality metrics (eg, GSDF conformance) and to define what constitutes image quality from a diagnostic perspective. Implementation of these three initiatives may further the reach and impact of DICOM toward quality medicine.
doi:10.1007/s10278-004-1031-5
PMCID: PMC3047179  PMID: 15551103
Display quality; display performance; display calibration; DICOM; AAPM; luminance response; image quality
6.  Picture archiving and communication system—Asynchronous transfer mode network in a midsized hospital 
Journal of Digital Imaging  1997;10(Suppl 1):99-102.
This article describes the pathway to full implementation of a hospital information system-picture archiving and communication system-wide area network (HIS-PACS-WAN) in a 300-bed acute care hospital, and the linking of that system to two other off-site medical centers. The PACS included direct digital capture of computed tomography (CT), magnetic resonance (MR) imaging, nuclear medicine, and ultrasonography images into an Olicon archive. Plain radiographs and fluoroscopy images were digitized manually and archived into an Olicon system. The active archive included current images on each Olicon workstation and the juke box. Long-term archiving of the images on removable optical discs, which would be loaded manually by an operator every time a request for one of these studies appeared on the operator’s monitor, also was implemented. Ability to store, retrieve, and display simultaneously the physician’s report of each procedure along with the images was an ultimate goal. The WAN is to be used for teleradiology and teleconferencing among the three medical centers involved in this study as well as other off-site locations. Phase I included the design and installation of the local area network (LAN) in the Department of Radiology at Olive View-UCLA Medical Center. This included the clinics and the inpatient and hospitalwide fiber-optic network and its linkage to the local telephone company. Phase II involved linkage of the Olicon workstations to imaging equipment. This implementation has been delayed significantly because of inadequate needs assessment, absence of planning for forward-compatibility to imaging equipment, and incompatibilities in DICOM conformance among vendors. Every PACS project must include an in-depth needs analysis, which should be updated yearly because of rapid turnover of technology. Although this analysis should have a heavy emphasis on clinical needs, it must incorporate the hospital-wide needs for an integrated information systems network. Integration of PACS, HIS, RIS, and a dictation/transcription system is a complex task that requires a full-time, clinically oriented project officer for successful completion.
doi:10.1007/BF03168669
PMCID: PMC3452833  PMID: 9268851
PACS; LAN; WAN; ATM
7.  Digital radiography and film scanners: Automating the transition to filmless radiology 
Journal of Digital Imaging  2001;14(Suppl 1):128-130.
To facilitate the integration of digital radiography (DR) and legacy film/screen technology, we have devised a methodology for film digitization that optimizes workflow and integrates well with the picture archiving and communication system (PACS). This work was performed at Mercy Medical Center (Cedar Rapids, IA) using a film digitizer with built-in Digital Imaging and Communications in Medicine (DICOM) communication. The radiology department at Mercy has one DR system and three separate film/screen systems. The DR system software suite features DICOM Modality Worklist capability to provide complete radiology information system (RIS) integration functionality. This provides for patient demographic information to be automatically downloaded from the RIS worklist to populate the DICOM image header. Likewise, we have taken advantage of the film scanner’s DICOM capability to develop software linking it with the hospital RIS. This capability provides a worklist downloading functionality equivalent to that of the DR. Patient demographics can then be rapidly downloaded as each film is digitized. The worklist capability of the scanner is essential in several respects. First, it guarantees that patient demographic information is completely accurate and, therefore, that the digitized x-ray image will be merged with the correct patient file in the PACS. Additionally, high film scanner throughput is achieved, guaranteeing that all inpatient-digitized films are as readily available on the PACS as their DR image counterparts. The digitized images have proven to be of diagnostic quality on the typical 1K by IK PACS workstation. Also, as patients are admitted to the hospital, prior films from the radiology archive are digitized to form a readily available patient history for in-house physicians. Over time, we are building archival patient histories of soft-copy images that will enable increased availability of patient x-rays to both in-hospital and outside referring physicians, especially as more internet-viewing software becomes available to the out-of-hospital medical community. Finally, the results of this study show that high-throughput RIS integraton of film scanning equipment is a key component to making a graceful transition to the filmless hospital as more DR systems are installed.
doi:10.1007/BF03190315
PMCID: PMC3452673  PMID: 11442072
8.  Performance and function of a high-speed multiple star topology image management system at Mayo Clinic Scottsdale 
Journal of Digital Imaging  1999;12(Suppl 1):168-174.
Mayo Clinic Scottsdale (MCS) is a busy outpatient facility (150,000 examinations per year) connected via asynchronous transfer mode (ATM; OC-3 155 MB/s) to a new Mayo Clinic Hospital (178 beds) located more than 12 miles distant. A primary care facility staffed by radiology lies roughly halfway between the hospital and clinic connected to both. Installed at each of the three locations is a high-speed star topology image network providing direct fiber connection (160 MB/s) from the local image storage unit (ISU) to the local radiology and clinical workstations. The clinic has 22 workstations in its star, the hospital has 13, and the primary care practice has two. In response to Mayo’s request for a seamless service among the three locations, the vendor (GE Medical Systems, Milwaukee, WI) provided enhanced connectivity capability in a two-step process. First, a transfer gateway (TGW) was installed, tested, and implemented to provide the needed communication of the examinations generated at the three sites. Any examinations generated at either the hospital or the primary care facility (specified as the remote stars) automatically transfer their images to the ISU at the clinic. Permanent storage (Kodak optical jukebox, Rochester, NY) is only connected to the hub (Clinic) star. Thus, the hub ISU is provided with a copy of all examinations, while the two remote ISUs maintain local exams. Prefetching from the archive is intelligently accomplished during the off hours only to the hub star, thus providing the remote stars with network dependent access to comparison images. Image transfer is possible via remote log-on. The second step was the installation of an image transfer server (ITS) to replace the slower Digital Imaging and Communications in Medicine (DICOM)-based TGW, and a central higher performance database to replace the multiple database environment. This topology provides an enterprise view of the images at the three locations, while maintaining the high-speed performance of the local star connection to what is now called the short-term storage (STS). Performance was measured and 25 chest examinations (17 MB each) transferred in just over 4 minutes. Integration of the radiology information management system (RIMS) was modified to provide location-specific report and examination interfaces, thereby allowing local filtering of the worklist to remote and near real-time consultation, and remote examination monitoring of modalities are addressed with this technologic approach. The installation of the single database ITS environment has occurred for testing prior to implementation.
doi:10.1007/BF03168791
PMCID: PMC3452928  PMID: 10342202
9.  Large-scale PACS implementation 
Journal of Digital Imaging  1998;11(Suppl 1):3-7.
The transition to filmless radiology is a much more formidable task than making the request for proposal to purchase a (Picture Archiving and Communications System) PACS. The Department of Defense and the Veterans Administration have been pioneers in the transformation of medical diagnostic imaging to the electronic environment. Many civilian sites are expected to implement large-scale PACS in the next five to ten years. This presentation will relate the empirical insights gleaned at our institution from a large-scale PACS implementation. Our PACS integration was introduced into a fully operational department (not a new hospital) in which work flow had to continue with minimal impact. Impediments to user acceptance will be addressed. The critical components of this enormous task will be discussed. The topics covered during this session will include issues such as phased implementation, DICOM (digital imaging and communications in medicine) standard-based interaction of devices, hospital information system (HIS)/radiology information system (RIS) interface, user approval, networking, workstation deployment and backup procedures. The presentation will make specific suggestions regarding the implementation team, operating instructions, quality control (QC), training and education. the concept of identifying key functional areas is relevant to transitioning the facility to be entirely on line. Special attention must be paid to specific functional areas such as the operating rooms and trauma rooms where the clinical requirements may not match the PACS capabilities. The printing of films may be necessary for certain circumstances. The integration of teleradiology and remote clinics into a PACS is a salient topic with respect to the overall role of the radiologists providing rapid consultation. A Webbased server allows a clinician to review images and reports on a desk-top (personal) computer and thus reduce the number of dedicated PACS review workstations. This session will focus on effective strategies for a seamless transition. Critical issues involve maintaining a good working relationship with the vendor, cultivating personnel readiness and instituting well-defined support systems. Success depends on the ability to integrate the institutional directives, user expectations and available technologies. A team approach is mandatory for success.
doi:10.1007/BF03168246
PMCID: PMC3453381  PMID: 9735422
10.  Five Levels of PACS Modularity: Integrating 3D and Other Advanced Visualization Tools 
Journal of Digital Imaging  2011;24(6):1096-1102.
The current array of PACS products and 3D visualization tools presents a wide range of options for applying advanced visualization methods in clinical radiology. The emergence of server-based rendering techniques creates new opportunities for raising the level of clinical image review. However, best-of-breed implementations of core PACS technology, volumetric image navigation, and application-specific 3D packages will, in general, be supplied by different vendors. Integration issues should be carefully considered before deploying such systems. This work presents a classification scheme describing five tiers of PACS modularity and integration with advanced visualization tools, with the goals of characterizing current options for such integration, providing an approach for evaluating such systems, and discussing possible future architectures. These five levels of increasing PACS modularity begin with what was until recently the dominant model for integrating advanced visualization into the clinical radiologist's workflow, consisting of a dedicated stand-alone post-processing workstation in the reading room. Introduction of context-sharing, thin clients using server-based rendering, archive integration, and user-level application hosting at successive levels of the hierarchy lead to a modularized imaging architecture, which promotes user interface integration, resource efficiency, system performance, supportability, and flexibility. These technical factors and system metrics are discussed in the context of the proposed five-level classification scheme.
doi:10.1007/s10278-011-9366-1
PMCID: PMC3222550  PMID: 21301923
PACS; 3D imaging (imaging, three-dimensional); Computer systems; Advanced visualization; Server-based rendering; Application hosting
11.  The department of veterans affairs integration of imaging into the healthcare enterprise using the VistA hospital information system and Digital Imaging and Communications in Medicine 
Journal of Digital Imaging  1998;11(2):53-64.
The United States Department of Veterans Affairs is integrating imaging into the healthcare enterprise by using the Digital Imaging and Communication in Medicine (DICOM) standard protocols. Image management is directly integrated into the VistA Hospital Information System (HIS) software and clinical database. Radiology images are acquired with DICOM and are stored directly in the HIS database. Images can be displayed on low-cost clinician’s workstations throughout the medical center. High-resolution diagnostic quality multimonitor VistA workstations with specialized viewing software can be used for reading radiology images. Two approaches are used to acquire and handle images within the radiology department. Some sites have a commercial Picture Archiving and Communications System (PACS) interfaced to the VistA HIS, whereas other sites use the direct image acquisition and integrated diagnostic display capabilities of VistA itself. A small set of DICOM services has been implemented by VistA to allow patient and study text data to be transmitted to image producing modalities and the commercial PACS, and to enable images and study data to be transferred back. DICOM has been the cornerstone in the ability to integrate imaging functionality into the healthcare enterprise. Because of its openness, it allows the integration of system components from commercial and noncommercial sources to work together to provide functional cost-effective solutions.
doi:10.1007/BF03168727
PMCID: PMC3452993  PMID: 9608928
HIS/RIS; DICOM; PACS
12.  A case for automated tape in clinical imaging 
Journal of Digital Imaging  1998;11(Suppl 1):42-45.
Electronic archiving of radiology images over many years will require many terabytes of storage with a need for rapid retrieval of these images. As more large PACS installations are installed and implemented, a data crisis occurs. The ability to store this large amount of data using the traditional method of optical jukeboxes or online disk alone becomes an unworkable solution. The amount of floor space, number of optical jukeboxes, and off-line shelf storage required to store the images becomes unmanageable. With the recent advances in tape and tape drives, the use of tape for long term storage of PACS data has become the preferred alternative. A PACS system consisting of a centrally managed system of RAID disk, software and at the heart of the system, tape, presents a solution that for the first time solves the problems of multi-modality high end PACS, non-DICOM image, electronic medical record and ADT data storage. This paper will examine the installation of the University of Utah, Department of Radiology PACS system and the integration of automated tape archive. The tape archive is also capable of storing data other than traditional PACS data. The implementation of an automated data archive to serve the many other needs of a large hospital will also be discussed. This will include the integration of a filmless cardiology department and the backup/archival needs of a traditional MIS department. The need for high bandwidth to tape with a large RAID cache will be examined and how with an interface to a RIS pre-fetch engine, tape can be a superior solution to optical platters or other archival solutions. The data management software will be discussed in detail. The performance and cost of RAID disk cache and automated tape compared to a solution that includes optical will be examined.
doi:10.1007/BF03168257
PMCID: PMC3453353  PMID: 9735431
13.  Linking Whole-Slide Microscope Images with DICOM by Using JPEG2000 Interactive Protocol 
Journal of Digital Imaging  2009;23(4):454-462.
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 (http://jvsmicroscope.uta.fi/), 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.
doi:10.1007/s10278-009-9200-1
PMCID: PMC2896636  PMID: 19415383
Digital pathology; telepathology; DICOM; JPEG2000; JPIP; virtual slide; whole-slide imaging; WSI
14.  Linking Whole-Slide Microscope Images with DICOM by Using JPEG2000 Interactive Protocol 
Journal of Digital Imaging  2009;23(4):454-462.
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 (http://jvsmicroscope.uta.fi/), 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.
doi:10.1007/s10278-009-9200-1
PMCID: PMC2896636  PMID: 19415383
Digital pathology; telepathology; DICOM; JPEG2000; JPIP; virtual slide; whole-slide imaging; WSI
15.  DICOM Modality Worklist: An essential component in a PACS environment 
Journal of Digital Imaging  2000;13(3):101-108.
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.
doi:10.1007/BF03168381
PMCID: PMC3452969  PMID: 15359747
DICOM; PACS; worklist
16.  Continuing quality improvement procedures for a clinical PACS 
Journal of Digital Imaging  1998;11(Suppl 1):111-114.
The University of California at San Francisco (USCF) Department of Radiology currently has a clinically operational picture archiving and communication system (PACS) that is thirty-five percent filmless, with the goal of becoming seventy-five percent filmless within the year. The design and implementation of the clinical PACS has been a collaborative effort between an academic research laboratory and a commercial vendor partner. Images are digitally acquired from three computed radiography (CR) scanners, five computed tomography (CT) scanners, five magnetic resonance (MR) imagers, three digital fluoroscopic rooms, an ultrasound mini-PACS and a nuclear medicine mini-PACS. The DICOM (Digital Imaging and Communications in Medicine) standard communications protocol and image format is adhered to throughout the PACS. Images are archived in hierarchical staged fashion, on a RAID (redundant array of inexpensive disks) and on magneto-optical disk jukeboxes. The clinical PACS uses an object-oriented Oracle SQL (systems query language) database, and interfaces to the Radiology Information System using the HL7 (Health Languages 7) standard. Components are networked using a combination of switched and fast ethernet, and ATM (asynchronous transfer mode), all over fiber optics. The wide area network links six UCSF sites in San Francisco. A combination of high and medium resolution dual-monitor display stations have been placed throughout the Department of Radiology, the Emergency Department (ED) and Intensive Care Units (ICU). A continuing quality improvement (CQI) committee has been formed to facilitate the PACS installation and training, workflow modifications, quality assurance and clinical acceptance. This committee includes radiologists at all levels (resident, fellow, attending), radiology technologists, film library personnel, ED and ICU clinian end-users, and PACS team members. The CQI committee has proved vital in the creation of new management procedures, providing a means for user feedback and education, and contributing to the overall acceptance of, and user satisfaction with the system. Well developed CQI procedures have been essential to the successful clinical operation of the PACS as UCSF Radiology moves toward, a filmless department.
doi:10.1007/BF03168275
PMCID: PMC3453403  PMID: 9735446
PACS; continuing quality improvement (CQI); quality assurance (QA); filmless
17.  Use of a low-cost, PC-based image review workstation at a radiology department 
Journal of Digital Imaging  2001;14(Suppl 1):222-223.
Despite the increasing use of diagnostic workstations, film reading is still commonplace in most radiology departments all over the world. The purpose of this work is to assess the adoption of image review workstations in a radiology department where the usual primary diagnosis is film-based and cannot be replaced with diagnostic workstations. At our institution, a tertiary care center specialized in diagnostic imaging, a pair of PC-based review workstations running a Digital Imaging and Communications in Medicine (DICOM)-conformant public domain software for image display and analysis were installed in two reading rooms. Studies are automatically routed after acquisition from the picture archiving and communication system (PACS) server to the workstations and remain available for visualization for approximately 15 to 20 days. Data from two radiologists and two technologists collected over a 3-month period were analyzed, including purpose of use, time savings as compared to traditional manual methods, and overall user satisfaction. The results from the analysis presented in this work indicate a high degree of approval from the users, who report significant timesavings in numerous circumstances, in particular when it comes to discussing findings with referring physicians whenever films are not available. It also enriches communication between radiologists, facilitating peer review on the telephone when one of them has questions at the outcome of any given study. One of the main advantages associated with the system is the possibility of using it as a powerful tool for teaching and research. In conclusion, even when primary diagnosis is performed on film, the availability of a PACS for review can be helpful to enhance communication with referring physicians, as well as technologists and radiologists’ efficiency. Our experience shows that it is possible to implement such a system using low-cost or freely available components without compromising ease of use while keeping costs down, which is a major concern in developing countries.
doi:10.1007/BF03190346
PMCID: PMC3452710  PMID: 11442105
18.  Tools to manage the enterprise-wide picture archiving and communications system environment 
Journal of Digital Imaging  2001;14(Suppl 1):17-21.
The presentation will focus on the implementation and utilization of a central picture archiving and communications system (PACS) network-monitoring tool that allows for enterprise-wide operations management and support of the image distribution network. The MagicWatch (Siemens, Iselin, NJ) PACS/radiology information system (RIS) monitoring station from Siemens has allowed our organization to create a service support structure that has given us proactive control of our environment and has allowed us to meet the service level performance expectations of the users. The Radiology Help Desk has used the MagicWatch PACS monitoring station as an applications support tool that has allowed the group to monitor network activity and individual systems performance at each node. Fast and timely recognition of the effects of single events within the PACS/RIS environment has allowed the group to proactively recognize possible performance issues and resolve problems. The PACS/operations group performs network management control, image storage management, and software distribution management from a single, central point in the enterprise. The MagicWatch station allows for the complete automation of software distribution, installation, and configuration process across all the nodes in the system. The tool has allowed for the standardization of the workstations and provides a central configuration control for the establishment and maintenance of the system standards. This report will describe the PACS management and operation prior to the implementation of the MagicWatch PACS monitoring station and will highlight the operational benefits of a centralized network and system-monitoring tool.
doi:10.1007/BF03190288
PMCID: PMC3452670  PMID: 11442085
19.  TME14/457: Teleradiology: Opinion and technical requirements of German radiologists 
Journal of Medical Internet Research  1999;1(Suppl 1):e121.
Introduction
For the evolution and acceptance of solutions in telemedicine - concerning e. g. liability, economics, security, medical and technical quality - it is very important to learn what the opinion and concepts of the present and future users - the medical professionals - are.
Methods
In 1997 a questionnaire was sent to 4400 German radiologists in hospitals and private offices with a response rate of 5 %. Intensive statistical analysis has been performed by SAS. The survey has been funded by the German government represented by BMBF and DFN. To evaluate the changes in the opinion and technical requirements a second questionnaire was sent to 1500 radiologists in May 1999.
Results
The results showed that in 1997 only 47 % of responders felt well informed about teleradiology. 83% of the radiologists use PC, 52% have installed workstations, 33% use the DICOM 3.0 Standard, PACS are installed in 14 % of the institutions. In the opinion of German radiologists its main future application areas will be the emergency and expert consultation, but - more and more - radiologist services were expected to be provided from home or central offices too. Image and report transfer plus common telemedicine integration as well as interfaces to reference databases, educational applications, technical quality surveillance and product support (maintenance) were considered to be increasingly important areas. Smaller institutions judged expert consultation as more important than bigger institutions. Technical standardization and system stability were strongly demanded. From the medico-legal point of view, there was a demand for as strong as possible an association between radiological report and image, appropriate data security, and solutions of liability questions as well as for guidelines, e. g. of correct documentation and necessary image quality. Links to RIS and PACS were considered especially important for those who already work with these systems. The introduction of fair payments was mainly a matter of the radiologists in private consulting rooms. Most of radiologists thought that lossy compression should be allowed if no loss of relevant information occurs.
Discussion
Technically most demands can be fulfilled today but are not yet commonly included in teleradiology or telemedicine systems. Other aspects as legal or financial requirements must be discussed and solutions provided before the majority will use telemedicine. It must be recognized that there exist many different application areas with different requirements. Local conditions and interests of radiologists - and other medical or non-medical groups - are different too.
doi:10.2196/jmir.1.suppl1.e121
PMCID: PMC1761734
Teleradiology; Telemedicine
20.  Radiology information systems, picture archiving and communication systems, teleradiology— Overview and design criteria 
Journal of Digital Imaging  1998;11(Suppl 2):2-7.
Information technology (IT), long taken for granted in commercial settings, is now being utilized for healthcare applications. Medical imaging has lagged comparatively due to the extremely vast data content of each frame; thus, the requirement for expensive high-end components. Further, IT in radiology has evolved from two distinctly separate camps—information systems, known as RIS (radiology information systems) and PACS (picture archiving and communications systems). Both RIS and PACS applications have migrated to the PC environment, enabling cost-effective implementation, but from two backgrounds: RIS from vendors using conventional information systems platforms and products, and PACS from radiographic film and modality vendors. The radiology department at Texas Tech University has assembled a seamlessly integrated, enterprise-wide RIS/PACS/teleradiology intranet. The design criteria include user-friendliness, flexibility to respond to changing needs, and open modular architecture to assure interoperability, cost-effectiveness, and future-proofing of investment. Since no single venor could provide an integrated system meeting our specifications, we decided to assume the burden of constructing our own system. As the system integrator, we embrace open architecture, thus enabling the incorporation of industry-standard-compliant, COTS (commercially off the shelf) products as modules. Microsoft Windows NT operating system, Visual C++ programming language, TCP/IP (transmission control protocol/internetworking protocol), relational SQL (structured query language) database, ODBC (open database connectivity), HL-7 (health level seven) and DICOM (digital imaging and communications in medicine) interfaces are utilized. The usage of COTS components reduces the cost to very affordable levels. With this approach, any module in our system can be replaced when outmoded, without affecting other modules in our system, making it truly future-proof. Construction and evolution of our system (TECHRAD) is reviewed.
doi:10.1007/BF03168169
PMCID: PMC3453327  PMID: 9848053
21.  Enhancing availability of the electronic image record for patients and caregivers during follow-up care 
Journal of Digital Imaging  1999;12(Suppl 1):78-80.
Purpose
To develop a personal computer (PC)-based software package that allows portability of the electronic imaging record. To create custom software that enhances the transfer of images in two fashions. Firstly, to an end user, whether physician or patient, provide a browser capable of viewing digital images on a conventional personal computer. Second, to provide the ability to transfer the archived Digital Imaging and Communications in Medicine (DICOM) images to other institutional picture archiving and communications systems (PACS) through a transfer engine.Method/materials: Radiologic studies are provided on a CD-ROM. This CD-ROM contains a copy of the browser to view images, a DICOM-based engine to transfer images to the receiving institutional PACS, and copies of all pertinent imaging studies for the particular patient. The host computer system in an Intel based Pentium 90 MHz PC with Microsoft Windows 95 software (Microsoft Inc, Seattle, WA). The system has 48 MB of random access memory, a 3.0 GB hard disk, and a Smart and Friendly CD-R 2006 CD-ROM recorder (Smart and Friendly Inc, Chatsworth, CA).Results: Each CD-ROM disc can hold 640 MB of data. In our experience, this houses anywhere from, based on Table 1, 12 to 30 computed tomography (CT) examinations, 24 to 80 magnetic resonance (MR) examinations, 60 to 128 ultrasound examinations, 32 to 64 computed radiographic examinations, 80 digitized x-rays, or five digitized mammography examinations. We have been able to successfully transfer DICOM images from one DICOM-based PACS to another DICOM-based PACS. This is accomplished by inserting the created CD-ROM onto a CD drive attached to the receiving PACS and running the transfer engine application.Conclusions: Providing copies of radiologic studies performed to the patient is a necessity in every radiology department. Conventionally, film libraries have provided copies to the patient generating issues of cost of loss of film, as well as mailing costs. This software package saves costs and loss of studies, as well as improving patient care by enabling the patient to maintain an archive of their electronic imaging record.
doi:10.1007/BF03168762
PMCID: PMC3452908  PMID: 10342173
22.  Implementation of a Radiology Electronic Imaging Network: The community teaching hospital experience 
Journal of Digital Imaging  1997;10(Suppl 1):146-149.
Because of their typically small in-house computer and network staff, non-university hospitals often hesitate to consider picture archiving and communication system (PACS) as a solution to the very demanding financial, clinical, and technological needs of today’s Radiology Department. This article presents the experiences of the 3-year process for the design and implementation of the Radiology Electronic Imaging Network (REIN) in the Department of Radiology at The Western Pennsylvania Hospital (WPH). WPH embarked on this project in late 1994 to find a solution to the very pressing demands to reduce operating costs and improve service to primary care clinicians, both on-site and at WPH-affiliated clinics. A five-member committee consisting of in-house medical, administrative, information services, and medical physics staff was formed to design a network that would satisfy specific needs of WPH by using a phased mini-PACS approach and to select the various vendors to implement it. Suppliers for individual mini-PACS were selected to provide modality-specific solutions. For the backbone network, vendors were evaluated based on their technological progress, competence and resources, the commitment of the company to the imaging network business, and their willingness to embark on a mid-sized PACS project such as this. Based on patient volume, workflow patterns, and image quality requirements, the committee produced proposals detailing number and location of workstations, short- and long-term memory requirements, and so on. Computed tomography/magnetic resonance imaging, computer radiography, ultrasound, nuclear medicine, digital fluoroscopy, and angiography mini-PACS have been implemented over the past 2 years, and most of these are already integrated into the main REIN. This article presents detailed information concerning the design, selection and implementation processes, including storage requirement calculations. This indicates that PACS implementation is achievable for community hospitals with small computer, networking, and physics departments. Also presented are recommendations concerning design and vendor selection, that may be helpful for similar institutions.
doi:10.1007/BF03168682
PMCID: PMC3452795  PMID: 9268864
PACS; CR; RFP; RIS; display workstation
23.  The VA's use of DICOM to integrate image data seamlessly into the online patient record. 
The US Department of Veterans Affairs (VA) is using the Digital Imaging and Communications in Medicine (DICOM) standard to integrate image data objects from multiple systems for use across the healthcare enterprise. DICOM uses a structured representation of image data and a communication mechanism that allows the VA to easily acquire radiology images and store them directly into the online patient record. Images can then be displayed on low-cost clinician's workstations throughout the medical center. High-resolution diagnostic quality multi-monitor VistA workstations with specialized viewing software can be used for reading radiology images. Various image and study specific items from the DICOM data object are essential for the correct display of images. The VA's DICOM capabilities are now used to interface seven different commercial Picture Archiving and Communication Systems (PACS) and over twenty different radiology image acquisition modalities.
PMCID: PMC2232574  PMID: 10566327
24.  TME10/380: Remote Transmission of Radiological Images by means of Intranet/Internet Technology 
Journal of Medical Internet Research  1999;1(Suppl 1):e117.
At the Istituto Nazionale Neurologico C. Besta in Milano a network architecture has been developed to connect computers and diagnostic modalities, based on Intranet technology in order to allow the hospital to have an external access through the Internet. The Internet technology has become the "glue" that allows to link different computers and to develop applications able to work independently from the hardware/software platform. Using a PACS (Picture Archiving and Communication System) system integrated to the diagnostic modalities by means of the standardized DICOM image format, the digital radiological images can be transferred, displayed and processed on special visualization workstations all around the hospital. From the workstations the same images can be transferred in DICOM format to a teleconsulting workstation. In fact the hospital is involved in a national project for the remote connection between many Italian hospitals. This national network is linked to already developed regional networks like the Toscana MAN and the ATM Sirius Network. Some links are performed directly in ATM (155 Mbps), others are based on CDN (Direct Numerical Connection, 2Mbps), others are simply based on ISDN connections. The system allows to make it simpler and faster the already established daily exchange of radiological reports between the involved hospitals, especially from Istituto Nazionale Neurologico and Istituto Nazionale deiTumori. All the actions performed by the radiologist are translated by the software into "events" and replied to the remote workstation and vice-versa. In this way the radiologists can see each others, speak together and act in real time on a common "board" of diagnostic images, each one with his own pointer. The adopted technology is evolving on a system based on a web architecture and Java applications, useful for small clinical centers not endowed with expensive information systems. These centers will be able to get consulting performances by the excellence centers, making available accurate diagnoses and therapy protocols.
doi:10.2196/jmir.1.suppl1.e117
PMCID: PMC1761785
Web; Booking
25.  Computers in imaging and health care: Now and in the future 
Journal of Digital Imaging  2000;13(4):145-156.
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 mangement 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.
doi:10.1007/BF03168389
PMCID: PMC3453069  PMID: 11110253
picture archiving and communication systems (PACS); image storage and retrieval; folder manager; workflow manager; radiology information systems; computers; digital radiology

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