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1.  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
2.  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
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.  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
5.  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
6.  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
7.  Transparent image access in a distributed picture archiving and communications system: The master database broker 
Journal of Digital Imaging  1999;12(Suppl 1):175-177.
A distributed design is the most cost-effective system for small- to medium-scale picture archiving and communications systems (PACS) implementations. However, the design presents an interesting challenge to developers and implementers: to make stored image data, distributed throughout the PACS network, appear to be centralized with a single access point for users. A key component for the distributed system is a central or master database, containing all the studies that have been scanned into the PACS. Each study includes a list of one or more locations for that particular dataset so that applications can easily find it. Non-Digital Imaging and Communications in Medicine (DICOM) clients, such as our worldwide web (WWW)-based PACS browser, query the master database directly to find the images, then jump to the most appropriate location via a distributed web-based viewing system. The Master Database Broker provides DICOM clients with the same functionality by translating DICOM queries to master database searches and distributing retrieval requests transparently to the appropriate source. The Broker also acts as a storage service class provider, allowing users to store selected image subsets and reformatted images with the original study, without having to know on which server the original data are stored.
doi:10.1007/BF03168792
PMCID: PMC3452888  PMID: 10342203
8.  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
9.  Challenges associated with interfacing computed tomography to a picture archiving and communication system at the Baltimore Veterans Affairs Medical Center—A historical perspective 
Journal of Digital Imaging  2000;13(Suppl 1):83-87.
The interfacing of digital image acquisition modalities to the picture archiving and communication system (PACS) plays a major part in the conversion from a traditional film-based radiology practice to one that relies almost entirely on soft-copy reading. The Baltimore Veterans Affairs Medical Center (VAMC) is one of the first filmless hospitals in the world. Since 1993, it has used computed tomography (CT) scanners connected to a commercial PACS to provide digitized patient images for filmless reading. Over the years, the evolution of Digital Imaging and Communications in Medicine (DICOM) standards, advances in networking technologies, and enhancements in PACS and hospital information system (HIS) software have greatly improved this system’s robustness and patient/study identification accuracy. The result has been a major increase in productivity.
doi:10.1007/BF03167632
PMCID: PMC3453294  PMID: 10847370
10.  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
11.  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
12.  Can radiologic images be incorporated into the electronic patient record? 
Journal of Digital Imaging  2000;13(Suppl 1):138-141.
As radiology makes advances toward filmlessness, all of medicine is headed, just as rapidly, toward paperless transmission of patient information. While there are obvious advantages to this electronic approach, and several standards to conform to for the transmission of textual (Health Level 7 [HL-7]) and image (Digital Imaging and Communications in Medicine [DICOM]) data, it is the integration of these two data sets that is clinically essential and yet poorly defined. This report defines an approach for, and the successful implementation of, the integration of radiologic image data with textual data contained within the electronic patient record (EPR) through the use of standard internet protocols. Incorporation of medical images in the EPR has proven to be critical to the successful deployment of picture archiving and communications systems (PACS) and the reduction of film consumption at Massachusetts General Hospital (MGH). Since the installation of the first internet-based Image Data Repository (IDR) at MGH in 1995, the system has adequately served to meet the needs of clinical requests by both radiology-only browser users and users of the EPR. It has drastically reduced the need for film and provided concurrent display of images and text throughout the institution and beyond. *** DIRECT SUPPORT *** A00RM031 00009
doi:10.1007/BF03167645
PMCID: PMC3453286  PMID: 10847383
13.  Maintaining continuity of clinical operations while implementing large-scale filmless operations 
Journal of Digital Imaging  1999;12(Suppl 1):50-53.
Texas Children’s Hospital is a pediatric tertiary care facility in the Texas Medical Center with a large-scale, Digital Imaging and Communications in Medicine (DICOM)-compliant picture archival and communications system (PACS) installation. As our PACS has grown from an ultrasound niche PACS into a full-scale, multimodality operation, assuring continuity of clinical operations has become the number one task of the PACS staff. As new equipment is acquired and incorporated into the PACS, workflow processes, responsibilities, and job descriptions must be revised to accommodate filmless operations. Round-the-clock clinical operations must be supported with round-the-clock service, including three shifts, weekends, and holidays. To avoid unnecessary interruptions in clinical service, this requirement includes properly trained operators and users, as well as service personnel. Redundancy is a cornerstone in assuring continuity of clinical operations. This includes all PACS components such as acquisition, network interfaces, gateways, archive, and display. Where redundancy is not feasible, spare parts must be readily available. The need for redundancy also includes trained personnel. Procedures for contingency operations in the event of equipment failures must be devised, documented, and rehearsed. Contingency operations might be required in the event of scheduled as well as unscheduled service events, power outages, network outages, or interruption of the radiology information system (RIS) interface. Methods must be developed and implemented for reporting and documenting problems. We have a Trouble Call service that records a voice message and automatically pages the PACS Console Operator on duty. We also have developed a Maintenance Module on our RIS system where service calls are recorded by technologists and service actions are recorded and monitored by PACS support personnel. In a filmless environment, responsibility for the delivery of images to the radiologist and referring physician must be accepted by each imaging supervisor. Thus, each supervisor must initiate processes to verify correct patient and examination identification and the correct count and routing of images with each examination.
doi:10.1007/BF03168754
PMCID: PMC3452870  PMID: 10342165
14.  Benchmark testing the Digital Imaging Network-Picture Archiving and Communications System proposal of the Department of Defense 
Journal of Digital Imaging  1999;12(2):94-98.
The Department of Defense issued a Request for Proposal (RFP) for its next generation Picture Archiving and Communications System in January of 1997. The RFP was titled Digital Imaging Network—Picture Archiving and Communications System (DIN-PACS). Benchmark testing of the proposed vendors' systems occurred during the summer of 1997. This article highlights the methods for test material and test system organization, the major areas tested, and conduct of actual testing. Department of Defense and contract personnel wrote test procedures for benchmark testing based on the important features of the DIN-PACS Request for Proposal. Identical testing was performed with each vendor's system. The Digital Imaging and Communications in Medicine (DICOM) standard images used for the Benchmark Testing included all modalities. The images were verified as being DICOM standard compliant by the Mallinckrodt Institute of Radiology, Electronic Radiology Laboratory. The Johns Hopkins University Applied Physics Laboratory prepared the Unix-based server for the DICOM images and operated it during testing. The server was loaded with the images and shipped to each vendor's facility for on-site testing. The Defense Supply Center, Philadelphia (DSCP), the Department of Defense agency managing the DIN-PACS contract, provided representatives at each vendor site to ensure all tests were performed equitably and without bias. Each vendor's system was evaluated in the following nine major areas: DICOM Compliance; System Storage and Archive of Images; Network Performance; Workstation Performance; Radiology Information System Performance; Composite Health Care System/ Health Level 7 communications standard Interface Performance; Teleradiology Performance; Quality Control; and Failover Functionality. These major sections were subdivided into workable test procedures and were then scored. A combined score for each section was compiled from this data. The names of the involved vendors and the scoring for each is contract sensitive and therefore can not be discussed. All of the vendors that underwent the benchmark testing did well. There was no one vendor that was markedly superior or inferior. There was a typical bell shaped curve of abilities. Each vendor had their own strong points and weaknesses. A standardized benchmark protocol and testing system for PACS architectures would be of great value to all agencies planning to purchase a PACS. This added information would assure the purchased system meets the needed functional requirements as outlined by the purchasers PACS Request for Proposal.
doi:10.1007/BF03168848
PMCID: PMC3452494  PMID: 10342252
PACS; DICOM; benchmark testing; RIS; Health Level 7
15.  Multi-series DICOM: an Extension of DICOM That Stores a Whole Study in a Single Object 
Journal of Digital Imaging  2013;26(4):691-697.
Today, most medical images are stored as a set of single-frame composite Digital Imaging and Communications in Medicine (DICOM) objects that contain the four levels of the DICOM information model—patient, study, series, and instance. Although DICOM addresses most of the issues related to medical image archiving, it has some limitations. Replicating the header information with each DICOM object increases the study size and the parsing overhead. Multi-frame DICOM (MFD) was developed to address this, among other issues. The MFD combines all DICOM objects belonging to a series into a single DICOM object. Hence, the series-level attributes are normalized, and the amount of header data repetition is reduced. In this paper, multi-series DICOM (MSD) is introduced as a potential extension to the DICOM standard that allows faster parsing, transmission, and storage of studies. MSD extends the MFD de-duplication of series-level attributes to study-level attributes. A single DICOM object that stores the whole study is proposed. An efficient algorithm, called the one-pass de-duplication algorithm, was developed to find and eliminate the replicated data elements within the study. A group of experiments were done that evaluate MSD and the one-pass de-duplication algorithm performance. The experiments show that MSD significantly reduces the amount of data repetition and decreases the time required to read and parse DICOM studies. MSD is one possible solution that addresses the DICOM limitations regarding header information repetition.
doi:10.1007/s10278-013-9577-8
PMCID: PMC3705029  PMID: 23404629
DICOM; Algorithms; Imaging informatics; Image data; Multi-frame DICOM; Multi-series DICOM
16.  Integration of digital gross pathology images for enterprise-wide access 
Background:
Sharing digital pathology images for enterprise- wide use into a picture archiving and communication system (PACS) is not yet widely adopted. We share our solution and 3-year experience of transmitting such images to an enterprise image server (EIS).
Methods:
Gross pathology images acquired by prosectors were integrated with clinical cases into the laboratory information system's image management module, and stored in JPEG2000 format on a networked image server. Automated daily searches for cases with gross images were used to compile an ASCII text file that was forwarded to a separate institutional Enterprise Digital Imaging and Communications in Medicine (DICOM) Wrapper (EDW) server. Concurrently, an HL7-based image order for these cases was generated, containing the locations of images and patient data, and forwarded to the EDW, which combined data in these locations to generate images with patient data, as required by DICOM standards. The image and data were then “wrapped” according to DICOM standards, transferred to the PACS servers, and made accessible on an institution-wide basis.
Results:
In total, 26,966 gross images from 9,733 cases were transmitted over the 3-year period from the laboratory information system to the EIS. The average process time for cases with successful automatic uploads (n=9,688) to the EIS was 98 seconds. Only 45 cases (0.5%) failed requiring manual intervention. Uploaded images were immediately available to institution- wide PACS users. Since inception, user feedback has been positive.
Conclusions:
Enterprise- wide PACS- based sharing of pathology images is feasible, provides useful services to clinical staff, and utilizes existing information system and telecommunications infrastructure. PACS-shared pathology images, however, require a “DICOM wrapper” for multisystem compatibility.
doi:10.4103/2153-3539.93892
PMCID: PMC3327039  PMID: 22530178
DICOM; digital image; LIS; PACS; pathology; wrapper
17.  OpenRIMS: An Open Architecture Radiology Informatics Management System  
Journal of Digital Imaging  2002;15(2):91-97.
The benefits of an integrated picture archiving and communication system/radiology information system (PACS/RIS) archive built with open source tools and methods are 2-fold. Open source permits an inexpensive development model where interfaces can be updated as needed, and the code is peer reviewed by many eyes (analogous to the scientific model). Integration of PACS/RIS functionality reduces the risk of inconsistent data by reducing interfaces among databases that contain largely redundant information. Also, wide adoption would promote standard data mining tools—reducing user needs to learn multiple methods to perform the same task. A model has been constructed capable of accepting HL7 orders, performing examination and resource scheduling, providing digital imaging and communications in medicine (DICOM) worklist information to modalities, archiving studies, and supporting DICOM query/retrieve from third party viewing software. The multitiered architecture uses a single database communicating via an ODBC bridge to a Linux server with HL7, DICOM, and HTTP connections. Human interaction is supported via a web browser, whereas automated informatics services communicate over the HL7 and DICOM links. The system is still under development, but the primary database schema is complete as well as key pieces of the web user interface. Additional work is needed on the DICOM/HL7 interface broker and completion of the base DICOM service classes.
doi:10.1007/s10278-002-0010-y
PMCID: PMC3611608  PMID: 12297975
18.  Evaluation of the Use of CD-ROM Upload into the PACS or Institutional Web Server 
Journal of Digital Imaging  2006;19(Suppl 1):72-77.
Purpose
Patient data are increasingly distributed between hospitals using CD-ROMs instead of actual films. This introduces problems because different viewers from different vendors are provided, and sometimes viewers are unusable because local software installation is not allowed. In 2004, we started to facilitate the incorporation of CD-ROM data into the normal workflow of the hospital by using commercially available software to perform patient reconciliation based on the DICOM (digital imaging and communication in medicine) modality worklist. The purpose of the current study is to evaluate this new procedure.
Methods and Materials
A questionnaire was sent to all users to evaluate the satisfaction with the current facility and to evaluate possible improvements. Several quality parameters on speed and satisfaction were rated on a 5-point scale (1 = bad to 5 = excellent).
Results
Replies from 17 different respondents were evaluated, accounting for an average of 76 CD-ROMs per week. Mean (median) results showed a score of 3.6 (4) for handling time, 3.4 (4) for archival of second opinion data, 3.8 (median 4) for archival of external data onto the web server, and 4.5 (median 5) for the overall performance of the current procedure.
Conclusion
Although some improvements can be made, storage of the study data from CDs from outpatients into PACS (picture archiving and communication system) and web server already provides for an existing need. Using this service, physicians can access the data with ease and familiarity. User satisfaction with the provided solution is high.
doi:10.1007/s10278-006-0932-x
PMCID: PMC3045170  PMID: 17024522
PACS; clinical workflow; computers in medicine; Integrating Healthcare Enterprise (IHE); medical informatics applications; radiology workflow; radiology information systems (RIS)
19.  Development of a Next-Generation Automated DICOM Processing System in a PACS-Less Research Environment 
Journal of Digital Imaging  2012;25(5):670-677.
The use of clinical imaging modalities within the pharmaceutical research space provides value and challenges. Typical clinical settings will utilize a Picture Archive and Communication System (PACS) to transmit and manage Digital Imaging and Communications in Medicine (DICOM) images generated by clinical imaging systems. However, a PACS is complex and provides many features that are not required within a research setting, making it difficult to generate a business case and determine the return on investment. We have developed a next-generation DICOM processing system using open-source software, commodity server hardware such as Apple Xserve®, high-performance network-attached storage (NAS), and in-house-developed preprocessing programs. DICOM-transmitted files are arranged in a flat file folder hierarchy easily accessible via our downstream analysis tools and a standard file browser. This next-generation system had a minimal construction cost due to the reuse of all the components from our first-generation system with the addition of a second server for a few thousand dollars. Performance metrics were gathered and the system was found to be highly scalable, performed significantly better than the first-generation system, is modular, has satisfactory image integrity, and is easier to maintain than the first-generation system. The resulting system is also portable across platforms and utilizes minimal hardware resources, allowing for easier upgrades and migration to smaller form factors at the hardware end-of-life. This system has been in production successfully for 8 months and services five clinical instruments and three pre-clinical instruments. This system has provided us with the necessary DICOM C-Store functionality, eliminating the need for a clinical PACS for day-to-day image processing.
doi:10.1007/s10278-012-9482-6
PMCID: PMC3447098  PMID: 22546983
PACS; DCMTK; DICOM; DICOM workflow; DICOM storage
20.  Implementation of an anonymisation tool for clinical trials using a clinical trial processor integrated with an existing trial patient data information system 
European Radiology  2011;22(1):144-151.
Objectives
To present an adapted Clinical Trial Processor (CTP) test set-up for receiving, anonymising and saving Digital Imaging and Communications in Medicine (DICOM) data using external input from the original database of an existing clinical study information system to guide the anonymisation process.
Methods
Two methods are presented for an adapted CTP test set-up. In the first method, images are pushed from the Picture Archiving and Communication System (PACS) using the DICOM protocol through a local network. In the second method, images are transferred through the internet using the HTTPS protocol.
Results
In total 25,000 images from 50 patients were moved from the PACS, anonymised and stored within roughly 2 h using the first method. In the second method, an average of 10 images per minute were transferred and processed over a residential connection. In both methods, no duplicated images were stored when previous images were retransferred. The anonymised images are stored in appropriate directories.
Conclusions
The CTP can transfer and process DICOM images correctly in a very easy set-up providing a fast, secure and stable environment. The adapted CTP allows easy integration into an environment in which patient data are already included in an existing information system.
Key Points
Store DICOM images correctly in a very easy set-up in a fast, secure and stable environmentAllows adaptation of the software to perform a certain task based on specific needsAllows easy integration into an existing environmentReduce the possibility of inappropriate anonymisation
doi:10.1007/s00330-011-2235-y
PMCID: PMC3229700  PMID: 21842431
Anonymisation tool; Clinical trial processor; Privacy; Clinical trials; Software; Patient data
21.  Impact of cross-enterprise data sharing on portable media with decentralised upload of DICOM data into PACS 
Insights into Imaging  2013;5(1):157-164.
Objectives
To evaluate portable media utilisation for image data sharing between enterprises. To predict the costs required to keep up with the trend. To identify related problems.
Methods
A software package was developed to include patient image data from CD into our normal workflow. The trend in the workload of CDs that were uploaded into a Picture Archiving and Communication System (PACS) over 89 months was analysed. The average number of images per month (and per investigation) was calculated to provide the estimation of storage and cost required in the whole process.
Results
All Digital Imaging and Communications in Medicine (DICOM) files can be read from compact disc (CD) on any workstation in the hospital, processed quickly to the central server and checked after storage using the software tool. A total of 33,982,404 images from 88,952 CDs have been stored into the PACS system. In recent years, the stored images have reached an average of 4.2 terabytes (TB) uncompressed annually.
Conclusion
Integrated information about patients is clearly needed to provide easy and timely access to these data. The steadily growing storage can be solved by a more automated approach to portable media handling or the installation and acceptance of network-based transfer using cross-enterprise document sharing (XDS).
Key points
• Rapid assimilation of external imaging into a PACS system is essential.
• But data distribution using portable media also carries some disadvantages.
• A DICOM data uploader incorporates studies from portable media to hospital workflow.
• Automated media handling or XDS should solve the steadily growing storage problem.
• Software improvements will facilitate the steady increase in the amount of CDs processed.
doi:10.1007/s13244-013-0296-y
PMCID: PMC3948904  PMID: 24243497
Data sharing; Information distribution; CDROM; PACS (Radiology); Radiology information system
22.  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
23.  A picture archiving and communications system featuring multiple monitors using Windows98 
Journal of Digital Imaging  1999;12(Suppl 1):106-108.
We present an effective approach to manage, review, and distribute Digital Imaging and Communications in Medicine (DICOM) images with multiple monitors using Windows98 (Microsoft Corp, Redmond, WA) that can be implemented in an office-based setting. Computed tomography (CT), magnetic resonance imaging (MRI), and angiographic DICOM images were collected, compressed, and stored using Medweb (Medweb, Inc, San Francisco, CA) software. The Medweb server used the Linux/UNIX operating system on a Pentium 333-MHz processor with 128 MB of RAM. Short-term storage capacity was about 2 weeks with routine usage of an 11-GB hard drive. Images were presented for reading on a dual-monitor Windows98 Pentium display station with 160 MB of RAM using a Medweb/Netscape (Netscape Communications Corp, Mountain View, CA) viewer. There was no significant discrepancy in diagnosis between electronic and conventional film images. Mean reading time for 32 cases was 118 seconds. The Medweb JAVA plug-in viewer loaded the first image within 30 seconds of selecting the case for review. Full uncompressed 16-bit images allowed different window setting to better assess for pathology. Multiple monitors allowed viewing various hanging protocols. Cine viewing was also possible. Key diagnostic images were electronically transmitted to referring physicians. On-call radiologists were able to access images through the Internet. By combining Medweb, DICOM, and web-browser software using desktop personal computers (PCs), an easily accessible picture archiving and communications system (PACS) is available to radiologists and referring physicians. Multiple monitors are easily configured and managed using Windows98. This system can sustain changes and can be extended to provide variable functions using inexpensive PCs.
doi:10.1007/BF03168771
PMCID: PMC3452922  PMID: 10342182
24.  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
25.  Bio-Image Warehouse System: Concept and Implementation of a Diagnosis-Based Data Warehouse for Advanced Imaging Modalities in Neuroradiology 
Journal of Digital Imaging  2006;20(1):32-41.
Advanced neuroimaging techniques, such as functional magnetic resonance imaging (fMRI), chemical shift spectroscopy imaging (CSI), diffusion tensor imaging (DTI), and perfusion-weighted imaging (PWI) create novel challenges in terms of data storage and management: huge amounts of raw data are generated, the results of analysis may depend on the software and settings that have been used, and most often intermediate files are inherently not compliant with the current DICOM (digital imaging and communication in medicine) standard, as they contain multidimensional complex and tensor arrays and various other types of data structures. A software architecture, referred to as Bio-Image Warehouse System (BIWS), which can be used alongside a radiology information system/picture archiving and communication system (RIS/PACS) system to store neuroimaging data for research purposes, is presented. The system architecture is conceived with the purpose of enabling to query by diagnosis according to a predefined two-layered classification taxonomy. The operational impact of the system and the time needed to get acquainted with the web-based interface and with the taxonomy are found to be limited. The development of modules enabling automated creation of statistical templates is proposed.
doi:10.1007/s10278-006-0859-2
PMCID: PMC3043890  PMID: 16953339
PACS; image repository; data warehouse; web-based; neuroradiology

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