Transcript PACS outside Radiology - UK Imaging Informatics Group

PACS
Outside
Radiology
Dr Keith Foord
Consultant Radiologist
East Sussex Hospitals, UK
`basic’ web viewers used in
many clinical settings
Radiology integration in the
multi-disciplinary
workplace
Enterprise wide
Multi-speciality
PACS
“In an Enterprise PACS Radiology images account for 30% or less
of image volume…. It quickly became clear that many images sources outside of
radiology were not being captured, and if they were they were not available for
enterprise distribution, nor linked to the electronic patient record
Another problem related to workflow. There was no RIS entry – no accession
number and no entry on the DICOM MWL….. Perhaps the biggest problem with
expanding PACS is the lack of informatics standards in other departments.
Some ophthalmology images are so proprietary that there is (essentially) no out
put.”
Gary Wendt U Wisconsin SCAR 2005
Enterprise
PACS
“One of the things we believe is that a radiology PACS, by itself, will not provide
an adequate return on investment.
The (enterprise) PACS must become part of the Electronic Patient Record to
take advantage of electronic ordering, scheduling and reporting.
To accommodate this we add 1.5 to 2 TB of storage EACH MONTH”
Ramin Khorasani MD,
Director of Information Management for Radiology,
Brigham and Women’s Hospital, Boston
Q. Who works with images?
Image producers
Image viewers – passive/learning
Image interpreters and reporters
Image interpreters / concurrent operators
Image users – planning
Image users – virtual endoscopy
Image users – real time guided therapy and surgery
A. Almost everyone, and if they don’t access to images would enrich their clinical lives
Image producers
and many others
The IT systems they use and how they record and manage images
affects the remainder of the operation……
Scanned Images
Visual Light
and
Radiotherapy
Capturing non radiological, scanned in images
(includes images of request forms if no Order-Entry
system linked via an EPR)
Scanned images – TWAIN
High end Scanned images – ISIS
Both can be converted using DICOM Secondary capture and DICOM GWL
via a PACSport computer.
Pdf files can now be DICOM encapsulated
Capturing Visual Light Images
What is DICOM-VL?
DICOM-Visible Light is an Supplement to integrate visible light images into DICOM
Microscopy, endoscopy and digital photography.
In particular, DICOM-VL specifies how to store preparation
procedures and image-acquisition conditions in the image
headers. It allows other ‘ologies’ to implement the DICOM
standard, allowing their integration into EPRs
It is the first real visible light image standard and allows display of
these images next to radiological images on a DICOM viewing
station.
Part of the DICOM standard since 1999. DICOM minutes
show struggle to obtain interest or expertise from medical VL companies,
but better recently and DICOM MPEG2 Video soon (?now)
Pathology PACS…a rather special case!
“Glass slides must be scanned at at least 400x
Generates up to 6 GB per slide
Scanning a single slide can take up to 20 mins, but
developments are expected to reduce this to 1 minute.
Compression of 15:1 can be applied, but will still
generate 134 GB per day – 3 TB per month
This will require 350 TB storage over 10 years”
Kai Saeger, Charite Institute of Pathology, Berlin
CARS2003
“In the last few years, dynamic telepathology has been the only real digital
application that has been able to transmit wide areas of microscopic preparations
Dynamic telepathology is a real-time technology system. Only a few systems are
able to store and create a database of the transmitted cases e.g. Bliss by
BacusLabs. http://www.bacuslabs.com//.
A WebSlide can be created either in uncompressed .bmp format or in .jpg format.
These systems are very expensive because they work by means of a robotic
microscope, and the software for image viewing and interaction is often
sophisticated and only available with the purchase of apparatus. A WebSlide can be
created either in uncompressed .bmp format or in .jpg format”
Each of these slides from one
pathological specimen must be
Scanned
(BacusLabs system)
Francesco Alfredo Zito1, Franco Marzullo1, Diego D'Errico1, Cesare Salvatore1, Rosanna Digirolamo1, Angela Labriola1 and Antonio Pellecchia2
1 Division of Pathology
2 Division of Digestive Endoscopy, National Cancer Institute, Bari, Italy
This is a
3  2 mm image of an endoscopic gastric biopsy.
7200  5200 pixel image was digitized at an objective
The
magnification of  20.
A total of 20 still pictures are required to generate a large image of
85 MB in TIFF format, which is then
compressed into a 9 MB Quick Time VR
file.
process takes 60 min
The entire digitization
. The
quality of the movie is related to the quality of initial images
Quicktime virtual reality technology in light microscopy to support medical education in pathology
Francesco Alfredo Zito1, Franco Marzullo1, Diego D'Errico1, Cesare Salvatore1, Rosanna Digirolamo1, Angela
Labriola1 and Antonio Pellecchia2
1Division of Pathology
2Division of Digestive Endoscopy, National Cancer Institute, Bari, Italy
Image viewers – passive/learners
Agfa Web 1000
Bachuslabs.com
PET-CT
SPECT-CT
As most viewers are not specialists need skilled interpretive reports with images.
Means must have coherent IT systems to input these with no error.
Related images – and their reports should be linked together
Potential for systems
fragmentation if need
to maximise integration
not recognised by different
project groups.
A corporate knowledge
deficit / lateral thinking
issue
Image interpreters and reporters
•
•
•
•
A & B scan Ultrasound
Corneal Topography
Automated field analysers
Optical Coherence Tomography (OCT)
Reminder….
“Perhaps the biggest problem with expanding
PACS is the lack of informatics standards in
other departments.
Some ophthalmology images are so
proprietary that there is (essentially) no out
put.”
Gary Wendt U Wisconsin SCAR 2005
Image interpreters and concurrent
operators. Use old images to plan, but dynamic image users in
operation, recording new images - still and short video clips to be added to
patient file
Image users – planning
3D CT images –
help with Ortho
reconstruction
CTA – diagnostic
study prior to IR
angioplasty of ext.
iliac artery
Radiotherapy Planning
DICOM RT is the the extension of the DICOM 3.0
standard which handles the Radiotherapy modality.
It was developed to extend the current DICOM 3.0 standard to include the RT
modality, rather than produce a completely new standard
Seven new objects define the RT modality
DICOM-RT is not a separate standard - it is an extension, defining 7 new objects:
- RT image
- RT dose
- RT structure set
- RT plan
- RT treatment record (beam session, brachy session, summary).
Beams are defined with a system of "control points
RT Image
Includes all the normal RT images, DRRs, portal images, simulator images and radiograms
RT Dose
The total dose distributions from the planning system; dose matrix, dose points, isodose curves and
dose volume histograms.
RT Structure Set
Patient related structures identified from diagnostic data, CT, virtual simulations and treatment
planning systems.
RT Plan
This is the geometric and dosimetric data for course of external beam treatment or brachy-therapy.
RT Treatment Record
Records all the treatment session data.
Image users – virtual endoscopy
“Virtual endoscopy focuses on the virtual representation of minimally invasive
procedures for training, planning, and diagnosis without an actual invasive
intervention.
In the past few years, virtual endoscopy modes have been transferred from
research systems in virtually every commercial medical imaging software, but
with a varying quality and exibility.
It is based on a 3D scan of the respective body region. Examples for these scans
are CT (Computed Tomography) scans, MRI (Magnet Resonance Imaging)
scans of the abdominal area, the heart, the head, the lungs, or rotational
angiography of blood vessels in various body parts. Based on the resulting
volumetric data, the organs of interest are visualized and inspected from interior
(.endo.) viewpoints.”
Virtual Endoscopy in Research and Clinical Practice
Dirk Bartz, Visual Computing for Medicine Group, University of Tübingen
Eurographics 2003
The video images need embedding in PACS…this video is 36 kBytes
More VIRTUAL
ENDOSCOPY
Planning endoscopic neurosurgery
The lung tumour is not visible
on virtual bronchoscopy, but
the site for a trans-bronchial
biopsy is mapped in green
These VE images should be
available in the VL endoscopy suite
via enterprise PACS
Virtual Endoscopy in Research and Clinical Practice
Dirk Bartz, Visual Computing for Medicine Group, University of Tübingen
Eurographics 2003
Image users – real time guided therapy and surgery
midturbvirtendosc.jpg
GE Medical Systems
Sinus surgery.
The cross lines show
The position of the probe
on the corresponding
CT in x,y and z axes
Digital OR Images
BrainLAB AG
Smith and Nephew website :UPMC Southside Hospital
HEAD-MOUNTED DISPLAYS AND AUGMENTED REALITY
Visual interfaces—like haptic interfaces—are used to immerse participants in a
virtual environment. These displays range from conventional desktop screens to
head-mounted displays, depending on the degree of reality required.
Head-mounted displays consist of goggles that afford a stereoscopic view of the
computer-generated environment. A sense of motion is created by continuously
updating the visual input with positional information derived from the participant's
head movements. Collected by a tracking system connected to the display, this
information is fed back to the computer controlling the
graphics.
Vectorvision’s FDA
Approval to market
2004
Microvision's display system uses anatomical, biochemical, and physiological images and other data to
guide surgeons through procedures.
The computer assisted approach allowed a smaller, exactly placed craniotomy
primarily in MCA aneurysms. 3D presentation of the aneurysms and the adjacent
arteries in correct orientation facilitated identification and dissection the aneurysms.
Current navigation systems are not precise enough to allow “blind” aneurysm
clipping by placing a real clip on the virtual aneurysm neck.
R. Schmid-Elsaesser1, A. Muacevic1, M. Holtmannspötter2, E. Uhl1, H.-J. Steiger1
Neuronavigation Based on CT Angiography for Surgery of Intracranial Aneurysms:
Primary Experience with Unruptured Aneurysms
Minim Invasive Neurosurg 2003; 46: 269-277
Structured reporting
DICOM SR – is an ‘envelope’, but within this useful structure is available.
It allows linkage to other DICOM objects, including between associated
radiological and other images and waveforms. CAD outputs can be in SR
format.
User decides how much structure to use and controls with templates the type of
content, if it is mandatory or optional and modes of expression
Incorporated into the report are captured
images of key findings (which can be exploded
to full screen presentation), structured
diagnosis information, recorded video and
audio, the ability to sort findings by anatomy or
priority, to view prior findings associated with
the corresponding patient and hyperlinks to
related information.
DICOM Structured Reporting", Dr. David A. Clunie, ISBN 09701369-0-0
PointDx
Dilemma
– products from many different vendors
– hardware & software incompatibility
Goal
– prevent being vendor dependent
- consumer locked into specific products
– component interoperability “plug and play”
– seamless integration with “other” IT
John A. Carrino, M.D.
Assistant Professor of Radiology
Information Management Group
Jefferson Health System
ISSUES for Enterprise PACS
•
•
•
•
Image data set size – MDCT/Pathology
Image storage volumes
Networking
Integration
• RIS becomes IIS within EPR, but preferably an
integrated component of the EPR
• Image and data Protocols
• Lack of protocol standards and expertise with
some vendors
• DICOM & IHE
• Corporate awareness and lateral thinking
Quite clearly if we do not all
eat and think together
Enterprise wide PACS may be a very long time coming
“Perhaps the biggest problem with expanding PACS is
the lack of informatics standards in other
departments.”Gary Wendt U Wisconsin SCAR 2005
Vendors of all medical imaging equipment, not just in
radiology, must be brought into the IHE and DICOM
fraternities. We need to educate hospital operators and
image users in all clinical specialities not to buy bespoke
IT solutions.
Keith Foord Conquest Hospital UK CARS 2005
CfH looking to integrate other
‘ologies’ within 2 to 4 years