Transcript U-HealthCare System

What is PACS ?
P: Picture, Images & Reports
A: Archive, Online, Near line, Offline
C: Communication, Networking, Transfer Protocols
S: System, Components & Architecture
PACS: for storage and distribution of images and i
nformation when necessary
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PACS: Small or Large
Web Server Distribution
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Scale of PACS
• No. of Beds in Hospital/ Exams per year
• No. of Modalities
• No. of Switches
Considerations:
System connectivity, expandability, reliabilit
y and cost-effectiveness
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Types of images
• 1D, 2D, 3D, 4D
• Different DICOM Modality type: Cardiac / PET / 4D U/
S…..
• Image size: Resolution and bit depth
• Image quality: Bit Depth and resolution
• Color / Monochromatic
• Exam. Size: image size x no. of images
• Structured Reports
• New DICOM IOD:
Endoscopic & Microscopic images / ECGs / Security Pr
ofiles…..
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1D, 2D, 3D, 4D, fusion
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1D, 2D, 3D, 4D, fusion
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Image Resolution/ Bit depth
U/S
DF
CR
CR Mammogram
256 x 256
8 bit
65 KBytes
1k x 1k
10 bit
1.25 MByte
2k x 2.5k
12 bit
4k x 5k
7.5 MByte
12 bit
30 MByte
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Properties of image
• Bit depth
• Grayscale or color
• Resolution in pixe
l
 Example image si
ze of mammogra
m = 4k x 5k x 12
bit = 30 MB
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PACS Architecture
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PACS – Central Architecture
DICOM
Modality
Non-DICOM
Modality
Diagnostic
Workstations (DICOM)
Gateway or
Frame Grabber
Clinical
Workstations (DICOM)
Image
Server
(RAID)
Diagnostic
Workstation
Film
Digitizer
Computed
Radiography
or DR
CR/ DR QA
Workstation
Web Server
Data Base
Server
Archive
RIS
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Central Architecture
• Image Server and Database Manager is t
he HEART
• Any image, any where, any time
• Unique central copy
• Easy update of data
• Requires high performance servers
• Potential single point of failure at server
• Bandwidth demanding
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PACS – Distributed Architecture
DICOM
Modality
Gateway or
Frame Grabber
Non-DICOM
Modality
CR QA
Workstation
Film
Digitizer
Diagnostic
Workstations
(DICOM)
Clinical
Workstations
(DICOM)
Web Server
Diagnostic
Workstation
Data Base
Server
Archive
Computed
Radiography
RIS
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Distributed Architecture
• Exams are routed from modality to select
ed workstations
• Complex routing algorithms based on de
partment / user preference
• Difficult to support concurrent review of i
mages
• Less destructive for failure at database se
rver
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Components of PACS
•
•
•
•
•
•
•
•
HIS/ RIS
Broker
ePR gateway
Database Server
Image Server (RAID)
Long Term/ Near line Archive
Networks
Digitizer
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Components of PACS
•
•
•
•
•
•
•
•
Acquisition Gateways
Non-DICOM modality gateway
DICOM Print Server
Media Server
Reporting Server
Monitor QC Server
Web Server
Workstations
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PACS layout 1
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PACS layout 2
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PACS layout 3
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PACS Components
ePR gateway
Enterprise Archive
DICOM
Modality
Diagnostic
Workstations (DICOM)
Through Acq.
gateway
Non-DICOM
Modality
W/S QA Server
Clinical
Workstations (DICOM)
Image
Server
(RAID)
Gateway or
Frame Grabber
Diagnostic
Workstation
Film
Digitizer
Web Server
Data Base
Server
Computed
Radiography
or DR
LTS Archive
SAN/NAS
CR/ DR QA
Workstation
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Broker for
RIS/HIS
Media Server
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Acquisition (DICOM) Gateway
HIS/RIS
Interface
(Broker)
DG
RIS
CT
W/S
M
R
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R&F
NM
PCs
CR QA
CR
Film
Digitizer
XRAY
Frame
Grabber
US
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Role of Acquisition gateway
• Compression/ decompression and security
• Check the images for integrity
• Convert to PACS format (header, byte-ord
er, matrix size)
• Queue for images (priority) to database se
rver (background)
• Share the workload and no point of failur
e for multiple Acquisition gateway
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Database Server and Image Server
Database
Server
RAID
HIS/RIS
Interface
(Broker)
DG
RIS
CT
W/S
M
R
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R&F
NM
PCs
CR QA
CR
Film
Digitizer
XRAY
Frame
Grabber
US
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Database Server (PACS controller)
• The Heart of the system
• Integration cross point between HIS/RIS an
d PACS (status update)
• Create and manages patient folders
• Manage reading worklists and user profiles
• Manage data transfer within the system
• Support data mining and teaching folders
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Image Server (RAID)
• Online (rapid access) exam storage and d
istribution device
• Support simultaneous exam input and o
utput transfer operations
• Up to Three months of storage capacity
• Scalable capacity
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What is RAID
Redundant Array of Independent Disks
Bandwidth equal to sum of disk transfer rates
Highest speed disk storage available
Hot Swap
1
2
2 MB/s
3
4
5
6
7
Image
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16 MB/s
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Parity
Disk Array
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RAID 5 configuration
• If disk fails, disk can be
rebuilt- fault tolerant
• High data transfer rate f
or read, write slower
• Min. 3 disks to start
• Array capacity is N-1
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Bandwidth
Bandwidth is a measure of the informati
on (data) carrying capacity of a network
10/100/1000 MB/sec
Information Flow
Data Pipe (Network)
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Network Bottleneck
The bandwidth of an information delivery system i
s limited to the bandwidth of the slowest compon
ent in the system
Network Bottleneck
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Data Compression
Data compression reduces the information rate
a network must support
Uncompressed Data
Compressed Data
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Lossless Image Compression
I-D=0
C
I
D
Decompressed image is identical to original im
age
JPEG lossless compression
Average compression of 2:1 for x-ray images
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JPEG 2000 Compression
• Selected parts of the image can be defined as
Regions of Interest, they can then be delivered
before other parts of the image, or losslessly,
whilst other parts of the image that are less cri
tical use normal lossy compression
• JPEG 2000 codestream can be ordered to deliv
er images of lower resolution before the full i
mage can be transmitted
• Motion JPEG 2000 does not have any form of
extrapolation (and hence potential distortion) i
n the time domain. Each frame is a separate J
PEG 2000 coded image
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JPEG 2000 images
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Storage Device (Long Term)
Database
Server
RAID
MOD
DLT
HIS/RIS
Interface
(Broker)
DG
RIS
CT
W/S
M
R
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R&F
NM
PCs
CR QA
CR
Film
Digitizer
XRAY
Frame
Grabber
US
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Types of storage media
Media
DVD
MOD
DLT
9840
AIT2
WORM
3.8
5.2
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20
50
Less
Expen.
Expen.
Expen.
Cheap
Most
Expen.
Load + Very fast Very fast 113 sec
Assess
5
5.1
5
Max. T
rate
MB/s
15 sec
45 sec
10
6
GB
Cost
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Long Term Archive



Used to store digital data for longer peri
ods of time
Storage ranges from 100 MB to 10 TB
Optical disk most common media
- 5 1/4” MOD
- 2.6 GB and 5.2 GB Capacity


DLT used for longer term storage and re
dundancy
ISP module
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Storage Device (Near line)
Database
Server
RAID
MOD
SAN/NAS
DLT
HIS/RIS
Interface
(Broker)
DG
RIS
CT
W/S
M
R
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R&F
NM
PCs
CR QA
CR
Film
Digitizer
XRAY
Frame
Grabber
US
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Storage Area Network
• SAN is a high-speed sub-n
etwork of shared storage d
evices
• Contains storage device (di
sk) for storing data
• SAN's architecture works in
a way that makes all storag
e devices available to all se
rvers
• Use of Fiber Channel
• High scalability for additio
nal storage and redundant
networks
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PCs
Storage devices
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Network Area Storage
• NAS is a class of dedicated hard disk-based storage de
vices which provide LAN users with additional disk stor
age through a standard network connection
• In most cases, a NAS device (or NAS server) receives a
n IP address, connects to the LAN through an Ethernet
cable, and resides on the LAN as an independent netw
ork device
• Users are not demanding the server's processing time
for mundane storage tasks -- often improving the perf
ormance of local application servers
• NAS systems also include some onboard memory (RA
M) to cache network data to or from the disks
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SAN Vs NAS
• Difference between NAS and SAN is subtle
• NAS devices are big, single purpose storage ap
pliances that you plug into network
• NAS sits between your application server and
your file system
• As perform only 1 task, can serve files very fas
t
• NAS is network-centric
• SAN is a defined architecture that sits between
your file system and your underlying physical s
torage
• SAN is data-centric
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Display
HIS/RIS
Interface
(Broker)
Database
Server
RAID
MOD
DLT
Diagnostic W/S
SAN/NAS
Dedicate W/S
DG
RIS
CT
W/S
M
R
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R&F
NM
PCs
CR QA
CR
Film
Digitizer
XRAY
Frame
Grabber
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Workstations
• Four Primary Categories
- Advanced Analysis: Used by specialists for advance
d diagnosis - 3D, volume rendering
- Diagnostic: For primary diagnosis; located in readin
g rooms; high-end 2K monitors
- Clinical: Used by clinicians and staff to consult; ICU
/ ER applications; less costly than diagnostic; 1K mo
nitors
- At Home Review: low-end; PC based; cost-effective;
review application; lossy compressed for faster trans
mit
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Standalone Vs direct PACS w/s
Standalone Workstation
Direct PACS Client
Workstation
Hard Disk Storage
Yes, varies
Minimal
Query PACS
number
All PACS system (CT, ACC,
Angio.)
Single PACS system (ACC
PACS)
Retrieval
mechanism
DICOM Q/R and association
made with different vendors
Direct attached, same vendor
Retrieval time
Slower
Faster
Diagnostic value
Depends on Monitor Grade and
Modules like MPR, 3D etc
Depends on Monitor Grade and
Modules like MPR, 3D etc
Suggested usage
1.for meeting/museum purpose
2.for single modality image
reviewing and reporting like
Radworks in U/S Rm
Direct PACS workstation for
reporting
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Web distribution
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
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High availability, low cost
Reports / select images to referring physi
cian desktop
Point of integration with electronic patie
nt record
Lossy compression for performance
Potential for TeleRadiology
Security issues to be resolved
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RIS, HIS, ePR and PACS integra
tion
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Broker HIS/RIS and PACS interface
HIS/RIS
Interface
(Broker)
DG
RIS
CT
W/S
M
R
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R&F
NM
PCs
CR QA
CR
Film
Digitizer
XRAY
Frame
Grabber
US
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Hospital Information System
• Support clinical and medical patient care
activities in the hospital
• Administer the hospital’s daily business tr
ansactions like finance, payroll etc
• Evaluate hospital performances and costs
and make long-term forecast
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Clinical System in HA, HK
• Patient Administration
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•
•
•
In-Patient and Out-Patient Administration System
Accident & Emergency Information System
Medical Record Abstract System
Medical Record Tracking System
•
•
•
•
Laboratory Information System
Radiology Information System
Pharmacy Management System
Dietetics Catering Management System
•
•
•
•
Clinical Management System (In-Patient) Discharge Summary
Clinical Management System (Out-Patient)
Electronic Patient Records
Clinical Data Analysis and Reporting System
• Clinical Support
• Clinical Management
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Non-Clinical System in HA
Human Resources and Payroll Systems
Hospital Based Financial System
Materials Management System
Patient Billing and Revenue Collection Sy
stem
• Executive Information System
•
•
•
•
Code 9 and view codes
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Radiology Information Systems
• Similar to HIS but of smaller scale
• Interfaces to PACS based on HL7
• Department administrative management
- Scheduling and Film tracking
- Resource management and reporting
- Monitor patient status
 Link to Hospital Information System (HIS)
- Billing and Master Record
• Link to Clinical Management System (CMS)
- Prefetch for Clinical visit
- ePR integration
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Exam
Order
Exam
Scheduled
Modality Worklist
Demographics
Downloaded
RIS
RIS workflow
Web
distribution
to referring
physicians
Patient Exam
Is Performed
Images
transferred
in STS
Order
Event
Database
server
/Archive
Prefetch Exams
From Storage
PACS Worklist
Updated
Images /
Prior Reports
Dictated
status
Image migration STS to LTA
Final report
available
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Report
Verified
Exam
Read
Preliminary status
Exam
Transcribed
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Broker service
DR
HA
HIS
CR
ADT
HA
RIS
HA CMS
Appt.,
X-ray reques
t
Mitra
PACS
Broker
interface
Clinical visit
US
DF
Database s
erver
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Modalities: Get WORKLIST
Get REPORT, Get INFO
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Broker service
• A restricted access account will be created at S
ybase that gives limited authority for the DICO
M Broker solely for the purpose of the interfac
es
• In general, for data flow from RIS to the Broker,
the RIS write the supported events to the table,
and the Broker polls against the events table a
nd calls the associated stored procedures for t
he conversion to DICOM messages
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Broker service
• Broker main function:
- Worklist generation
- Reports storage
Registration + Post exa
m data capture (RIS)
Acc # generation + ca
ll broker for update
Need SOME time!!
Modalities query Bro
ker for worklist upda
te
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Broker poll RIS event
table and convert to D
ICOM info
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ePR Architecture
• Selected images fro
m individual hospital’
s PACS are sent
• make use of the ePR
record indexing and
browsing capabilities
to read the radiology
images through CMS
workstations
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Data Flow Diagram
RIS
ePR
HA system
Appointment
Attendance
RIS operational Exam records
data
Reports (15mins)
ePR
PACS
RIS statistical d
ata
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CMS
Web Se
rver
Attendance
Data wareh
Exam & worklo
ouse
ad units (daily)
Non clinical syste
m
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Characteristics of ePR
• Near instant image review
• Web distribution can be within hospital, t
o other hospitals or even private clinics
• TeleRadiography possible
• Update of patient information
• Lossy Vs lossless
• Broken pathway
• 15 minutes time lag
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Guidelines for HIS, RIS, PACS interface
• Each system remain unchanged in its con
figuration and function, only data are sha
red
• Identify the subset data to be shared an
d set up access rights/ authorization
• Convert the subset data to HL7 standard
• Define transfer protocol (TCP/IP or DICO
M)
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Typical patient and data flow
• Admission: Patient registration, notify HIS (HL7)
• Order entry/Arrival: Schedule exam and notify RIS
• Broker notified and PACS database server updated (pre
fetch)
• DICOM worklist to modality
• Exam completed: data to DICOM gateway (MPPS)
• Information/images to database/image server through
gateway (DICOM store)
• Images stored in PACS archive
• Images to workstations from PACS archive
• Dictation, transcription etc: workstation to RIS/PACS
• RIS reporting and PACS updated for reports
• Transfer: HIS/RIS to PACS, images to other PACS
• Discharge: HIS/RIS to PACS, images rub out
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Mobile PACS
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What is DICOM?
• The standard for Digital Imaging and
Communications in Medicine.
• Developed by the National Electrical Manufacturers
Association (NEMA) in conjunction with the American
College of Radiology (ACR).
• Covers most image formats for all of medicine.
• Specification for messaging and communication
between imaging machines.
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A little history
• The first version was ACR-NEMA, released in 1985.
• Its goal in developing a standard was
– To enable users to retrieve images and associated
information from digital imaging equipment in a
standard format using point-to-point connection.
– To hide differences same across multiple image
equipment manufacturers.
• To handle developing network and image standarts,
a new standard, DICOM, was proposed in 1981.
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DICOM Application Domain
LiteBox
Storage, Query/Retrieve,
Study Component
MAGN
ETOM
Print Management
Query/Retrieve
Results Management
Media Exchange
Information Management System
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Summary of DICOM Features
• NETWORK PROTOCOL
● DICOM incorporates negotiation to permit peers to
agree on the functions to be performed
• MESSAGE ENCODING
● DICOM defines 24 data types (V2.0 had 4)
● DICOM message encoding includes JPEG
compression (17 varients)
● DICOM supports multiple character repertoires
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Summary of DICOM Features
• OBJECT DATA MODEL
● DICOM is based on a completely specified data model
● DICOM includes a robust UID mechanism
• DATA DICTIONARY
● DICOM includes a large number of new data elements
• SERVICE CLASSES
● DICOM defines classes of service for specific
applications (e.g. image management, printing) and
conformance levels
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DICOM Objects
• Things such as images, reports, and patients are all objects
and are called information objects.
• Two kinds of objects in DICOM:
– Composite objects (Old objects inherited from NEMA).
– Normalized objects (New objects defined in DICOM).
• All objects and their format constitutes Data Dictionary.
• DICOM uses UIDs to identify information objects, such as
the images, reports, or transfer syntaxes.
• The form of the UID conforms to an international standard.
– 1.2.840.10008 is the root and the same for every DICOM
UID.
– Example: UID for the DICOM explicit VR little endian transfer
syntax is 1.2.840.10008.1.2.1
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DICOM Service Classes
• Composite
● Verification
● Storage
● Query/Retrieve
● Study Content Notification
• Normalized
● Patient Management
● Study Management
● Results Management
● Basic Print Management
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Hardcopy Image Reading +
Dictation/Transcription (Use Case 1)
Image Reading:
• Hardcopy Reading
• Hardcopy DICOM Print as Seen at Modality
Reporting:
• RIS-Based Transcription / Validation of Narrati
ve Report
• RIS-Based Report Storage and Management
– Send Reports
– Query Prior Reports
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Hardcopy Image Reading +
Dictation/Transcription (Use Case 1)
Report Storage
/ Mgmt.
RIS
sen
d
Narrative
Info Only
Transcription
& Correction
prin
t
Paper
print/
Mail/
Fax/Email
Electronic Report
quer
y
Acquisition
Electronic Report
Report
Repository
Validation
Film Archive
Filming
Hardcopy
Interpretation
& Dictation
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network
DICOM
optional
manual
HL7/other
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Hardcopy and Softcopy Image Reading +
Dictation/Transcription (Use Case 2)
Image Reading:
•
•
•
•
Hardcopy Reading
Hardcopy DICOM Print as Seen at Modality
Softcopy Reading
Hardcopy DICOM Print as Seen During Softcopy Readin
g
Reporting:
• RIS-Based Transcription / Validation of Narrative Report
• RIS-Based Report Storage and Management
– Send Reports
– Query Prior Reports
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Hardcopy and Softcopy Image Reading +
Dictation/Transcription (Use Case 2)
stor
e
Selected
Images
Softcopy
Interpretation
& Dictation
Report Storage
/ Mgmt.
RIS
sen
d
Narrative
Info Only
Acquisition
Paper
print/
Mail/
Fax/Email
Electronic Report
quer
y
Transcription
& Correction
prin
t
Electronic Report
Report
Repository
Validation
Film Archive
Filming
Hardcopy
Interpretation
& Dictation
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network
DICOM
optional
manual
HL7/other
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Acquisition Workflow Support +
Burn CD/DVD (Use Case 3)
Image Acquisition:
• RIS-based Acquisition Workflow Support (Modality Worklist)
Image Reading:
•
•
•
•
•
Hardcopy Reading
Hardcopy DICOM Print as Seen at Modality
Softcopy Reading
Hardcopy DICOM Print as Seen During Softcopy Reading
DICOM Store Images -> Burn CD/DVD
Reporting:
• RIS-Based Transcription / Validation of Narrative Report
• RIS-Based Report Storage and Management
– Send Reports
– Query Prior Reports
– Optional DICOM Store Reports -> Burn CD/DVD
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Hardcopy and Softcopy Image Reading +
Dictation/Transcription (Use Case 3)
Modality Worklist
stor
e
Selected
Images
Softcopy
Interpretation
& Dictation
Report Storage
/ Mgmt.
RIS
sen
d
Narrative
Info Only
Acquisition
Electronic Report
Paper
print/
Mail/
Fax/Email
Electronic Report
quer
y
Report
Repository
Transcription
& Correction
prin
t
Burn CD/DVD
Validation
Off-Line Archive
store
Film Archive
Hardcopy
Filming
Interpretation
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& Dictation
network
DICOM
optional
manual
HL7/other
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PACS for Management of DICOM Persistent O
bjects (Use Case 4)
Image Acquisition:
• RIS-based Acquisition Workflow Support (Modality Worklist)
Image Reading:
• Hardcopy Reading
• Hardcopy DICOM Print as Seen at Modality
• Softcopy Reading
• Hardcopy DICOM Print as Seen During Softcopy Reading
• DICOM Store Images for Burning CD/DVD
• PACS-based Storage and Management of DICOM Persistent Objects
– Archive Imaging Studies
– Query Prior Imaging Studies
Reporting:
• RIS-Based Transcription / Validation of Narrative Report
• RIS-Based Report Storage and Management
– Send Reports
– Query Prior Reports
– Optional DICOM Store Reports for Burning CD/DVD
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PACS for Management of DICOM Persistent Objects (
Use Case 4)
Modality Worklist
stor
e
Selected
Images
Softcopy
Interpretation
& Dictation
Narrative
Info Only
Transcription
& Correction
sen
d
Electronic
Report
quer
y
Acquisition
Object Storage /
Mgmt.RIS
store
Validation
store
store
q/
r
Off-Line Archive
Film Archive
Hardcopy
Interpretation
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& Dictation
Filming
Paper
print/
Mail/
Fax/Email
Report
Repository
Image
Repository
PACS
prin
t
Electronic Report
Burn CD/DVD
network
DICOM
optional
manual
74
HL7/other