Integrating image processing in PACS

Design and Implementation of a Cloud PACS Architecture

The limitations of the classic PACS (picture archiving and communication system), such as the backward-compatible DICOM network architecture and poor security and maintenance, are well-known. They are challenged by various existing solutions employing cloud-related patterns and services. However, a full-scale cloud-native PACS has not yet been demonstrated. The paper introduces a vendor-neutral cloud PACS architecture. It is divided into two main components: a cloud platform and an access device. The cloud platform is responsible for nearline (long-term) image archive, data flow, and backend management. It operates in multi-tenant mode. The access device is responsible for the local DICOM (Digital Imaging and Communications in Medicine) interface and serves as a gateway to cloud services. The cloud PACS was first implemented in an Amazon Web Services environment. It employs a number of general-purpose services designed or adapted for a cloud environment, including Kafka, OpenSearch, and Memcached. Custom services, such as a central PACS node, queue manager, or flow worker, also developed as cloud microservices, bring DICOM support, external integration, and a management layer. The PACS was verified using image traffic from, among others, computed tomography (CT), magnetic resonance (MR), and computed radiography (CR) modalities. During the test, the system was reliably storing and accessing image data. In following tests, scaling behavior differences between the monolithic Dcm4chee server and the proposed solution are shown. The growing number of parallel connections did not influence the monolithic server's overall throughput, whereas the performance of cloud PACS noticeably increased. In the final test, different retrieval patterns were evaluated to assess performance under different scenarios. The current production environment stores over 450 TB of image data and handles over 4000 DICOM nodes.

Performance of an Automated Versus a Manual Whole-Body Magnetic Resonance Imaging Workflow

OBJECTIVES

The aim of this study was to evaluate the performance of an automated workflow for whole-body magnetic resonance imaging (WB-MRI), which reduces user interaction compared with the manual WB-MRI workflow.

MATERIALS AND METHODS

This prospective study was approved by the local ethics committee. Twenty patients underwent WB-MRI for myopathy evaluation on a 3 T MRI scanner. Ten patients (7 women; age, 52 ± 13 years; body weight, 69.9 ± 13.3 kg; height, 173 ± 9.3 cm; body mass index, 23.2 ± 3.0) were examined with a prototypical automated WB-MRI workflow, which automatically segments the whole body, and 10 patients (6 women; age, 35.9 ± 12.4 years; body weight, 72 ± 21 kg; height, 169.2 ± 10.4 cm; body mass index, 24.9 ± 5.6) with a manual scan. Overall image quality (IQ; 5-point scale: 5, excellent; 1, poor) and coverage of the study volume were assessed by 2 readers for each sequence (coronal T2-weighted turbo inversion recovery magnitude [TIRM] and axial contrast-enhanced T1-weighted [ce-T1w] gradient dual-echo sequence). Interreader agreement was evaluated with intraclass correlation coefficients. Examination time, number of user interactions, and MR technicians' acceptance rating (1, highest; 10, lowest) was compared between both groups.

RESULTS

Total examination time was significantly shorter for automated WB-MRI workflow versus manual WB-MRI workflow (30.0 ± 4.2 vs 41.5 ± 3.4 minutes, P < 0.0001) with significantly shorter planning time (2.5 ± 0.8 vs 14.0 ± 7.0 minutes, P < 0.0001). Planning took 8% of the total examination time with automated versus 34% with manual WB-MRI workflow (P < 0.0001). The number of user interactions with automated WB-MRI workflow was significantly lower compared with manual WB-MRI workflow (10.2 ± 4.4 vs 48.2 ± 17.2, P < 0.0001). Planning efforts were rated significantly lower by the MR technicians for the automated WB-MRI workflow than for the manual WB-MRI workflow (2.20 ± 0.92 vs 4.80 ± 2.39, respectively; P = 0.005). Overall IQ was similar between automated and manual WB-MRI workflow (TIRM: 4.00 ± 0.94 vs 3.45 ± 1.19, P = 0.264; ce-T1w: 4.20 ± 0.88 vs 4.55 ± .55, P = 0.423). Interreader agreement for overall IQ was excellent for TIRM and ce-T1w with an intraclass correlation coefficient of 0.95 (95% confidence interval, 0.86-0.98) and 0.88 (95% confidence interval, 0.70-0.95). Incomplete coverage of the thoracic compartment in the ce-T1w sequence occurred more often in the automated WB-MRI workflow (P = 0.008) for reader 2. No other significant differences in the study volume coverage were found.

CONCLUSIONS

In conclusion, the automated WB-MRI scanner workflow showed a significant reduction of the examination time and the user interaction compared with the manual WB-MRI workflow. Image quality and the coverage of the study volume were comparable in both groups.

Challenges of Implementing Picture Archiving and Communication System in Multiple Hospitals: Perspectives of Involved Staff and Users

Today, despite the advantages of the PACS system, its implementation in some healthcare organizations faces many challenges. One of the important factors in the successful implementation of a PACS system is identifying and prioritizing the challenges from the perspectives of involved staff and user of this system. Therefore, the aim of this study was to determine and compare the challenges of implementing PACS from perspectives these users in educational hospitals. This study was conducted on all IT and medical equipment staff, and radiology residents (n = 140) in Kerman University of Medical Sciences (KUMS) and Shiraz University of Medical Sciences (SUMS) in 2016. The data were collected through two researcher-made questionnaires. Their validity was approved by radiologists, IT staff, and medical informatics specialists and their reliability through calculation of Cronbach's Alpha (0.969 and 0.795). We used Multivariate Analysis of Variance (MANOVA) to compare the scores given by three groups of participants in the challenges and Univariate Analysis of Variance (ANOVA) to compare the scores in two universities. The participants believed that technical challenges were more important than other challenges (x̄=3.74, SD = 0.7). IT experts (x̄=3.87, SD = 1) and radiology residents (x̄=3.95, SD = 0.9) gave the higher scores to the "shortage of high quality monitors" factor and medical equipment experts (x̄=4.26, SD = 0.87) to the "low speed of communication networks" factor among all technical challenges. The mean scores given to technical (x̄=76.1, SD = 13.5) and managerial (x̄=16, SD = 5.9) challenges in SUMS were more than the scores of the same challenges in KUMS (x̄=69.9, SD = 15.7) and (x̄=11.9, SD = 6.4) (p < 0.05). The technical challenges are the most common challenges to PACS implementation, and different universities experience different levels of technical challenges. Eliminating implementation challenges can reduce the risk of failure in the utilization process. Based on the results of this study, providing necessary infrastructures such as appropriate monitors and upgraded IT equipment can prevent many of the PACS implementation challenges.

Dematerialisation of patient's informed consent in radiology: insights on current status and radiologists' opinion from an Italian online survey

PURPOSE

To assess the current status of patient's informed consent (PIC) management at radiological centres and the overall opinion of radiologist active members of the Italian Society of Medical Radiology (SIRM) about PIC dematerialisation through an online survey.

METHODS AND MATERIALS

All members were invited to join the survey as an initiative by the Imaging Informatics Chapter of SIRM. The survey consisted of 11 multiple-choice questions about participants' demographics, current local modalities of PIC acquisition and storage, perceived advantages and disadvantages of PIC dematerialisation over conventional paper-based PIC, and overall opinion about PIC dematerialisation.

RESULTS

A total of 1791 radiologists (amounting to 17.4% of active SIRM members for the year 2016) joined the survey. Perceived advantages of PIC dematerialisation were easier and faster PIC recovery (96.5%), safer storage and conservation (94.5%), and reduced costs (90.7%). Conversely, the need to create dedicated areas for PIC acquisition inside each radiological unit (64.0%) and to gain preliminary approval for the use of advanced digital signature tools from patients (51.8%) were seen as potential disadvantages. Overall, 94.5% of respondents had a positive opinion about PIC dematerialisation.

CONCLUSION

Radiologists were mostly favourable to PIC dematerialisation. However, concerns were raised that its practical implementation might face hurdles due to its complexity in current real life working conditions.

Mobile Workflow in Computed Tomography of the Chest

A CT system with a tablet as mobile user interface and a wireless remote control for positioning and radiation release has recently been presented. Our aim was to evaluate the effects of a mobile CT examination workflow on the radiographers’ performance compared to conventional examinations. A prototype of a radiation protection cabin was installed besides the gantry of a CT system. The CT system was equipped with a simplified user interface on a portable tablet and a mobile remote control. 98 patients with an indication for CT of the chest were randomly assigned to examination using the mobile devices (study group, n = 47) or using the conventional stationary workflow on the console (reference group, n = 51). Three ceiling mounted fisheye cameras were used for motion tracking of the radiographers, two in the examination room and one in the control room. Relative density of detection heat-maps and area counts were assessed using a dedicated software tool to quantify radiographers’ movements. Duration of each task of the examination was manually recorded using a stopwatch. In the reference group 25% of the area counts were located inside of the examination room, while it was 48% in the study group. The time spent in the same room with the patient increased from 3:06 min (29%) to 6:01 min (57%) using the mobile workflow (p < 0.05), thereof 0:59 min (9%) were spent in moderate separation with maintained voice and visual contact in the radiation protection cabin. Heat-maps showed an increase of the radiographer’s working area, indicating a higher freedom of movement. Total duration of the examination was slightly less in the study group without statistical significance (median time: study 10:36, reference 10:50 min; p = 0.29). A mobile CT examination transfers the radiographers’ interaction with the scanner from the control room into the examination room. There, radiographers’ freedom of movement is higher, without any tradeoffs regarding the examination duration.

Extending PACS Functionality: Towards Facilitating the Conversion of Clinical Necessities into Research-Derived Applications

The Picture Administration and Communications System (PACS) was designed to replace the old film archiving system in hospitals in order to store and move varying medical image modalities. Using the standard Internet transport protocol, PACS creators designed a robust digital signaling platform to optimize media use, availability, and confidentiality. Nowadays PACS has become ubiquitous in medical facilities but lacks imaging analytical capabilities. A myriad of initiatives have been launched in the hope of achieving this goal, but current solutions face issues with security and ease-of-use that have precluded their widespread adoption. Here, we present a PACS-based image processing tool that safeguards patient confidentiality, is user-friendly and is easy to implement. The final product is platform-independent, has a small degree of intrusiveness and is well suited to clinical and research workflows.

An Evaluation Protocol for Picture Archiving and Communication System: a Systematic Review

Introduction:

Picture archiving and communication system (PACS) serves to store, transmit, communicate and manage medical images. A logical evaluation protocol assists to determine whether the system is technically, structurally and operationally fit. The purpose of this systematic review was to propose a logical evaluation protocol for PACS, particularly useful for new hospitals and other healthcare institutions in developing countries.

Methods and Materials:

We systematically reviewed 25 out of 267 full-length articles, published between 2000 and 2017, retrieved from four sources: Science Direct, Scopus, PubMed and Google Scholar. The extracted data were tabulated and reviewed successively by three independent panels of experts that oversaw the design of this study and the process by which the PACS evaluation protocol was systematically developed.

Results:

The outcome data were ranked by expert panels and analyzed statistically, with the reliability established at 0.82 based on the Pearson’s correlation coefficient. The essential components and the best options to establish an optimal PACS were organized under nine main sections: system configuration;system network;data storage; datacompression;image input; image characteristics; image presentation; communication link; and system security, with a total of 20 components, each of which capable of working optimally with one or more program options.

Conclusions:

This systematic review presents an objective protocol that is an ideal tool for the evaluation of new or existing PACS at healthcare institutions, particularly in developing countries. Despite the significant advantages, the protocol may face minor limitations, largely due to lack of appropriate technical resources in various clinical settings and the host countries.

MIAPS: a web-based system for remotely accessing and presenting medical images

MIAPS (medical image access and presentation system) is a web-based system designed for remotely accessing and presenting DICOM image. MIAPS is accessed with web browser through the Internet. MIAPS provides four features: DICOM image retrieval, maintenance, presentation and output. MIAPS does not intent to replace sophisticated commercial and open source packages, but it provides a web-based solution for teleradiology and medical image sharing. The system has been evaluated by 39 hospitals in China for 10 months.

Video-atlas of open thoracoabdominal aortic aneurysm repair

Open surgical repair of thoracoabdominal aortic aneurysms has evolved significantly over the last decades thanks to technical improvements, especially in the area of organ protection. However, despite adjunctive strategies, morbidity and mortality rates are still not negligible. Repair of the thoracoabdominal aorta represents a formidable challenge for surgeons, anesthesiologists and patients alike. While operative repair is generally carried out in specialized institutions, knowledge of the state-of-the-art diagnostic, anesthesiologic, surgical and endovascular aspects will certainly be of great value to all physicians involved in the care of these patients at any level. This "How to" video will explain all of these diagnostic, anesthesiologic and surgical aspects in our daily practice.

Workflow efficiency of two 1.5 T MR scanners with and without an automated user interface for head examinations

RATIONALE AND OBJECTIVES

Workflow efficiency and workload of radiological technologists (RTs) were compared in head examinations performed with two 1.5 T magnetic resonance (MR) scanners equipped with or without an automated user interface called "day optimizing throughput" (Dot) workflow engine.

MATERIALS AND METHODS

Thirty-four patients with known intracranial pathology were examined with a 1.5 T MR scanner with Dot workflow engine (Siemens MAGNETOM Aera) and with a 1.5 T MR scanner with conventional user interface (Siemens MAGNETOM Avanto) using four standardized examination protocols. The elapsed time for all necessary work steps, which were performed by 11 RTs within the total examination time, was compared for each examination at both MR scanners. The RTs evaluated the user-friendliness of both scanners by a questionnaire. Normality of distribution was checked for all continuous variables by use of the Shapiro-Wilk test. Normally distributed variables were analyzed by Student's paired t-test, otherwise Wilcoxon signed-rank test was used to compare means.

RESULTS

Total examination time of MR examinations performed with Dot engine was reduced from 24:53 to 20:01 minutes (P < .001) and the necessary RT intervention decreased by 61% (P < .001). The Dot engine's automated choice of MR protocols was significantly better assessed by the RTs than the conventional user interface (P = .001).

CONCLUSIONS

According to this preliminary study, the Dot workflow engine is a time-saving user assistance software, which decreases the RTs' effort significantly and may help to automate neuroradiological examinations for a higher workflow efficiency.

Unusual stent after ureteral substitution. A first case

Background

To the best of our knowledge this is the first case where a Silastic drain is used in ureteral surgery instead of a common urological stent. Patients coming from other institutions, especially in peripheral areas, can be treated with non conventional devices and if traditional imaging is inconclusive, computed tomography (CT) can provide valuable information to make the right diagnosis.

Case presentation

We present the unusual case of a 32F Silastic drain found inside the urinary tract in a female patient who had previously undergone ileal loop replacement of the left ureter for post-hysterectomy stricture at another Institution, and had subsequently repeated surgery due to persistent hydronephrosis. Radiological findings on plain abdominal X-ray were quite misleading, while CT allowed a correct assessment of the drain features.

Conclusion

While double J stents of different lengths, sizes and materials are used in ureteral surgery, the use of Silastic drains has not been previously reported. In light of the present experience we don’t suggest its routinely use.

[Digital X-ray: interhospital data transfer by CD-ROM. Prospective data evaluation during the import process]

BACKGROUND

Increasing numbers of radiological imaging diagnostics are archived in digital form. In addition to the results of diagnostics performed in hospital a growing number of patients present with digital results of outpatient radiological investigations. These digitized images represent a challenge for the internal hospital work flow. The aim of the study was to determine the expenditure for the hospital when dealing with digital outpatient diagnostic results.

METHOD

Several parameters were observed and analyzed within the import process of nearly 400 CD-ROMs over a time period of 5 months. Only a negligible number of data on CD-ROMs could not be transferred into the hospital archive (1.5%). The duration of the process depended on the amount of data and the time period.

RESULTS

During regular hours the import process took on average 13 min per CD and 19 min per patient while the time increased significantly during on-call duties. This study demonstrates the significance of the import of digital outpatient radiological diagnostic results into the hospital archive which can in particular influence patient treatment.

Empirical investigation of radiologists' priorities for PACS selection: an analytical hierarchy process approach

Picture archiving and communication systems (PACS) are being widely adopted in radiology practice. The objective of this study was to find radiologists' perspective on the relative importance of the required features when selecting or developing a PACS. Important features for PACS were identified based on the literature and consultation/interviews with radiologists. These features were categorized and organized into a logical hierarchy consisting of the main dimensions and sub-dimensions. An online survey was conducted to obtain data from 58 radiologists about their relative preferences. Analytical hierarchy process methodology was used to determine the relative priority weights for different dimensions along with the consistency of responses. System continuity and functionality was found to be the most important dimension, followed by system performance and architecture, user interface for workflow management, user interface for image manipulation, and display quality. Among the sub-dimensions, the top two features were: security, backup, and downtime prevention; and voice recognition, transcription, and reporting. Structured reporting was also given very high priority. The results point to the dimensions that can be critical discriminators between different PACS and highlight the importance of faster integration of the emerging developments in radiology into PACS.