The digital imaging workstation

Digital Imaging and PACS: An Update

The instant and simultaneous availability of radiologic examinations has long been of interest to referring clinicians, and certainly to radiologists, within and outside of the hospital. In daily clinical routine, the term “film management problem” has been used to describe a lack of access to this essential part of clinical information. Comprehensive picture archiving and communication systems (PACSs) have been proposed and implemented only within few institutions. This article discusses some of the most important standards, and technical and practical aspects of digital imaging and PACS.

The Empirical Foundations of Teleradiology and Related Applications: A Review of the Evidence

INTRODUCTION

Radiology was founded on a technological discovery by Wilhelm Roentgen in 1895. Teleradiology also had its roots in technology dating back to 1947 with the successful transmission of radiographic images through telephone lines. Diagnostic radiology has become the eye of medicine in terms of diagnosing and treating injury and disease. This article documents the empirical foundations of teleradiology.

METHODS

A selective review of the credible literature during the past decade (2005-2015) was conducted, using robust research design and adequate sample size as criteria for inclusion.

FINDINGS

The evidence regarding feasibility of teleradiology and related information technology applications has been well documented for several decades. The majority of studies focused on intermediate outcomes, as indicated by comparability between teleradiology and conventional radiology. A consistent trend of concordance between the two modalities was observed in terms of diagnostic accuracy and reliability. Additional benefits include reductions in patient transfer, rehospitalization, and length of stay.

Digital Luminescence Radiography Using a Chest Phantom

Ninety-eight digital radiographs of a chest phantom with simulated tumors in the mediastinum and left lung and a pneumothorax-simulation in the right hemithorax were compared with the corresponding examinations saved on optical disk and viewed on a 1 000-line monitor. The examinations were reviewed by 7 radiologists with different experience, and receiver operating characteristic (ROC) curves were constructed. There was no significant difference between the hard-copy and the monitor results. A significant interobserver difference was seen only with the low attenuating 6 mm “tumor” and then only between the observer with the highest and the one with the lowest scores.

Experiences with a Teleradiology System in Pulmonary Diseases

Chest radiographs of 43 patients were digitized and sent from Paimio Hospital to Turku University Central Hospital. Fifteen of the patients had a pneumothorax, 12 had interstitial lung disease and 16 were controls. The images were interpreted by 5 radiologists during their duty shift. The first reading session consisted of images with 1 024 × 1 024 pixel resolution and the second of images with 2 048 × 2 048 matrix followed by the original chest radiographs. ROC studies were performed from the answers based on a 5-point confidence scale. In the pneumothorax group the average area under the individual ROC curve was 0.928 with the 1 024 × 1 024 matrix and 0.983 with the 2 048 × 2 048 matrix. In the fibrosis group the average area under the individual ROC curve was 0.877 with the 1 024 × 1 024 matrix and 0.831 with the 2 048 × 2 048 matrix. The results suggest that the 1 024 × 1 024 matrix is adequate in the detection of pneumothoraces and fibrosis.

Digital Luminescence Radiography Using a Chest Phantom

With the introduction of picture and archiving communicating systems an alternative image display for the wards might be a personal computer (PC). The intention with this study was to evaluate the diagnostic image quality of the monitor of a PC compared to that of a workstation. Eighty-five digital radiographs of a chest phantom with simulated tumors in the mediastinum and right lung were saved on optical discs. The examinations were reviewed by 4 radiologists on a monitor at a workstation and at a PC, and receiver operating characteristic (ROC) curves were constructed. No significant difference was found between performance of the PC and the workstation.

Effect of LCD monitor type and observer experience on diagnostic performance in soft-copy interpretations of the maxillary sinus on panoramic radiographs

Purpose

The aim of this study was to evaluate the effect of liquid crystal display (LCD) monitor type and observer experience on the diagnostic performance in soft-copy interpretations of maxillary sinus inflammatory lesions on panoramic radiographs.

Materials and Methods

Ninety maxillary sinuses on panoramic images were grouped into negative and positive groups according to the presence of inflammatory lesions, using CT for confirmation. Monochrome and color LCDs were used. Six observers participated and ROC analysis was performed to evaluate the diagnostic performance. The reading time, fatigue score, and inter-/intra-observer agreements were assessed.

Results

The interpretation of maxillary sinus inflammatory lesions was affected by the LCD monitor type used and by the experience of the observer. The reading time was not significantly different, however the fatigue score was significantly different between two LCD monitors. Inter-observer agreement was relatively good in experienced observers, while the intra-observer agreement for all observers was good with monochrome LCD but not with color LCD.

Conclusion

The less experienced observers showed lowered diagnostic ability with a general color LCD.

Contrast sensitivity of digital imaging display systems: contrast threshold dependency on object type and implications for monitor quality assurance and quality control in PACS

The American Association of Physicists in Medicine Task Group 18 has published standards and quality control (QC) guidelines to ensure consistency and optimal quality for digital image display systems (DIDSs). In many of these recommended QC tests, static test patterns that contain low-contrast objects are often used to assess and validate the quality of a DIDS. These low-contrast objects often have the shape of circular disks or squares with sharp edges, neither of which resemble most of the diagnostic findings in medical images. On the other hand, circular objects with fuzzy boundaries bear a closer resemblance to lung nodules in chest radiography and masses in mammography; thus, they may be more clinically relevant in assessing display system quality. In this article human observers' contrast sensitivities of circular objects with sharp edges and those with fuzzy ones were investigated. The contrast thresholds of human viewers using a consumer-grade color LCD monitor and a medical-grade monochrome LCD monitor were measured for objects of various sizes displayed against uniform backgrounds with various luminance levels. Contrast-detail curves for circular objects with sharp edges and those with fuzzy boundaries were measured and compared. It was found that contrast thresholds for objects with fuzzy boundaries were higher (i.e., the objects were more difficult to detect) than those with sharp edges. Objects with fuzzy boundaries were potentially more sensitive in distinguishing quality differences among image display devices and thus may be a better QC measurement in detecting subtle deterioration in image display devices.

A methodology to integrate clinical data for the efficient assessment of brain-tumor patients

Careful examination of the medical record of brain-tumor patients can be an overwhelming task for the neuroradiologist. The number of clinical documents alone may approach 100 for a patient that has a 3-year-old brain tumor. The neuroradiologist's evaluation of a patient's brain tumor involves examining the current imaging exam and checking for previous imaging exams that may occur pre- or post-treatment. The goal of this research is to develop an effective method to review all of the pertinent patient information from the medical record. We have designed and developed a medical system that incorporates Hospital Information Systems, Radiology Information Systems, and Picture Archiving and Communications Systems information. Our research improves clinical review of patient's data by organizing image display, removing unnecessary documents, and mining for key clinical scenarios that are important in the assessment and care of brain-tumor patients.

Influence of the display monitor on observer performance in detection of dental caries

Background and aims

Digital imaging continues to gain acceptance in dentistry and video display used for this becomes important. The aim of this study was to assess the influence of the display monitor on observer performance on caries detection.

Materials and methods

Artificial enamel lesions were created in 40 extracted teeth at random using 1/4 and 1/2 round burs. Teeth were mounted in dental stone blocks to simulate a hemi-dentition. Approximate exposures were recorded at 70 kVp using a Planmeca (Planmeca Co, Helsinki, Finland) digital imaging system. Three oral and maxillofacial radiologists rated each image on a five-point scale for the presence or absence of lesion. Radiographic images were viewed on the following monitors: (1) LG Flatron 700p (LG Electronics Co., South Korea); (2) Samsung Magicgreen (Samsung Electronics Corp., South Korea); (3) Hansol 710p (Hansol Electronics Corp., South Korea) and (4) Toshiba satellite laptop (Toshiba Computer Corp., Philippines). Examiners were allowed to magnify and adjust density and contrast of each image at will. Receiver Operating Characteristic (ROC) analysis was performed. Data was subjected to repeated measures analysis of variance and ordinal logistic regression to test for significance between variables and to determine odds ratios.

Results

Mean ROC curve areas ranged from 0.8728 for the LG monitor to 0.8395 for the Samsung. Repeated measures analysis of variance showed significant differences between observers (P<0.0001), lesion size (P<0.0001), examiner/monitor interaction (P<0.033) and examiner/block interaction (P<0.013). However, no significant difference was found between monitors.

Conclusion

This study suggests that observer performance is independent of the visual characteristics of the display monitor.

Effect of ambient light and bit depth of digital radiograph on observer performance in determination of endodontic file positioning

OBJECTIVES

To examine the effects of the luminance and bit depth of digital image on observer performance for determination of endodontic file positioning.

STUDY DESIGN

Using extracted premolar teeth, no. 08 K-file was placed into the canal and positioned so that the tip was either flush or 1 mm short of the radiologic root apex. The samples were imaged with both conventional and digital radiographs at 8 and 12 bits. Eleven observers read the images under dark and bright condition, and receiver operating characteristics analysis was performed. Additionally, the interpreting time was measured.

RESULTS

The 12-bit images showed similar observer performance compared with conventional images, and better than the 8-bit images. The interpretation time for bright condition and 8-bit images was longer than for dark condition and 12-bit images.

CONCLUSION

Twelve-bit digital images were preferred to 8-bit for accurate determination of endodontic file position.

Multiprojection correlation imaging for improved detection of pulmonary nodules

OBJECTIVE

The purpose of this study was the development and preliminary evaluation of multiprojection correlation imaging with 3D computer-aided detection (CAD) on chest radiographs for cost- and dose-effective improvement of early detection of pulmonary nodules.

SUBJECTS AND METHODS

Digital chest radiographs of 10 configurations of a chest phantom and of seven human subjects were acquired in multiple angular projections with an acquisition time of 11 seconds (single breath-hold) and total exposure comparable with that of a posteroanterior chest radiograph. An initial 2D CAD algorithm with two difference-of-gaussians filters and multilevel thresholds was developed with an independent database of 44 single-view chest radiographs with confirmed lesions. This 2D CAD algorithm was used on each projection image to find likely suspect nodules. The CAD outputs were reconstructed in 3D, reinforcing signals associated with true nodules while simultaneously decreasing false-positive findings produced by overlapping anatomic features. The performance of correlation imaging was tested on two to 15 projection images.

RESULTS

Optimum performance of correlation imaging was attained when nine projection images were used. Compared with conventional, single-view CAD, correlation imaging decreased as much as 79% the frequency of false-positive findings in phantom cases at a sensitivity level of 65%. The corresponding reduction in false-positive findings in the cases of human subjects was 78%.

CONCLUSION

Although limited by a relatively simple CAD implementation and a small number of cases, the findings suggest that correlation imaging performs substantially better than single-view CAD and may greatly enhance identification of subtle solitary pulmonary nodules on chest radiographs.

Neonatal Chest Computed Radiography: Image Processing and Optimal Image Display

OBJECTIVE

The purpose of this study was to determine soft-copy image display preferences of brightness, latitude, and detail contrast for neonatal chest computed radiography to establish a baseline for future work on low-dose imaging.

CONCLUSION

Observers preferred brighter images with higher detail contrast and narrow to middle latitude for soft-copy display compared with the typical screen-film hard-copy appearance. Future research on low-dose neonatal chest imaging will be facilitated by an understanding of optimal soft-copy image display.

Choosing a radiology workstation: technical and clinical considerations

Choosing a workstation for daily use in the interpretation of digital radiologic images can be a daunting task. There are numerous products available on the market, but differentiating among them and deciding on what is best for a particular environment can be confusing and frustrating. There is no "one-size-fits-all" workstation, so users must consider a variety of factors when choosing a workstation. This review summarizes the critical elements in a radiology workstation and the characteristics one should be aware of and look for in the selection of a workstation. Issues pertaining to both hardware and software aspects of medical workstations, including interface design, are reviewed, particularly as they may affect the interpretation process.

Designing better radiology workstations: impact of two user interfaces on interpretation errors and user satisfaction

This paper presents our solution for supporting radiologists' interpretation of digital images by automating image presentation during sequential interpretation steps. We extended current hanging protocols with support for "stages" which reflect the presentation of digital information required to complete a single step within a complex task. We demonstrated the benefits of staging in a user experiment with 20 lay subjects involved in a comparative visual search for targets, similar to a radiology task of identifying anatomical abnormalities. We designed a task and a set of stimuli that allowed us to simulate the interpretation workflow from a typical radiology scenario-reading a chest radiography exam when a prior study is also available. The simulation was enabled by abstracting both the radiologist's task and the basic workstation navigation functionality. The staged interface was significantly faster than the traditional user interface, provided a 37% reduction in the interpretation errors, and improved user satisfaction.

Addressing the coming radiology crisis-the Society for Computer Applications in Radiology transforming the radiological interpretation process (TRIP) initiative

The Society for Computer Applications in Radiology (SCAR) Transforming the Radiological Interpretation Process (TRIP) Initiative aims to spearhead research, education, and discovery of innovative solutions to address the problem of information and image data overload. The initiative will foster interdisciplinary research on technological, environmental and human factors to better manage and exploit the massive amounts of data. TRIP will focus on the following basic objectives: improving the efficiency of interpretation of large data sets, improving the timeliness and effectiveness of communication, and decreasing medical errors. The ultimate goal of the initiative is to improve the quality and safety of patient care. Interdisciplinary research into several broad areas will be necessary to make progress in managing the ever-increasing volume of data. The six concepts involved are human perception, image processing and computer-aided detection (CAD), visualization, navigation and usability, databases and integration, and evaluation and validation of methods and performance. The result of this transformation will affect several key processes in radiology, including image interpretation; communication of imaging results; workflow and efficiency within the health care enterprise; diagnostic accuracy and a reduction in medical errors; and, ultimately, the overall quality of care.

Financing a large-scale picture archival and communication system

RATIONALE AND OBJECTIVES

An attempt to finance a large-scale multi-hospital picture archival and communication system (PACS) solely based on cost savings from current film operations is reported.

MATERIALS AND METHODS

A modified Request for Proposal described the technical requirements, PACS architecture, and performance targets. The Request for Proposal was complemented by a set of desired financial goals-the main one being the ability to use film savings to pay for the implementation and operation of the PACS.

RESULTS

Financing of the enterprise-wide PACS was completed through an operating lease agreement including all PACS equipment, implementation, service, and support for an 8-year term, much like a complete outsourcing. Equipment refreshes, both hardware and software, are included. Our agreement also linked the management of the digital imaging operation (PACS) and the traditional film printing, shifting the operational risks of continued printing and costs related to implementation delays to the PACS vendor. An additional optimization step provided the elimination of the negative film budget variances in the beginning of the project when PACS costs tend to be higher than film and film-related expenses.

CONCLUSION

An enterprise-wide PACS has been adopted to achieve clinical workflow improvements and cost savings. PACS financing was solely based on film savings, which included the entire digital solution (PACS) and any residual film printing. These goals were achieved with simultaneous elimination of any over-budget scenarios providing a non-negative cash flow in each year of an 8-year term.

Effect of monitor luminance and ambient light on observer performance in soft-copy reading of digital chest radiographs

PURPOSE

To examine the combined effects of monitor luminance and ambient light on observer performance for detecting abnormalities in a soft-copy interpretation of digital chest radiographs.

MATERIALS AND METHODS

A total of 254 digital chest radiographs were displayed on a high-resolution cathode ray tube monitor at three luminance levels (25, 50, and 100 foot-lamberts) under three ambient light levels (0, 50, and 460 lux). Six chest radiologists reviewed each image in nine modes of combined luminance and ambient light. The observers were allowed to adjust the window width and level of the soft-copy images. The abnormalities included nodule, pneumothorax, and interstitial disease. Observer performance was analyzed in terms of the receiver operating characteristics. The observers reported their subjective level of visual fatigue with each viewing mode. A statistical test was conducted for each of the abnormalities and for fatigue score by using repeated-measures two-way analysis of variance with an interaction.

RESULTS

The detection of nodules was the only reading that was affected by the ambient light with a statistically significant difference (P <.05). Otherwise, observer performance for detecting a nodule, pneumothorax, and interstitial disease was not significantly different in the nine-mode comparison. There was no evidence that the luminance of the monitors was related to the ambient light for any of the abnormalities. The fatigue score showed a statistically significant difference due to both the luminance and ambient light.

CONCLUSION

When adequate window width and level are applied to soft-copy images, the primary diagnosis with chest radiographs on the monitor is unlikely to be affected under low ambient light and a monitor luminance of 25 foot-lamberts or more.

PACS adoption

Once the decision has been made to adopt PACS instead of a film-based radiology practice, there are a number of hurdles to jump. Users need to be aware of the impact the change will make on end users and be prepared to address issues that arise before they become problems. Someone who understands the technology of PACS must be identified to help make an informed decision about vendor selection, network architecture, workstation functionality, and archives. A PACS administrator should have the tools available to avoid problems with the system after implementation and should be able to repair the inevitable mistakes that will happen. Hopefully, this article can serve as a starting point for a potential new PACS adoption.

Proposal of a quality-index or metric for soft copy display systems: contrast sensitivity study

In addition to the inherent qualities of a digital image, the qualities of the monitor and graphics control card as well as the viewing conditions will affect the perceived quality of an image that is displayed on a soft copy display (SD) system. With the implementation of picture archiving and communication systems (PACS), many diagnoses are being made based on images displayed on SD devices, and consequently SD quality may affect the accuracy of diagnosis. Unlike the traditional film-on-lightbox display, optimal SD system parameters are not well defined, and many issues remain unsettled. In this article, the human observer performance, as measured by contrast sensitivity, for several SD devices including an active matrix liquid crystal flat panel monitor is reported. Contrast sensitivities were measured with various display system configurations. Experimental results showed that contrast sensitivity depends on many factors such as the type of monitor, the monitor brightness, and the gamma settings of the graphics card in a complex manner. However, there is a clear correlation between the measured contrast thresholds and the gradient of the display device's luminance response curve. Based on this correlation, it is proposed to use the gradient of luminance response curve as a quality-index or metric for SD devices.

Teleradiology: another revolution in radiology?

Teleradiology systems are rapidly being deployed by an increasing number of radiological services. Many articles have already been published on the technological developments of teleradiology but little attention has been given to its expected impact on the delivery of health care. This review article will therefore outline the historical and current technological developments of teleradiology and its potential future implementation into mainstream radiology.

Viewport: an object-oriented approach to integrate workstation software for tile and stack mode display

Diagnostic workstation design has migrated towards display presentation in one of two modes: tiled images or stacked images. It is our impression that the workstation setup or configuration in each of these two modes is rather distinct. We sought to establish a commonality to simplify software design, and to enable a single descriptor method to facilitate folder manager development of "hanging" protocols. All current workstation designs use a combination of "off-screen" and "on-screen" memory whether or not they use a dedicated display subsystem, or merely a video board. Most diagnostic workstations also have two or more monitors. Our central concept is that of a "logical" viewport that can be smaller than, the same size as, or larger than a single monitor. Each port "views" an image data sequence loaded into offscreen memory. Each viewport can display one or more images in sequence in a one-on-one or traditionally tiled presentation. Viewports can be assigned to the available monitor "real estate" in any manner that fits. For example, a single sequence computed tomography (CT) study could be displayed across all monitors in a tiled appearance by assigning a single large viewport to the monitors. At the other extreme, a multisequence magnetic resonance (MR) study could be compared with a similar previous study by assigning four viewports to each monitor, single image display per viewport, and assigning four of the sequences of the current study to the left monitor viewports, and four of the earlier study to the right monitor viewports. Ergonomic controls activate scrolling through the off-screen image sequence data. Workstation folder manager hanging protocols could then specify viewports, number of images per viewport, and the automatic assignment of appropriately named sequences of current and previous studies to the viewports on a radiologist-specific basis. Furthermore, software development is simplified by common base objects and methods of the tile and stack modes. Prototype workstation display software and folder manager protocol implementation will be described and demonstrated.

A simple image display application for windows

The purpose of this project was to develop a simple application for displaying low-to-moderate resolution digital images under the Windows operating environment. The display of scintigraphic images was of special interest, and for this reason the program was designed to show sequences of images and to account for broad ranges of pixel values. In order to function under a variety of Windows versions, the program was developed using the 16-bit Microsoft C +2 compiler and targeted for Windows 3.1 enhanced. It was tested with Trionix images for nuclear medicine and Siemens for computed tomography (CT) and magnetic resonance (MR). The resulting application, called SID, successfully read Magnetom, Somatom, Trionix, and Interfile images of dimension 512 or less on Intel-based Windows PCs with 256 color SVGA-compatible (Super Video Graphics Adapters) video hardware. Early applications of the program included remote monitoring of image studies, resident review of teaching cases, review of research images, and preparation of educational materials. This article describes the features, operation, and potential applications of SID.

Processes involved in reading imaging studies: workflow analysis and implications for workstation development

Software development for imaging workstations has lagged behind hardware availability. To guide development and to analyze work flow involved in interpretation of cross-sectional imaging studies, we assessed the cognitive and physical processes. We observed the performance and interpretation of body computed tomography (CT) scans and recorded the events that occurred during this process. We studied work flow using a bottleneck analysis. Twenty-four of a total of 54 cases (44%) involved comparing the images with those of prior scans. Forty-seven of 54 scans (87%) were viewed using windows other than soft tissue, or compared with precontrast scans. In 46 cases (85%), the interpretation stopped to return to a previous level for review. Measurement of lesions was performed in 24 of 54 (44%) cases, and in 15 (63%) of these cases, measurements were taken of lesions on old studies for comparison. Interpretation was interrupted in 14 of 54 cases (26%) by referring clinicians desiring consultation. The work flow analysis showed film folder retrieval by the film room to be the bottleneck for interpretation by film. For picture archiving and communication system (PACS) reading, the CT examination itself proved to be the bottleneck. We conclude that workstations for CT interpretation should facilitate movement within scans, comparison with prior examinations, and measuring lesions on these scans. Workstation design should consider means of optimizing time currently not used between interpretation sessions, minimizing interruptions and providing more automated functions currently requiring physician interaction.

The full-scale PACS archive. A prerequisite for the filmless hospital

PURPOSE

Increasing percentages of digital modalities in radiology, in particular of digital image acquisition in conventional radiography, call for digital reporting, communication, and archiving techniques. These techniques are prerequisites for the "filmless" hospital. The first 2 have been covered extensively in the literature and by vendors. However, as regards online digital image archives there are still no satisfactory concepts available in the medical field. The present paper puts forward some suggestions as to how this situation could be improved.

MATERIAL AND METHODS

Analyses of radiology operations consider the prevailing PACS (picture archiving and communication system) archive concepts that use optical discs to be too small, too slow and too cumbersome to manage and therefore unable to function as comprehensive image archives for filmless hospitals. We suggest borrowing and adapting the well tested archive technologies from space research and the oil and broadcasting industries which have much higher capacities and speeds and better software interfacing possibilities. With such technologies the needs of filmless hospital operations can be met.

RESULTS

A feasible concept for a transition strategy from conventional analog to digital archives is presented. Model calculations of the necessary investments and potential savings, including generous placement of viewing stations in the entire hospital, indicate amortization periods of 3.8-4.8 years.

CONCLUSION

Alternative technologies for digital image archives already today make full-scale PACS for filmless hospitals technologically and conceptually feasible and financially mandatory.

Digital chest radiography--comparing two types of CRT monitors in a ROC experiment with a chest phantom

Two principally different 1000-line CRT (cathode ray tube) monitors connected to a digital image intensifier system for chest radiography were compared in terms of image quality and viewing comfort. Image quality was assessed by means of ROC analysis. Five observers tried to find simulated pathology positioned over the lungs and the mediastinum of an anthropomorphic phantom. The observers also graded the viewing comfort of the two CRTs in terms of flicker, light levels, and general comfort. No significant difference in the detection of simulated pathology was demonstrated between the two monitors. A slight preference for the newer CRT (Imlogix) was seen as compared to the older standard CRT (Siemens) regarding flicker and general comfort.

A multimedia perioperative record keeper for clinical research

OBJECTIVE

To develop a multimedia perioperative recordkeeper that provides: 1. synchronous, real-time acquisition of multimedia data, 2. on-line access to the patient's chart data, and 3. advanced data analysis capabilities through integrated, multimedia database and analysis applications.

DESIGN

To minimize cost and development time, the system design utilized industry standard hardware components and graphical. software development tools. The system was configured to use a Pentium PC complemented with a variety of hardware interfaces to external data sources. These sources included physiologic monitors with data in digital, analog, video, and audio as well as paper-based formats.

DEVELOPMENT

The development process was guided by trials in over 80 clinical cases and by the critiques from numerous users. As a result of this process, a suite of custom software applications were created to meet the design goals. The Perioperative Data Acquisition application manages data collection from a variety of physiological monitors. The Charter application provides for rapid creation of an electronic medical record from the patient's paper-based chart and investigator's notes. The Multimedia Medical Database application provides a relational database for the organization and management of multimedia data. The Triscreen application provides an integrated data analysis environment with simultaneous, full-motion data display.

CONCLUSION

With recent technological advances in PC power, data acquisition hardware, and software development tools, the clinical researcher now has the ability to collect and examine a more complete perioperative record. It is hoped that the description of the MPR and its development process will assist and encourage others to advance these tools for perioperative research.

Clinical evaluation of newly developed CRT viewing station: CT reading and observer's performance

The clinical performance of the new viewing station with six CRT monitors (17-inch, 1,024 x 1,280) was evaluated. In the primary interpretation of CT images, time measurements were carried out for eight radiologists. No significant differences in reading time existed between CRT and film in 3 of 4 readers in head CT series, and in 2 of 6 readers in body CT series. Compared with the previous system, the new prototype system achieved an approximately 30% decrease in reading time in both head and body CT studies and could reduce mental and eye fatigue.

Evaluation of the medical diagnostic imaging support system based on 2 years of clinical experience

The Medical Diagnostic Imaging Support (MDIS) system at Madigan Army Medical Center (MAMC) has been operational in a phased approach since March 1992. Since then, nearly all image acquisition has been digital with progressively increasing primary softcopy diagnosis used. More than 375,000 computed radiography (CR) images as well as other modality images have been archived. Considerable experience in installation and implementation phasing has been gained. The location and ergonomic aspects of equipment placement were refined with time. The original clinical scenario was insufficiently detailed and additions were made to facilitate smoother and more complete transition toward a filmless environment. The MDIS system effectiveness and performance have been good in terms of operational workload throughout, background operations, and reliability. The important areas regarding reliability are image acquisition, output, display, database operations, storage, and the local area network. Fail-safe strategies have been continually improved to maintain continuous clinical image availability during the times when the MDIS system or components malfunction. Many invaluable lessons have been learned for effective quality assurance in a hospital-wide picture archiving and communication system. These issues include training, operational quality control, practical aspects of CR image quality, and increased timeliness in the generation and distribution of radiographic reports. Clinical acceptability has been a continuous process as each phase has been implemented. Clinical physicians quickly used the workstations soon after the start of MDIS at MAMC. The major advantage for clinicians has been the amount of time saved when retrieving multimodality images for review. On the other hand, the radiologists have been slower in their acceptance of the workstation for routine use.(ABSTRACT TRUNCATED AT 250 WORDS)

Default display arrangements of images on PACS monitors

Our hospital is currently installing one of the largest non-military hospital-wide picture archiving and communications systems (PACS) in the world [1, 2]. We are designing default modes for the display of images on PACS workstation monitors so that these can be implemented in future software releases. In this article we present the considerations and reasoning influencing our decisions upon how best to arrange and present the images from the various radiological modalities for ease of soft copy reporting.

Computed tomography interpretations with a low-cost workstation: a timing study

An ergonomically simple prototype workstation with two 900 x 1,100-pixel monitors capable of displaying eight full-resolution computed tomography (CT) images in 0.2 seconds, was compared with film for interpretation of computed tomographic images of the chest and abdomen. The hardware platform for this workstation cost less than $11,500 in 1993. A repeated-measures experiment was used to generate average interpretation times of 6.17 minutes for the workstation and 6.03 minutes for the film, including loading and unloading films, with three of the four subjects averaging about a minute longer for each workstation interpretation. All dictated reports were of clinically acceptable accuracy. All radiologists stated that workstations based on this design would be an acceptable clinical tool. However, observation suggested human working-memory strain among infrequent CT readers that could indicate the need for additional training. These data suggest that low-cost workstations can have practical application in interpretation of digital medical images such as CT, with the possibility of small increases in interpretation time.

Picture archiving and communications systems (PACS)

Although there has been a recent increase in interest in picture archiving and communications systems (PACS) topics, little has been published to assist the non-technical person in understanding the complexities of the technologies required for a PACS implementation. This issue of Current Problems in Radiology defines each PACS component and explains why each is important in a system design. PACS installations at the University of Florida are used as examples to tie the concepts together. The infrastructure required for PACS consists of the information system interfaces, networks, and databases. Information system interfaces guarantee consistent patient data across all platforms and reduce labor requirements by eliminating duplicate data entry. Data networks move information from the originating location to users around the hospital, clinic, campus, city, or world. In the PACS environment, the data consist of patient and study information as well as images and information about these images. Databases organize the data from multiple sources into a coherent package that can be queried for many different purposes, such as retrieving images, reviewing patient and study information, studying practice statistics, and performing outcomes analysis. PACS components consist of acquisition nodes, archives, and output devices. Acquisition nodes may include "digital modalities" such as CT, MRI, nuclear medicine, and computed radiography (CR), along with devices to convert from analog to digital, such as digitizers and frame grabbers. Options for archives are discussed along with configuration schemes. Output devices include both hard copy (film and paper prints) and soft copy (workstations for display and diagnosis). Finally, a description of the PACS installations at the University of Florida is presented, with comments on some of the difficulties and complexities encountered. A discussion of the cost and benefits of PACS is included, along with a forecast of the future of PACS.

How many screens does a CT workstation need?

A considerable number of prototype and commercial workstations have been developed during the last 10 years for electronic display of computed tomographic (CT) images during clinical interpretation. These CT workstations have varied widely in the number and size of monitors available for the display of the medical images ranging from a single 1,024 x 1,204-pixel monitor, to eight 2,500 x 2,000-pixel monitors. Image display times also have varied considerably, ranging from as fast as .11 seconds, to as slow as 26 seconds to fill a single monitor. No consensus has formed in the workstation community with regard to display area and response time requirements. To address this issue, we have constructed a time-motion model of CT interpretation. Model accuracy is experimentally verified with three workstations as well as with the film alternator. In general, CT interpretations with an electronic workstation become faster as display area increases and display time decreases. Results can be used by workstation designers and purchasers to roughly estimate differences in interpretation speeds among contending CT workstation designs.

Costs and benefits of picture archiving and communication systems

A picture archiving and communication system (PACS) is an electronic and ideally filmless information system for acquiring, sorting, transporting, storing, and electronically displaying medical images. PACS have developed rapidly and are in operation in a number of hospitals. Before widespread adoption of PACSs can occur, however, their cost-effectiveness must be proven. This article introduces the basic components of a PACS. The current PACS cost-analysis literature is reviewed. Some authors conclude that the PACS would pay for itself, while others find the PACS much more expensive. Explanations for these differences are explored. Almost all of these studies focus on direct costs and ignore indirect costs and benefits. The literature characterizing the indirect costs of PACS is reviewed. The authors conclude that there is a need for uniform, well-defined criteria for the calculation of the costs and savings of PACSs.

Selective archiving of radiologic images

The increasing number of radiographic images is a problem in most radiology departments. The problem will be emphasized with the introduction of digital acquisition and storage of radiographs. Changes in image management strategies will therefore become necessary. Such strategies will have great technologic and financial impact and will probably determine the applicability and success of digital radiography. Based on the experience that not all radiographs are equally important and on the assumption that not every image in a radiology archive can be maintained on-line, we investigated the effect of storing only selected, clinically informative radiographs; i.e., clinical data compression. In 165 routine examinations (77 barium enemas, 16 barium meals and 72 urographies) 2433 films were used (14.7 films per examination). We archived only the 461 films (19%) which were considered to be of future informative value. During a one-year follow-up period none of the 1972 removed films was requested. This indicates that a considerable number of films and a considerable amount of image data can be removed from the archive without affecting the clinical work.

Overview of some methodological problems in assessment of PACS

The purpose of technology assessment of picture archiving and communications systems (PACS) is to establish the need for the technology, provide a measure of functionality and to establish the costs and benefits associated with the introduction of the system. Given concerns about the clinical acceptability of PACS, it is unlikely that radiologists will change from existing film based systems until a clear demonstration of costs and benefits has been performed. The major need at present is to quantify the benefits which may flow from the introduction of PACS system in a standard manner which can be accepted by all parties involved.

A view from the Nijmegen PACS project

A view on PACS is given from a radiology department involved in PACS as part of its medical research environment. Special attention is payed to historical developments in medical imaging to study the context of actual PACS developments. Some directions of future diagnostic developments are indicated. Both image data-acquisition and presentation techniques are of interest to medical as well as industrial applications. It is pointed out how PACS is thought to depend on contextual factors.

Evaluation of teleradiology for interpretation of intravenous urograms

The diagnostic yield of a commercial teleradiology/picture archiving and communication system (ATT-Philips Comm View T/PACS) was evaluated for 100 urograms. A single image from each examination was digitized (2048 x 1684 x 12-bit pixels) and transmitted from a satellite hospital over a T-1 line using the T/PACS system. The video display of each digitized image was reviewed independently by four radiologists. The same four radiologists reviewed the original film images at a different time without knowledge of their T/PACS interpretation. There was no statistically significant difference in the sensitivity for clinical findings between T/PACS (86%) and film (89%). The false positive rate, however, was significantly higher with T/PACS than with film (44 versus 32 false positive findings per 100 films). We conclude that T/PACS of the type studied here demonstrates sufficient sensitivity for the detection of clinically important urographic findings in the emergency setting. A final reading of the original films is still necessary, however, to assure appropriate specificity.

Hardware and software requirements for a picture archiving and communication system's diagnostic workstations

Electronic systems (picture archiving and communications systems [PACS]) for image and multimedia data distribution, archiving, and transmission, represent the future of radiology. The workstation is the point of contact between a PACS and the radiologist or referring physician. Therefore, the acceptance of PACS is highly dependent on workstation functionality and performance. This paper, based on our experience in evaluating commercial workstations and on a review of recent literature, describes hardware and software requirements for diagnostic workstations that could be used for making primary diagnoses in a radiology department. Requirements for PACS workstations for use in referring clinics are also briefly described. These workstations must be able to handle the large volume of images to be viewed efficiently, add new functionality to improve the productivity of physicians, technologists, and other health care providers, and provide enough flexibility to allow the electronic systems to grow as medical imaging technology evolves.