Digital Image Management: the Basics

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1 Digital Image Management: the Basics Napapong Pongnapang, Ph.D. Department of Radiological Technology Faculty of Medical Technology Mahidol University

2 Outline From screen/film to digital radiography PACS/Tele radiology Setting up digital department Digital Imaging

3 Why do we go for Digital? Limitations of film-screen characteristics Limitation of physical storage space in hospital Need for electronic type imaging (PACS) Workflow convenience Image Quality Dose efficiency

4 PACS/Tele Radiology Picture Archiving and Communication System (PACS) A PACS system displays, archives and communicates medical digital images Tele Radiology The transmission of radiological patient images, such x-rays, CTs and MRIs from one location to another for the purpose of interpretation and/or consultation

5 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 information when necessary

6 PACS Simple Look CTs DICOM CRs MRs DICOM Study Server DICOM Work Station Diagnostic Station

7 Importance of PACS Improve flow patient management, timing report from radiologists and work flow Enable the image comparison between pre and post treatment Solving problems of film lost, misplace and storage space Improve image and patient related data storage and accessibility

8 PACS: Small or Large Web Server Distribution

9 Scale of PACS Hospital Size (No. of beds)/ Exams per year Radiology Department ( No. of Modalities) No. of Switches Considerations: System connectivity, expandability, reliability and cost-effectiveness

10 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 Profiles.. Types of images

11 PACS Consists of different components Radiologist reading stations Clinician review stations Web access Technologist/Radiographe r quality control stations Administrative stations Archive systems Multiple interfaces to other hospital and radiology systems 11

12 Properties of good PACS Highly availability: Fault Tolerant Enough bandwidth for sending/receiving data: Networking Flexibility: Process Connectivity with HIS : Application DICOM compatibility: Application Scalability: Storage Network-wide connection: Intranet/Application

13 PACS connection with HIS/RIS HIS RIS Study Server RIS/PACS interface Work Station Work Station Work Station CTs CRs MRs

14 PACS connection with HIS/RIS HIS: Hospital Information System with all patient data RIS: Radiology Information System connects with HIS for example; name, HN RIS: Saves additional information that is not available in HIS for example, image/exam diagnostic results PACS can connect and use data from HIS/RIS

15 PACS Central Architecture DICOM Modality Diagnostic Workstations (DICOM) Non-DICOM Modality Gateway or Frame Grabber Image Server (RAID) Clinical Workstations (DICOM) Diagnostic Workstation Film Digitizer Web Server Computed Radiography or DR CR/ DR QA Workstation Data Base Server Archive RIS

16 PACS Distributed Architecture DICOM Modality Non-DICOM Modality Gateway or Frame Grabber Diagnostic Workstations (DICOM) Clinical Workstations (DICOM) Web Server CR QA Workstation Film Digitizer Data Base Server Diagnostic Workstation Computed Radiography Archive RIS

17 Storage Device (Long Term) HIS/RIS Interface (Broker) Database Server RAID MOD DLT DG RIS W/S PCs CR QA Film Digitizer Frame Grabber C T M R R& F NM CR XRAY US

18 Display HIS/RIS Interface (Broker) SAN/NAS Database Server RAID MOD DLT Diagnostic W/S Dedicate W/S DG RIS W/S PCs CR QA Film Digitizer Frame Grabber C T M R R& F NM CR XRAY US

19 PACS Workstation PACS Server: Standard Server Class machine (run 24/7/365) One or two Intel Xeon processors with Intel Extended Memory 64 technology Up to 16 GB of ECC DDR-2 memory One PCI Express x4 slot, three 64-bit PCI-X slots, and two legacy PCI slots Up to 4 internal SATA or 5 SCSI hard drives PCI Express graphics (x16) Integrated dual-channel SATA/150 controller with RAID and dual channel Ultra320 SCSI controller PACS Workstation: an example of Intel Core 2 Duo class machine General Use PCs: separation from general use and clinical use Concept of Machine Separations Security Performance Cost

20 Diagnostic Medical Monitor LCD must support 3-5 MP at Native Resolution Backlight stabilization QC/QA of display uniformity

21 Video Card Must: Provide the high level of image quality and performance required for diagnostic excellence Support 10-bit capabilities, and supports a variety of up to 5 MP grayscale displays, making them the ultimate solution for precise and accurate display representation Example: Matrox MED series $1000

22 Benefit of PACS: Source:

23 Benefit of PACS: Workflow Source: Philips

24 Benefit of PACS: Real-time clinical consultation Radiology PACS Clinician

25 How to get start? Set up project management team Project planning and execution Training

26 A step further digital modality Digital ready modalities CT MRI Ultrasound NM Modalities that may need to be replaced Plain film

27 Digital Radiography

28 From screen/film to DR Images from analog to digital Image viewing, transferring and archiving Digital image processing Factors affecting techniques: Dynamic range Detector energy response Detector efficiency

29 DR: Acquisition Technology Photostimulable Phosphors ( CR or PSP ) Photostimulable phosphor plates Flat-panel Detectors Direct DR (DDR): Amorphous Selenium Detector matrix of transistors, without photon conversion layer Indirect DR (IDR): Amorphous Silicon TFT or CCD with CsI conversion layer

30 Interesting Points Screen-film characteristics are different from digital radiography Among types of digital radiography, they are different Technical settings by Technologist are different for conventional vs. digital imaging QC procedures/film Reporting for each type of these modalities are different

31 Transforming to Digital : Workflow changes

32 Workflow: DR vs. Conventional CONVENTIONAL X-RAY IMAGING SYSTEM X-RAY TUBE CASSETTE SCREEN X-RAY FILM PROCESER X-RAY IMAGE

33 Workflow: DR vs. Conventional DIGITAL X-RAY IMAGING SYSTEM

34 DR IMAGE PROCESSING FLOW DIAGRAM ID Station Imagespecific parameters Image Readout Raw image Image Enhancement Processed image Image Output Reduced image Analysis Imagederived parameters

35 Workflow: Computed Radiography (CR) Plate Reader ADC / EDR PACS Soft-Copy Read Hard Copy QCW Network

36 Workflow: Flat Panel System Technique Image Processing (QC) & Acquisition PACS Image Display Hard Copy QCW WLM (RIS)

37 What about dose?

38 It has been proved that DR reduces dose Bacher K., et, al.2003;181(4): Dose reduction in patients undergoing chest imaging: digital amorphous silicon flat-panel detector radiography versus conventional film-screen radiography and phosphor-based computed radiography. RESULTS: The amorphous silicon flat-panel detector radiography system allowed an important and significant reduction in both entrance skin dose and effective dose compared with the film- screen radiography (x 2.7 decrease) or computed radiography (x 1.7 decrease) system. In addition, image quality produced by the amorphous silicon flat-panel detector radiography system was significantly better than the image quality produced by the film-screen or computed radiography systems, confirming that the dose reduction was not detrimental to image quality. Bacher K., et, al.2006;187(3):630-7.image quality and radiation dose on digital chest imaging: comparison of amorphous silicon and amorphous selenium flat-panel systems RESULTS: The amorphous silicon flat-panel system allowed an important and significant reduction in effective dose in comparison with the amorphous selenium flat-panel system (p < ) for both the posteroanterior and lateral views. In addition, clinical image quality analysis showed that the dose reduction was not detrimental to image quality.

39 It has been proved that DR reduces dose Hamer OW., et, al Nov;237(2): Chest radiography with a flat-panel detector: image quality with dose reduction after copper filtration. RESULTS: Subjectively equivalent chest radiographic image quality was found with estimated 30% reduction after addition of 0.3-mm copper filtration with flat-panel cesium iodideamorphous silicon technology. dose BJR (2007), RESULTS: Preliminary findings suggested that possible 50% dose reduction can be achieved.

40 Why dose reduction? Reduce dose = reduce stochastic risks Dose optimization Pediatrics patients

41 PACS and patient dose monitoring Regulatory requirements Accreditation requirements Liability and Public Relations Research Quality Assurance Awareness & Patient Safety Individual Patient cumulative dose record

42 Dedicated dose tracking software Integrate dose metrics from imaging systems or PACS typical formats: DICOM RDSR preferred Integrate with PACS, RIS, EMR Analysis capabilities Selection of Reference Doses Automated notification

43 Conclusions Digital radiography is different from conventional screen/film system in dynamic range, detector response and the form of images. Transition from analoqe to digital imaging will result in work flow changes DR technologies include direct and indirect systems for x- ray detection, and the indirect systems include PSP and flat-panel detectors PACS helps manage image archiving and distribution

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