Elizabeth A. Krupinski, PhD

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• Elizabeth A. Krupinski, PhD
• Arizona Telemedicine Program

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Ovitt, et al.Intravenous angiography using
digital video subtraction x-ray imaging
system.AJR 135(6)1141-4, 1980. An x-ray
imaging system, using digital subtraction
techniques, has been developed. The system
requires (1) high output generation equipment
(2) an image intensifier capable of receiving
high output exposures, 1 mR (2.58 X 10(-7) C/kg)
at the face of the intensifier, without loss of
either contrast or resolution (3) a precision
digital video camera (4) processing computer
with sufficient storage capacity and (5) digital
image storage. With this system it is possible to
visualize the major arteries after intravenous
contrast injection.
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• Capp et al.
• The digital radiology department of the future.
• Rad Clin N Am 23(2)349-55, 1985.
• The boom in microelectronics, including
  cost-effectiveness, has
• now allowed us to consider the use of these
  objects to store
• digital images. There remains much research,
  development,
• And clinical evaluation to be done in receptor
  technology.
• Further improvements in image processing, optical
  laser disk
• storage, optical transmission and further
  commercial
• Development of display technology must take
  place. All of
• These developments are occurring simultaneously.
  Within 5 to
• 10 years, radiology departments will most likely
  be totally
• electronic, probably cost-effective, and, it is
  hoped, more
• diagnostically accurate.

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• Oldest established TM application
• Well integrated in numerous settings
• Facilitated by co-evolution PACS
• Few to no reimbursement issues
• Only interventional radiology currently less
  amenable to teleradiology applications
• Little/no differences between teleradiology
  on-site radiology

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• ACR-NEMA development DICOM
• Continual updates of DICOM
• Development of standards practice guidelines
  that explicitly include teleradiology
• http//medical.nema.org/
• http//deckard.duhs.duke.edu/samei/tg18.htm

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Standards Guidelines
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Standards Guidelines
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Standards Guidelines
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• Key is the human-computer interface
• Series of observer performance studies designed
  to optimize the digital reading room environment
• Performance metrics
• Diagnostic accuracy (ROC)
• Search efficiency (eye position)
• Human Visual System Modeling

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• Softcopy display parameters
• Luminance
• Calibration (tone scale)
• Type of phosphor
• CRT vs LCD
• MTF
• Viewing angle
• Number of displays
• Ambient lighting
• Compression
• Role of color

P45
P104
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Spatial contrast resolution limitations require
radiologists to search images. The UVF is about
2.5 deg radius. Probability of target detection
falls off as a function of target eccentricity
from axis of gaze.
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• Total viewing time shorter
• Time to first hit shorter
• Total time on lesion shorter
• Fewer returns to lesion
• Total path length shorter
• Overall more EFFICIENT

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Task
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Experience
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Med Student Resident Pathologist
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Display Interface
20 fixations fell outside diagnostic image
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• Hospital/MC
• Clinics
• Mobile van
• Mammo
• Dedicated
• PET clinic
• THH
• UASA
• Public Health
• Battlefield
• Hand-held

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• Medical Imaging Consultants -gt ?
• Data acquisition archiving
• RadWorks (GE) -gt Siemens/Fuji
• Viewing station
• 35 of departments reading volume
• 25 departments income
• Reading only reading archiving
• /case /set volume

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• 68 sites using AHSC hub for TM services use TR
  service
• TR typically 1st service requested
• 79 of sites with TR use only TR
• 21 started with TR added services
• TR specialty with most volume

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• Time from mammography to consult with oncologist
  28 days
• Screening mammography
• Diagnostic mammography
• Biopsy
• Pathology processing report
• Oncology consultation
• THIS IS TOO LONG!

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Even Worse in Rural
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• DS3 (45 Mbps) backbone
• ATM protocol
• T1 (1.5 Mbps) links
• 65 direct link sites
• 85 with affiliated
• NARBHA
• DOC
• IHS
• RT SF applications
• 55 sub-specialties
• Teleradiology core app.

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• Started in 2001 to rural sites
• 7/28 telerad sites send mammo
• Mostly use GE system
• Directly to TBC for reading
• Some archive some do not
• Contracts specify 30-45 min TAT
• gt 26,000 telemammography

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UltraClinic Model
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Quick Processing
Milestone Medical Systems RHS-1-30 Vacuum
Histoprocessor
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Telepathology
DMetrixTM -40 Slide Scanner System
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Lab Process Minutes
Grossing 3
Tissue Processing 58
Embedding 13
Cutting 10
Stain/Dry/Coverslip 32
Scanning (2 Slides) 13
LM Interpretation 6
Telepathology 14
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• Telepathology report sent SF to oncologist
• Oncologist connects RT videoconference to rural
  location
• Discuss pathology results
• If necessary discuss treatment options and plan
  of action

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The Future of TR PACS

• MI prevention, detection, diagnosis, treatment
  therapy
• Acquisition display technology continually
  changes
• Clinician shortages are not easing
• Rapidly expanding types number images
• Multi-modality fusion complimentary information
  sources is becoming common
• Anatomy function gross molecular levels
• Merging specialties

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(Quon et al. J Clin Oncol 2005 231664-1673)
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Clarke et al. Validation if Tumor Burden
Measurements Using 3D Histopathology. In
Digital Mammography 2008. Springer-Verlag.
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The Future of TR PACS

• Image Display, Analysis Processing are key
  links in the imaging chain
• Need to present data to the clinician in the most
  efficient informative manner
• Taking into account perceptual cognitive
  capabilities of human observer
• Ultimate goal facilitate decision-making
  process enhance patient care
• Related goal improve workflow the reading
  environment

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• Stereo vs Traditional
• Az 0.85 to 0.94
• 23 increase TPs
• 105 increase calcs
• 46 decrease FPs

Getty et al. Stereoscopic Digital Mammography
Improved Accuracy of Lesion Detection in Breast
Cancer Screening. In Digital Mammography 2008.
Springer-Verlag.
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• 50 DR chest images (PA) 1/2 solitary pulmonary
  nodule verified CT 1/2 nodule free
• 6 radiologists (3 sr residents, 3
  board-certified)
• 3MP Barco color medical-grade display (Barco
  Coronis MDCC-3120-DL) vs COTS color 2MP monitor
  (Dell 2405)
• Calibrated (DICOM GSDF ) to luminance
  corresponding to backlight aging 1-year time
• Max Barco 500 cd/m2 min 0.77 cd/m2
• Max Dell COTS 342 cd/m2 min 0.376 cd/m2

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Color vs Color
F 4.1496, p 0.0471 Sensitivity 0.91 vs
0.86 Specificity 0.93 vs 0.92
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Color vs Color
F 3.38, p 0.067
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Color vs Color
No significant differences
TN significantly different
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• Carpal tunnel syndrome
• Elbow shoulder (cubital tunnel)
• Neck, back shoulder strains
• Computer vision syndrome
• Eye strain
• Dry eyes
• Glaucoma
• Headaches
• Corneal erosion and abrasions
• Contact lens problems

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Reader Fatigue
BLURRED VISION
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Variable How long correlation How many correlation
Blurred vision R 0.344 p 0.0113 R 0.422 p 0.0015
Eyestrain R 0.429 p 0.0012 R 0.475 p 0.0003
Difficulty focus R 0.384 p 0.0042 R 0.446 p 0.0007
Headache R 0.235 p 0.0899 R 0.432 p 0.0011
Neck strain R 0.384 p 0.0042 R 0.549 p lt 0.0001
Shoulder strain R 0.250 p 0.0711 R 0.469 p 0.0003
Back strain R 0.304 p 0.0265 R 0.424 p 0.0014
General fatigue R 0.471 p 0.0003 R 0.642 p lt 0.0001
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• TR has made a significant impact on patient care
  over the past 20 years
• Advances in technology will further change MI
  interpretation of medical data by more clinicians
• Costs can increase decrease
• Optimizing observer accuracy while maintaining
  efficiency comfort are critical to continued
  success

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THANK YOU!