DIGITAL REVOLUTION IN IMAGING

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DIGITAL REVOLUTION IN IMAGING HIS/RIS/PACS
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DIGITAL REVOLUTION IN IMAGING.HIS/RIS/PACS

• Advances in digital technology, particularly in
  the fields of computing, imaging and
  communication, have progressed to the point that
  it is now possible to acquire medical images in
  digital form, archive them on computers systems,
  and display them in diagnostic quality. The
  display monitor used to present images can be at
  an adjacent or distant location to the original
  point of acquisition .

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DIGITAL REVOLUTION IN IMAGING HIS/RIS/PACS

• In radiology, the report is the king. An
  exquisitely designed facility, friendly and
  knowledgeable Radiographers, state of the art
  modalities, and world-class radiologists mean
  little if a patient's diagnostic report does not
  make it back to the referring physician in a
  timely manner.
• ByJonathan S. Batchelor.

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WHAT IS HOSPITAL INFORMATION SYSTEM. (HIS)

• HIS is a computerized management system for
  handling three categories of tasks in a health
  care environment.
• 1. It supports clinical and medical patient care
  activities in the hospital.
• 2. It administers the hospital's daily business
  transactions.
• 3.It evaluates hospital performances and costs
  etc.
• H.K.Huang et al

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WHAT IS RADIOLOGY INFORMATION SYSTEM. (RIS)

• RIS is a computerized management system designed
  to support both administrative and clinical
  operation of the Radiology department, to reduce
  administrative overheads, and to improve the
  quality of radiological examination service. It
  therefore manages general radiology patient
  information, from scheduling to examination to
  reporting. Its equipment consists of a computer
  system with peripheral devices such as RIS
  workstations, printers and bar code readers etc.
• It maintains many types of patient and
  examination related information. Patient related
  information includes medical, administrative,
  patient demographics and billing information.
  Examination related information includes
  procedural descriptions, and scheduling,
  diagnostic reporting, patient arrival
  documentation, image location, image movement
  and examination room scheduling
• Its major tasks are as follows
• 1.Process patient and film (image) folder
  records.
• 2.Monitor patient status, examinations and
  examination resources.
• 3.Schedules radiological examinations.
• 4.Creates,formats and store diagnostic reports
  with digital signatures.
• 5. Tracks image folders.
• 6. It performs profile and statistical analysis.
• 7.Maintains timely billing information.
• H.K.Huang et al

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WHAT IS PACS

• Picture Archiving and Communication System (PACS)
  comprises data storage devices, image display
  devices, database management software and links
  to image/or image data acquisition devices,
  connected by computer networks.
• The major components of PACS are
• Image and data acquisition gateways There are
  two types of gateways to the PACS server and
  archive, the data base gate way for textual data
  and the image acquisition gateway for imaging
  data.
• A PACS server and archive Their major functions
  are
• Receipt of images via acquisition gateways.
• Extraction of text information via data base gate
  way .
• Update the database management system.
• Determine the destination workstations to which
  newly generated exams are to be forwarded.
• Retrieve necessary old patient images.
• Interface PACS application servers.

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PACS BENEFITS

• Improved image reporting.

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PACS BENEFITS

• Easy access to patient images.

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PACS BENEFITS

• Reduced image storage space.

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PACS BENEFITS

• Eliminated number of lost x-ray films.
• Improved patient turnaround time.
• Reduced number of printed x-ray films.

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PACS BENEFITS

• No Darkroom and photographic chemicals.

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PACS BENEFITS

• Improved image workflow.
• Film Based PACS Based
• Study scheduled. Study scheduled
• Study Scanned. Study Scanned.
• Films printed.
• Films send to Radiologist inbox
• Films hung on light box.
  
• Radiologist Reviews images. Radiologist Reviews
  images
• Radiologist dictates report. Radiologist
  dictates report.
• Report is typed. Report is finalized
• Report is reviewed
• Report is finalized.

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COMMUNICATION ENABLERS IN HIS/RIS/PACS

• Transmission of images and textual information
  between healthcare information systems has
  always been difficult for two reasons. first,
  information systems use different computer
  platforms, and second, images and data are
  generated from various imaging modalities by
  different manufacturers. With the emergent
  healthcare industry standards, Health level 7
  (HL7) and Digital Imaging and Communications in
  Medicine (DICOM), it has become feasible to
  integrate all these heterogeneous, disparate
  medical images and textual data into an organized
  system.
• Interfacing two healthcare components requires
  two ingredients a common data format and a
  communication protocol. HL7 is a standard textual
  data format, whereas DICOM includes data format
  and communication protocols. In conforming to the
  HL7 standard, It is possible to share healthcare
  information between the hospital information
  systems (HIS), the radiology information systems
  (RIS), and PACS. By adapting the DICOM standard,
  medical images generated from a variety of
  modalities and manufacturers can be interfaced as
  an integrated healthcare system.

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THE HEALTH LEVEL 7 (HL7) STANDARD

• Health Level 7 (HL7), established in March 1987,
  was organized by a committee to develop a
  standard
• for electronic data exchange in health care
  environments, particularly for hospital
  applications. In the HL7 standard, the basic data
  unit is a message. Each message is composed of
  multiple segments in a defined sequence. Each
  segment contains multiple data fields and is
  identified by a unique, predefined
  three-character code. The first segment is the
  message header segment with the three-letter code
  MSH, which defines the intent, source,
  destination, and some other relevant information
  such as message control identification and time
  stamp. The other segments are event dependent.
  Within each segment, related information is
  bundled together based on the HL7 protocol. A
  typical message, such as patient admission, may
  contain the following segments
• MSHMessage header segment
• EVNEvent type segment
• PIDPatient identification segment
• NK1Next of kin segment
• PV1Patient visit segment

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THE HEALTH LEVEL 7 (HL7) STANDARD

• When an event occurs, such as patient admission,
  discharge, or transfer (ADT),the HIS would
  initiate an unsolicited message to the RIS that
  takes charge of the next event. If the message is
  in HL7 format, the RIS parses the message,
  updates its local database automatically, and
  sends a confirmation to the HIS Otherwise, a
  "rejected" message would be sent instead.

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THE HEALTH LEVEL 7 (HL7) MESSAGE EXAMPLE

• (1) Message header segment
• MSH STOREHOLLYWOODMIMEVERMONT2003051810071se
  curity
• ADTJMSG00201 ltCRgt
• (2) Event type segment
• EVN 101 12003051810051 ltCRgt
• (3) Patient identification segment
• PID PATID12345671 DoeAJohnABAII 19470701
  M C
• 272 INDUSTRIAL STANDARDS (HL7 AND DICOM) AND IHE
• 3976 Sunset BlvdALos Angeles ACAA90027
  323-681-2888ltCRgt
• (4) Next of kin segment
• NK1 !DoeALindaAEwifeltCRgt
• (5) Patient visit segment
• PV1 11 111100A345A0100135ASMITHAWILLIAMAKSU
  RADM
• ltCRgt

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THE HEALTH LEVEL 7 (HL7) MESSAGE EXAMPLE

• Combining these five segments, these messages
  translate to"Patient John B. Doe,II, male,
  Caucasian, born on July 1, 1947, lives in Los
  Angeles, was admitted on May l8, 2003 at 1005
  a.m. by Doctor William K. Smith (00135) for
  surgery. The patient has been assigned to Room
  345, bed 01 on nursing unit l00.The next of kin
  is Linda E. Doe, wife. The ADT (admission,
  discharge, and transfer) message 201 was sent
  from system STORE at the Hollywood site to system
  MIME at the Vermont site on the same date two
  minutes after the admit."

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DICOM STANDARD

• ACR-NEMA, formally known as the American College
  of Radiology and the National Electrical
  Manufacturers Association, created a committee to
  develop a set of standards to serve as the common
  ground for various medical imaging equipment
  vendors. The goal was that newly developed
  instruments be able to communicate and
  participate in sharing medical image information,
  in particular, within the PACS environment. The
  committee, which focused chiefly on issues
  concerning information exchange,
  interconnectivity, and communications among
  medical systems, began work in 1982.
• The first version, which emerged in
  1985,specified standards in point-to-point
  message transmission, data formatting, and
  presentation and included a preliminary set of
  communication commands and a data format
  dictionary. The second version, ACR-NEMA 2.0,
  published in 1988,was an enhancement to the first
  release. It included both hardware definitions
  and software protocols, as well as a standard
  data dictionary. Networking issues were not
  addressed adequately in either version. For this
  reason a new version aiming to include network
  protocols was released in 1992. Because of the
  magnitude of changes and additions, it was given
  a new name Digital Imaging and Communications in
  Medicine (DICOM 3.0). In 1996 a new version was
  released consisting of 13 published parts that
  form the basis of future DICOM new versions and
  parts.

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DICOM STANDARD

• Manufacturers readily adopted this version to
  their imaging products. Each DICOM document is
  identified by title and standard number in the
  form PS 3.X-YYYY where "X" is the part number
  and "YYYY" is the year of publication. Thus PS
  3.1-1996 means DICOM 3.0 document part 1
  (Introduction and Overview)released in 1996.
  Although the complexity and involvement of the
  standards were increased by many fold, DICOM
  remains compatible with the previous ACR-NEMA
  versions. The two most distinguished new features
  in DICOM are adaptation of the object-oriented
  data model for message exchange and utilization
  of existing standard network communication
  protocols.

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DICOM DOCUMENT

• The current DICOM standard PS 3.1-2008 includes
  18 related but independent parts following the
  ISO (International Standardization Organization)
  directives andare referred to as
• Part 1 Introduction and Overview
• Part 2 Conformance
• Part 3 Information Object Definitions
• Part 4 Service Class Specifications
• Part 5 Data Structures and Encoding
• Part 6 Data Dictionary
• Part 7 Message Exchange
• Part 8 Network-Communication Support for Message
  Exchange
• Part 9 Point-to-Point Communication Support for
  Message Exchange (Retired)
• Part 10 Media Storage and File Format for Media
  Interchange
• Part 11 Media Storage Application Profiles
• Part 12 Media Formats and Physical
  Media-for-Media Interchange
• Part 13 Print Management Point-to-Point
  Communication Support (Retired)
• Part 14 Gray Scale Standard Display Function
• Part 15 Security and System Management Profiles
• Part 16 Content Mapping Resource
• Part 17 Explanatory Information Part 18 Web
  Access to DICOM Persistent Objects (WADO)

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INTERGRATING HEALTHCARE ENTERPRISE (IHE)

• IHE is not a standard nor a certifying authority
  instead it is a high-level information model for
  driving adoption of HL7 and DICOM standards. IHE
  is a joint initiative of RSNA '(Radiological
  Society of North America) and HIMSS (Healthcare
  Information and Management Systems Society)
  started in 1998. The mission was to define and
  stimulate manufacturers to use DICOM and
  HL-7-compliant equipment and information systems
  to facilitate daily clinical operation.
• The first large-scale demonstration was held at
  the RSNA annual meeting in 1999, and thereafter
  at RSNA in 2000 and 2001, at HIMSS in 2001and
  2002, and annually since at RSNA. In these
  demonstrations manufacturers came together to
  show how their products could be integrated
  together according to IHE protocols. It is the
  belief of RSNA and HIMSS that with successful
  adoption of IHE, life would become more pleasant
  in healthcare systems integration for both the
  users and the providers.
• The IHE(Connectethon) developed technical
  framework which defines a common information
  model and vocabulary for using DICOM and HL7 to
  complete a set of well-defined radiological and
  clinical transactions for a certain task.

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INTERGRATING HEALTHCARE ENTERPRISE (IHE)

• There are three key concepts in the IHE technical
  framework data model, actors, and integration
  profiles.
• Data Model
• The data model is adapted from HL-7 and DICOM and
  shows the relationships between the key frames of
  reference, for example, patient, visit, order,
  and study defined in the framework.
• IHE Actor
• An actor is one that exchanges messages with
  other actors to achieve specific tasks or
  transactions. An actor, not necessarily a person,
  is defined at the enterprise level in generic,
  product-neutral terms.
• Integration Profile An integration profile is the
  organization of functions segmented into discrete
  units. It includes actors and transactions
  required to address a particular clinical task or
  need. An example is the scheduled workflow
  profiles, which incorporate all the process steps
  in a typical scheduled patient encounter from
  registration, ordering, image acquisition, and
  examination to viewing.
• IHE integration profiles provide a common
  language, vocabulary, and platform for healthcare
  providers and manufacturers to discuss
  integration needs and the integration
  capabilities of products. IHE integration
  profiles started first in the domain of
  radiology. During the 2003 implementation there
  were 12 radiology integration profiles.

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ARE YOU STILL AWAKE
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SECURITY ISSUES
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WITHOUT MAKE-UP

• PATIENTS ALLOW HEALTHCARE STAFF TO COLLATE
  PERSONAL INFORMATION RELATED TO THEIR TREATMENT,
  BUT THEY DO SO IN CONFIDENCE WITH THE EXPECTATION
  THAT SUCH INFORMATION IS KEPT CONFIDENT AND THEIR
  PRIVACY IS RESPECTED

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SECURITY ISSUES

• Computer security experts agree that the weakest
  link in the security chain is the system's users.
  
• Confidentiality of Patient Data.Confidentiality
  is breached when information provided in
  confidence by one person to another is disclosed
  to a third party without the consent of the
  provider of the information
• .Data Integrity.
• Develop clearly written security policies.

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SECURITY ISSUES

• Having passwords assigned to users will almost
  guarantee unauthorized access to patient
  information.
• Passwords should also be changed on a quarterly
  basis and should be non-generic.
• Passwords should not be lying around at the
  workstation or on sticky notes.
• An automatic log off functionality after an
  elapsed time frame.

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HIS/RIS/PACS DEPLOYMENT

• Develop a PACS team.
• Team members
• Representatives of referring medical disciplines
  in the hospital e.g. Orthopedics
• Representatives from IT department.
• Medical Physicists.
• Radiologist.
• Project manager.
• Financial management rep.
• Radiographer/s.
• Terms of reference of the team.
• Analysis of workflows.
• Financial acquisition models.
• Analysis of the work volumes and equipment.
• Develop Quality assurance protocols .
• Prepare a PACS Plan.
• Develop a business case.
• Develop and evaluate requests for proposal.

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CONCLUSION

• Our deepest fear is not that we are inadequate.
  Our deepest fear is that we are powerful beyond
  measure. It is our light, not our darkness that
  frightens us. We ask ourselves, who am I to be
  brilliant, gorgeous, talented and fabulous?
  Actually, who are you not to be?
• Marianne Williamson.

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REFERENCES

• Auntminnie.com.
• Anthology of PACS. Michael.J.Canavo.
• Integrating the Healthcare Enterprise (IHE)
  Radiology user's handbook.
• IHE technical framework Volumes 1 and 2.
• Beginners guide to VPN on PACS.
  www.pasa.nhs.uk/cep
• Beginners guide to PACS. www.pasa.nhs.uk/cep
• A guide to the Digital revolution. Second
  Edition. Keith.J..Dreyer.
• PACS and Imaging informatics Basic principles and
  Applications. H.K.Huang.
• Buyers guide to PACS workstations.
  www.pasa.nhs.uk/cep

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THANK YOU