Medical Image Distribution, Networks, and Communications

3. Medical Image Data Transfers

Medical image sharing is the electronic exchange of medical images between hospitals,
physicians and patients. Rather than using traditional media, such as a CD or DVD, and either shipping it
out or having patients carry it with them, technology now allows for the sharing of these images using
the cloud.

The primary format for images is DICOM (Digital Imaging and Communications in Medicine).
Typically, non-image data such as reports may be attached in standard formats like PDF (Portable
Document Format) during the sending process.

A typical architecture involved in setup is a locally installed server, which sits behind the firewall,
allowing secure transmissions with outside facilities. In 2009, the Radiological Society of North America
launched the "Image Share" project, with the goal of giving patients control of their imaging histories
(reports and images) by allowing them to manage these records as they would online banking or
shopping.

Purview: Medical Image Management, Sharing, and Transferring.=

https://www.youtube.com/watch?v=DvHf25NV-0M

USES

✓ Care Facilities: Institutions use medical image sharing to facilitate transfers between other facilities
that may or may not be on the same network. They are also able to instantly send results to
referring physicians in the community, as well as directly to patients.

✓ Physicians: Doctors use the technology to have immediate access to images, as opposed to waiting
for physical media to arrive. Having access to a patient's medical history improves the point of care
service.

✓ Patients: In conjunction with recent US government initiatives, patients are able to receive their
imaging exams electronically, without needing to carry and store physical media. It allows for the
ability to see physicians in multiple locations and have their imaging at the ready.

BENEFITS

 Improved access to patients’ medical imaging histories

 Ability to view images instantly

 Real-time collaboration by specialists

 Avoiding duplicate care reduces costs

 Decreased radiation exposure for patients

 Expertise and specialized opinion is remotely accessible to patients

HEALTH

Medical Image Sharing contributes to many of the "Health" initiatives across the industry. Being
able to instantly and electronically exchange medical information can improve communication between
physicians, as well as with patients.

➢ Meaningful Use: The goal of meaningful use is to promote the spread of electronic health records
to improve health care in the United States, which is to be rolled out in 3 stages through 2015.
Some benefits of the initiative include better access to medical information and patient
empowerment. Medical image sharing helps achieve meaningful use by improving access to
medical images to patients and physicians.

➢ Telehealth: The practice of delivering healthcare services utilizing telecommunication technologies

is known as Telehealth. A major goal is to support long-distance health care for patients who are
unable to easily travel to the point of care. Patients and professionals are also able to obtain further
knowledge on health topics. As a part of the U.S. Department of Health and Human Services, the
Office for the Advancement of Telehealth (OAT) promotes the use of telehealth technologies.
Sharing medical images over long distances can happen instantaneously with these technologies,
allowing a physician to review a patient's images during the conference.

➢ Patient Engagement: Recent changes in the healthcare industry have placed more emphasis on
empowering patients to control and have access to more of their medical information. The use of
tools such as Electronic health records will help patients take a more active role in their health.
With medical image sharing, patients can receive their medical imaging electronically, and then be
able to share that information with the next physician they are seeing.

➢ Cloud Computing: Using software that is delivered as a service over the internet is referred to as
Cloud computing. Typically, medical image sharing will be rolled out as a service for hospitals,
clinicians and patients.

➢ Mobile: The use of mobile electronic devices has been rising across many industries, with
healthcare included. As a physician, having access to medical images on the go is an important
development in the field.

ARCHITECTURE

A typical architecture for a medical image sharing platform includes transmitting data from a
system installed directly on the hospital network and behind the firewall, to and from an outside entity.
Some of the standard architectural pieces involved include:

✓ Data transmission is the physical transfer of data through a communication channel, such as wires,
wireless technologies or physical media. The most common use case for image sharing would be
transmitting the image files using the cloud, allowing for instant access and exchange with anyone,
anywhere. A Virtual private network (VPN) can be set up to enable exchange, but this is typically
requires more to maintain for the facilities involved.
✓ Data compression is used to help facilitate the exchange of large files by encoding using smaller bits
than the original version. This process helps reduce the resources being used and improves the
transmission capabilities.

✓ Security: One widely utilized security tool is TSL/SSL, or Transport Layer Security. The Transport
Layer Security (TLS)/Secure Sockets Layer (SSLv3) is used to secure electronic communications.
TLS/SSLv3 helps to secure transmitted data using encryption. TLS/SSLv3 authenticates clients to
prove the identities of parties engaged in secure communication, as well as authenticates servers.
The TLS/SSLv3 security protocol can protect against data disclosure, masquerade attacks, bucket
brigade attacks, rollback attacks, and replay attacks.

✓ Data Centers: A Data center is used to house computer systems and associated pieces. The main
use of these facilities in medical image sharing is to provide backup. The infrastructure commonly
includes redundant power, redundant generators, redundant Internet connections, redundant
firewalls, redundant network switches, and redundant storage. This is a vital piece to ensure that
medical images are safe and secure in the cloud.

INTEGRATIONS

Image sharing platforms can integrate directly with many hospital systems, such as:

➢ Active Directory - Link to a hospital Active Directory for seamless use by staffed physicians.

➢ Picture archiving and communication system (PACS) - A medical imaging technology that provides
economical storage of, and convenient access to, images from multiple modalities within a facility.

➢ Electronic medical record (EMR) - A computerized medical record created in an organization that
delivers care, such as a hospital or physician's office.

➢ Vendor Neutral Archive (VNA) - A medical imaging technology in which images and documents
(and potentially any file of clinical relevance) are stored (archived) in a standard format with a
standard interface, such that they can be accessed in a vendor-neutral manner by other systems.

➢ Decision support system - A computer-based information system that supports business or

organizational decision-making activities.

➢ Health information exchange (HIE) - The mobilization of healthcare information electronically

across organizations within a region, community or hospital system.

➢ Personal health record (PHR) - A health record where health data and information related to the
care of a patient is maintained by the patient.

STANDARDS

✓ DICOM - A standard for handling, storing, printing, and transmitting information in medical imaging.
✓ Cross Enterprise Document Sharing (XDS) - Focused on providing a standards-based specification
for managing the sharing of documents between any healthcare enterprise, ranging from a private
physician office to a clinic to an acute care in-patient facility and personal health record systems.

✓ Cross-enterprise Document Sharing for Imaging (XDS-I) - Extends XDS to share images, diagnostic
reports and related information across a group of care sites.

✓ HL7

PRIVACY

Health Insurance Portability and Accountability Act (HIPAA) - Enacted by the United States Congress
and signed by President Bill Clinton in 1996. Title II of HIPAA, known as the Administrative Simplification
(AS) provisions, requires the establishment of national standards for electronic health care transactions
and national identifiers for providers, health insurance plans, and employers.

GOVERNMENT INITIATIVES

⚫ HITECH Act: The Health Information Technology for Economic and Clinical Health (HITECH) Act was
instituted on February 17, 2009, in hopes of raising the overall meaningful use of health IT. It was
created as a part of the American Recovery and Reinvestment Act of 2009. It also addressed
security and privacy issues related to electronic exchange of medical information.

⚫ Blue Button: A patient is provided with a highly visible, clickable button to download his or her
medical records in digital form from a secure website offered by their doctors, insurers, pharmacies
or other health-related service. People can log into this secure website to view and have the option
to download their health information, so they can examine it, check it, and share it with their
doctors and others as they see fit. The Blue Button download capability is a tool that can help
individuals get access to their information so they can more effectively participate in and manage
their health and health care. It is mainly being used by the Department of Veteran Affairs in the
United States.

RSNA Image Share Project

RSNA Image Share is a network created to enable radiologists to share medical images with patients
using personal health record (PHR) accounts. This pilot project, funded by the National Institute for
Biomedical Imaging and Bioengineering (Nibib) and administered by RSNA, began enrolling patients in
2011.

Currently, there are five participating medical centers in the program - Mount Sinai Hospital, New York,
UCSF Medical Center, University of Maryland Medical Center, University of Chicago Medical Center, and
Mayo Clinic. Patients at these sites are able to receive and access their medical images electronically. As
of January 2017, there were seven software companies who have completed the RSNA Image Share
Validation, Agfa Healthcare, Ambra Health (formerly DICOM Grid), GE Healthcare, Lexmark Healthcare,
LifeImage, Inc., Mach7 Technologies and Novarad.

There are three main architectural pieces to the project:

✓ A clearinghouse in the cloud

✓ An Edge Server at each local radiology site

✓ A PHR to receive the images and reports

Electronic Medical Image Transfer = https://www.youtube.com/watch?v=_8sI7IP6878

4. Internet Services

Internet Services allows us to access huge amount of information such as text, graphics, sound and
software over the internet. Following diagram shows the four different categories of Internet Services.

Communication Services

There are various Communication Services available that offer exchange of information with individuals
or groups. The following table gives a brief introduction to these services:

S.N. Service Description

1 Electronic Mail
2 Telnet
3 Newsgroup
4 Internet Relay Chat (IRC)
5 Mailing Lists
6 Internet Telephony (VoIP)
7 Instant Messaging
Used to send electronic message over the internet.
Used to log on to a remote computer that is attached to internet.
Offers a forum for people to discuss topics of common interests.
Allows the people from all over the world to communicate in real time.
Used to organize group of internet users to share common information
through e-mail.
Allows the internet users to talk across internet to any PC equipped to
receive the call.
Offers real time chat between individuals and group of people. Eg.
Yahoo messenger, MSN messenger.
Information Retrieval Services

There exist several Information retrieval services offering easy access to information present on the
internet. The following table gives a brief introduction to these services:

S.N. Service Description

1 File Transfer Protocol (FTP)
2 Archie
3 Gopher
4 Very Easy Rodent Oriented Netwide Index
to Computer Achieved (VERONICA)
Enable the users to transfer files.
It’s updated database of public FTP sites and their
content. It helps to search a file by its name.
Used to search, retrieve, and display documents on
remote sites.
VERONICA is gopher based resource. It allows access
to the information resource stored on gopher’s
servers.

Web Services

Web services allow exchange of information between applications on the web. Using web services,
applications can easily interact with each other.

The web services are offered using concept of Utility Computing.

World Wide Web (WWW)

WWW is also known as W3. It offers a way to access documents spread over the several servers over the
internet. These documents may contain texts, graphics, audio, video, hyperlinks. The hyperlinks allow
the users to navigate between the documents.

Video Conferencing

Video conferencing or Video teleconferencing is a method of communicating by two-way video and

audio transmission with help of telecommunication technologies.

Modes of Video Conferencing

Point-to-Point

This mode of conferencing connects two locations only.

Multi-point

This mode of conferencing connects more than two locations through Multi-point Control Unit (MCU).

Internet Services = https://www.youtube.com/watch?v=JHXesz-7Hq4

Internet Services = https://www.youtube.com/watch?v=xAhSPQsw34s

Internet services | basic | Web Technology | Lec-2 | Bhanu Priya =

https://www.youtube.com/watch?v=72z8C9WM8x0

INTERNET SERVICE PROVIDERS (ISP)

Internet Service Provider (ISP) is a company offering access to internet. They offer various services:

⚫ Internet Access
⚫ Domain name registration
⚫ Dial-up access
⚫ Leased line access
ISP Types

ISPs can broadly be classified into six categories as shown in the following diagram:

Access providers - They provide access to internet through telephone lines, cable wi-fi or fiber optics.

Mailbox Provider - Such providers offer mailbox hosting services.

Hosting ISPs - Hosting ISPs offers e-mail, and other web hosting services such as virtual machines, clouds
etc.

Virtual ISPs - Such ISPs offer internet access via other ISP services.

Free ISPs - Free ISPs do not charge for internet services.

Connection Types

There exist several ways to connect to the internet. Following are these connection types available:

1. Dial-up Connection
2. ISDN
3. DSL
4. Cable TV Internet connections
5. Satellite Internet connections
6. Wireless Internet Connections

Dial-up Connection

Dial-up connection uses telephone line to connect PC to the internet. It requires a modem to setup dial-
up connection. This modem works as an interface between PC and the telephone line.
There is also a communication program that instructs the modem to make a call to specific number
provided by an ISP.

Dial-up connection uses either of the following protocols:

⚫ Serial Line Internet Protocol (SLIP)

⚫ Point to Point Protocol (PPP)

The following diagram shows the accessing internet using modem:

ISDN

ISDN is acronym of Integrated Services Digital Network. It establishes the connection using the phone
lines which carry digital signals instead of analog signals.

There are two techniques to deliver ISDN services:

⚫ Basic Rate Interface (BRI)

⚫ Primary Rate Interface (PRI)

Key points:

The BRI ISDN consists of three distinct channels on a single ISDN line: t1o 64kbps B (Bearer) channel and
one 16kbps D (Delta or Data) channels.

The PRI ISDN consists of 23 B channels and one D channels with both have operating capacity of 64kbps
individually making a total transmission rate of 1.54Mbps.
The following diagram shows accessing internet using ISDN connection:

DSL

DSL is acronym of Digital Subscriber Line. It is a form of broadband connection as it provides connection
over ordinary telephone lines.

Following are the several versions of DSL technique available today:

◼ Asymmetric DSL (ADSL)

◼ Symmetric DSL (SDSL)
◼ High bit-rate DSL (HDSL)
◼ Rate adaptive DSL (RDSL)
◼ Very high bit-rate DSL (VDSL)
◼ ISDN DSL (IDSL)
All of the above mentioned technologies differ in their upload and download speed, bit transfer rate and
level of service.

The following diagram shows that how we can connect to internet using DSL technology:
Cable TV Internet Connection

Cable TV Internet connection is provided through Cable TV lines. It uses coaxial cable which is capable of
transferring data at much higher speed than common telephone line.

Key Points:

⚫ A cable modem is used to access this service, provided by the cable operator.
⚫ The Cable modem comprises of two connections: one for internet service and other for Cable TV
signals.
⚫ Since Cable TV internet connections share a set amount of bandwidth with a group of customers,
therefore, data transfer rate also depends on number of customers using the internet at the same
time.
The following diagram shows that how internet is accessed using Cable TV connection:

Satellite Internet Connection

Satellite Internet connection offers high speed connection to the internet. There are two types of
satellite internet connection: one way connection or two way connection.
In one way connection, we can only download data but if we want to upload, we need a dialup access
through ISP over telephone line.
In two way connection, we can download and upload the data by the satellite. It does not require any
dialup connection.
The following diagram shows how internet is accessed using satellite internet connection:
Wireless Internet Connection

Wireless Internet Connection makes use of radio frequency bands to connect to the internet and offers
a very high speed. The wireless internet connection can be obtained by either WiFi or Bluetooth.

Key Points:

✓ Wi Fi wireless technology is based on IEEE 802.11 standards which allow the electronic device to
connect to the internet.

✓ Bluetooth wireless technology makes use of short-wavelength radio waves and helps to create
personal area network (PAN).

What is Internet Service Provider | How Internet Service Provider Works | Intellipaat =
https://www.youtube.com/watch?v=IrE6RlcXVdk

5. Web Applications, Web Services, and Client/Server Distributed Computing

Web Application

A web application (or web app) is application software that is accessed using a web browser. Web
applications are delivered on the World Wide Web to users with an active network connection.

A Web application (Web app) is an application program that is stored on a remote server and delivered
over the Internet through a browser interface. Web services are Web apps by definition and many,
although not all, websites contain Web apps. According to Web.AppStorm editor Jarel Remick, any
website component that performs some function for the user qualifies as a Web app.

Web applications can be designed for a wide variety of uses and can be used by anyone; from an
organization to an individual for numerous reasons. Commonly used Web applications can include
webmail, online calculators, or e-commerce shops. Some Web apps can be only accessed by a specific
browser; however, most are available no matter the browser.

Overview

Millions of businesses use the Internet as a cost-effective communications channel. It lets them
exchange information with their target market and make fast, secure transactions. However, effective
engagement is only possible when the business is able to capture and store all the necessary data, and
have a means of processing this information and presenting the results to the user.

Web applications use a combination of server-side scripts (PHP and ASP) to handle the storage and
retrieval of the information, and client-side scripts (JavaScript and HTML) to present information to
users. This allows users to interact with the company using online forms, content management systems,
shopping carts and more. In addition, the applications allow employees to create documents, share
information, collaborate on projects, and work on common documents regardless of location or device.
How Web applications work:

Web applications do not need to be downloaded since they are accessed through a network. Users can
access a Web application through a web browser such as Google Chrome, Mozilla Firefox or Safari.

For a web app to operate, it needs a Web server, application server, and a database. Web servers
manage the requests that come from a client, while the application server completes the requested
task. A database can be used to store any needed information.

Web applications typically have short development cycles and can be made with small development
teams. Most Web apps are written in JavaScript, HTML5, or Cascading Style Sheets (CSS). Client-side
programming typically utilizes these languages, which help build an applications front-end. Server-side
programming is done to create the scripts a Web app will use. Languages such as Python, Java, and Ruby
are commonly used in server-side programming.

Web applications are usually coded in browser-supported language such as JavaScript and HTML as
these languages rely on the browser to render the program executable. Some applications are dynamic,
requiring server-side processing. Others are completely static with no processing required at the server.

The web application requires a web server to manage requests from the client, an application server to
perform the tasks requested, and, sometimes, a database to store the information. Application server
technology ranges from ASP.NET, ASP and ColdFusion, to PHP and JSP.

Here’s what a typical web application flow looks like:

1. User triggers a request to the web server over the internet, either through a web browser or the
application’s user interface
2. Web server forwards this request to the appropriate web application server
3. Web application server performs the requested task – such as querying the database or
processing the data – then generates the results of the requested data
4. Web application server sends results to the web server with the requested information or
processed data
5. Web server responds back to the client with the requested information that then appears on the
user’s display

Example of a web application

Web applications include online forms, shopping carts, word processors, spreadsheets, video and photo
editing, file conversion, file scanning, and email programs such as Gmail, Yahoo and AOL. Popular
applications include Google Apps and Microsoft 365.

Google Apps for Work has Gmail, Google Docs, Google Sheets, Google Slides, online storage and more.
Other functionalities include online sharing of documents and calendars. This lets all team members
access the same version of a document simultaneously.

Benefits
Web applications have many different uses, and with those uses, comes many potential benefits. Some
common benefits of Web apps include:

• Allowing multiple users access to the same version of an application.

• Web apps don’t need to be installed.
• Web apps can be accessed through various platforms such as a desktop, laptop, or mobile.
• Can be accessed through multiple browsers.
• Web applications run on multiple platforms regardless of OS or device as long as the browser is
compatible
• All users access the same version, eliminating any compatibility issues
• They are not installed on the hard drive, thus eliminating space limitations
• They reduce software piracy in subscription-based web applications (i.e. SaaS)
• They reduce costs for both the business and end user as there is less support and maintenance
required by the business and lower requirements for the end user’s computer

Web Application vs. other application types

Within the mobile computing sector, Web apps are sometimes contrasted with native apps, which are
applications that are developed specifically for a particular platform or device and installed on that
device. However, the two are not mutually exclusive. Native applications are applications typically
downloaded and made specifically for the type of device it is downloaded on. Native apps can
commonly make use of the device-specific hardware, such as a GPS or camera on a mobile native app.

Programs that combine the two approaches are sometimes referred to as hybrid applications. Hybrid
apps work similar to a Web app but are installed to the device as a native app would be. Hybrid apps can
also take advantage of device-specific resources by using internal APIs. Downloaded native apps can
sometimes operate offline; however, hybrid apps don’t have this functionality. A hybrid app will typically
share similar navigation elements are a Web app since they are based on Web apps.

Conclusion

Increased Internet usage among companies and individuals has influenced the way businesses are run.
This has led to the widespread adoption of web applications as companies shift from traditional models
to cloud-based and grid models. Web applications give businesses the ability to streamline their
operations, increase efficiency, and reduce costs.

These online apps such as email clients, word processors, spreadsheets, and other programs provide the
same functionality as the desktop versions. However, they have an added advantage of working across
multiple platforms, having a broader reach, and being easily accessible from anywhere.

WHAT IS WEB APP | Websites Vs Web Applications | Web Based

https://www.youtube.com/watch?v=lYbATjjjDxM

Web pages, Websites, and Web Applications

https://www.youtube.com/watch?v=ylbQrYhfa18
Web Services

A web service (WS) is either:

• a service offered by an electronic device to another electronic device, communicating with each
other via the Internet, or
• a server running on a computer device, listening for requests at a particular port over a network,
serving web documents (HTML, JSON, XML, images).

The use of the term "Web" in Web Service is a misnomer. Web Services do not use the World Wide Web
(WWW), a human user interface running on the Internet, but rather a machine-to-machine service
running on the Internet using the WWW protocols.

In a web service, a web technology such as HTTP is used for transferring machine-readable file formats
such as XML and JSON.

In practice, a web service commonly provides an object-oriented web-based interface to a database

server, utilized for example by another web server, or by a mobile app, that provides a user interface to
the end-user. Many organizations that provide data in formatted HTML pages will also provide that data
on their server as XML or JSON, often through a Web service to allow syndication. Another application
offered to the end-user may be a mashup, where a Web server consumes several Web services at
different machines and compiles the content into one user interface.

The term "Web service" describes a standardized way of integrating Web-based applications using the
XML, SOAP, WSDL and UDDI open standards over an Internet Protocol backbone. XML is the data format
used to contain the data and provide metadata around it, SOAP is used to transfer the data, WSDL is
used for describing the services available and UDDI lists what services are available.

A Web service is a method of communication between two electronic devices over a network. It is a
software function provided at a network address over the Web with the service always-on as in the
concept of utility computing.

Many organizations use multiple software systems for management.[citation needed] Different software
systems often need to exchange data with each other, and a Web service is a method of communication
that allows two software systems to exchange this data over the Internet. The software system that
requests data is called a service requester, whereas the software system that would process the request
and provide the data is called a service provider.

Different software may use different programming languages, and hence there is a need for a method of
data exchange that doesn't depend upon a particular programming language. Most types of software
can, however, interpret XML tags. Thus, Web services can use XML files for data exchange.

Asynchronous JavaScript and XML

Asynchronous JavaScript And XML (AJAX) is a dominant technology for Web services. Developing from
the combination of HTTP servers, JavaScript clients and Plain Old XML (as distinct from SOAP and W3C
Web Services), now it is frequently used with JSON as well as, or instead of, XML.
REST

Representational State Transfer (REST) is an architecture for well-behaved Web services that can
function at Internet scale.
In a 2004 document, the W3C sets following REST as a key distinguishing feature of Web services:

We can identify two major classes of Web services:

• REST-compliant Web services, in which the primary purpose of the service is to manipulate XML
representations of Web resources using a uniform set of stateless operations; and
• arbitrary Web services, in which the service may expose an arbitrary set of operations. — W3C,
Web Services Architecture[1]

Web services that use markup languages

There are a number of Web services that use markup languages:

• JSON-RPC.
• JSON-WSP
• Representational state transfer (REST) versus remote procedure call (RPC)
• Web Services Conversation Language (WSCL)
• Web Services Description Language (WSDL), developed by the W3C
• Web Services Flow Language (WSFL), superseded by BPEL
• Web template
• WS-MetadataExchange
• XML Interface for Network Services (XINS), provides a POX-style web service specification
format

Web API

A Web API is a development in Web services where emphasis has been moving to simpler
representational state transfer (REST) based communications.[2] Restful APIs do not require XML-based
Web service protocols (SOAP and WSDL) to support their interfaces.

W3C Web services

In relation to W3C Web services, the W3C defined a Web service as:

A web service is a software system designed to support interoperable machine-to-machine interaction

over a network. It has an interface described in a machine-processable format (specifically WSDL). Other
systems interact with the web service in a manner prescribed by its description using SOAP-messages,
typically conveyed using HTTP with an XML serialization in conjunction with other web-related
standards.

— W3C, Web Services Glossary

W3C Web Services may use SOAP over HTTP protocol, allowing less costly (more efficient) interactions
over the Internet than via proprietary solutions like EDI/B2B. Besides SOAP over HTTP, Web services can
also be implemented on other reliable transport mechanisms like FTP. In a 2002 document, the Web
Services Architecture Working Group defined a Web services architecture, requiring a standardized
implementation of a "Web service."

Rules for communication with different systems need to be defined, such as:

• How one system can request data from another system.

• Which specific parameters are needed in the data request.
• What would be the structure of the data produced. (Normally, data is exchanged in XML files,
and the structure of the XML file is validated against a .xsd file.)
• What error messages to display when a certain rule for communication is not observed, to make
troubleshooting easier.

All of these rules for communication are defined in a file called WSDL (Web Services Description
Language), which has a .wsdl extension. (Proposals for Autonomous Web Services (AWS) seek to
develop more flexible Web services that do not rely on strict rules.[a])

A directory called UDDI (Universal Description, Discovery, and Integration) defines which software
system should be contacted for which type of data. So when one software system needs one particular
report/data, it would go to the UDDI and find out which other systems it can contact for receiving that
data. Once the software system finds out which other systems it should contact, it would then contact
that system using a special protocol called SOAP (Simple Object Access Protocol). The service provider
system would first validate the data request by referring to the WSDL file, and then process the request
and send the data under the SOAP protocol.

Web Services - Demystified!

https://www.youtube.com/watch?v=oaM27ETgxic

Client/Server Distributed Computing

The Client-Server Model and Distributed Systems

The client-server model is basic to distributed systems. It is a response to the limitations presented by
the traditional mainframe client-host model, in which a single mainframe provides shared data access to
many dumb terminals. The client-server model is also a response to the local area network (LAN) model,
in which many isolated systems access a file server that provides no processing power.

Client-server architecture provides integration of data and services and allows clients to be isolated from
inherent complexities, such as communication protocols. The simplicity of the client-server architecture
allows clients to make requests that are routed to the appropriate server. These requests are made in
the form of transactions. Client transactions are often SQL or PL/SQL procedures and functions that
access individual databases and services.

The Client Server Model | Clients and Servers

https://www.youtube.com/watch?v=L5BlpPU_muY
Distributed Systems | Distributed Computing Explained
https://www.youtube.com/watch?v=ajjOEltiZm4

6. Enterprise Computing for Medical Imaging Informatics

What is Enterprise Imaging?

The most commonly accepted definition of enterprise imaging is, “a set of strategies, initiatives, and
workflows implemented across a healthcare enterprise to consistently and optimally capture, index,
manage, store, distribute, view, exchange, and analyze all clinical imaging and multimedia content to
enhance the electronic health record.”

Enterprise imaging in its broader framework is typically achieved through a single archive. Medical
images include standard DICOM images from traditional imaging modalities, such as CT or MRI, as well
as visible light images, such as photographs, images from arthroscopes and endoscopes, fundal
examinations, and any examination in which the data are displayed as an image and not as text, a graph,
or a diagram. All of these images are a part of the comprehensive longitudinal medical record.
Incorporation of images into the EMR/EHR supports the concept of the EMR as a single source of truth
about the patient’s medical care.

Evolution of Enterprise Imaging

Healthcare delivery has evolved for the better due to many technological advances that continue today.
For some time, the medical sector has been pivoting away from traditional picture archiving and
communications systems (PACS, now known as MIMPS) and cardiovascular information systems (CVS) in
favor of enterprise imaging and data management systems. The advent of vendor-neutral archive
technology (VNA), and especially its accelerated adoption over the past decade, has been an important
aspect of enterprise imaging.

Many departments within healthcare organizations such as Dentistry, Pathology, Dermatology, and
Gastrointestinal (GI) Endoscopy, produce images in the visible light spectrum. However, in many
healthcare enterprises, these images are not easily available through the standard electronic health
record, and frequently departments fail to securely digitally archive them. This oversight represents a
failure to consider the full effect on patient care and patient experiences, the caregiver’s quality of work,
and other factors impacting the quality of service. However, in healthcare enterprises where VNAs have
been adopted, the availability of images through a single login has been shown to help improve the
quality of interpretation by clinicians, reduce the number of duplicate exams, and improve overall
efficiency.

Enterprise imaging refers to the conglomeration of multiple hospitals or radiology departments into a
single imaging system that allows the routing of images for the interpretation of examinations. It also
has been defined as the incorporation of all medical images into a single archive, frequently integrated
into the EMR. While these two practices are different, they are by no means mutually exclusive. The
field will continue to evolve, and the practices will converge. Rather than a productivity tool primarily
used by radiologists, enterprise imaging has the potential to become a platform of communication for
the medical community.
Healthcare’s reimbursement model is changing, as is the role of radiologists. Other departments are
incorporating radiology equipment into their own practice. Luckily, the adoption of an enterprise
approach to imaging technology instead of a narrow focus on radiology will encourage internal
collaboration to face external pressures. Care coordination requires the exchange of clinical care among
providers. The ordering of imaging data, the reduction of costs, and the increase in efficiency help
improve patient outcomes. Connectivity will help facilitate these leaps forward.

Enterprise Imaging for Clinicians

Enterprise imaging has different connotations for different specialists. Traditionally, each department
had its own specialty PACS/MIMPS, but now these disparate systems are connected via a single
electronic patient record. The medical imaging records of Cardiology, Oncology, Pediatrics, or other
specialties can be accessed by Radiology, as healthcare data is exchanged between different vendor
software. The popularization of VNAs has expedited connectivity across healthcare enterprises. Imagine
it in a similar light to how the Internet suddenly enabled connectivity between millions of people
worldwide, despite different operating systems.

Vendor-neutral connectivity is not the only advantage for clinicians. Automation of complex imaging
workflows, including automatic upload and delivery of images from remote locations, provides a
substantial efficiency boost. Enterprise mobile imaging, ensuring timely access to clinical resources and
patient summaries at point of care, is also a substantial improvement. Mobile medical imaging
capabilities mean that clinicians can quickly capture and integrate visible light images, as well as videos
and corresponding notes with patient health records. Another substantial boon to clinicians of various
stripes in the age of enterprise imaging is the availability of cognitive intelligence and analytics. Some
enterprise imaging solutions come with built-in analytics engines, that extract crucial health information
from a variety of complex data sources. They can also identify high-risk patients and provide
intervention via understanding unstructured clinical notes in appropriate contexts.

From a compliance perspective, well-implemented enterprise imaging platforms are able to securely
store and distribute clinical contents in standardized healthcare data formats, while supporting the
gamut of clinical specialties. These platforms can also reduce storage costs and provide tools for
information life cycle management while offering business continuity solutions and disaster recovery
options in the event of catastrophes. Overall, an enterprise imaging platform that is suitably furnished
with clinical collaboration and synchronization tools can facilitate substantial leaps forward in efforts
towards care personalization and patient-centric service.

Enterprise Imaging for IT Professionals

Building and implementing a successful enterprise imaging platform represents a significant undertaking
for an institution. Even a highly-skilled IT team may need help from consultants to implement and
complete this type of project.

An IT professional working in a healthcare enterprise should be able to advocate for enterprise imaging
as a means of improving patient care and operational efficiency with the following benefits:
A patient-centric view of all clinical information on a patient, including images, accessible from the point
of care, enables the care provider to make better and quicker clinical decisions. The patient can more
easily be kept up to date on their condition and treatment.
The availability of imaging data in the electronic health record (and its accessibility by imaging analytics
and AI applications) has positive repercussions for macro-level preventative efforts: essentially,
managing health on a population-wide level.
There are also financial savings that can be achieved as a result of consolidating imaging data into a
smaller number of repositories, even with the initial investment required to purchase a new system.
Centralized data management cuts maintenance costs significantly, reducing or entirely eliminating the
necessity of data migrations.
Healthcare costs continue to rise for the average American, and so do patient expectations related to
the convenience of care. A Kelton Global survey found that 94% of patients were of the opinion that
their medical data and records should be centrally stored and electronically accessible. Patients are used
to having their financial details available at their fingertips and are often dissatisfied when their personal
health records are not similarly easy to access and share.

Enterprise Imaging Challenges

Enterprise healthcare providers use medical images to help diagnose disease, document abnormalities
or interventions, and guide treatment for their patients. As a point of reference, nearly 40 million MRI
scans are performed annually in the United States. In addition to MRI scans, medical imaging includes CT
scans, PET scans, ultrasounds, X-rays, arthrograms, myelograms, and several types of mammography.
Together, these images help to tell the story of each patient’s clinical journey. Unfortunately, the
majority of images are not visible to the team of doctors, nurses, therapists, technologists, and other
clinicians caring for a patient. This is true for a number of reasons, most importantly including a lack of
systems and workflows required to acquire, upload, and view images. While historically, the radiology
and cardiology services have done a good job creating automated workflows for image acquisition and
information systems for image distribution, these practices have not been adopted by other services in
the hospital.

As images have increased in importance, hospitals have struggled to effectively store, display, and
distribute these images throughout the enterprise. This has remained a struggle because of inefficient
workflow and incomplete solutions.

Imaging Workflow Challenges

By analyzing clinical and informatics workflow challenges, enterprise imaging companies can identify
potential solutions and opportunities for improved workflow and, ultimately, better patient care.
Workflow challenges are usually caused by one or more of the categories below:

• Workflow
• Patient Identification
• Information Needed in an Image
• Reporting
• Metadata
• Legal Concerns
• Mobile Devices
Every imaging study begins and ends with a workflow. An imaging workflow is the sequence of steps
required for the image to be ordered, requested, read, evaluated, and stored. While each medical
specialty acquires and uses images differently, most begin with an order placed by a referring physician.
Once the order is placed, it is transferred to the Radiology Information System (RIS). The RIS uses the
information contained within the order to create a worklist for the imaging modality. Technologists
select the patient from the worklist, ensuring that all demographic and order information is correct.
After the images are obtained, they are sent to PACS/MIMPS for storage and viewing. Even though this
workflow is fairly simple, it is not standard. There are numerous variations to the workflow, depending
on the ordering physician and their specialty, the differential diagnosis, the time and location of the
clinician’s evaluation, and many other factors.

Hospitals have taken one of two approaches to accommodate the numerous variations of workflows.
They either use an order-based workflow or the encounter to drive the workflow. In an order-based
workflow, the physician order initiates an automated workflow which includes the unique study
identifier and a PACS worklist of patient studies that require review. If an order for imaging is not
needed by other specialties, an encounter to drive workflow method is used which creates a unique
study identifier and patient worklist. Encounter-based imaging is defined as medical imaging that is
intentionally performed during a patient encounter without an associated imaging order. Images are
generally acquired at the discretion of the provider.

Healthcare organizations can also experience workflow challenges related to: patient identification,
information needed in an image, reporting, metadata, legal concerns, and mobile devices.

Enterprise Imaging and Patient Data Security

One of the most pressing health IT concerns in the industry is patient data security and keeping patient
information protected. Healthcare providers represent significant targets for cyber attackers. Digital
security threats are constantly emerging from unexpected avenues. One potential downside of an
enterprise imaging solution is that a centralized network, while offering substantial efficiency gains and
savings on storage solutions, is more vulnerable to cybersecurity threats than networks acting
individually. Cyber attacks can quickly spread malware and compromise vital operations. Security must
be taken seriously by any enterprise that implements an integrated care delivery network. If a hacker is
able to penetrate a network to interfere with a medical imaging acquisition device, its safe operation
can be jeopardized, which in turn endangers patient safety. Organizational cybersecurity requires a
unified effort from departmental staff and the rest of the enterprise. In a 2014 statement, IBM identified
‘human error’ as a contributing factor in over 95% of all cybersecurity incidents.

Preventing cybersecurity risks involves a delicate, closely monitored, system of people, processes, and
technologies. IT departments must work closely with imaging service lines to develop operational plans
and strategies that are practical and robust. Imaging staff must be kept aware of best practices and
cybersecurity threats. Healthcare organizations are now looking at Artificial Intelligence (AI) to rise to
the challenge to help ransomware victims fight back.

Another challenge is the use of different data standards for medical imaging as opposed to non-imaged
data. Perhaps the most well-known standard is Digital Imaging and Communications in Medicine
(DICOM), which was specially developed by the American College of Radiologists (ACR) and National
Electrical Manufacturers Association (NEMA). The DICOM standard applies to imaging equipment,
printers, and PACS/MIMPS. This format focuses on the workflow of images, as well as provides protocols
for the integration of image data. It also allows functions like film printing or CD burning.

Enterprise Imaging and HIPAA

Patient privacy is another challenge for enterprise imaging. is patient privacy. In accordance with federal
law, all patient data must be protected and HIPAA-compliant. However, one of the main advantages of
enterprise imaging is the possibility of sharing significant data banks with other enterprises for the
purpose of medical research, AI training, and similar projects. It is essential that, whenever data sharing
is offered, identifying information is stripped away to protect individuals’ medical data. De-identification
is the most common method of performing this information removal for DICOM data in Cross-Enterprise
Document Sharing (also known as XDS-I). DICOM files consist of the image and the header, which
contains meta-elements containing patient information, as well as institution and study data. The
patient name and number must be obscured in order to prevent the patient from being identified.
Hence, de-identification. There are two main approaches to de-identification: anonymization and
pseudonymization. Anonymization is considered to be more secure, as it involves removing all sensitive
information from the header. The aim of this method is to irreversibly remove any probability of
revealing the patient’s identity. Meanwhile, pseudonymization instead replaces identifying fields in the
data record with artificial identifiers. The intention of this process is to make the data record less
identifying. However, this process is used when there is considered to be a potential for the necessity of
tracing the actual identity of the subject involved. Typically, the principal investigator or data manager
of a research project would be able to obtain the real identity of the subject, while direct attempts to
identify the patient would be avoided. Fields not necessary to this process are instead anonymized.

HL7 Interoperability in Enterprise Imaging

A format that is seeking wider acceptance is Health Level Seven (HL7), intended for general use of
electronic health information in hospitals. This format manages non-imaging data, and provides
protocols for exchange, management, and integration of clinical and administrative electronic health
data. It allows interoperability between different systems including patient administration, laboratory
information systems, billing systems, electronic medical record and health record systems, and more.

Looking Ahead: Enterprise Imaging Innovations

The field of enterprise imaging is one with a great deal of potential, but also challenges to be
surmounted. It took the U.S. healthcare industry almost a decade to adjust after its investment in
enterprise HER. What’s more, the changing legislative environment and consolidations of hospital
infrastructure have quenched enthusiasm for pursuing the kind of complex implementations enterprise
imaging needs. There are certain departments and care areas that are, as a general rule, more
enthusiastic about converting to enterprise imaging than others. Radiology is obviously one of them, but
dermatology, non-invasive cardiology, and standard mammography are also typically receptive to the
shift. Departments with which progress for the adoption of enterprise imaging is generally less keen
include Core Pathology, Genomics, Multimedia Endoscopy, and Oncology. The reasons why vary, but
may involve a lack of leadership, a reliance on committee or cross-department decision making,
adherence to a broader contract involving non-software equipment and services, or a desire to use a
dedicated best-of-breed functionality in a specific care area.
The long-term impact of enterprise imaging will be substantial and measurable. From small community
hospitals to large institutions, enterprise imaging is an essential component of information technology
infrastructure that can promote interoperability between different sites. Communication, via image
sharing and other means, within the hospital and beyond, is made easier along different points of the
care continuum. As a result of healthcare increasingly being absorbed into the Cloud, data migrations
will become obsolete. This in turn will reduce the image management role of healthcare IT vendors and
place more power in the hands of the providers. Vendor-neutral data will give providers the freedom to
innovate their own solutions to progress, rather than obeying the strictures of the vendors. The most
tangible benefit of this shift in imaging structure will be better patient care, by virtue of faster diagnosis
and imaging orders.

AI In Enterprise Imaging

One of the biggest innovations that widespread enterprise imaging will facilitate is the ‘on-ramp’ of
artificial intelligence for diagnostics. Thanks to AI, radiologists foresee a future in which machines
enhance patient outcomes and reduce misdiagnosis. As more departments and enterprises consolidate
their image management into enterprise imaging health systems, AI developers’ ability to source the
terabytes of deidentified images necessary to train their machine learning diagnostician algorithms will
increase. The ability of machines to, in a split second, assess a mammogram, MRI, or other medical scan
and accurately (more accurately than any human diagnostician) diagnose a patient will represent a
significant leap forward in the efficiency of medicine as a whole.

Cloud Computing Solutions for VNA

A Vendor Neutral Archive (VNA) is highly beneficial to the average healthcare enterprise. The ability to
switch PACS/MIMPS vendors regardless of image data migration/conversion is highly significant. A
cloud-based archive can remove one of the biggest impediments to implementing a VNA: how to store
all that data? Data migrations within a cloud are far more painless, and operational and maintenance
costs for data storage drop off considerably. There are additional benefits, including flexibility in terms
of archive size, and the capability to homogenize data from disparate systems. Data stored on a cloud is
much more affordable to recover in the event of a disaster. Furthermore, many solutions are capable of
expanding the capability and longevity of a client’s current PACS/MIMPS. In addition, these solutions de-
identify personal and healthcare information contained in DICOM metadata and pixels helping protect
patients’ confidentiality and offering greater research possibilities.

Imaging on Mobile Devices

In the time since DICOM became one of the imaging data standards, cell phones and other mobile
technologies have gone from being unwieldy and limited-use machines to highly sophisticated personal
electronic devices capable of not only communication, but imaging, analysis, and more. Healthcare
Organizations deserve solutions that make clinical communication and collaboration easier and more
efficient. Certain enterprise imaging options on the market also provide opportunities to utilize mobile
medical photography and collaboration solutions. These users can capture images, label and organize
data, collaborate with colleagues, and import data into the PACS/MIMPS while complying with HIPAA
and compliance audit reporting. Data is encrypted on devices at all times and transmitted, processed,
and stored on encrypted systems. Photos are automatically organized by patient encounters, and all
data can be seamlessly integrated via DICOM or any of the other prevalent data standards. Users are not
restricted to capturing medical images; they can also use a smart document scanner to scan printed
orders. Additionally, they can use the device to search across PACS/MIMPS and EHR systems from a
single search field, loading images for comparison. Nicklaus Children’s Hospital, a leading pediatric
hospital in Florida, implemented a mobile medical photography and collaboration tool, which resulted in
a faster, more intuitive viewing workflow for clinicians. Images captured at the point of care were
automatically added to the EHR. Multidisciplinary teams found it far easier to collaborate, thanks to
their straightforward access to all types of imaging through the EHR. The vast compatibility of the
system meant that all staff were able to use the mobile devices they were comfortable with while at the
same time ensuring a compliant and secure remote solution.

Enterprise imaging is a complex and ever-evolving universe with an important role in enhancing patient
care. As the number and rate of imaging studies grows, enterprise imaging enables diagnostics,
research, AI-based innovations, and increased productivity. While there are challenges and limitations
from legacy protocols to compliance and security, the future looks bright, and we expect enterprise
imaging to continue playing an ever-expanding part in the clinical and operational aspects of healthcare
systems.

Enterprise Imaging Informatics

https://www.youtube.com/watch?v=8B0o9Td78Fk

Intro to enterprise imaging

https://www.youtube.com/watch?v=5tY98iAOGnU

How to Become a PACS Administrator 1 - What is a PACS Analyst?

https://www.youtube.com/watch?v=NXm33BJq81Q

How to Become A PACS Administrator 2 - Step by Step Guide

https://www.youtube.com/watch?v=vkKktjYnYMw

What PACS Admins Should Know | Topics for Imaging Informatics Exam
https://www.youtube.com/watch?v=rNRUNiDbM1g