Medical Imaging Informatics

- also referred as “Radiology Informatics” or simply as “Imaging Informatics”

- the use of information technology to deliver efficient, accurate, and reliable medical imaging
services within a healthcare network.
- field responsible for storing, managing, and accessing image related information and data.
 Goal: to improve patient care by better managing imaging data and making it as
accurate and accessible as possible

Information Science
- A field that is primarily concerned with analysis, collection, classification, manipulation,
storage, retrieval, movement, dissemination, and protection of information.

Information Technology
- It includes the development, design, implementation, and management of computer-based
information systems and focuses on the practical application of technology to support
information processing and management.

Computer Science
- the study of computers and how they process information using algorithms, hardware, and
software.
- applies the principles of mathematics, engineering, and logic to a plethora of functions,
including algorithm formulation, software and hardware development, and artificial
intelligence.

Computer Technology
- A broad term referring to computer-specific technology; Any inventions related to or
associated with the use of computers and devices with a central processing unit, such as the
hardware and software of a computer, the internet and storage devices

Biomedicine
- branch of medicine concerned with the application of the principles of biology and
biochemistry to medical research or practice

Digital Biomedicine (Digital Medicine) refers to the field concerned with the use of
technologies as tools for measurement, and intervention in the service of human health.

Telemedicine refers the use of technology to provide health care remotely, such as through
phone, video, or internet

Healthcare Information Technology

- is the use of electronic systems to store, share, and analyze health date.
- helps healthcare providers and patients access and exchange information more efficiently
and securely.
- supports clinical decision making, quality improvement, and public health reporting

Electronic Medical Record - stores patients citical health information.

E-Prescribing- allows physician to send electronic prescriptions to pharmacies.

Other examples are storing personal health record, allowing patients to track their various
heath conditions such as diabetes and heart disease

DICOM -Digital Imaging and Communications in Medicine

- the internationally accepted standard used for storing, exchanging, and transmitting
medical image data
- allows imaging modalities and PACs to communicate in the same "language."
PACS -Picture Archival and Communication System
- is a networked group of computers, servers, and archives that can be used to manage
digital images
- serves as the file room, reading room, duplicator, and courier,
- can provide image access to multiple users at the same time, on-demand images,
electronic annotation of images, and specially image processing

RIS - Radiology Information System

- holds all radiology-specific patient data, from the patient scheduling information to the
radiologist’s dictated and transcribed report.

HIS - Hospital Information System

- holds the patient's full medical information, from hospital billing to the inpatient ordering
system

BIOMEDICAL INFORMATICS
- Uses computers and information technologies to assist physicians in the diagnosis and
treatment of patients
- is loosely categorized into four levels of study:
A. Bioinformatics (molecular level)
В. Imaging Informatics (cellular, tissue, and organ system level)
C. Clinical Informatics (individual healthcare system)
D. Public Health Informatics (population level)

Imaging Informatics
- Also refereed to as "Radiology Informatics" or "Medical Imaging Informatics"
- is the collective name given to the field of work and combination of technologies that
provide the features of a paper-less or paper-lite department.
- concerned as a speciality with the electronic acquisition, storage, and distribution of the
tent and image data produced and utilized within a diagnostics department (Radiology
Pathology, Cardiology, etc.) for the wider provision of care and benefit to patients

History and Development:

- Within radiology, for almost a century film was the primary method of handling imaging -
with transferring and filing being a manual clerical process.
- Early 2000s onwards, the move away from film-producing departments towards the
integration of more modern electronic methods began to take place
 PACS - Picture Archiving and Communication System
 RIS - Radiology Information System
 OCS - Order Communication System
 EPR - Electronic Patient Record

Medical Imaging, PACS, Imaging Informatics R&D progress overtime

1980s - Medical Imaging, PACS, and imaging informatics R&D progress

- CR, MRI, CT, US, DR, WS, storage, networking
Late 1980s - Imaging systems integration
- PACS. ACR/NEMA, DICOM. high-speed networks
Early 1990s - Integration of HIS/RIS/PACS
- DICOM, HL7. Intranet and Internet
Late 1990s-present - Workflow and application servers
- IHE, ePR. enterprise PACS, Web-based PACS
2000s- present - Imaging informatics
- Computer-aided diagnosis (CAD), image contents indexing.
- Knowledge base, decision support.
- Image-assisted diagnosis and treatment
Digital Imaging
- is what allows text, photos, drawings, animations, and video to appear on the World Wide
Web.
- In medicine, it refers to any imaging acquisition process that produces an electronic image
that can be viewed and manipulated on a computer.

BASIC COMPUTER PRINCIPLES

I. Computer
Has two (2) principal parts:
1. Hardware - is everything about the computer that is visible; the physical components of
the system. that include the various input, output, and processing devices
 categorized according to which operation it performs (input
processing, memory, storage, output, and communications)
2. Software - consists of computer programs that tell the hardware what to do and how to
store and manipulate data (Application Softwares, Operating System and Middleware
Software)

Input devices:
- any hardware device that sends data to a computer, allowing you to interact with and control
it.
* Keyboards
* Mice
* Microphones
* barcode readers
* touch screens
* image scanners

Output devices:
- any piece of computer hardware equipment which converts information into human readable
form. It can be text, graphics, tactile, audio, and video.
1. Monitors
2. Printers
3. speakers.

Processing devices:
- used to process data using program instructions
* Motherboard
* Microprocessor
* BIOS
* Bus
* Memory
* Ports
* CMOS

"HARDWARE COMPONENTS"

1. The "Box" - the encasement

- For holding all the other components
- To shield the outside environment from radiofrequencies being emitted by the electronic
components of the computer.

Figure 2-1 A basic personal computer consisting of a CPU, keyboard, mouse, and LCD
monitor.

2. "The Motherboard" - largest circuitry board inside the computer, and it contains many
important small components to make the computer function properly

I. "The CPU" - or "Microprocessor", a small chip found on the motherboard

- The brain of the computer which consists a series of transistors arranged to manipulate data
II. "The BIOS" - contains a simple set of instructions
- Used by the microprocessor for booting up the computer to life
- Simply, the intermediary between the Operating system and the Hardware

III. "The Bus is a series of connections, controllers, and chips that creates the information
highway of the computer
- Provides the connections for the information to flow within the computer

IV. "The Memory" - used to store information currently being processed in the CPU
- Also known as the "RAM (Random Access Memory"
- a short-term storage for open programs

DIFFERENT TYPES OF "RAM"

1. DRAM - Dynamic Random Access Memory
2. EDO-RAM - Extended Data Out- Random Access Memory
3. VRAM - Video Random Access Memory
4. SRAM - Static Random Access Memory
5. SDRAM - Synchronous Dynamic Random Access Memory
6. SIMM - Single In-line Memory Module
7. DIMM - Dual In-line Memory Module
8. ECO - Extended Data Out

V. "The Port - collection of connectors sticking out of the back of the PC that link adapter
cards, drives, printers, scanners, keyboards, mice, and other peripherals that may be used.

TYPES OF PORTS

1. Parallel
- a 25-pin connector found on the back of most modern PCs
- can send 8-bits of data through the connection
2. Serial - can be used universally for many components plugged into the computer, such as
a mouse
- mostly of this type of port is a 9-pin variety, but some can have up to 25-pin connectors
- can only send 1 bit of data down on a single wire
3. USB
- common interface connection; can connect up to 127 devices to one single USB port
- Offers many possible connection
4. Integrated Drive Electronics (IDE) - can be found on the motherboard and connects the
hard drive, floppy drive, and CD-ROM drive to the board
5. Small Computer System Interface (SCSI) - the fastest and most versatile way for a PC to
communicate with its peripherals.
- can mange up to seven (7) devices through a daisy chain connection

vi. "Complementary Metal Oxide Semiconductor (CMOS)" - a special type of memory chip
that uses a small rechargeable or lithium battery to retain information about the PC's
hardware while the computer is turned off.
- Also, the location of the system clock that keeps track of the date and time

3. The "Sound Card"

- Contains all circuitry for recording and reproducing sound on the PC
- It may be in the form of an expansion card or may be built into several chips found on the
motherboard
- Ports are located externally to connect amplified speakers, headphones, microphone, and
a compact disk (CD) player input into the computer
- Interprets many different file types such as Waveform Audio(WAV) files, Moving Picture
Experts Group Audio Player (MP3) files, and Musical Instrument Digital Interface (MIDI) files.
4. The "Network Card"
- Enables PC to connect to other PCs that are on the same network
- Can be an expansion card plugged not a slot or as a part of the PC motherboard circuitry
- Have an RJ-45 jack at the rear o the PC for the acceptance of a twisted pair wire with RJ-
- 45 connector

5. The "Power Supply"

- Delivers all the electricity to the PC and contains a fan to help keep the inside of the
computer cool.
- Contains a Transformer that converts the wall outlet alternating current (AC) to direct
current (DC) in the voltages appropriate for each powered device.

6. "Hard Drive"
- the main repository for programs and documents on a PC.

7. "CD/DVD Drive"
- found on the front of the encasement of a computer.
- reads and writes all common CD and DVD formats

"PERIPHERALS"
- refers to the devices that connects to a computer and enhance its functionality

Examples:
1. Keyboard
- It is used to input text, characters, and other commands into a computer
2. Mouse
- It allow the user to move the computer's cursor to activate and perform functions within the
computer's software.
* has three common types:
1. Mechanical - This mouse uses a hard rubber ball inside an opening on the
bottom that is surrounded by sensing devices.
2. Optical - This mouse has a high-intensity diode that bounces light off surfaces
and back to a receiver inside the mouse.
3. Optomechanical: This mouse is a hybrid of mechanical and optical mouse. It
uses a rubber ball that interacts with rollers that trigger the optical sensors within the mouse.
Light is reflected back to the sensors based on the movement of the rollers.
3. Scanners
- devices that capture drawings or written paper documents and convert them into a digital
image or document that can be edited.
* Radiology Department - it is used to convert analog (film) into a digital image
* Purpose: To provide a way to compare a hardcopy image with a digital image on a PAC
system (PACS)

4. Speakers
- receive sound data from a sound card that is either built into the motherboard or is an
expansion card.
* It gives audible signals from the software to alert us to various task by converting electrical
signal to a series of vibrations in the speaker.

5. Microphones
- are used to record voice or to use voice dictation software.

MONITOR
- One of the most important elements in a PACS display station
- A computer hardware that displays the images, videos, and/or any graphics information

3 types of monitors:
* CRT (Cathode Ray Tube)
* LCD (Liquid Crystal Display) Widely used
* Plasma Screen - Heavily used in government and military applications in late 1960s
CRT MONITORS - CATHODE RAY TUBE MONITORS
- The most popular monitors on the market; consists of a cathode and anode within a
vacuum tube.
- Works with the cathode boiling off a cloud of electrons which are sent to the monitors
anode. Then, the electrons interact with either green, blue, or red dot to form the color that is
sent to the video card signal.

LCD MONITORS - LIQUID CRYSTAL DISPLAY MONITORS

- produces images by shining or reflecting light through a layer of liquid crystal and a series of
color filters
- An LCD has two pieces of polarized glass with a liquid crystal material between the two.
Light is allowed through the first layer of glass, and when a current is applied to the liquid
crystal, it aligns and allows light in varying intensities through to the next layer of glass
through color filters to form the colors and images seen on the display

PLASMA DISPLAY MONITORS

- are still new to the consumer market and were most commonly used in government and
military applications in the late 1960s
- Made up of many small fluorescent lights that are illuminated to form the color of the image

Basic Terms and Measurements related to onscreen viewing:

 MATRIX
- Arrangement of pixels in a rectangular or square table of numbers that represents the pixel
intensity to be displayed on the monitor
 Pixel
- Basic picture element on a display
- A small square in the image that has set values
 Dot Triad
- A grouping of one red dot, one green dot, and one blue dot
 Dot Pitch
- The measurement on how close the dots are located to one another within a pixel
- The smaller the dot pitch of a display, the finer the resolution
- expressed as Aperture Grille Pitch, Shadow Mask or Slot Pitch, depending on the monitor
maker
 Resolution
 Refers to the number of pixels on a display.
- The more pixels in an image, the higher the resolution of an image and the more
information can be displayed.
- Also defined as the process or capability of distinguishing between individual parts
of an image that are adjacent

SPATIAL RESOLUTION
- Another term for "Detail Resolution"
- Is the system's ability to resolve, as separate forms, small objects that are very close
together
- expressed in line pairs per millimeter (lp/mm)
Spatial frequency - the number of line pairs in a given length
CONTRAST RESOLUTION
- The ability of the system to differentiate structures that has a varying density from its
surrounding
- Also referred to as the sensitivity of the system
High Subject Contrast - structures that are easy to distinguish (e.g bone-soft tissue
interface)
Low Subject Contrast - structures that has almost the same appearance (e.g Liver
spleen)
TEMPORAL RESOLUTION
- Refers to the speed that the data can be acquired
- particularly important to reduce or eliminate artifacts that result from object motion, such as
those commonly seen when imaging the heart
LINEAR ATTENUATION COEFFICIENT - characterizes the absorption of x-rays in tissue.
• X-RAY: is a function of x-ray energy and the atomic number of the tissue
• For CT: absorption of x-rays by the patient is determined also by the mass density
of the body part

The ability to image low-contrast objects with CT is limited by the

• Size of the object
• Uniformity of the object
• Noise of the system

CONTRAST RESOLUTION IN MAGNETIC RESONANCE IMAGING

- the MRI system uses and sends magnetic and radiofrequency waves into the patient's body.
The energy emitted by the atoms in the magnetic field sends a signal to a computer. Then,
the computer uses mathematical formulas to convert the signal to an image.

 REFRESH RATE
- Measure of how fast the monitor rewrites the screen or the number of times that the
image is redrawn on the display each second.
 ASPECT RATIO
- the ratio of the with of the monitor to the height of the monitor
 VIEWABLE AREA
- measured diagonally from one corner of the display to the opposite corner

History of Computers

 Abacus - earliest calculating to invented in China thousands of years ago.

 17Century - Mechanical calculators built with pegged wheels that could perform 4 basic
arithmetic functions
- designed by blaise pascal and gottfried leibniz
 Charles Babbage (1842) - designed an analytical engine that performed general
calculations automatically.
 Herman Hollerith (1890) - designed a tabulating machine to record census data
- [ ] The tabulating machine stored information as holes in the cards that were
interpreted by machine with electronic censors.
 Collusus (dec. 1943) - built by the british
- [ ] First fully operational working computer; designed to crack encrypted
german military codes.
 Automatic Sequence Controlled Calculator (ASCO)
- [ ] first general-purpose modern calculator developed at Harvard Universihy
in 1944) - Now known as the "Mark 1"
- [ ] An electromechanical device that was exceedingly slow and was prone to
malfunction
 (ENIAC)
- first large-scale general-purpose electronic computer developed in 1946 by
J. Presper Eckert and John Mauchly at the universty of Pennsylvania at a cost of
$500,00
- Contains more than 18, 000 vacuun tube that failed at an average rate of
one every 7 minutes
 Transistor 1948) - developed by Wiliam Shockley at the Bell Telephone Laboratories
- An electronic switch that alternately allows or does not allow electronic
signal to pass.
- it made possible the development of the "stored program" computer
 UNIVersal Automatic Computer (UNIVAC)
- Developed by Eckert and Mauchly of the Sperry-Rand Corporation which
appeared in 1951 as the fist commercially successful general-purpose, stored
program electronic digital computer.
 Computer Generations:
 First Generation Computers (1838-1958)
- Vacuum-tube devices

 Second Generation Computers (1958)

- Based on individually packaged transistors

 Third Generation Computers (1964)

- Used integrated circuts (ICs), Which consists of many transisors and other electronic
elements focuses onto a “chip” a tiny piece of semiconductor material, usually Silicon.
- Microprocessor being developed in 1971 by Ted Hoff of Intel Corporation

 Fourth Generation Computers

- Extension of the 3d Generation and incorporated a Large-Scale Integration (LSI) which has
now been replaced now with a Very Large-Scale Integration (VLSI) which places millions of
circuit elements on a chip that measures less than 1 cm.

1642 - Blaise Pascal (France): Invents first mechanical adding machine

Early 1800s - Joseph Hacquard (France): Punch cards control a weaving loom
1832 - Charles Babbage (England): INvents first general-purpose mechanical digital computer
1835 - Ada Byron (England): Punch cards used in Babbage “engine”
1890 - Herman Holleright (USA): Invents punch card tabulator used in the 1890 census.
Starts what becomes IBM
1944 - IBM builds Mark 1 mechanical computer
1946 ENIAC, first electronic general-purpose computer
1970s Integrated circuits and silicon chips
1970s - Today Personal Computers
1980s - Today World WIde Web
2000s - Today Smart Phones and Tablets

Digital Image
- Is an image that has been discretized (digitized) both in space (physical location) and in
ampliude (gray level).

Voxel (Volume Element)

- A small cube of data

Pixel (Picture Element)

- A basic picture element; a smal square in the image

Image Matrix
- An array of numbers in rows and columns

Common Digital Image Formats

 Graphics Interchange Format (GIf) (gif)
 Joint Photographic Expert Group Image (JPEG)
 Portable Network Graphics (PNG)

DICOM
-Digital Imaging and Communications in Medicine
- the internationally accepted standard used for storing, exchanging, and transmitting
medical image data
- allows imaging modalities and PACS to communicate in the same "language."
- Developed by the American College of Radiology (ACR) and the National Electrical
Manufactures Association (NEMA)
FILM DIGITIZERS
- Scans the analog film and produces numeric signals for each part of the scanned film.

- Has two major types:

* Laser-Film Digitizers
* Charge-Coupled Device (CD) Digitizers

Common Use of Digitizers

* Teleradiology
* Compare outside or old films
* Film Duplication
* Computer-Aided Diagnosis (CAD)

LASER FILM DIGITIZERS

- uses a helium neon laser beam to convert the analog film image into a digital image
- considered the gold standard for film digitization

CCD FILM DIGITIZERS

- uses fluorescent bulbs that shine through the film and a CCD array that detects the light and
transforms it into an electrical signal
- Preferred by most companies because it is less expensive compared to Laser Technology

PRINTERS
- Also called as "Imagers"
- receive an image from a workstation and print the image based on the printer LUls and
preset print layouts.
- Three main types of printers are found in a typical imaging department:
1. Plain Paper
2. Thermal
3. Film

Common uses:
* Backup
* Difficult PACS locations
* Outside Physician
* Legal Cases
* Teaching purposes

Medical Imaging Modalities

• Three Broad Types:
1. Single Image Modalities
2. Multi-Image Modalities
3. Hybrid Image Modalities

NETWORK
- provide the physical interconnections and backbone between pieces of IT
- two or more objects sharing resources and information

3 Types of Computers in a Network:

1. Server
2. Thin-Client
3. Thick-Client.

SERVERS
- devices that run centralized applications, such as the backend functionality of a PACS or
RIS, and in most cases are housed within a dedicated environment managed by the local IT
department, known as the server room.
- a system that controls access to the hardware, software, and other resources on a network
and provides a centralized storage area for programs, data, and information

Thin-Client
- is a device that is found on a network that requests services and resources from a server.
The thin-client may be another computer, a printer, or any other networkable device that
needs a server to complete its tasks. Almost any personal computer (PC) can be a client, as
long as it can be attached to the network.

Thick-Client
- is a computer that can work independently of the network and process and manage its own
files.
- networked so that it can share resources such as printing and take advantage of the
additional security available on networks through dedicated servers

Role Classification of a Network

1. Peer-to-peer network
- each computer on the network is considered equal; no computer has utimate control over
another

2. Server/Client-based Network
- (Server-based) there is a centralized computer (the server) that controls the operations,
files, and sometimes the programs of the computers (the clients) attached to the network.
- (Client-based) similar to server-based network, however, rather than sending the entire
original resource to the client for processing, the server processes the resource as requested
by the client and returns only the results back to the client

Communication Medium
- connects pieces of equipment for the transfer of files and resources

4 types of connection between devices:

1. Coaxial Cable
2. Twisted-pair Wire
3. Fiberoptic Cable
4. Wireless

Network Topology
- the physical (geometric) layout of the connected devices

4 Common Network Topology configurations

1. Bus - is a network in which all devices are physically attached to and listen for
communication on a single wire
2. Ring - is a network in which the devices are connected in a circle.
3. Star - is a network that has the devices connected to a central hub or switch. The data are
sent through the hub out to the destination device.
4. Mesh - is a network that has multiple pathways interconnecting devices and networks.

Picture Archiving and Communication System

- is a centralized computer-based system designed to manage healthcare images acquired
as part of the examination process via digital image acquisition modalities
- It provides the facility for the storage, distribution, and electronic display of the acquired
images, supporting clinical diagnostics, improving the patient journey, enhancing clinical care,
and allowing for more detailed treatment or follow-up planning

PACS Major Components:

 Image and Data Acquisition Gateway - imaging modalities (devices) OCT, MRI, US, CR,
DR, XA, etc.
 PACS Server and Archive
 Display Workstations - any computer that a health care worker uses to view a digital
image, The most interactive part of a PACS

PACS: System Architecture

- Defined as the hardware and software infrastructure of a computer system
- Normally consists of acquisition devices, storage, display workstations, and an image
management system

- Three common PACS architecture that manages the flow of images after acquisition
1. Client/Server Based Systems - images are sent directly to the archive server after
acquisition and are centrally located

Advantages:
- Any examination sent to the PACS is available anywhere without other interventions.
- Only one person can open the study with the intent to read it. Others that open the study
will receive a message that the study is open and being read.
- There is no need to pull or send historic images to a particular workstation because the old
studies are available with the new on the archive.

Disadvantages:
- The archive server is seen as a single point of failure. If the archive goes down, the entire
system is down, and no image. movement can take place. All newly acquired images must
remain at the modality until the archive is up and can again receive the images.
- The system is very network dependent. The images are flying back and forth belween the
archive and the workstations, and the network can become bogged down because of the
large volume of data being move.
- The archive server is handling many requests at once and can become bottlenecked
because of the high volume of requests.

2. Distributed Systems (Stand-alone Systems) - the acquisition modalities send the images
to a designated reading station and possibly to review stations, depending on where the order
originated

Advantages:
- If the archive server goes down, local reading at the workstations is not interrupted, other
than not being able to get historic images. Her the archive comes back up, the images that
have been changed and signedoff by the radiologist will be forwarded automaticaly bo the
arcive to besaved.
- Because the images can be distributed to many locations at once, copies of an
examination exist at various locations. Therefore it is less likely that PACS data will be lost.
- The system is less dependent on the network for its speed. The user can be working on
one examination while the workstation is puling and getting the next examination ready to be
read. The workstation can fetch historic images according to rules the user sets up.

Disadvantages:
- There is heavy reliance on the assumption that the distribution of images is being done
correctly. If the distribution is wrong, the preleching of historic examinations will not be correct
either.
- Each workstation has a different worklist, and therefore only one person can be working on
that list at a time.
- It can be inconvenient to read aditional studies; the radiologist would havetomove to
another workstation to read the images designated for thatworkstation
- The users must depend on the query-and-retrieve function when nonscheduled
examinations arrive at the workstation to be read.
- It is also possible for two radiologists to be reading the same examination and not know
that the other has it until they try to start dictation. The paper requisition is very important with
this type of PACS.
3. Web-based Systems - is very similar to a client/server system in how data flow. The
significant difference is that both the images and the application software for the client display
are held centrally

Advantages:
- The hardware at the dient can be anything that will support an appropriate web browser.
This allows for greater flexibility with hardware but can also be a disadvantage because
image displays (monitors) may not be able to support diagnostic quality.
- The same application can be used on site and at home in teleradiology situations.

Disadvantages:
- The system's functionality may be limited because the software is not installed locally. The
bandwidth of the network connection limits the amount of data that can be transmitted for
download, and some programs are too large to be transmitted over the network that is
installed.
- As with client/server systems, the network is the biggest obstacle to performance

Integration of HIS, RIS, PACS, and ePR

HIS - Hospital Information System

- is a computerized management system for handling three categories of tasks in a healthcare
environment:

1. Support clinical and medical patient care activities in the hospital.

2. Administer the hospital's daily business transactions (financial, personnel, payrl bed
census, etc.).
3. Evaluate hospital performances and costs and project the long-term forecast.

A typical HIS with two categories of software packages: business and administration, and
clinical operation. Rectangles are major components in each category

RIS - Radiology Information System

- manages general radiology patient information, from scheduling to examination to
reporting.
- The RIS maintains many types of patient and examination-related information.

 Patient-Related Information:
- Medical, Administrative, Patient Demographics, and Biling Information

 Examination-Related Information:
- Procedural descriptions and scheduling, diagnostic reporting, patient
arrival documentation, film location, film movement, and examination room
scheduling.

The major task of the system include:

- Process patient and film (image) folder records
- Monitor he status of patients, examinations, and examination resources.
- Schedule examinations.
- Create, format, and store diagnostic reports with digital signatures.
- Track film (softcopy) folders.
- Maintain timely billing information.
- Perform profile and statistics analysis.

"HL-7" - Health Level 7

- is an American National Standards Institute (ANS) accredited Standards Developing
Organization (SD0)
- It is the standard generally used in communication between the hospital information system
(IS) and the radiology information system (RIS); and the recently introduced Electronic
Medical Record (EMR)
- Common goal is to simplity the interface implementation between computer applications
from multiple vendors.

Seven-layer open systems interconnect (OSI) protocols

Layer Protocol Definition

7 Application layer Provide services to users

6 Presentation layer
5 Session Layer
4 Transport Layer
3 Network Layer
2 Data Link Layer
1 Physical Layer
Transformation of data (encryption,
compression, reformatting)
Control application running on different
workstations
Transfer of data between endpoints with
error recovery
Establish, maintain, and terminate network
connections
Medium access control-network access
(collision detection, token passing) and
network control logical links control-send and
receive data messages or packets
Hardware layer

"ІНЕ" - Integrating the Healthcare Enterprise

- exists to utilize existing standards and processes to better facilitate sharing of data between
healthcare IT systems

FHIR" - Fast Healthcare Interoperability Resources

- Is being developed to address some of the inflexibilities the traditional HL7 standards
possess by utilizing newer programming methodologies and web-based coding languages.

"EMR - Electronic Medical Record

- is either a part of the HIS or runs along with it and contains al of the patient's record,
including lab results, radiology reports, pathology results, and nurses and doctors notes
- Its purpose is to provide a computerized access to patient information

Spectrum of data Elements that comprises ER/EMR/EPR:

- Individual's medical history and current status
* Demographics
* Vital Signs,
* Lab Results
* Reports
* Medications
* Imaging Tests (e.g, Radiology, endoscopy)

Benefits:
- Improved Quality of Healthcare
- Improve Efficiency
- Reduction in Errors

WORKFLOW
- Is a term that simply means how a process is done, step by step.
- In radiology, we have always used the term workflow to describe how we complete an
examination from order entry to transcribed report.

Film-based workflow
Order-entry - patients information and request for examination
Exam performed - passed to the radiographer to take examination
Film processed
Film interpreted - passed to the radiologist for interpretation of image
Transcribed report - radiologist passed the interpreted report to be transcribed

PACS-based workflow
Order-entry
Exam performed
Image processed
Image interpreted - passed to the radiologist with the use of PACS system
Transcribed report

Master Patient Index (MPI)

- Also commonly known as the HIS or PAS (Patient Information System)
- A database application, which primarily stores the demographic and contact details of
patients, as well as any national identifiers

Order Communication System (OCS)

-Also known as eRequesting System; allow referrers to place requests for a range of
diagnostic tests (including radiology examinations) into a single online application, which then
directly sends the request to the relevant department, removing the paper transit delay' and
potential for loss/ misdirection

Electronic Patient Record (EPR)

- is a method of storing a patient's medical records and notes electronically rather than in
bound paper bundles, which are difficult to search (and sometimes read)

Advantage of Integrating HIS, RIS and v:

- A more complete patient record
- Increased consistency, accuracy, and availability of information
- Automation of mundane and error-prone activities
- Reduce data entry errors
- Lower costs
- Increased quality of care
- Better outcomes

INFRASTRUCTURE OPTIONS/DECISION

Single System Encompassing All

- One supplier providing the majority of the components (from MPI to RIS) individually (or as a
single system) would result in seamless communications, simply because the data will be
stored on fewer databases (perhaps even
just one)

Point-to-Point Model

- multiple systems have direct connections to each other and thus have no single point of
failure, which could also occur with the
single system (the individual components, Such as RIS/PACS or LIMS, can continue to
operate if other sections of the system are
unavailable)

Hub-and-Spoke Model

— links the various systems, reducing the need to maintain each connection as for the point-
to-point model
- main point of failure becoming the actual integration engine
KEY BUILDING BLOCKS OF INTEROPERABILITY

Patient ID
—Patient identifier (single) to avoid confusion due to muliple identifiers

Open Application Program Interfaces

—Open and fully documented Application Program Interface (API) that conforms to eriting
guidance to allow relevant information to be made available

Best Practice
—Benefit of achieving interoperability is present such as flow of meaningful data for clinical
and administrative process), the ability to redesign process, monitor quality including patient
safety), and being able to retrieve data from frozen legacy systems

Current common information flow for patient needing diagnostics:

1. Initial patient interactions.
2. Clinician and patient interactions.
3. Diagnostic interactions.
4. Results.
5. Results distribution and further collaborative steps

HISTORICALDEVELOPMENTOFMEDICALIMAGING

COMPUTED TOMOGRAPHY
 CT brought about the coupling of the computer and imaging devices.
 The earliest CT unit built by Hounsfield took several hours to acquire a single slice of
information. The machine then took a few days to reconstruct the raw data into a
recognizable image.
 The first commercial CT scanners built were made to image the head only.

MAGNETIC RESONANCE IMAGING (MRI)

 Was introduced commercially for health care use in the early 1980s.
 Several companies began pioneering efforts in the mid to late 1970s after the publication
of an article by Paul Lauterbur in 1973.
 Many scientists and researchers were involved in the development of the MRI as we
know it today.

Fluoroscopy
 Saw many advances during the 1970s as well thanks to the advances in computer
technology Analog-to-digital converters made it possible to see the dynamic (real- time)
image on a television monitor in higher resolution and to store the frames digitally on a
computer.

ULTRASOUND AND NUCMED

 Ultrasound and nuclear medicine were easy converts to the digital world early on
because the images created in these modalities were simply frame-grabbed (the current
image on the screen is captured and sent as an image file) and converted to a digital
image. Improved image quality in computed radiography (CR) and digital radiography
opened the way for mammography to con- vert to a digital format.

PICTURE ARCHIVAL AND COMMUNICATION SYSTEM (pacs)

 The advent of the 21st century has brought forth a total revolution in medical imaging.
 Radiology adopted digital imaging very rapidly so that today all medical images are
digital. The term digital image is being sustained with DR. Further, the Department of
Radiology is being replaced with the Medical Imaging Department.

ELECTRONIC PROGRAMS
 In earlier times, the RT was primarily responsible for the chemical processing of film and
positioning the film (hanging) for the radiologist to interpret.
 The radiologist is ultimately responsible for the interpretation of medical images, but each
of the other members of the team, has specific responsibilities.
 RIS deals with schedules, protocol descriptors, diagnostic conclusions, and billing. PACS
deals strictly with image manipulation and document storage.

Electronic Medical Imaging Programs:

 ACR-AAPM-SIIM TECHNICAL STANDARD
 DICOM - DIGITAL IMAGING AND COMMUNICATION
 CAD - COMPUTER-AIDED DETECTION/DIAGNOSES
 EMR - ELECTRONIC MEDICAL RECORD
 HIS - HOSPITAL INFORMATION SYSTEM
 HL7 - HEALTH LEVEL SEVEN
 IAC - INTERSOCIETAL ACCREDITATION COMMISSION
 IHE - INTEGRATING THE HEALTHCARE ENTERPRISE
 PACS - PICTURE ARCHIVAL AND COMMUNICATION SYSTEMS
 RIS - RADIOLOGY INFORMATION SYSTEM

PACS -Picture Archival and Communication System

- is a networked group of computers, servers, and archives that can be used to manage
digital images
- serves as the file room, reading room, duplicator, and courier.
- can provide image access to multiple users at the same time, on-demand images, electronic
annotation of images, and specialty image processing

RIS - Radiology Information System

- holds all radiology-specific patient data, from the patient scheduling information to the
radiologists dictated and transcribed report.

4 COMPONENTS OF PACS

IMAGE ACQUISITION SYSTEM

DISPLAY SYSTEM
STORAGE SYSTEM
NETWORK

NETWORK
- To be truly effective, each of these image-processing modes must be quick and easy to use.
This requires that each workstation must be microprocessor controlled and must interact with
each imaging system and with the central computer. To provide for such interaction, a
NETWORK is required.

Computer scientists use the term network to describe the manner in which many computers
can be connected to interact with one another.

TELERADIOLOGY
- the process of remote transmission and viewing of medical image
 the American College of Radiology (ACR), in cooperation with the National Electrical
Manufacturers Association (NEMA), has produced a standard imaging and interface
format called Digital Imaging and Communications in Medicine (DICOM).

DICOM -Digital Imaging and Communications in Medicine

- the internationally accepted standard used for storing, exchanging, and transmitting medical
image data
- allows imaging modalities and PACS to communicate in the same "language.
 Instead of running films up to surgery for viewing on a viewbox, one simply transfers the
image electronically to the PACS workstation in surgery
 From the RIS workstation, any number of coded diagnostic reports can be initiated and
transferred to a secretarial workstation for report generation.
 The moment a patient reports to any reception desk anywhere in the facility, the process
of recovering archived records commences automatically.
 A secretarial workstation at the departmental reception desk can interact with a
departmental computer for scheduling of patients, technologists, and radiologists and for
analysis of departmental statistics.
 Finally,at the completion of an examination, PACS allows for more efficient image
archiving.Many applications now exist for electronic notepads and mobile phones that
allow these devices to serve as viewing stations.

STORAGE SYSTEM

 Just the cost of the hospital space to accommodate a film file room is sufficient to justify
PACS.
 Image storage requirements are determined by the number of images and the image
data file size. Image file size is the product of the matrix size and the grayscale bit depth.

Approximate Digital File Size for Various Medical Images

Medical Image Image Size (MB) Examination Size (MB)

Nuclear medicine 0.25 5
Diagnostic ultrasonography 0.25 8
Magnetic resonance imaging 0.25 12
Computed tomography 0.5 20
Digital radiography 5 20
Digital mammography 10 60

 One of the disappointing features of PACS/RIS applications in medical imaging is the

reduced, if not totally absent, face time between the radiologist and the RhT.

ELECTRONIC MEDICAL RECORDS

 When the patient checks into the hospital or other health care facility, a document is
prepared in order to properly identify the patient.
 Incorporated with a similar docu-ment, the Hospital Information System (HIS), which is
integrated with other hospital sections for information transfer and storage.
 RIS is specific within radiology and requires PACS. HIS is the principal component of the
EMR
 A new patient upon arrival will be registered in the EMR, which may, if appropriate, lodge
a request for a medical image. Such a request is relayed to the RIS, where a specific
protocol, the Protocol Worklist, is opened and the request filed with a specific Imaging
Modality Worklist.
Informatics Communication

 The requirement for efficient communication among various computers and physical
sites is managed by the DICOM standard and the Health Level Seven (HL7) standard.
 Integrating the Healthcare Enterprise (IHE) is a project that manages these connections,

DICOM - Digital Imaging and Communications in Medicine

 Allows imaging modalities and PACS to communicate in the same "Language."
 The DICOM image header metadata is specific for each type of imaging modality, and
the RT should become familiar with such information, as shown in Fig. 18.5. Much of the
header metadata is automatic, but some are input by the RT.

MEDICAL INFORMATION ORGANIZATIONS

 The standardized approach to medical imaging electronic programs is continually
improved by the efforts of organizations dedicated to the standardization of vocabulary.
The goal is for constancy and uniformity in describing medical symptoms, procedures,
and results.
 Standardized vocabulary, the lexicon, and standardized term relationships, the ontology,
are undergoing constant development.
 The Current Procedural Terminology (CPT codes) is a lexicon developed by the
American Medical Association (AMA), which now numbers over 15,000 items.Each CPT
code refers to a specific clinical situation. Personnel identified as coders in the billing
office deal with CPT codes to produce the patient bill.
 The International Classification of Diseases (ICD) codes were developed by the Center
for Medicare and Medicaid Services (CMS) for identifying disease and symptoms of
disease.
 RadLex is a recent creation of the RSNA (Radiological Society of North America).
 Imaging modality vendors must pledge conformance with the evolving DICOM standard.
 Consider the ACR Dose Index Registry as we continually work to make patient radiation
dose ALARA (as low as reasonably achievable).

RADIOLOGIC TECHNOLOGIST RESPONSIBILITIES

 The American College of Radiology (ACR), American Association of Physicists in
Medicine (AAPM), and Society for Imaging Informatics in Medicine (SIIM) have
collaborated to create "The Technical Standard for Electronic Practice of Medical
Imaging, " emphasizing the radiologist's responsibility for image acquisition and
interpretation tasks. (Fig. 18.1)
 Regardless of the tasks associated with image acquisition and interpretation, the
radiologist is responsible for every step in the process and the personnel actions
required.
 During earlier years, an RT would aspire, with age and experience, to be promoted to the
position of Chief Technologist. The Chief Technologist was the department administrator,
but that position has been abandoned to the job of Department Administrator, which is
now filled by someone with an Masters of Business Administration (MBA), educated in
the administration of a medical department.
 An RT can now become an RA (Radiology Assistant) and work more closely with the
radiologist in implementing all of the areas previously described for electronic imaging.
 An RA does not perform examinations on the various imaging modalities. Rather, the RA
helps the radiologist make better use of time by managing patients through the imaging
procedure and assisting in the PACS/RIS read by the radiologist.
 The RA must be well versed in PACS/RIS and DICOM.
 The RT is principally engaged in performing the examination on the various imaging
modalities. This requires skill in both operating the imaging modality but also managing
the PACS/RIS electronic data and images. Both the RA and RT must be credentialed by
the Philippine Association of Radiologic Technologist (PART)
 Using PACS/RIS with digital imaging, the workflow chart is greatly reduced. This leads to
greatly improved imaging efficiency.