Henry Ford
Health System
RADIOLOGY RESEARCH
PACS, HIS, and RIS
What Does a Physicist
Need to Know?
Michael Flynn
Department of Radiology
mikef@rad.hfh.edu
Outline
Or rather,
‘What might a Physicist want to know’.
Radiological Terminology
• Workflow Improvement
• Network Architecture
• Storage Technology
•
AAPM 2004
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Part 1.
Radiological Terminology
Radiology has evolved a highly
standardized lexicon of terms to
describe the body parts and procedures
used in medical imaging examinations.
AAPM 2004
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DICOM Part 16
PS 3.16-2003
Digital Imaging and Communications in Medicine (DICOM)
Part 16: Content Mapping Resource
Published by
National Electrical Manufacturers Association
1300 N. 17th Street
Rosslyn, Virginia 22209 USA
© Copyright 2003
306 Pages
http://medical.nema.org/dicom/2003/03_16PU.PDF
AAPM 2004
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3.16 Context ID tables
Context ID 6103
Context
6011
AbnormalContext
LinesIDIDFinding
or Feature
18
Calcification
Types
from BI-RADS®
Type:Context
Extensible
Version:
20020904
ID
7
Isotopes
in
Radiopharmaceuticals
Type:
Extensible
Version:
20020904
Context
4012
Note: Original
source
ofIDterms
isPath
[Fraser
and Pare].
Ultrasound
Beam
Type:
Extensible
Version:
20020904
Context
ID
4010
Note:
From
BI-RADS®
ThirdValue
EditionName
Projection
Eponymous
Coding
Scheme
Code
Code Meaning
Type:
Extensible
Version: 20020904
Context
ID
4009
DX
View
Coding
Scheme
Code
Value20020904
Code
Meaning
Type:
Extensible
Version:
(0008,0102)
(0008,0104)
Context
ID(0008,0100)
4 Images
DX
Anatomy
Type: Extensible
Version:
Coding
Scheme
Code
Value20020904
Code
Meaning
(0008,0102)
(0008,0100)
(0008,0104)
Type:
Extensible
Version:
20020904
Coding
Scheme
Anatomic
Code
Region
Value
Code
Meaning
(0008,0102)
(0008,0100)
(0008,0104)
DCM
112065
Reticulonodular pattern
Coding
Scheme
Code
Value
Code
Meaning
(0008,0102)
(0008,0100)
(0008,0104)
Type:
Extensible
Version:
20020904
SRT
F-01762
Dystrophic
calcification
Coding
Scheme
Code
Value
Code
Meaning
(0008,0102)
(0008,0100)
(0008,0104)
DCM
112104
Air-fluid
level
Coding
Scheme
Code
Value
Code
Meaning
SNM3
C-111A1
^18^Fluorine
(0008,0102)
(0008,0100)
(0008,0104)
SRT
F-01763
Eggshell
calcification
DCM
112105
Corona
radiata
SNM3
G-A1A9
Trans-hepatic
(0008,0102)
(0008,0100)
(0008,0104)
SNM3Code ValueC-114A4
^123^Iodine
Coding Scheme
Code Meaning
SRT
F-01767
Punctate
calcification
SNM3
R-10269
Caldwell
DCM
112106
Honeycomb
pattern
SNM3
G-A1B2
Trans-gastric
SNM3
C-114A6
^125^Iodine
(0008,0102)
(0008,0100)
(0008,0104)
SNM3
R-10226
lateral
oblique
SRT
F-01769
Calcified
skin
of breast
SNM3
R-1026A
Camp-Coventry
SNM3
DCM
T-26000
112110
Bronchus
Kerley
B
line
SNM3
G-A1A5
Trans-pleural
SNM3
C-114B1
^131^Iodine
SNM3
R-10228
lateral-medial
SRT
F-0176A
Calcified
suture
material
SNM3
R-10279
Grashey
SNM3SNM3
DCM
T-24100
112113
Larynx
Reticular
pattern
G-A1B3
Trans-mural
SNM3
T-04000
Breast
SNM3
C-122A5
^133^Barium
SNM3
R-10230
medial
obliquecalcification
SRT
F-0176B
Vascular
SNM3
R-10283
Judd
SNM3
T-D3300
Mediastinum
SNM3
G-A1A8
Trans-orbital
SNM3
Wristright
joint
SNM3 T-15460
C-131A2
^67^Gallium
SNM3
R-10232
lateral
SNM3
R-10297
Merchant
SNM3SNM3 T-15750
T-32000
Heart
G-A1A6 Ankle
Trans-pancreatic
SNM3
joint
SNM3
R-10234
right
oblique
SNM3
R-102AB
Towne
SNM3
T-D1600
Neck
SNM3
T-21000
Noseleft lateral
SNM3
R-10236
SNM3
T-11210
Sternum
SNM3
T-24100
Larynx
SNM3
T-25000
Trachea
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3.16 Normative References (selected)
• SNOMED
The Systematized Nomenclature of Medicine Clinical Terms,
© 1999 College of American Pathologists (CAP).
• BI-RADS®
BI-RADS® Third Edition, Addendum 3.1 (lexicon of
Mammography screening terminology and Nomenclature),
American College of Radiology.
• Fraser and Pare
“Terms Used in Chest Radiology” and “Terms For CT of the
Lungs”, from Fraser and Pare’s Diagnosis of Diseases of the
Chest, Fourth Edition, Volume I
• ACR Standards
Performance of Pediatric and Adult Chest Radiography
Perf. of CT for Detection of Pulmonary Embolism in Adults
AAPM 2004
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Consistent Terminology
• Consistent terminology allows studies to
be accessed based on database entries
derived from the DICOM object.
• Newer DICOM objects require the code
value in addition to the meaning for
terms associated with a context ID.
• The availability of these code values
facilitates database management.
• However, the persistence of older
DICOM objects that do not have
standardized terminology prevents
consistent access to prior studies.
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A database alternative
• At HFHS, when an
imaging study is received
by the PACS archive, the
accession number is used
to match the study with
the order.
• A table of Body Part,
Modality, and Workgroup
(BMW table) versus
order code is then used
to consistently assign
the anatomical region to
the imaging study.
AAPM 2004
DCM-Image
ACC#
ACC#
RIS-Orders
…
…
DOB
MRN
…
…
ACC#
ORBITS
Body Part
…
…
…
…
NAME
…..
RIS-BMW
Order
BodyPart Mod Workgrp
…
…
…
…
…
…
…
…
ORBITS
ORBIT
CR
Neuro
CTORBW
ORBIT
CT
Neuro
MRORBW
ORBIT
MR
Neuro
…
…
…
…
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HFHS Body Part Terms
All body part terms in the RIS database table
are derived from DICOM PS 3.16 terminology
Database Terms
(Image Suite)
Code (4)
Term (10)
HAND
FING
ELBO
HUME
SHOU
ARM
CLAV
…
Hand
Fingers
Elbow
Humerus
Shoulder
Arm
Clavicle
…
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DICOM PS 3.16-2001
DX Anatomy Imaged
(Snomed terms, SNM3)
Code Val. Code Meaning
T-D8700
T-D8800
T-D8300
T-12410
T-D2220
T-D8200
T-12310
…
Hand
Finger
Elbow
Humerus
Shoulder
Arm
Clavicle
…
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Part 2.
Workflow Optimization
Information technologies offer
opportunities to alter the work
processes used in Radiology and
improve productivity.
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Radiology Meta-Processes
Players :
• Care givers
Diagnostic Radiology practice
involves a small number of well
understood meta-processes
• Receptionists
• Technologists
• Radiologists
• Transcriptionists
• Physicists
• Informaticists
ORDER
REPORT
SCHEDULE
INTERPRET
EXAMINE
PATIENT
CREATE
IMAGE
RECORDS
Objects:
• Forms
• Cassettes
• Films
• Computer files
•Images
•Reports
•Values
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IHE profiles
IHE defines specific profiles for
improving workflow by integrating image
and information systems in Radiology
IHE Radiology Technical Framework
ORDER
REPORT
SCHEDULE
INTERPRET
EX AMINE
P ATIENT
CREATE
IMAGE
RECORDS
Integration Profiles :
(SWF) Scheduled Workflow
(CPI)
(KIN)
Consistent Presentation of Images
Key Image Note
(PIR)
Patient Information Reconciliation
(ARI) Access to Radiology Information
(SINR) Simple Image and Numeric Rpt.
(CHG) Charge Posting
(RID)
AAPM 2004
Retrieve Information for Display
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IHE
• The ‘Integrating the Healthcare Enterprise’
(IHE) initiative defines a consensus effort and
framework for integrating information systems
in a healthcare environment.
• Joint effort:
Radiological Society of North America (RSNA)
• Healthcare Information and Management
Systems Society (HIMSS)
•
• Since 2000, the IHE has demonstrated progress
at the RSNA and HIMSS annual meetings.
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Modality Communication Processes
HFHS DICOM
Radiology RIS-PACS
Supported Services
•Modality Worklist
• All modalities
• Patient oriented
• accession #
RIS
RPT
PAC
•Image Send
Not Supported
•PPS complete
•PPS commit
•Key Img Note
Query
LIST
IMG
90 Modalities
AAPM 2004
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DICOM MWL
The MWL services on both the modality and
the server must be consistently configured
• Patient oriented query
• Worklist oriented query
• MWL Query Keys
W• (0040,0001)ae Scheduled Station AE Title
W• (0040,0002)ae Scheduled Procedure Step Start Date
W• (0040,0003)e Scheduled Procedure Step Start Time
P • (0040,0010)e Scheduled Station Name
P • (0008,0050)ae Accession Number
(0010,0010)ae
P • (0010,0020)ae
P • (0008,0060)ae
W
• (0040,0006)a
•
AAPM 2004
Patient’s Name, last^first
Patient ID
Modality
Scheduled Performing Phys. Name
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MPPS and KIN
• DICOM Modality Performed Procedure Step (MPPS)
Modality to RIS transactions
• Modality Procedure Step in Progress
• Modality Procedure Step Completed
•
• DICOM Key object selection document
Modality to PACS transaction
• IHE Key Image Note (KIN) profile
• Example: Technologists attaches a note to a chest
2 view study indicating that the patient
has an amputated arm and the stub
appears in the lateral view.
•
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HIS Communication Processes
HFHS IS
550 Clinical HIS Stations
REG
ADT
Report
RIS-PACS
Images
HL7
• Registration, ADT
• Report text
EMR
RIS
Query
RPT
LIST
PAC
IMG
WEB
• Images
• Reports
AAPM 2004
90 Modalities
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RAD Communication Processes
HFHS IS
51 RAD Reading
550 Clinical HIS Stations
REG
EMR
ADT
Images
Report
RIS-PACS
List
Radiology
Reading
Stations
• Exam List
• Images
• VR report
AAPM 2004
RIS
RPT
Images
PAC
VR Rpt
Query
LIST
IMG
90 Modalities
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Order Entry Processes
HFHS IS
51 RAD Reading
550 Clinical HIS Stations
REG
ADT
Images
EMR
Report
RIS-PACS
List
Order
RIS
RPT
Images
PAC
Complete
VR Rpt
Query
LIST
IMG
RIS Stations
RIS Orders
AAPM 2004
90 Modalities
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Order Entry Processes
HFHS IS
51 RAD Reading
550 Clinical HIS Stations
REG
ADT
Images
EMR
Report
RIS-PACS
List
Order
RIS
RPT
Images
PAC
Complete
VR Rpt
Query
LIST
IMG
HIS - Orders
AAPM 2004
90 Modalities
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Part 3.
Network Architecture
The design and performance of
computer networks has significantly
changed over the last 10 years.
AAPM 2004
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Technology Gartner #1
Gartner analysts list of
10 predictions that will
impact enterprise businesses.
1. Bandwidth will be more cost effective than computing
Network capacity will increase faster than computing,
memory and storage capacity to produce a major shift
in the relative cost of remote versus local computing.
Cheap and plentiful bandwidth will catalyze a move
toward more centralized network services, using grid
computing models and thin clients.
Ten predictions to shake your world
AAPM 2004
By Dan Farber, Tech Update
October 10, 2002
22
Enterprise
Network
Architecture
|
|
|
WAN
ARCHIVE
DATABASE
Disaster recovery
•
•
•
Central Storage
Integrated RIS
On-demand access
CT
HIS
ARCHIVE
MR
DATABASE
CR
HFH LAN
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HFHS Wide Area Network (PACS)
OC3 – 150 Mbps IP
100 PACS
DS3 – 45 Mbps
Voice,IPX
DS3 – 45 Mbps
PACS
2 T1 – 3 Mbps
PACS
Corp.
IT
STH
WBL
LKS
FRL
1FP
LIV
TAY
HFH
DNW
•
•
All large centers are directly connected to the Main Campus HFH
PACS facility using synchronous optical network (SONET) service.
Alternative communication channels through the corporate IT
facility provide are utilized if the direct channel fails.
AAPM 2004
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Stentor iSyntax (Dynamic Transfer Syntax)
Dicom processors convert modality data to
compressed coefficients that are stored in cache
units while migrating to the central archive.
D
TAY
D
LIV
D
Dnw
D – DICOM Proc.
C – Cache Store
S – Archive Store
D
AAPM 2004
STH
C
D
D
FRL
D
D
D
C
C
D
D
C
D
D
C
S
WBL
S
S
S
HFH
LKS
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Suburban Network Configuration
OC3
OC3
S
– Multiservice Switch
R
– Building Router
PACS – Radiology router
S
R
PACS
100 Mb/s
1 Gb/s
• The large suburban clinics use a dedicate router
for Modalities, Workstations, and Storage units
• The PACS router is connected using dual fiber to
the building router that similarly connect to the
switch servicing the OC3 connection.
AAPM 2004
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Main Campus Network
Redundant fiber
connected routers.
OC3
OC3
S
R
PACS
PACS
modalities
and work
stations
16 PACS
Routers
AAPM 2004
OC3
Fiber
Cluster
1G/100M
27
Network management
Nodes: servers, workstations,
routers, switches, hubs etc.
• SNMP is the Internet standard protocol
developed to manage nodes on an IP network.
• SNMP enables network administrators to
manage network performance, find and solve
network problems, and plan for network growth.
• Numerous commercial and public domain
software applications and toolkits are available.
MSU Radiology
switch traffic
graphed updated
every 5 minutes
using MRTG
AAPM 2004
http://www.snmplink.org/
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Phys. Rev. Letters – Jan 2004
Argollo recently evaluated internet traffic
dynamics in relation to other natural
processes to demonstrate a unique scaling law
that relates fluctuations to average flux.
AAPM 2004
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Phys. Rev. Letters – Jan 2004 – Fig 1a
(a) Time dependent traffic on three Internet routers of the MidAtlantic Crossroads network, whose activity is monitored by the
Multi Router Traffic Grapher software (MRTG). The figure
shows the number of bytes per second for each of the routers in 5
min intervals for a two day period.
AAPM 2004
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Phys. Rev. Letters – Jan 2004 – Fig 1b
(b) Streamflow, measured in cubic feet per second, on three rivers in
the U.S. river basin, based on data collected by the U.S.
Geological Survey in 2001.
AAPM 2004
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PACS performance
Facility
PACS apps.
monitor the
total network
data rate
from a
modality to
the storage
server and
from the
server to a
workstations
Net
MB/s
Sec/CR
Main Campus
LAN
7–9
.5
Fairlane
OC3
7–9
.5
W. Bloomfield OC3
7–9
.5
Lakeside
OC3
7–9
.5
Sterling Hts.
DS3
2.5 – 3.5
1.3
Taylor
2 T1
.25 - .35
13
Livonia
2 T1
.30 - .35
12
Detroit N.W.
2 T1
.25 - .35
13
Acquisition and Radiology Display.
Acquisition and Clinical Display.
AAPM 2004
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Part 4.
Storage Technology
Similarly, rapid change in the design
and performance of storage devices
impacts our approach to long term
image archival and disaster recovery.
AAPM 2004
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Technology – price of storage
x ½ per yr
IBM, Grochowski, Almaden
Jul
Dec
IDE DRIVEs $ 1,500
650 USD/TB
USD/TB $.0006
$.0015 USD/MB
USD/MB
2002
2004
$10,000USD/TB
USD/TB $.0062
$.0100 USD/MB
USD/MB34
AAPM 2004SCSI RAID5 $6,250
Computers: 1982 to 2002
20 years
1/30 th the cost
500 times more disk storage
250 times more memory
900 times faster processor
Circa 1982
VAX 11/780
IBM xseries 345
Purdue Univ.*
HFHS Radiology
$250,000
AAPM 2004
Circa 2002
$8,000
3 x 300 MB disks
6 x 73 GB disks
8 MB memory
2 GB memory
5 Mhz VAX
2 x 2.2 Ghz Xeon
* Purdue University
Tech. Report TR-EE 81-31
35
AAPM 2004
Intro – computer power/cost
Hans Moravec
Robotics Institute
Carnegie Mellon University
36
Technology Gartner #6
Gartner analysts list of
10 predictions that will
impact enterprise businesses.
6. Moore's Law continues to hold true through this decade
Gartner gives Moore's Law, which says that cpu power
doubles every 24 months, a 70% chance to continue
through 2011. Gartner projects that the typical desktop
computer in 2008 will have:
4 to 8 CPUs running at 40 GHz,
4 to 12 gigabytes of RAM,
1.5 terabytes of storage,
and 100Gbit LAN technology.
By 2011 - 150 GHz CPUs and have 6 TB of storage.
AAPM 2004
Ten predictions to shake your world
By Dan Farber, Tech Update
October 10, 2002
37
Technology Gartner 9 & 10
Gartner analysts list of
10 predictions that will
impact enterprise businesses.
9. Business units, not IT, will make most application decisions
Gartner says that business units, rather than centralized
IT departments, will make decisions on applications. By
2007, this trend has a 70 percent probability of governing
purchasing in 65 percent of enterprises.
10. Pendulum swings back from centralized to decentralized
Gartner predicts the focus on more centralized IT during
this time of economic contraction will shift by 2004 to a
more decentralized model.
Ten predictions to shake your world
AAPM 2004
By Dan Farber, Tech Update
October 10, 2002
38
Technology
change
1964
• Continuous rapid
improvement in
price/performance makes
computerized technology
markedly different than
other technologies.
• Developers, purchasers,
and operators of medical
PACS system must
understand and plan for
technology change.
1984
2002
1981
Porsche 911
3.3L Turbo
300 hp
260 km/hr
2001
Porsche 996
3.6L Turbo
415 hp
305 km/hr
AAPM 2004
39
Outline
‘What might a Physicist want to know’.
Radiological Terminology
• Workflow Improvement
• Network Architecture
• Storage Technology
•
AAPM 2004
40