Dr. David Hareva
Medical Informatics
ITT Telkom, 24 September 2011
What is Telemedicine & Teleradiology?
Teleradiology
Medicine
Clinical
Genomics
Medical
Informatics
Biomedical
Informatics
Telemedicine
Telemedicine
informatics
Genomics
Communications
Bioinformatics
Telematics
Informatics
Definition of Telemedicine
Telemedicine may be defined as the use of electronic
information and telecommunications technologies to
support
 long-distance clinical healthcare,
 patient and professional health-related education,
 public health and
 health administration.
Nihal FG and Elif DU. Theory and Applications of Telemedicine. Journal of Medical Systems, Vol. 26, No. 3, June 2002
Specialties in telemedicine
Specialties that use telemedicine often use a 'tele-'
prefix;
Fix line, wireless, microwave,
Tele Tele-radiology
satellite, mobile network.
Security
Communication
 Tele-cardiology
+
Modalities of Medical Imaging
 Tele-psychiatry
(X-Ray, Ultrasound, CT, MRI, etc) and
Radiology
Data acquisition.
 Tele-pharmacy
+
 etc
DICOM and PACS
Informatics
Image Processing/Analysis
Image compressing
What is Teleradiology?
 Teleradiology is the
transmission of radiologic
images from a site of image
acquisition to a remote
location for interpretation.
 Today, image transmission
depends primarily on highspeed electronic
communication networks,
such as an ATM or the
internet, which enable the
rapid transmission of digital
images without loss of
content or resolution.
Why is teleradioogy necessary?
 Teleradiology provides a means to provide rapid diagnosis and report
turnaround for radiological examinations acquired locally or
transmitted to a radiologist from anywhere in the world.
 At Hospital for Special Surgery (HSS), teleradiology has been employed
to provide improved and timely care to patients imaged at a hospital, as
well as to provide our radiology subspecialty expertise in orthopaedic
and rheumatologic conditions.
 Through teleradiology services the musculoskeletal imaging and
diagnosis can be network with orthopaedic centers or expanded
worldwide with other hospitals in the world to maximize the diagnostic
information needed to treat their patients.
 With the constant improvement of digital imaging modalities, the role
of teleradiology will continue to expand in the future, enabling expert
diagnostic interpretation by HSS radiologists around the globe or
around the corner.
How is teleradiology performed?
 The interpretation of digital images, whether MRI, CT,
ultrasound or conventional x-ray images, acquired digitally
e.g. computed radiography (CR) or direct radiography
(DR), is accomplished utilizing workstations with highresolution monitors.
 Each workstation is part of an image management
network, which also has access to image archives and
patient databases.
 Current computer software innovations provide the
capacity to transmit and receive images from outside a
medical facility while maintaining image security and
patient confidentiality.
Modalities of image acquisition
 Computed Tomography (CT)
 Radiographic (X-ray)
 Ultrasound
 Magnetic Resonance Imaging (MRI)
 Nuclear Medicine Imaging (NMI)
 etc
Radiographic (X-ray)
 Function: It is a painless test used by
medical professionals to help
diagnose and treat a wide range of
medical problems.
 Feature: An X-ray uses
electromagnetic radiation (shorter
wavelength) to take photo like images
of different areas of the human body.
 X-rays, demonstrate body structures
proportionally with their density ,
bone (high body tissue density) which
is white and fat(low density) which is
gray or air (no density) which is black.
 Benefits: X-ray is the fastest and
easiest way to assess sprains, torn
muscles and broken bones.
Computer Tomographic (CT)
 Function: It good for bone spine and
joints abnormalities (abdomen, pelvis or
head), bony structures, joints, soft tissue
structures, and soft tissue calcifications.
 Feature: A type of x-ray examination
using a thin x-ray beam with a series of
detectors that are contained in a
doughnut shaped machine.
 Benefits: still digital x-rays with multiple
shots without movement or noise
disturbances.
 Cons: cost involved with digital x-ray is
twice x-ray film. Some CT examinations
will require an injection of an iodinated
contrast agent into your vein.
Magnetic Resonance Imaging (MRI)
 Function: MRI scans can be used to
diagnose tumors, strokes and torn
ligaments. Many MRIs are done on the
head to determine the cause of
headaches, nervous system problems or
developmental disorders of the brain.
 Feature: MRI is a diagnostic test that
depicts both soft tissue and bone. MRI
depicts soft tissue injury and
abnormalities with greater sensitivity
and specificity than x-ray even CT.
 Benefits: MRI scans are better than Xrays at showing soft tissue, showing
inflammation, detailing blood vessels
and creating cross-sectional pictures.
In addition, the patient is not subjected
to any radiation.
Ultrasound (sonography)
 Function: The ultrasound waves enable
things inside the body to be measured, such
as fetuses, gallstones, kidney stones, cysts or
other growths.
 Features: The probe sends out sound
waves, and receives their echos. The
sonographic scanner, which interprets the
echos to determine the size, shape, depth
and what the internal object is made of
(fluid, solid).
 Benefits: non-invasive and non-radiation
tool for diagnostics. An ultrasound is able to
capture more information about soft tissue
than an x-ray scan, though it has trouble
with harder tissue such as bone.
Ultrasounds are also readily available, and
less expensive than other diagnostic or
treatment options.
3D/4D
ultrasound
Nuclear Medicine Imaging (NMI)
 Function: a bone scan, lung scan, cancer scan, gallium scan or Indium
III WBC scan
 Features: A nuclear medicine examination relies on specific
radioactive isotopes to detect specific suspected pathology. Nuclear
materials called radiopharmaceuticals are either injected, ingested or
inhaled. They travel through the body and cause the organs to release
gamma rays. These rays illuminate the organs or bones, and make them
easily observable by a special gamma camera.
 Benefits: This exam is used
mainly to allow evaluation of
organs and regions within
organs that cannot be seen or
tested on conventional X-Ray
images.
Digital mammography
 Function: the early detection of
breast cancer, typically through
detection of characteristic masses
and / or microcalcifications.
 Feature: is the process of using
low-energy-X-rays (usually around
30 kVp) to examine the human
breast and is used as a diagnostic
and a screening tool.
 Benefits: low radiation. Most
doctors believe that mammography
reduces deaths from breast cancer,
although a minority do not.
X-Ray/
CT
Ultrasound
Nuclear
(+) excellent
(–) no,
(+) except for
heart
(+) growing
(+) extensive use
cardiac
in heart
applications
(+) widely used
(+) excellent
(+) excellent,
(–) problems
with gas
Merge w/ CT
(+) minor role
(+) widely used
(–) bleeding,
trauma
(–) poor
(+) PET
(+) standard
Chest
(+) widely used
Abdomen
Head
Cardiovascu(+) X-ray
lar
Skeletal /
Muscular
(+) strong for
skeletal system
(+) real-time,
(+) Excellent,
(+) functional
non-invasive,
with (-) catheterinformation on
cheap, (–) but,
injected contrast
perfusion
poorer images
(+) strong for
skeletal system
MR
(+) getting better
High resolution
Myocardium
viability
(–) not used
(+) Research in (+) functional (-)
(+) excellent
elastography
bone marrow
How are plain film (standard
radiograph) images captured?
 Standard radiographs can be digitized by either a video camera or a film
scanner.
 Video cameras (commonly referred to as a "camera on a stick") were in fact the
method of digitizing any image for transmission as recently as about 15 years
ago.
 Typical camera systems utilize a light box designed to illuminate radiographs,
an extension arm for holding the camera above the film, and a high-sensitivity
video camera with a zoom lens.
This is an inexpensive but poor-quality method of image acquisition.
 Film scanners and digitizers arrived on the teleradiology scene about 10 years
ago. There are two basic types of film scanners:
 CCD (charge coupled device) digitizers and
 laser digitizers.
Over the past few years, and today high quality CCD digitizers produce images as
good as (or nearly as good as) top-of-the-line laser digitizers.
The major difference between images produced with laser digitizers and CCD
digitizers is in the optical density captured from the film.
DICOM and PACS
 DICOM
(Digital
Imaging
and
Communications in Medicine) is a
standard for handling, storing, printing,
and transmitting (TCP/IP) information in
medical imaging. It consists of a number
of attributes, including items such as
name, ID, etc., and also one special
attribute containing the image pixel data.
 Pixel data can be compressed using a
variety of standards, including JPEG,
JPEG Lossless, JPEG 2000, and Runlength encoding (RLE).
 DICOM enables the integration of
scanners, servers, workstations, printers,
and network hardware from multiple
manufacturers into a picture archiving
and communication system (PACS).
PACS typically comprised of
an image acquisition device,
data management system,
image storage devices, local
or wide area network,
display stations, and devices
to produce hard-copy
images.
DICOM format: size and transmission
Medical Image Processing
 Medical image processing that produces from
modalities allows physicians to view the inside of the
human body for clinical purposes or medical sciences.
 Medical image processing techniques can yield more
detailed and easily manipulated images. This allows
for a more in-depth review of the internal organs and
structures of the human body.
Medical Image processing
Cancer in the posterior right breast on
digital mammography. All images
courtesy of Maxine Jochelson, MD.
Enhancement after contrast.
Same view on MRI.
Medical Image Processing
Structure of digital images
Improvement of image quality
Enhancement of abnormal
lesions
Determination of image
features of abnormal
lesions
Image Analysis
Image analysis involves manipulating the image
data to determine exactly the information
necessary to help solve a computer imaging
problem. It can be divided into three primary
stages:
 Preprocessing: It is used to remove noise
and eliminate irrelevant, visually
unnecessary information.
 Data Reduction: It involves either reducing
the data in the spatial domain or
transforming it into another domain called
the frequency domain and then extracting
features for the analysis process.
 Feature Analysis: In this the features
extracted by the data reduction process are
examined and evaluated for their use in the
application.
After the analysis we have a feedback loop that
provides for an application-specific review of the
analysis results.
Input Image
Preprocessing
Transform
Segmentation
Filtering
Feature extraction
Feature Analysis
Image Compression
Image compression involves reducing the size of image data files, while retaining necessary
information. The resulting file is called the compressed file and is used to reconstruct the
image, resulting in the decompressed image. It consists of two parts:
 Compressor: It consists of a preprocessing stage and encoding stage.
 The first stage in preprocessing is data reduction. For example, the image data can be
reduced by gray level and/or spatial quantization. The second step in preprocessing is the
mapping process, which maps the original image data in to another mathematical space,
where it is easier to compress the data.
 Next, as part of the encoding process, is the quantization stage, which takes the potentially
continuous data from the mapping stage and puts it in discrete form. The final stage of
encoding involves the coding the resulting data, which maps the discrete data from the
quantizer onto a code in an optimal manner.
 Decompressor: In this the decoding process is divided into two stages.
 First, it takes the compressed file and reverses the original coding by mapping the codes to
the original, quantized values.Next, these values are processed by a stage that performs an
inverse mapping to reverse the original mapping process.
 Finally, the image may be postprocessed to enhance the look of the final image.
Compressor- System Model
Decompressor- System Model
Open source software for medical
image analysis
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ImageJ
3D Slicer
ITK
OsiriX
GemIdent
MicroDicom
FreeSurfer
ClearCanvas
Seg3D [2]
NumPy + SciPy + MayaVi/Visvis
InVesalius
ImageJ
 ImageJ can display, edit, analyze, process, save, and print 8-bit, 16-bit and 32bit images.
 It can read many image formats including TIFF, PNG, GIF, JPEG, BMP, DICOM,
FITS, as well as raw formats.
 ImageJ supports image stacks, a series of images that share a single window,
and it is multithreaded, so time-consuming operations can be performed in
parallel on multi-CPU hardware.
 ImageJ can calculate area and pixel value statistics of user-defined selections
and intensity thresholded objects.
 It can measure distances and angles.
 It can create density histograms and line profile plots.
 It supports standard image processing functions such as logical and
arithmetical operations between images, contrast manipulation, convolution,
Fourier analysis, sharpening, smoothing, edge detection and median filtering.
 It does geometric transformations such as scaling, rotation and flips.
 The program supports any number of images simultaneously, limited only by
available memory.
CVIPTools
 Image Analysis
 Segmentation & Morphological Filtering
 Fourier Transform
 Histogram Features
 Image Restoration
 Image Enhancement
 Image Compression
Fix line and satellite technologies
 PSTN (public switched telephone network): Telkom,
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Indosat
ISDN (integrated service digital network)
Satellite Connection
Wireless Technology
Microwave Connection
Leased line
ATM (asynchronous transfer mode)
Cellular Technology: CDMA, GSM
Barrier to Telemedicine
 Physician/Patient Acceptance
 Funding/ Reimbursement Issues
 Convenience
 Legal
 Availability of Technology at a Reasonable Cost
 Privacy and Security Concerns
Application 1: Medical Imaging centered on Mobile
phone
 The World Health Organization (WHO) has reported that
about 75% of the world's population is without access to
ultrasounds, X-rays, magnetic resonance images, and other
medical imaging technology that can detect tumors,
diagnose tuberculosis infections, and monitor pregnant
women.
 Around 95% of medical technology in developing
countries is imported“.
 More than 50% of the medical equipment in developing
countries is left unused or broken because it is too
complicated or expensive to operate and repair, ….”
 The combined components of medical imaging devices
(data acquisition hardware, image processing software, and
a display device) into a solitary unit, causes the cost is
substantially increased.
Boris Rubinsky. A New Concept for Medical Imaging Centered on Cellular Phone Technology. Hebrew University of Jerusalem, April 30, 2008.
Application 1, Cont ...
Conventional stand-alone medical imaging device,
image reconstruction, control and transmit
processed images from the patient site.
A new medical imaging system made of two
independent components connected through
cellular phone technology. The independent units
are:
 a data acquisition device (DAD) at a remote patient
site that is simple, with limited controls and no image
display capability and
 an advanced image reconstruction and hardware
control multi-server unit at a central site.
the breast cancer tumors patient self-test screening
Frequency-Division
Multiplexing EIT, Seven AC
currents (at different
frequencies) are
injected simultaneously.
Signals from voltage electrodes
(V1 to V8) are connected to an
analogue multiplexer
Application 2: Ultrasound imaging with
a smartphone
 William D. Richard, Ph.D at
Washington University coupling
USB-based ultrasound probe
technology with a Windows mobilebased smartphones, $100,000 grant
by Microsoft awarded in 2008. It is
possible to
 ultrasound probes for imaging the
kidney, liver, bladder and eyes,
 endocavity probes for prostate and
uterine screenings and biopsies, and
 vascular probes for imaging veins
and arteries for starting IVs and
central lines.
http://news.wustl.edu/news/Pages/13928.aspx, April 20, 2009
Application 3: A Viewing and manipulated Medical
Image on Smartphone
A: A remote physician is
equiped with iOAS.
ResolutionMD is
visualization server and
picture archiving and
communication system
(PACS) is connected.
B.1: secure http connection,
B.2: user select an image for
interpretation.
D.1: This produce a touch
event, D.2: which is sesnt
into visualization server,
D.3: interaction event
causes a new rendered
frame, D.4: that display on
iOS device.
E: User exits the iOS
application. (+) no patient
data is located outside the
firewall; the large data can
be viewed and manipulated
on iOS without using its
memory.
C.1: load patient exam into
memory, C.2: reformat 2D
into 3D JPEG compression,
C.3: This frame is sent to
iOAS appl, C.4: display it on
iOS device.
J Ross Mitchel . A Smartphone Client-Server Teleradiology System for Primary Diagnosis of Acute Stroke. J Med Internet Res 2011;13(2):e31.
http://www.jmir.org/2011/2/e31/
Satellite Teleradiology
 In a poster presentation at the 2003 Symposium for
Computer Applications in Radiology (SCAR), Dr. Lance
Williams of Womack Army Medical Center (WAMC) at
Fort Bragg, NC, detailed a telemedicine solution the
Army used to provide radiology coverage both in Bosnia
and at WAMC.
Running Researches
 Analisis metode perbaikan citra untuk mengidentifikasi
kanker pada hasil mamografi menggunakan adaptive
contrast enhancement II.
 Optimalisasi sistem pemantauan gizi menggunakan
perangkat mobile dengan algoritma genetika dalam kasus
diabetes.
 Kemungkinan smartphone untuk pengolahan gambar medis
 Pengolahan citra irisan mata menggunakan mobile phone.
 Etc.
Thank you