SEAAPM Symposium 2014 Not Your Grandfather's PACS New Expectations for Image Management

David Clunie (dclunie@dclunie.com) PixelMed Publishing

PACS – Learning Objectives l  Understand the tradition roles, challenges and limitations

of departmental, enterprise and cross-enterprise PACS l  Identify contemporary forces impinging on PACS choice,

migration, design and deployment, including IS consolidation, EHR integration, provider and patient access, advanced quantitative applications, and document integration

l  Discuss alternatives to traditional PACS, including the role of Vendor-Neutral Archives and Universal Zero Footprint Viewers, "deconstruction", and other buzzwords of choice

l  Review the role of DICOM and IHE standards (or not) in this evolution

PACS Beginnings

l Lemke, 1979 • “A Network of Medical Workstations for

Integrated Word and Picture Communication in Medicine”

l Capp, 1981 • “Photoelectronic Radiology Department”

1982 - “The year of the PACS”

l  First International Conference and Workshop on Picture Archiving and Communications Systems, SPIE, Newport Beach

l  First International Symposium on PACS and PHD (Personal Health Data), Japan Association of Medical Imaging Technology

What does PACS mean?

l  Physics and Astronomy Classification Scheme

l  Political Action Committee(s) l  Pan-American Climate Studies

l  Picture Archiving and Communication System

What has PACS meant?

l  Multi-modality digital acquisition l  Storage (current, archival, local, off-site) l  Distribution, locally and remotely l  Display (diagnostic and review) l  Reporting creation, distribution, storage l  Workflow management l  Integration with other information (systems)

What did PACS mean in 1982 ?

l  Pretty much the same l  Less ambitious in scope l  Not all modalities (CR not yet available) l  More emphasis on storage, transfer and display

than workflow l  No standards, but recognition of the need for

them l  Relatively impractical given technology of the day l  A grand vision for the future

What does PACS mean today?

l  Multi-modality digital acquisition l  Storage (current, archival, local, off-site) l  Distribution, locally and remotely l  Display (diagnostic and review) l  Reporting creation, distribution, storage l  Workflow management l  Integration with other information (systems) l  Enterprise wide (multi-specialty) l  EHR Integration l  Access on mobile devices

Infrastructural trends

l  Home grown components, all local l  Commercial purchase – monolithic solution l  Commoditization – all vendors similar l  Factor out network and storage (NAS, SAN) l  Sharing enterprise IT infrastructure l  Workstation -> PC -> Web browser viewer l  Proprietary -> DICOM -> HTTP protocols l  Factor out archive (VNA) & viewer l  “Zero footprint” “universal” viewers

Lemke, 1979 – Ring of medical work stations (MWS’s)

Capp, 1981

DICOM Cluster or Mini-PACS

CT Modality

Laser Printer

Shared Archive

Workstation

Store

Store

Store

Print

Print

Q/R

Q/R

Basic PACS Components

Modality

Archive Modality

Modality

Modality

PACS +/- RIS

Manager

Workstations

Monolithic + DICOM Modalities

Modality

Archive Modality

Modality

Modality

PACS +/- RIS

Manager

Workstations

Standard Boundary

Workstation Interface

Modality

Archive Modality

Modality

Modality

PACS +/- RIS

Manager

Workstations

Standard Boundary Standard Boundary

DICOM Standard Interface

Modality

Archive Modality

Modality

Modality

PACS +/- RIS

Manager

Workstations

Standard Boundary Standard Boundary DICOM DICOM

DICOM PS3.8

Modality

Archive Modality

Modality

Modality

PACS +/- RIS

Manager

Workstations

Standard Boundary Standard Boundary DICOM DICOM

DIMSE/ULP

Web Access to DICOM Objects

Modality

Archive Modality

Modality

Modality

PACS +/- RIS

Manager

Workstations

Standard Boundary Standard Boundary DICOM DICOM WADO-URI

DICOM WS (SOAP)(IHE XDS-I)

Modality

Archive Modality

Modality

Modality

PACS +/- RIS

Manager

Workstations

Standard Boundary Standard Boundary DICOM DICOM

WADO-WS (XDS-I)

WADO-RS (RESTful)

Modality

Archive Modality

Modality

Modality

PACS +/- RIS

Manager

Workstations

Standard Boundary Standard Boundary DICOM DICOM

WADO-RS (REST)

Full Repertoire

Modality

Archive Modality

Modality

Modality

PACS +/- RIS

Manager

Workstations

Standard Boundary Standard Boundary DICOM DICOM

DIMSE/ULP WADO-URI WADO-WS (XDS-I) WADO-RS (REST)

Vendor Neutral Archive

Modality

Modality

Modality

Modality Manager

Workstations

Modality/Workstation <-> VNA

Modality

Modality

Modality

Modality Manager

Workstations

PACS <-> VNA Interface

Modality

Modality

Modality

Modality Manager

Workstations

Standard Boundary DICOM HL7 IHE

PACS <-> VNA Interface

Modality

Modality

Modality

Modality Manager

Workstations

Standard Boundary DICOM HL7 IHE ?

Multiple PACS – One Archive

PACS PACS PACS PACS

One Archive – Universal Viewer

PACS PACS

Universal (ZFP) Viewer

Universal (ZFP) Viewer

Modality

Modality

Modality

Modality Manager

Universal (ZFP) Viewer

Standard Boundary DICOM WADO-URI

WADO-RS (REST)

VNA: PACS by any other name

Modality

Modality

Modality

Modality

Universal (ZFP) Viewer

Storage Paradigms

Spinning Tape

or Optical

Jukebox Shelf

Storage Paradigms

Spinning Tape

or Optical

Jukebox Shelf

Spinning

Storage Paradigms

Spinning Tape

or Optical

Jukebox Shelf

Spinning Redundant Duplicate

Offsite

Storage Paradigms

Spinning Tape

or Optical

Jukebox Shelf

Spinning Redundant Duplicate

Offsite

Offsite

On-site

Backup

Storage Paradigms

Local Cache

Reliable “Cloud” Archive

Somebody else’s

problem

Storage Paradigms

Local Cache

Reliable “Cloud” Archive

Somebody else’s

problem

•  Cost of (fast) storage •  Cost of bandwidth •  Local versus remote production •  Local versus remote utilization

Zero Footprint Universal Viewer

l  Web browser viewer for all types of users l  Zero footprint

•  No helper apps, plugins, applets, Flash or SilverLight •  Not even any JavaScript ????

l  Absolute zero – HTML pre-5, frames, tables, images

l  Almost zero – JavaScript +/- HTML5 Canvas l  Pretending to be zero – Flash (etc.) dependency l  Not zero at all – just fine for many deployments l  Thick client spawned by browser (or EHR “app”) l  “Web-based” PACS & “remote” viewers 1990s

EHRs and Images

l  EHR vendors do NOT want to store images l  Separation of requestor from performer

•  EHR/PHR/etc. user requests viewing of study •  PACS/VNA/etc. actually performs it

l  A “link” - very common proprietary pattern •  e.g., encrypted URLs – identify, authorize, time-limited •  n:m permutations of requestor/performer to customize

l  Storing fully qualified links (URLs) – go stale l  Common identifiers, dates, etc. more reliable l  IHE Invoke Image Display (IID) profile (new)

•  standard display request – now only n+m permutations

IHE Invoke Image Display l  A minimalist means of image-enabling non-image-aware

systems l  Uses simplest available HTTP-based request l  Supports patient and study level invocation l  Usable with or without a priori knowledge of individual

study identifiers l  Requires servers to provide at request of the user

•  interactive viewing •  review or diagnostic quality •  key images only

l  Independent of how/where server gets/stores the images l  Any mutually agreed HTTP security mechanism

IHE IID – Process Flow

Image Display (ID)

Display Images

Image Display Invoker (IDI)

Invoke Image Display (RAD-106)

Mobile Device Considerations l  Relatively limited memory/CPU/network bandwidth l  Assuming that mobile devices are used only for low

quality use cases is not valid – e.g., are now some FDA-cleared mobile “apps”

l  RESTful versus SOAP for protocol l  JSON versus XML for meta data l  Not all browsers HTML5/Canvas yet l  New crop of MHD standards mirroring XDS l  Payload: DICOM v. JPEG v. proprietary l  Protocol: DICOM v. WADO v. proprietary l  Viewing environment and display quality (FDA) l  One day all viewing will be on mobile devices?

Special Considerations

l  Change management • deletion, correction •  life cycle management (purge, expire) •  IHE Imaging Object Change Management (IOCM)

l  Cross-enterprise • protocol (DICOM, WADO, XDS-I.b) • payload (DICOM images) •  identifiers (patient ID, accession#), codes • PACS <-> PACS, PACS <-> central repository •  IHE Multiple Image Manager Archive (MIMA)

Imaging Object Change Management

Cross Enterprise Gateways

Multiple Image Manager/Archive

Order Placer

DSS/ Order Filler

Image Manager

Image Archive

Acquisition Modality

ADT

Order Placer

DSS/ Order Filler

Image Manager Instances Stored [RAD-70] → Image Manager Storage Commitment [RAD-71] →

Image Manager Instances Query [RAD-72] → Image Manager Instances Retrieval [RAD-73] →

Assigning Authority “Site A”

Assigning Authority “Site B”

ADT

Image Manager

Image Archive

Acquisition Modality

Image Manager

Image Archive

↑ PIX Query [ITI-9] ↓ PIX Notification [ITI-10]

Patient Identifier Cross-reference Manager

← Image Manager Instances Stored [RAD-70] ← Image Manager Storage Commitment [RAD-71] ← Image Manager Instances Query [RAD-72] ← Image Manager Instances Retrieval [RAD-73]

Multiple Patient Identifier Assigning Authorities

MU – Health ITSC – Image Sharing TIER 1

Exchange of Text-Based Reports

TIER 2 Exchange of Non-Radiology/

Cardiology Images

TIER 3 Exchange of Radiology/

Cardiology Images - Full Study

TIER 4 Exchange of Radiology/Cardiology Images- Key

Images

CONTENT  

Plain  text  +/-­‐  structured  headings,  scanned/rendered  document  

 

"Clinical  Capture"  images  with  or  without  metadata  

Complete  set  of  images  of  diagnos<c  quality  

IHE  Key  Image  Note  (KIN)  and  images  referenced  therein  

ENCODING  

PDF,  HL7  2.x  OBX  segment  content,  CDA  L1,  or  CDA  L2  +  CCDA  DIR  

template  

Without  metadata:  JPEG,  PNG,  DNG,  PDF,  H.264;  with  metadata:  DICOM  

DICOM  (object  appropriate  to  modality)      

VOCABULARY  LOINC  to  describe  study/procedure,  LOINC  for  structured  headings  

LOINC  to  describe  study/procedure  (in  DICOM  header/

XDS    metadata)  

 

LOINC  to  describe  study/procedure  

LOINC  to  describe  study/procedure,  DICOM  DCID  7010  

for  <tles  

PUSH  HL7  V2  ORU/MDM  MLLP  over  VPN/TLS,  DIRECT  SMTP  or  XDR  preferred  

DIRECT  SMTP  or  XDR,  DICOM  DIMSE/ULP  or  STOW  over  

VPN/TLS,  IHE  XDR-­‐I  

DICOM  DIMSE/ULP  or  STOW  over  VPN/TLS,  IHE  XDR-­‐I  

DICOM  DIMSE/ULP  or  STOW  over  VPN/TLS,  IHE  XDR-­‐I  

PULL   IHE  XDS   IHE  XDS-­‐I,  DICOM  WADO-­‐URI  or  WADO-­‐RS  over  VPN/TLS  

IHE  XDS-­‐I,  DICOM  WADO-­‐URI  or  WADO-­‐RS  over  VPN/TLS  

IHE  XDS-­‐I,  DICOM  WADO-­‐URI  or  WADO-­‐RS  over  VPN/TLS  

VIEW          IHE  IID,  else  pull  (WADO-­‐URI+/-­‐XDS-­‐I  for  rendered  JPEGs  when  

sufficient)  

IHE  IID,  else  pull  (WADO-­‐URI+/-­‐XDS-­‐I  for  rendered  JPEGs  when  

sufficient  

New(er) DICOM Objects l  Images for new modalities

•  ophthalmology, Whole Slide Imaging (WSI), …

l  Better images for existing modalities •  enhanced multi-frame & legacy conversion

l  Images for derived stuff •  pretty pictures (screenshots), parametric maps, segmentations

l  Non-images •  annotations, measurements, ROIs, fiducials, registrations •  presentation states and structured reports •  key images (key object selection) •  radiotherapy stuff •  Radiation Dose SR (RDSR), Radiopharmaceutical Dose (RRD)

l  Encapsulated stuff •  PDF, CDA

Radiation Dose – Old Way – Screen Shots

DICOM CT RDSR

DICOM CT RDSR

RDSR & OCR Deployment

Modality PACS

OCR Dose Reporter

RDSR

Screen

Q/R

RDSR

Q/R

Screen RDSR RDSR

Screen

RDSR

Per-frame attributes Pixel data

Shared attributes

Enhanced Multi-frame Images

Temporal Position

Index

2

1

Trigger Delay Time

48 ms

0 ms

Space (2)

Time (1)

2 \ 1 \ 5 Dimension

Index Values

Dimension Index Pointers: 1.  Temporal Position Index 2.  Stack ID 3.  In-Stack Position

5 1\1\5

In-Stack Position

Stack ID = 1

4 1\1\4 3 1\1\3

2 1\1\2 1 1\1\1

5 2\1\5

In-Stack Position

Stack ID = 1

4 2\1\4 3 2\1\3

2 2\1\2 1 2\1\1

PACS to PACS (or VNA) with Legacy DICOM Object Conversion

Modality

Modality

Workstations

PACS

Convert SF -> MF

Convert MF -> SF

Classic SF

Legacy Converted MF

True Enhanced MF

PACS

Convert SF -> MF

Convert MF -> SF

DICOM Whole Slide Images

Thumbnail Image

Intermediate Image Tiles

BaselineImage Tiles

Multi-frame image(single object)

Multi-frame image(single object)may include multipleZ-planes, color planes

Single frame image

Quantification Considerations

l  Increasingly an area of attention for some advanced imaging applications

l  Increasingly important applications •  tumor response assessment, neurodegenerative

disease, etc. • not just research & clinical trials, but clinical care

l  Not novel, just not widely used/available • Lemke 1979 paper described segmentation and

lateral ventricle volume determination

l  Many PACS still fail to provide more than basic measurements

DICOM encoding of ROIs l  Private elements

•  evil & must be stopped

l  Curves in image •  weak semantics, old, retired

l  Overlays in image •  weak semantics

l  Presentation States •  weak semantics, PACS favorite

l  Structured Reports •  best choice, but more work

l  RT Structure Sets •  coordinates only

l  Segmentations •  per-voxel ROIs; use with SR

Date   Volume   Auto  LD   Auto  SD  20021207 27080 49 27

… … … …

Parametric Maps

Foster N L et al. Brain 2007;130:2616-2635 Meyer P T et al. J Neurol Neurosurg Psychiatry 2003;74:471-478

Label Maps

Brewer J et al. AJNR 2009; 30:578-580

Quantitative objects together

Analysis Workstation

Current DICOM

Images from Modality

DICOM Segmentation

DICOM Registration

DICOM SR

DICOM Real World Value

DICOM Parametric Map Images

PACS Store, Distribute

and Review

Previous DICOM

Images from PACS

Previous DICOM SR etc

Quantitative objects together

Analysis Workstation

Current DICOM

Images from Modality

DICOM Segmentation

DICOM Registration

DICOM SR

DICOM Real World Value

DICOM Parametric Map Images

PACS Store, Distribute

and Review

Previous DICOM

Images from PACS

Previous DICOM SR etc

Final thoughts …

l  Patient versus provider access •  just another universal viewer client • access through portal rather than EHR

l  Universal viewers •  really as capable as specialty workstations? •  “union” of all previously implemented features?

l  Reality check • most sites running an obsolete PACS version • migration (vendor/architecture change) is painful • VNAs need migration too