A proxy of DICOM services

The picture archiving and communication system (PACS) originated as an image management system for improving the efficiency of radiologic practices. It has evolved into a hospital-integrated system that stores information media in many forms, including voice, text, medical records, waveform images, and video recordings. The integration of these various types of information requires the technology of multimedia, including hardware platforms, information systems and databases, communication protocols, display technology, and system interfacing and integration. The purpose of this book is to discuss the conceptual and technologic advances in PACS development for all of these previously mentioned technologies. The book also emphasizes the growing field of PACS-based imaging informatics, where existing PACS resources are used for largescale horizontal and longitudinal clinical service, research, and education applications. The book is intended for those who are involved in a health care environment that manages the everyday practical realities of PACS planning, operation, and maintenance. The book will also serve as excellent curriculum material for the training of PACS information technology personnel because the author provides comprehensive concepts that tie medical imaging, medical physics, information technology, and clinical workflow with enterprise PACS (multiple, hospital-wide PACS). The author, H. K. Huang, has been involved in PACS development since the 1980s and is a leading scientist in the field. The book is divided into five parts and 23 chapters. Part 1, titled “Medical Imaging Principles,” summarizes the history of PACS, the fundamental concepts of digital medical imaging, and the different types of modalities integrated into PACS. Part 2, titled “PACS Fundamentals,” describes in detail the PACS subsystems and industry standards (Digital Imaging and Communications in Medicine and Health Level 7) that are used to integrate PACS with the hospital information system and radiology information system. Part 3, titled “PACS Operation,” describes the practical problems encountered by PACS administrators and users and discusses different techniques to solve these problems, with many examples from installed PACS sites around the world. Because the author developed PACS at the University of California, Los Angeles, in 1991 and the University of California, San Francisco, in 1995, he is able to draw from his expertise on the subject. The author also uses his experience from developing many state-of-theart prototypes (eg, fault tolerant storage system) funded by research grants. Part 4, titled “PACS-based Imaging Informatics,” presents image-processing techniques that can be used to mine the huge image and clinical data resources stored in the PACS archive. The analysis of lung nodules by using temporal computed tomographic and contentbased image indexing are some of the examples of advanced processing applications applied to PACS data mining. Part 5, titled “Enterprise PACS,” describes different models for implementing an enterprise PACS in terms of the architectural design of the system and financial and business models. This new book builds on two previous volumes on PACS that were written by the author. The text, image collections, and schematic diagrams in this current work achieve the author’s goal of providing up-to-date material concerning the technologic advances in PACS and imaging informatics. The text serves as a guide for those who are planning an enterprise PACS and provides teaching material for training PACS developers in industry and health care. The author has used portions of this book as lecture material for graduate courses at leading universities in the United States and abroad. The author also uses many examples to emphasize that the integration of heterogeneous health care information systems is becoming more complex and that, as more radiologists and clinicians expect higher standards in the reliability of the data, a systemic understanding of Digital Imaging and Communications in Medicine, Health Level 7, and Integrating the Healthcare Enterprise becomes ever more important to optimize enterprise workflow. The strength of the book lies in the vast experience that the author, who has implemented PACS at numerous institutions in the United States and abroad, has transmitted into this new book. Huang has conducted first-hand analysis of the various systems from PACS manufacturers that are used in clinical operation at large medical institutions and has performed up-to-date research in data mining of the huge image and data resources stored in the PACS repository.

PACS and Web-based image distribution and display

Enterprise-wide PACS: Beyond Radiology, an Architecture to Manage All Medical Images 1

PAC system is extending increasingly from the now well-established radiology applications into a hospital-wide PACS. New challenges are accompanying its spread into other clinical fields. With awareness of the importance of PAC systems among various medical experts, this system has been enhanced through the PAC system's pipeline, and simplification of image display for analysis via an interaction with the user. Generally PAC system consists of medical image, patients' data acquisition, storage, and display subsystems integrated by digital networks and application software. PAC system facilitates the systematic utilization of medical imaging for patient care. However, even though PAC system consist of medical image, data acquisition, storage and display subsystems, most of available PAC system does not have image analysis as required by the clinical expert. If the PAC system do have this element, it need interaction or interference from the clinical expert as user, and the PAC system storage mostly is an unstructured storage with no analysis element and report modules. And unfortunately in most cases, for the web-based PAC system, there are delayed in retrieval and visualize the required image from outside of the hospital. Most of the PACS with function of 3D display, it did not communicate information clearly and efficiently to users (clinical expert). Most of the visualization did not visual accurate information as required by the clinical expert. These listed constraints limited the clinical expert perspective regarding his/her decision. From market validation observation we concluded that most of the PAC system available in market does not have medical image processing functions for the purposes of decision analysis with minimum user interaction. Research towards this limitation has been conducted in accordance with the needs of clinical experts. Among these studies are: (i) angiography image processing for stenosis position detection and measurement of its dimensions, (ii) echocardiography image processing for detection of ventricular cardiac abnormalities (walls and volume) and (iii) 2D angiography images reconstructed to 3D images for display purposes and to identify the location of artery tree. With the result of these studies, the PAC system will integrate with extra modules, which are: i) 3D reconstruction function from single image angiogram with identification of the stenosis location, ii) Identification of abnormality heart wall chamber, iii) 3D reconstruction echocardiography left and right ventricular heart, and iv) 3D fused within CTA, angiography and MRI. As stated above, the common limitation for the web-based PAC system is the delayed in retrieval and visualize the required image from outside of the hospital/clinics. To overcome this limitation, we proposed a technique and integrated a related function for faster transmission of the processed image without sacrifice any importance information. And to complete the PAC system so that the new PAC system able to compete with current PAC system that available in market, we link the PACS with our Patients Clinical Record Database with report modules as required by the medical expert. The outputs of all those said researches will be integrated with the PAC system where each research output has been tested and validate by numbers of cardiac expert, the patients clinical record database has been tested in UKMMC and the PAC system currently being beta tested in a Private Clinic in Kelang, Selangor, Malaysia. Eventually the PAC system with the Patients Clinical Record Database will be integrated with these image analysis and 3D image visualization and it is plan to be tested in Veterinary Hospital of Universiti Putra Malaysia. To forward this project to commercialization activity, we have distributed questioners to Clinics in area Bangi (Selangor, Malaysia) and Nilai (Negeri Sembilan, Malaysia). There are 58 Medical, Veterinary and Dental Clinics received the questioner (currently we expand the distribution towards Serdang and Kajang (Selangor, Malaysia). Out of 58 clinics; a) 16% interested to collaborate and looking forward to see PAC system, b)8% interested with the PAC system but do not willing to have any demo, c) 44% not interested but open for demo of system, d) 28% not interested and not willing to have demo system and e) 4% return the form without answered for that particular question. To secure and protect the ownership, each research output has been submitted for Patent filed in Malaysia and with three chosen country, where 2 of the patent filed has been granted in Malaysia. We also copyrighted each module. This project has been selected by Universiti Putra Malaysia to be commercialized by a startup company seeded by UPM (CASD Medical Private Limited) under program INNOHUB. We realize to implement the complete PAC system in Hospital there are 10 main problems exist that we might need to overcome or try to minimize the consequences. These problems are; i) Integration with the Hospital Information System. Although a lack of inter-vendor device and IT integration can often make the problem worse, the market is improving as providers and meaningful use demand greater integration. Unfortunately, still, many radiologists and PACS administrators prefer to make full use of hospital IT to configure their own systems and achieve a bit more autonomy, ii) Every system has downtime where we need to establish alternate workflows. Both scheduled and unscheduled, but they need not have to be too serious to minimize the effect on patient care, iii) Non-standardized hanging protocol display is a common and pesky challenge for PACS users. Images from different modalities are not organized by default even though each of them generally will be transmitted through DICOM format getaway, each study takes a little longer to read. As the number of scanners increases and the sample of vendors expands, the problem grows worse, iv) Integration problems concern hardware, from digitizing pre-DICOM modalities to integrating systems for advanced image reconstruction. Add-ons like a DICOM converter can help squeeze out additional value from older CT, angiography and fluoroscopy systems, v) As with downtime, failures are unavoidable, there is a need to demonstrate strong support activities, vi) Effective training can be a cost-effective way to demonstrate to administrators and physicians many of PACS' underused and undervalued features. Training wil help to expose staff to what the system can do to make their jobs easier and more efficient, vii) The migration of data to the new PACS is often the most challenging part of the process, both in negotiating the release of data from the current PACS and in sorting out all the data entry errors that have accumulated over the lifespan of the system, viii) As other specialties realize the value of PACS, the system is slowly being taken out of radiologists' hands. PACS has become a mission-critical enterprise-wide tool used by nearly all specialties. With this change, decision-making for PACS-related purchases, upgrades and configurations has, in some cases, shifted from radiologists to a more central process, ix) Hiring a certified public ergonomist to evaluate the department's workstations can ease radiologists' repetitive stress symptoms and contribute substantially to productivity. Despite accelerating advances in technology, many interface tools have changed little since the introduction of PACS, and finally x) Like business continuity, disaster recovery can prevent a painful experience from becoming fatal. Many hospitals opt for either redundant servers, cloud storage or both. At the very least, preparation for downtime can spare physicians and patients from experiencing significant losses. To minimize the consequences of the listed 10 main problems, this project (in early stage) targeting potential customers among the owner of the small private clinics where the numbers of patients is less and the bureaucracy of the administration is limited.

Recently, characteristic of HTTP, FTP, SMTP, VoIP and other Internet applications are widely studied. It is very useful for Traffic Engineering (TE) and Traffic Simulation. PACS (Picture Archiving and Communication System) has been becoming a popular healthcare application for accessing to medical images and patient's data diagnostics on a wired-line or/and wireless hospital network. However, a characteristic of PACS traffic on both wired-line and wireless network is rarely studied. Therefore, this paper studies and presents the characteristic of PACS over the wired-line and wireless network based on terms of the packet interval time, the packet size distribution (byte), as well as the effect of variable PACS flows (traffic load) on the ping packet loss, which are on the actual measurement. In addition, the packet interval time is represented in the form of PDF. The packet size distribution is represented in the form of histogram graph. It is very useful for Traffic Simulation.

Objective: This research investigates the needs and opinions of radiologists on the use of enhanced information technologies and approaches to improve the functionality of Picture Archiving and Communication Systems (PACS). Method: Six interviews were conducted in the main governmental hospital in Kuwait (AL-Sabah Hospital) with radiologists, including two senior radiologists, two junior radiologists, and two trainee radiologists undertaking the Irish radiology board. Results: The radiologists identified a number of limitations that exist in current PACS and requirements to enhance usability and functionality. However, it was the case that some of the radiologists had little knowledge about the advanced trends in PACS. Four themes emerged from the thematic analysis of the data: (1) limitations of traditional PACS; (2) Features and requirements that can increase PACS functionality; (3) web based solutions of PACS; (4) PACS in mobile phones. Conclusion: It is widely recognized that PACS has limitations. This research has identified themes that, when incorporated, will enhance the functionality of PACS and provide better quality clinical practice. This research has determined the important future trends of PACS. Primarily web based solutions and use in mobile phones. The findings from this research can be used as recommendations to vendors, for product development and medical institutes to consider when undertaking implementation of PACS and training future radiologists.

Picture archiving and communication systems (PACS) is a current research topic in both the United States and Japan. During the past 6 years, our department has been working in this field very closely with our colleagues in Japan. In July 1 986, we attended the Third International Symposium on Picture Archiving and Communication Systems/Personal Health Data Recording Systems (JPACS) in conjunction with the Fifth Symposium on Medical Imaging and Technology (JAMIT) at the National Cancer Center in Tokyo. After the meeting, we visited various PACS research and development laboratories at major imaging manufacturers and hospitals. We summarized our impressions in a commentary: “Picture Archiving and Communication Systems in Japan” [1 ]. Since then, we have successfully implemented two PACS modules, one in the pediatric radiology section and one in the coronary care unit [2, 3]. More than 200 visitors from Japan have come to see our facilities. Among these visitors was Professor T. Takahasi from Kyoto University Hospital, who was the program chairman of the Eighth Symposium of JAMIT/Sixth International Symposium on PACS in July 1 989. After his visit, he extended an invitation to us to give the keynote speech, “Recent Progress in PACS” for the meeting. We took this opportunity to go back to Japan and repeat the hospital and laboratory tour in order to observe their research and development progress in PACS during the past 3 years. This paper is a summary of our opinion ofthe changes that have occurred in Japan since our last visit of the status of PACS in that country compared with that in ours. The JAMIT Meeting and the JPACS Meeting

Objective To evaluate the teaching effects of case introduced method based on pic- ture archiving and communication system （ PACS ） system in medical imaging course. Methods Totally 148 students （ 2009 grade ） majored in five-year clinical medicine from Xiangya Medical College were divided into 10 groups; the 10 groups were taken randomly as control group （ n=75 ） and experimental group （ n=73 ）. Control group used traditional teaching methods （ film teaching ） while experimental group used case introduced method based on PACS system. Effects of teaching between were evaluated by questionnaire and test. χ^2 test was used to compare students＇ theoretical test scores, with α level = 0.05. Results Based on results of questionnaires, more students in experimental group than in control group hold that case introduced method based on PACS system can achieve the purpose of teaching, improve interests in learning, and strengthen the mastery of knowledge. Test scores showed that the percentage of students scored 90-100 and 80-89 （ respectively 14%, 75% ） in experimental group was significantly higher than that in control group （respectively 5%, 66% ） （χ^2 =17.932, P=O.O00 ）. Conclusions Application of case introduced method based on PACS system in medical imaging course not only improve students＇ motivation to learn and their clinica~ ability-, but also allow teachers to find and correct short- comings of students timely, therefore, it is worth promoting. Key words: Picture archiving and communication system; Case introduced method; Prac-tice teaching

Picture archiving and communications systems (PACS)

Avoiding Unread Images with PACS

In recent times, technological advancements have remarkably improved picture archiving and communication system(PACS) capabilities beyond their conventional use in radiology departments. Researchers and instructors have started employing PACS functionalities to improve medical research processes, promote interdisciplinary collaborations, and facilitate learning. To illustrate this point further, the PACS enables researchers to handle and analyze huge amounts of imaging data with superior precision and speed, supporting innovative studies in areas like disease progression, treatment outcomes, and imaging modalities. Moreover, a PACSintegrated with artificial intelligence (AI) algorithms leads to significant improvements in image processing, diagnostic accuracy, and personalized treatment, thus marking a new approach to medical imaging. The PACSsupported by AI is mostly transformative since they allow for improved early disease detection capabilities as well as automated image processing and decision assistance, which increase diagnostic accuracy and clinical outcomes. Such systems can rapidly process large quantities of visual data with an accuracy rate surpassing earlier endeavors. In medical research, however, combining PACSwith AI allows challenging imaging datasets to be examined, thereby making findings that were not previously possible. The capacity to combine imaging outcomes with clinical information is valuable for medical students and professionals in the field of education. They can access extensive medical image collections and case studies using PACS. This link is critical for teaching and learning as it allows students to interact with concrete events and improve their diagnostic accuracy in a controlled environment. This review discusses how the PACS affects educational courses and clinical outcomes based on the available literature. Our aim was not only to outline recent research or developments but also to present a comprehensive overview regarding the growing role played by PACS in the modern healthcare system and academics. Similarly, we look at the challenges and opportunities associated with the wide adoption of PACS, highlighting possible future areas of study or teaching methodologies. Issues such as data security, interoperability, and the need for defined protocols are included to give an exhaustive understanding of what PACS can and cannot do. Through this study, we stress PACS's revolutionary potential in advancing research methodology and educational practices, eventually contributing to enhanced patient care and knowledge dissemination in healthcare areas. The continual growth of PACS technology and its applications is expected to reshape the landscape of medical research and education, making it a vital component in the quest for medical excellence. By knowing the present trends and future potential, stakeholders in healthcare and education may better employ PACS to reach their objectives and boost overall results.

Policies and procedures (P&P) constitute the mechanism for planning, standardizing, and documenting the provision of clinical services. Upon approval by hospital management, the P&P is an official statement of hospital rules and regulations. Each P&P establishes organizational responsibility for providing services. P&P are a mechanism for communicating standard operating procedures to hospital and medical staff. P&P serve as a reference document for unusual events, as well as routine procedures. P&P are often reviewed by inspection teams from the Joint Commission on Accreditation of Hospital Organizations (JCAHO) to determine whether the hospital has documented systematic practices. A picture archival and communications system (PACS) provides a new vehicle for providing radiology services. P&P that were designed for conventional film-based imaging are often not appropriate for electronic imaging. Because PACS is new and not yet widespread, good examples of PACS P&P are not yet available. JCAHO has no official requirements for PACS: PACS is viewed only as a means for the hospital to accomplish its work. Successful P&P development is a team effort, drafted by personnel responsible for executing the procedure, assisted by staff proficient in PACS technology, and tested in the field. The P&P should be reviewed and approved by management personnel knowledgeable about hospital and imaging operations. P&P should be written in clear and concise language. Successful P&P development is an ongoing effort. P&P must be periodically reviewed and updated to reflect changes in PACS technology and changes in clinical operations. New P&P must be developed when a deficit is noted. PACS security is a good example of a topic worthy of P&P development, especially in the face of the Health Insurance Portability and Accountability Act (HIPAA) legislation of 1996. What are the provisions for access control? Does the system include a feature for automatic shut-off of the software? Are there "generic" passwords and log-ins shared by a community of users? How are passwords assigned and how frequently are they changed? What security measures are in place to assure passwords are given to the appropriate user? Who grants and denies access? Service calls are another topic for P&P. Who initiates a service call? What is the process for escalating a service call from the operator level to the vendor? What immediate actions are expected by the operator in order to restore PACS services? How are service events documented? Who is responsible for determining when "downtime" procedures should be initiated or suspended? When our hospital's total electrical system had to be shut down for an extended period, we found that a P&P was lacking for a task as mundane as shutting down and restarting our PACS components. What is the sequence for the shutdown? Who is responsible for shutting down and restarting? How long can the devices operate on uninteruptible power supplies (UPS)? What components are on emergency power? Should we expect the components to survive the switchover to generator power? Developing this P&P was worth the effort: it made the PACS more fault-tolerant and served as a reference document 3 years later when expansion of our physical plant required two more power outages.

Since May 2002, temporal subtraction and nodule detection systems for digital chest radiographs have been integrated into our hospital's picture archiving and communication systems (PACS). Image data of digital chest radiographs were stored in PACS with the digital image and communication in medicine (DICOM) protocol. Temporal subtraction and nodule detection images were produced automatically in an exclusive server and delivered with current and previous images to the work stations. The problems that we faced and the solutions that we arrived at were analyzed. We encountered four major problems. The first problem, as a result of the storage of the original images' data with the upside-down, reverse, or lying-down positioning on portable chest radiographs, was solved by postponing the original data storage for 30 min. The second problem, the variable matrix sizes of chest radiographs obtained with flat-panel detectors (FPDs), was solved by improving the computer algorithm to produce consistent temporal subtraction images. The third problem, the production of temporal subtraction images of low quality, could not be solved fundamentally when the original images were obtained with different modalities. The fourth problem, an excessive false-positive rate on the nodule detection system, was solved by adjusting this system to chest radiographs obtained in our hospital. Integration of the temporal subtraction and nodule detection system into our hospital's PACS was customized successfully; this experience may be helpful to other hospitals.

Introduction/ Background In recent years different technological solutions have emerged for the scanning or digitization of histological and cytological slides in pathology, from several manufacturers. High resolution scanning is usually based in tile (small fragment) or stripes (longitudinal areas) that are combined or stitched together to create a high magnification (usually equivalent to 20x to 40x magnification) global image. Thus, a large digital slide can be displayed using specific viewers to simulate the functions of a conventional microscope. A pyramid of images is a common solution. But each scanner manufacturer optimizes the process of collecting, managing and storing images in its own format, making difficult the interconnection between systems and the ability to share images between different formats, and, generally a heavy process of image conversion and a loss of information is needed. Aims The objective is to present the process performed on proprietary image formats of histological and cytological slides in pathology to convert them the be compliant with the Digital Imaging and Communication in Medicine (DICOM) standard, according to 145 and 122 supplements, and their subsequent storage in a Picture Archiving and Communication System (PACS). Methods Python was chosen as programming platform due to its versatility and available tools. Furthermore, for future projects, Python can be used to apply signal analysis on digital images. A Pentium Core i3 4GB RAM, 1TB server with Ubuntu 14.04.3 LTS Server was used. In the server, a developer platform Eclipse Version 3.8.1 allowed the installation of PyDev for Eclipse 4.3.0 and Eclipse Jgit 1.3.0 plugins. It has been connected to a Github repository to manage developing versions. The solutions has been structured into a Python package to obtain images coming from proprietary images to be standardized to an image compliant with DICOM supplement 145, and sending them to the PACS. Results In order to test compatibility, David A. Clunie’s dicom3tools was used. This allowed verification of all Tags of the generated files, indicating those who are required according to each image, and also it offers information of those tags where included data does not match the standard and those with values that do not correspond to that standard. This tool helped to finally obtain a result of 0% errors in all generated files. Regarding storage tests, two different PACS were used. First, in collaboration with T-systems Company, an open source dcm4chee DICOM Archive 2 (dcm4che.org), and second, in collaboration with IRE Rayos X company, a commercial IRE Store Channel 4.3 was also used in several tests. After some tests with commercial and open source PACS, we could obtain the following conclusions: In the negotiation phase, the PACS did not recognize the predetermined configuration stated in supplement 145. The solution was changing SOP to “VL Microscopic Image Storage”. Each level of the pyramid will be stored as an instance inside the same series, and each tile as a frame inside a multi-frame object. The dcm4che.org PACS offers a WADO service that allows accessing each frame separately, inside the same object, which can be useful for the implementation of slide viewers in pathology. Acknowledgment: This work has been supported by the AIDPATH project, an EU 7FP IAPP Marie Curie action, contract number 612471

Introduction:Picture archiving and communication system (PACS) serves to store, transmit, communicate and manage medical images. A logical evaluation protocol assists to determine whether the system is technically, structurally and operationally fit. The purpose of this systematic review was to propose a logical evaluation protocol for PACS, particularly useful for new hospitals and other healthcare institutions in developing countries.Methods and Materials:We systematically reviewed 25 out of 267 full-length articles, published between 2000 and 2017, retrieved from four sources: Science Direct, Scopus, PubMed and Google Scholar. The extracted data were tabulated and reviewed successively by three independent panels of experts that oversaw the design of this study and the process by which the PACS evaluation protocol was systematically developed.Results:The outcome data were ranked by expert panels and analyzed statistically, with the reliability established at 0.82 based on the Pearson’s correlation coefficient. The essential components and the best options to establish an optimal PACS were organized under nine main sections: system configuration;system network;data storage; datacompression;image input; image characteristics; image presentation; communication link; and system security, with a total of 20 components, each of which capable of working optimally with one or more program options.Conclusions:This systematic review presents an objective protocol that is an ideal tool for the evaluation of new or existing PACS at healthcare institutions, particularly in developing countries. Despite the significant advantages, the protocol may face minor limitations, largely due to lack of appropriate technical resources in various clinical settings and the host countries.