Medical Imaging

Informatics
CARL DOMINIC M. OCA, RRT
 ABBREVIATIONS
• 3D – Three Dimensional • DNS – Domain Name System

• A&E – Accident and Emergency (Department) • DVD – Digital Versatile Disk

• AET – Application Entity Title • EHR – Electronic Healthcare Record

• AHP – Allied Health Professional • EPR – Electronic Patient Record

• API – Application Program Interface • HD – High Definition

• ARI – Access to Radiology Information (IHE) • HDD – Hard Disk Drive

• CD – Compact Disc • HDMI – High Definition Multi-media Interface

• CHI – Community Health Index (Scottish • HIS – Hospital Information System

National Identifier)
• HL7 – Health Level 7
• CPD – Continuing Professional Development
• ID – Identifier
• CSP – Cloud Service Provider
• IHI – Individual Health Identifier (Australia)
• DICOM – Digital Imaging and Communication
in Medicine • IP – Imaging plate/Internet Protocol(usually
suffix with “address”)
• DMWL – Dynamic Modality Worklist
 ABBREVIATIONS
• IRR – Ionizing Radiation Regulations • NAS – Network Attached Storage

• ISB – International Standard Board • OCS – Order Communication System

• ISO – International Standard Organization • PACS – Picture Archiving and Communication

System
• IT – Information Technology
• PPOC – Patient Plan of Care (IHE)
• LAN – Local Area Network
• RAM – Random Access Memory
• IVU – Intravenous Urography
• RIS – Radiology Information System
• JPEG – Joint Photography Experts Group
• UPS – Uninterrupted Power Supply
• LCD – Liquid Crystal Display
• USB – Universal Serial Bus
• LED – Light Emitting Diode
• VGA – Visual Graphic Array
• MOD – Magneto-Optical Disk
• VPN – Virtual Private Network
• MPI – Master Patient Index
• WAN – Wide Area Network
• MPR – Multiplanar Reconstruction
 IMAGING MODALITIES
ABBREVATIONS
• CT – Computer Tomography
• CR – Computed Radiography
• DR – Digital Radiography
• MG – Mammography
• MR – Magnetic Resonance Imaging
• NM – Nuclear Medicine
• PX – Panoramic X-ray
• PET/PT – Positron Emission Tomography
• RF – Radiofluoroscopy
• RTx – Radiotherapy Components
• US – Ultrasound
• XA –X-ray Angiography
What is Imaging Informatics?
Is the collective name given
is the discipline that to the field of work and
stands at the intersection
combination of technologies
of biomedical
that provide the features of
informatics and medical a paper-less or paper-lite
imaging.
department.

concerned as a speciality with

the electronic acquisition,
Imaging informatics is a sub-
storage, and distribution of the
speciality of health
text and image data produced
informatics.
and utilised within a
diagnostics department.
Medical Imaging
❖providing the only in vivo means of studying disease
and the human condition

Biomedical Informatics
❖concerns itself with the development and adaptation
of techniques from engineering, computer science,
and other fields to the creation and management of
medical data and knowledge.
What is Imaging Informatics?
Is the collective name given
is the discipline that to the field of work and
stands at the intersection
combination of technologies
of biomedical
that provide the features of
informatics and medical a paper-less or paper-lite
imaging.
department.

concerned as a speciality with

the electronic acquisition,
Imaging informatics is a sub-
storage, and distribution of the
speciality of health
text and image data produced
informatics.
and utilised within a
diagnostics department.
What is Imaging Informatics?
• which is itself defined as:
‘The knowledge, skills
and tools which enable information to be
collected, managed, used and shared to support
the delivery of healthcare and promote health’
(Department of Health, 2002).
 AQUISITION

IMAGING
INFORMATICS

DISTRIBUTION STORAGE
History and Development
For almost a century film
was the primary method of
handling imaging. (manual
clerical process)

Early 2000’s, the transition

from analogue to digital
radiology as began

The birth of PACS and

RIS
MAIN COMPONENTS
IN RADIOLOGY

• Picture Archiving and

Communications System
PACS • Involved in storing and
distributing diagnostic
images both local and online

• Radiology Information
System
RIS • Acquisition of all information
of the patient relevant to
diagnosis
PACS
PACS
PACS
RIS
HIS
 The Process of Care and the Role of
Imaging
• From a high-level perspective, the healthcare process
can be seen in terms of three clinical questions:

What is How serious is What to do?

wrong? it?

• Identify the • performing • Interpret the

problem, diagnostic results
develop procedures (analyze and
hypothesis (experiment) conclude)
 DATA FLOW FOR A
DIAGNOSTIC SERVICE
 Example:
• Mrs. Akomaba, a 37-year-old French national, falls and is taken by
ambulance to a London A&E department with a suspected fracture of the left
ankle.
Imaging Informatics Involvement in this Patient Pathway:
• The patient’s demographic details will first be entered into the hospital
master patient index (MPI) system; then focussing on radiology – she
will need an X-ray, with a request for imaging sent electronically via OCS
to RIS, the radiographer will create an attendance for this on RIS, which
passes details to the modality and image acquisition station. The
practitioner (radiographer in most cases) then acquires the images, makes
any post-processing changes needed, and commits the images to PACS.
 Example:

• The radiologist or reporting radiographer late views the image on a

reporting workstation and dictates a report into either PACS (modern
systems) or RIS (historic systems) using desktop integration (DTI)
to keep the systems synchronized. This report, once validated, passes to
the EPR and might well reach the A&E doctor. Meanwhile the images are
burned to disk on a compact disk (CD) robot for return to France, and
radiological dose information from the examination added to a national
dose audit database.
➢The main consideration is digital literacy, which
plays a large role in the smooth adoption and
correct, efficient use of informatics technologies.
 Correct and efficient use of
informatics
• 1. Examining the use of
The Human Factor information
• 2. Managing digital identities
• 3. Understanding the impact of
new technologies on existing
processes.
MR TRACTOGRAPHY
CT VIRTUAL COLONOSCOPY
CT PULMONARY ANGIOGRAPHY
CT CEREBRAL ANGIOGRAPHY
BONE REMOVAL (CT SCAN)
MR SPECTROSCOPY
PET-CT
BASIC IT FOR
RADIOGRAPHERS
 Hardware
Work Stations
• Processor: the heart of every work station; directly influences the
speed of the user perceives when using the work station.
• Memory: RAM; a high speed place for items currently in use to be
stored. Measured in Gb.
• Graphics Card: this is the second processor and extra memory
dedicated to displaying images.
• Storage: this is where data are stored; either a hard drive or a solid
state drive.
 • Inputs
information
Input from the user
Devices

• used to send
data from a
Output computer to
Devices another devic
e or user.
 Input Devices
• Provides navigation of the
Mouse cursor on-screen

• Use for insertion information

Keyboards on the computer, either with or
without a washable membrane

• Used for inputting shortcuts,

Foot pedals also useful for limited hand
movements.
 Input Devices
Dictation Microphones
▪ Has a built-in speaker for playback

Touch screen monitors

▪ Capacitive – using the surface to
discharge a tiny electric current
through the users body
▪ Resistive – a mesh sandwiched
between two clear sheets, which
closes electrical contacts at specific
places on each tap.
 Output Devices

▪ For playback of
Speakers
audio

Display ▪ Printers
Devices ▪ Monitors/Screens
 Dual Purpose Device
Memory • Low capacity removable media.
sticks/CD/Digital
• Used generally for the physical transfer of images to
Versatile Disk solicitors or by patients for onward care.
(DVD)/Bluray Disks
• These devices could also be used for input purposes.
and Drives

• Obsolete in many uses because of their lack of capacity.

3.5 inch • Still utilise these formats for both input and output in
‘floppy’ drives firmware updates for some CR machines (the raw machine
operating instruction coding).

Magneto- • For long-term archival of larger volumes of data.

• These were historically common for storing unprocessed
optical disks CT data (raw data) or older PACS archives
(MODs • These may be utilised for both input and output.
 Display Devices
VISIBLE DISPLAY UNITS (VDU)
➢Also known as Displays or Screens.
➢Different types of monitors are available depending on the purpose and use
of the workstation to which they are attached.
➢ High-quality monitors for reporting require dedicated graphics cards to
operate – these are specialist processors internal to the workstation in a
card shape, which provide the necessary outputs to the monitors.
➢The most widely used colour display devices are flat panel monitors with
images composed of a grid formed by millions of alternating red, green, and
blue pixels, which are backlit by bright white LED
 TYPES OF CABLES
➢High- Definition Multimedia Interface (HDMI)
➢Display Port
➢Digital Visual Interface (DVI)
➢Digital Visual Interface (DVI) – Digital Output Only(DVI-D)
➢Combined Digital And Analogue Output (DVI-I).
Outdated legacy interfaces:
➢Video Graphics Array (VGA)
➢S-video
➢Proprietary Interfaces
 PRINTERS
▪ Plain Paper: for appointment letters, documents, printed list, etc.
▪ Thermal: for labels, stickers, CD/DVD tops or patient wristbands,
being either direct thermal (burning the surface of the sticker) or
indirect dye sublimation (melting dye from a plastic carrier
ribbon to transfer ink onto the surface of the sticker).
▪ Film:returning to non digital health care system; continuity in
case PACS fails.
 PRINTERS
Plain • for appointment letters, documents, printed list, etc.
Paper

• For labels, stickers, CD/DVD tops or patient wristbands, being

either direct thermal (burning the surface of the sticker) or
Thermal indirect dye sublimation (melting dye from a plastic carrier ribbon
to transfer ink onto the surface of the sticker).

• Returning to non digital health care system; continuity in

Film case PACS fails.
 Uninterruptable Power Supply (UPS)
➢Provide a temporary source of replacement battery power should mains
supply be lost, either accidentally or as part of a planned test.
➢They connect in series between the wall socket and workstation to allow
enough time for either the mains power to be restored or for the computer
to be shut down gracefully (by saving documents, sending images or
completing any reports in progress, etc.).
➢They are recommended for all clinical workstations or devices (including
modalities) where abrupt shutdown of a machine would present a clinical
risk or disruption to the service.
 SERVERS
Servers are the devices that run centralised 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.

PIZZABOX SERVER

VIRTUAL SERVER
 Pizza Box Virtual
pizza box servers are Virtual servers can be
measured in physical size in measured in many ways, but
‘U’s, with 1 U being 4.4 cm of commonly with processor
height in a standard server ‘seats’ being indicated
rack
when adding or updating a virtual servers can share
dedicated server, physical hardware in the
considerations include server room
whether there is sufficient
power available, sufficient
cooling,
cooling requirements Have lower power, cabling,
measured in British thermal and cooling requirements
units (BTUs).
 Networks
Networks provide the physical interconnections and
backbone between pieces of IT.

Main components of network infrastructure are the routers

and switches with interconnecting cables.
Networks

Cabling
•The physical make-up of network
cabling is either traditional copper
or glass fibre-cabling
 Networks

Internet Protocol Address

• Data to be moved around, such as a webpage or radiology
image, is broken down into thousands of tiny ‘packets’ of
data, each containing a destination and technical data.
• The main ‘addressing’ system used throughout the world
is currently the same as that devised in 1981, namely
internet protocol (IP)V4
 Networks
Routers
• These connect several different networks and operate at the network
layer (level 3) of the open systems interconnection (OSI)
• These devices can broadcast data packets within an internal intranet
network
• Routers typically assign and maintain the local IP addresses and
associated directory to machines, workstations, and devices that
connect to the network, plus critically the most direct/ fastest routes
between various points.
 Networks
Switches
•These create a network, operating at the data
link layer (level 2) of the OSI model and receive
and forward data packets in the internal
network only, using the router’s instructions.
 Networks
Port
• This is a digital entry or exit point, similar to a real life
ferry terminal, bus station, or airport.
• The de facto port used for unsecure digital imaging and
communications in medicine (DICOM) transmission is 104
• with secure DICOM passing into the speciality allocated
and reserved port 2762.
 Networks
Virtual Private Network
• allows for connections between two normally separate
networks to take place, creating a secure ‘tunnel’
between the two points.
• Most typically this is observed between a hospital
network and the homes of staff – allowing for staff to
access internal hospital applications in a secure manner.
• VPN tunnelling can either be ‘full’ or ‘split’.
Networks
Bandwidth
•This is the amount of data that can be
simultaneously sent over a given connection
•a crucial consideration when a large number
of either modalities (perhaps CT scanners) or
radiology reporting workstations are
situated close together
SOFTWARE
OPERATING SYSTEM
▪ Themain component running on
any workstation or server – the
Microsoft Windows operating
system – is traditionally utilised in
healthcare environments.
• For the range of applications
available owing to the ‘openness’ of
programming tools, the familiarity
of the platform to many staff from
the domestic environment, and
overall the lifetime cost of
alternative competing systems.
 Backups
Backups can 1. Full backups take the entire dataset (e.g. a RIS
be either full, database, or a PACS repository) and create an identical
incremental copy, either by lossless compression or in raw 1:1 format.
or
differential
depending on 2. Incremental backups include only data that have
the chosen changed from the previous backup.
backup plan
and
requirements 3. Differential backups are similar to incremental
of the backups, but include all data changed from the very
applicatio first, full backup
IMAGE ACQUISITION
▪ An imaging ‘modality’ is a term given to a particular
type of image acquisition method, such as CR, DDR,
US, CT, MR, NM, or radiotherapy components (RTx).

▪ The majority of the image acquisition methods

communicate images electronically into the PACS
using the DICOM standards after the operator has
post-processed them.
▪ Regardlessof the type, acquisition equipment has
six standard functions:
❑Identify the patient and exam.
❑Acquire image(s).
❑Associate image(s) with patient and study data.
❑Provide necessary post-processing features.
❑Transmit the image(s) to a storage location (PACS).
❑Maintain a temporary local database for a short
period of time as a business continuity measure (in
the event of PACS or network failure).
 TYPES OF IMAGING
MODALITIES

❑SINGLE IMAGE MODALITIES

❑MULTI-SLICE MODALITIES

❑HYBRID MODALITIES
SINGLE IMAGE MODALITIES
➢ The post-acquisition processing functions may be
incorporated into a workstation at the acquiring
device and the amount of post- processing is
generally routine and less time-consuming
➢Traditionallycomprising applying secondary
shuttering, annotations, checking layout/
positioning, and minor adjustments to image
window widths/levels.
➢Angiographic or fluoroscopy equipment also falls
into this category.
SINGLE IMAGE MODALITIES
MULTI-SLICE MODALITIES
➢The which produce complex raw data imaging sets, have
separate workstations and applications to allow for the
intricate and detailed post-acquisition processing to take
place.

➢Commonly found with CT, MR, and NM imaging modalities.

➢Acquired imaging is re-processed to allow for the clinical

question to be answered. The re-processed data are then
stored to PACS for future reference and for clinicians
outside of radiology to refer to.
MULTI-SLICE MODALITIES
HYBRID MODALITIES
➢Where two types of imaging acquisition are combined
during one examination.
➢PETimaging utilises combinations of CT, MR and NM to
produce a fused image demonstrating both high quality
anatomical detail with radioactivity emissivity data.
➢3D volumetric motion imaging (for functional analysis of
joints during movement) draws on the combination of CT
and multi-angle visual light recording to generate 3D
renderings of the skin and skeletal isosurface for later
analysis by physiotherapists or other healthcare
professionals involved in rehabilitation.
HYBRID MODALITIES
Specialist Applications
▪ Several modalities now produce complex raw data

sets and in many cases it is not efficient from a

workflow process perspective to carry out all post-

processing at the actual acquisition station.

 Multi-planar and 3D
Reconstructions
▪ By taking raw data from multi-planar modalities,
such as CT or MR, almost limitless projections can
be generated to best optimize the images for
reporting.
▪ Multi-planar reconstruction (MPR) facilities are
routinely found on workstations attached to the
modality in question, but can also be provided in
modern image viewers attached to a PACS.
 Multi-planar and 3D
Reconstructions
▪ 3D rendering takes MPR a step further, allowing for
‘real-life’ dissections of imaging, removal of
obscuring structures (the scan table or head pads,
for instance) and colour rendering of structures at
pre-set depths to allow for better visual acuity
during reporting.
 Vessel Analysis and Colon
Navigation
▪ Both of these are now gaining in popularity but
require advanced graphics processing abilities –
effectively the ‘pipes’ (be they blood vessels or part
of the large bowel) are processed in 3D and
rendered so that the reviewer can either measure
the cross-sections, or ‘fly’ through them, staying
within the bounds of the structure
 Vessel Analysis and Colon
Navigation
▪ Until the latter part of the 2010s this type of
processing was limited to dedicated workstations,
and now many PACS providers include this
functionality as an add-on for any suitably powerful
PC.
 ORTHOPEDIC TEMPLATING
APPARATUS
▪ Orthopedic templating allows for the
removal of the manual processes
that historically took place in
theatres prior to an orthopedic
procedure.
▪ Now, instead of holding an
overhead projector (OHP)
transparency with an outline of the
implant options printed on it over a
piece of radiographic film, surgeons
can annotate images and plan
which sizes of implants to utilize in
advance, digitally.
 ORTHOPEDIC TEMPLATING
APPARATUS
▪ Although this has minimal impact
on the actual imaging departments,
it has provided significant time and
cost savings to the surgical
departments who can now better
choose the correct devices rather
than working from an
approximation (and having to open,
then potentially discard any wrong
choice of surgical implants).
▪ This type of application operates
from standard CR or DDR images,
but requires calibration.
 ORTHOPEDIC TEMPLATING
APPARATUS
▪ Tocalibrate, an object of known size
must be placed in line with the
patient’s anatomy in question at the
time of imaging.
▪ Thiscan be a perfectly spherical ball
bearing of known diameter attached
either directly or indirectly to
patient anatomy – perhaps the
lateral aspect of the hip when hip
replacements are being considered
 ORTHOPEDIC TEMPLATING
APPARATUS
▪ These spheres can be supported in
a flexible stand, a foam block, an
elastic holder or, more conveniently
and hygienically, stuck to the
patient with inexpensive disposable
foam rings.
 ORTHOPEDIC TEMPLATING
APPARATUS
▪ Orthopedic templating
modules now widely include
the ability to manipulate
prosthesis templates and
bone fragments identified
on radiographs in 3D
 ORTHOPEDIC TEMPLATING
APPARATUS
▪ Afterthe image post-
processing has been
completed in any specialist
application, the re-processed
data can be stored to PACS,
alongside the original imaging
if required.

▪ Some institution prefer to

store reconstructed data to a
separate location in order to
preserve storage space on the
main hospital PACS.
Engineering
▪ From an informatics point of view, image acquisition
modalities present a challenge, in that when
installed they are generally configured by the
supplier staff, who are constrained by a deadline.
▪ It is therefore good practice for a sheet showing the
correct default settings required for integration into
the various informatics systems (including examples
of acceptable machine names – application entity
titles (AETs) – and correct formatting of the
institution name, address, etc.) to be made available
to all modality superintendents/department heads in
order to prevent incorrect settings from having to be
rectified later
Engineering
▪ When tendering or purchasing modalities outright it
is recommended that purchasers require suppliers to
provide all engineering codes and items necessary
to obtain full access to engineering and installation
settings as a matter of course – preventing the need
for costly and difficult to co-ordinate call-outs to
make simple connection changes as is occasionally
necessary.
▪ This may require the modality suppliers to furnish a
service dongle, or simply a list of codes to the PACS
Manager or equivalent, updated as necessary.