Fundamentals of

CR, DR and PACS

J. Anthony Seibert, Ph.D.

Professor of Radiology

Sacramento, California

Learning Objectives

• Explain technology of available and future

digital radiography technology
• Understand underlying system operation and
characteristics
• Discuss Exposure Indices and the new
international standard for CR and DR
• Illustrate integration with PACS architecture
and DICOM

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 DIGITAL IMAGING IN RADIOLOGY

• Digital imaging is an essential component of

Electronic Imaging, Telemedicine and
Remote Diagnosis

• Steps for digital imaging

– Acquisition
– Display
– Diagnosis
– Distribution
– Archive

The “Big” Picture

• “Digital” Radiology
PACS
Digital Radiography

MRI
Interventional Angio

CT Nuclear Medicine Ultrasound

2
 Imaging Exams

• Projection imaging 70%

• Fluoroscopy 3%
• Computed tomography 8%
• MRI 6%
• Ultrasound 10%
• Nuclear Medicine 3%

Medical Imaging Modalities

• Common thread
– Digital data (and lots of it!!)

• Problems
– Proprietary structures
– Unknown data format

• Solutions
– DICOM and PACS
– HL-7 and RIS
– Networking and Informatics
– IHE integration “profiles”

3
 But First…… CR & DR
• CR: Computed Radiography using photo-
stimulable phosphors and passive detection
• DR: Direct / Digital Radiography using a
variety technologies and active detection
• An intrinsic part of the PACS
• Historically, the last electronically integrated
• Many advances in the past decade

Digital x-ray detector 2. Display

Digital Pixel Digital to Analog
1. Acquisition Matrix Conversion

Transmitted x-rays
through patient

Digital
processing
Analog to Digital
Conversion

Charge X-ray converter

collection x-rays  electrons
device
3. Archiving

4
 Analog versus Digital

Exposure Latitude

Film
Signal output Digital

100:1
10000:1

Log relative exposure

Digital sampling
MTF of pixel aperture (DEL)
Spatial Resolution
1
0.9
0.8 100 mm
0.7
Modulation

0.6 200 mm
0.5
500 mm
0.4
0.3
0.2
0.1
0
0 1 2 3 4 5 6 7 8 9 10 11
Frequency (lp/mm)

Fourier transform of Rect (Dx) = sinc(Dx)

Cutoff frequency fC = (Dx)-1
Sampling Detector With sampling pitch = sampling aperture, Dx
Pitch Element, Nyquist Frequency fN = (2 Dx)-1
“DEL”

5
Digital Radiography 2012: detectors and manufacturers
BaFBr
Storage Phosphors Fuji, Agfa, Kodak, Konica….
CsBr

Direct Selenium Hologic, Toshiba, Shimadzu…

Flat-panel
a-Si Gadox Canon, Carestream
Indirect
GE, Trixell, (Philips, Siemens..)
Cesium Iodide
Varian, others….
CsI
Optical Lens Imaging Dynamics, Imix,
Gadox Swissray, Wuestec
CCD
Slot-scanner CsI Delft Dx Imaging, LoDox

CMOS
Indirect CsI Bioptics
x-Si

Gas detector X-Counter

Photon counters Direct
Solid State Si Sectra

Digital Radiography common themes

• Separation of Acquisition, Display, and Archive

• Wide dynamic range

– ~0.01 to 100 mR (~0.1 to 1000 mGy) incident exposure

• Variable detector exposure operation

– 20 to 2000 “speed class”

• Appropriate SNR & image processing are crucial

for image optimization

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 Available digital radiography technology,
2012

• CR: Photostimulable Storage Phosphor (PSP)

– Cassette-based detectors/readers
– Flying spot mechanical changers
– Line scan integrated detectors
• CCD: Charge-Coupled Device
– 2-D lens coupled systems
– 1-D slot-scan systems
• Thin-Film-Transistor (TFT) flat panel
– Indirect detection (scintillator)
– Direct detection (semi-conductor)
– Portable wireless implementations

Future “in-progress” technologies

• Hybrid direct / indirect flat panel TFT with variable gain

• Complementary Metal Oxide Semiconductor (CMOS)

• X-ray “light valve” Liquid Crystal and reflective scanner

detector system

• X-ray photon counters based on gas or silicon strip

detectors

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 PSP Radiography (CR)

• Currently the major technology available for

large field-of-view digital imaging

• Based upon the principles of photostimulated

luminescence; 20+ years of experience

• Operation emulates the screen-film paradigm in

use and handling.. (flexible but labor intensive)

• Manufacturing trends:
– Smaller, faster, less expensive

Computed Radiography “reader”

Fuji Information panel Various capabilities, sizes, throughput

Plate
stacker

Carestream

Konica

Agfa

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 Phosphor Plate Cycle
PSP
Base support
x-ray exposure

plate exposure:
create latent image
reuse
laser beam scan
plate readout:
extract latent image
light erasure
plate erasure:
remove residual signal

“Direct” Radiography (DR)

....refers to the acquisition and capture of the

x-ray image without user intervention
(automatic electronic processing and display)

– “Indirect” detector: a conversion of x-rays into

light by a scintillator, and light into electrons
for signal capture

– “Direct” detector: a conversion of x-rays to

electron-hole pairs with direct signal capture

9
 Flat panel portability
• Initial products introduced by Canon
– Tethered, thick profile
• Wireless products now on the market
– Trixell, Carestream, Canon, Source one…

CR and DR mobile radiography

Tethered cassette CR reader / processor

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 Wireless DR cassette

• Integrated
• Battery powered
• On-board computer
and processing

Point of service direct imaging

• 14x17inch
cassette…

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 Point of service direct imaging

• Preview
image in
2-3 s

Point of service direct imaging

• For Processing image…. 15 seconds

• QC

• Annotation

• Send

12
 DR replacement trends
• Passive for active detector technology

Spatial Resolution – MTF

1.0
0.9
a-Selenium: 0.13 mm
0.8
0.7
Modulation

0.6
0.5 CR: 0.05 mm
0.4 CsI-TFT: 0.20 mm
Screen-film
0.3
0.2
0.1 CR: 0.10 mm
0.0
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0
Frequency (lp/mm)

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 Detective Quantum Efficiency (DQE)
2
SNR out MTF(f ) 2
DQE(f ) = 
SNR in2 NPSN ( f )  q

• A measure of the information transfer efficiency of a

detector system

• Dependent on:
– Absorption & conversion efficiency
– Spatial resolution (MTF)
– Conversion noise & electronic noise
– Detector non-uniformities / pattern noise
– Not necessarily indicative of clinical performance

Detective Quantum Efficiency

Radiography
0.8
CsI - TFT

0.6
DQE( f )

a-Se - TFT
0.4
CR “dual-side”
Screen-film
0.2
CR Conventional
0.0
0.0 0.5 1.0 1.5 2.0 2.5
Spatial Frequency (cycles/mm)

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 High DQE does not “guarantee” good
image quality

• Appropriate radiographic technique is required

• Optimization of acquisition technique
– kV, mAs, SID, filtration, anti-scatter grid

• For similar acquisition techniques and grid use, the SNR

requires radiation dose proportional to DQE-1
• “Effective DQE” concept takes into account clinical
situations (magnification, grid)

Attribute CR DR CCD

Positioning flexibility **** ** **

Replacement for screen/film **** ** **

DQE / dose efficiency ** *** **

Patient throughput * *** **

X-ray system integration ** **** ****

Access to advanced
** **** ***
technology applications
Cost for comparable image
*** ** ***
throughput
Radiographer ease of use
* *** **
(manufacturer dependent)

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Standardized Exposure Index for Digital
Radiography – Technical Issues
• CR & DR systems have variable speed, wide
dynamic range, and internal signal scaling
• Consistent (and often inconsistent) image
appearance eliminates exposure feedback loop
• There is no direct link between image appearance
and detector “speed class”
• Overexposures can easily be unnoticed, resulting
in needless overexposure to the patient
• Underexposures have increased image noise that
can reduce diagnostic accuracy
31

Screen-Film system indicators

Traditional screen-film systems use overall film
density as an exposure indicator

J. Shepard and M. Flynn

Direct feedback to the technologist regarding exposure 32

16
 CR & DR system indicators
CR & DR systems use image processing to align
the grayscale with the signals

J. Shepard and M. Flynn

Direct visual cues (dark/light) are lost regarding exposure 33

Noise
The image processing adjusts the grayscale, however;
• Images with low signals are noisy and
• Images with high signal are associated with high dose

Exposure
Indicators
describe
image
quality in
terms of the
signal to
noise ratio
(SNR)

Underexposed, low SNR Overexposed?, high SNR 34

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 Exposure Indicators

CR and DR systems assess the recorded signal to

indicate whether the radiographic technique used is
appropriate

• Tests with defined beam conditions are used to

verify that correct indicators are being reported

• Recommended exposure indicator ranges are

used by technologists to check each radiographic
exposure

35

Region to assess signal indicator

Systems vary in the

region used to
assess the signal for
an image.

• Full Image

• Regular regions

• Anatomic regions

J. Shepard and M. Flynn presentation

36

18
 Region to assess signal indicator
IEC 62494-1
• Gray histogram for the entire image
• Black histogram for the anatomic
region (relevant region)

37

Computation of an exposure indicator

…. computed from the probability distribution of signal
values in the relevant image region, based on the median

Manufacturers have adopted proprietary methods

• Algorithms, values, and calibration methods are

widely different, leading to confusion amongst users

• Inappropriate image segmentation or histogram

‘values of interest’ range can produce inaccuracies

38

19
 Summary of manufacturer Exposure Indices
Manu- Indicator Exposure
Symbol Units Calibration Conditions
facturer Name Dependence
80 kVp, 3 mm Al “total
Fujifilm S Value S Unitless 200/S  X (mR) filtration”
S=200 @ 1 mR
80 kVp + 1.0 mm Al + 0.5
Kodak Exposure Index EI mbels EI + 300 = 2X mm Cu
EI = 2000 @ 1 mR

for 400 Speed Class, 75

Log of Median
Agfa of histogram
lgM bels lgM + 0.3 = 2X kVp + 1.5 mm Cu
lgM=1.96 at 2.5 µGy

Sensitivity for QR = k, for QR=200, 80 kVP S=200

Konica Number
S Unitless
200/S  X (mR) @ 1 mR
Brightness = c1, for Brightness = 16,
Reached
Canon Exposure Value
REX Unitless Contrast = c2, Contrast = 10,
REX  X 1 REX ≈ 106 @ 1 mR1
80 kVp, 26 mm Al HVL =
8.2 mm Al
Canon EXP EXP Unitless EXP  X
DFEI = 1.5
EXP = 2000 @ 1 mR
1 From empirical data
39

Summary of manufacturer Exposure Indices

Manu- Indicator Exposure
Symbol Units Calibration Conditions
facturer Name Dependence
Uncompensated
GE Detector UDExp mGy Air UDExp  X (μGy) 80 kVp, standard filtration,
Exposure KERMA no grid

Compensated mGy Air

GE Detector CDExp KERMA CDExp  X (μGy)
Exposure
GE Detector DEI Unitless DEI ≈ 2.4X (mR) 1 Not available
Exposure Index
Swissray Dose Indicator DI Unitless Not available Not available
Imaging
Dynamics Accutech f# Unitless 2f#=X(mR)/Xtgt(mR) 80 kVp + 1 mm Cu
Company
Philips Exposure Index EI Unitless 100/S  X (mR) RQA5, 70 kV, +21 mm Al, HVL=7.1
mm Al
Siemens mGy Air RQA5, 70 kV +0.6 mm Cu,
Medical Exposure Index EXI KERMA X(mGy)=EI/100 HVL=6.8 mm Al
Systems

Alara CR Exposure EIV mbels EIV + 300 = 2X 1 mR at RQA5, 70 kV, +21 mm Al,
Indicator Value HVL=7.1 mm Al => EIV=2000

iCRco Exposure Index none Unitless Exposure Index 1 mR at 80 kVp + 1.5 mm Cu => =0
 log [X (mR)]
40

20
 Approximate EI Values vs. Receptor Exposure

Manufacturer Symbol 50 mGy 100 mGy 200 mGy

Canon (Brightness
REX 50 100 200
=16, contrast = 10

IDC (ST = 200) F# -1 0 1

Philips EI 200 100 50
Fuji, Konica S 400 200 100
Kodak (CR, STD) EI 1700 2000 2300
Siemens EI 500 1000 2000

….. The need for a standard clearly evident

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Standardization
• American Association of Physicists in Medicine
Task Group 116 and International Electrotechnical
Commission (IEC)
• Collaborative effort
• Physicists
• Manufacturers/Vendors representatives
• MITA (Medical Imaging and Technology Alliance)
• Develop common “Exposure Indices” and “Deviation
Indices” across detectors and manufacturers/vendors
• Provide means for placing data in DICOM metadata

42

21
AAPM TG 116
The AAPM TG 116 report on exposure indicators
was published in July of 2009

IEC Standard
IEC published a standard for Exposure
Index definitions in August of 2008

43

Description of Exposure Indices Parameters

AAPM IEC
TG116 Med Physics 2009 62494-1 IEC:2008

Exposure Air-kerma at the receptor EI = KCAL × 100 μGy-1

Index KIND = KCAL (μGy) (unitless)

Calibration RQA-5 RQA-5

Energy 66 - 74 kVp 66 - 74 kVp
RQA-5 Equivalent RQA-5 Equivalent
Calibration 0.5 mm Cu (+ 0-3 mm Al) 0.5 mm Cu + 2 mm Al or
Filtration or 21 mm Al 21 mm Al
6.8 ± 0.2 mm Al HVL 6.8 ± 0.3 mm Al HVL
Deviation Deviation Index Deviation Index
Index DI = 10*log10(KIND/KTGT) DI = 10*log10(EI/ET)

Signed decimal string with

DI format Unspecified
1 decimal point
44

22
Exposure Indices

Deviation Index (DI)

 EI 
DI  10  Log10  
 EIT (b.v) 

• EIT is a target index value that is to be determined for each

body part b, view v, procedure type, and clinical site
• When EI equals EIT, DI = 0
• DI = +3.0 for 2x target exposures
• DI = -3.0 for ½ target exposure
• ± 1 is one step on a standard generator mAs control or
AEC compensation (ISO R5 scale)

45

Need to have robust methods of determining DI

What about VOI modification by the technologist?

EI = EIT
EI and DI DI = 0.0
calculated from
this pixel value
Number of pixels

Values of Interest

Pixel Value
46

23
Need robust methods of determining EI & DI
VOI recognition algorithm fails
• Gonadal shields, prosthetics, etc. EI = EIT
• False DI reported
DI = 0.0
EI and DI EI and DI EI  EIT
incorrectly calculated calculated from
from this pixel value this pixel value DI = -1.3
Number of pixels

Correct
Values of Interest

Pixel Value
Incorrect Values of Interest 47

Need robust methods of determining EI & DI

User adjusts VOI for proper grayscale rendition manually,
and DI returns to zero
EI = EITGT
EI and DI EI and DI DI = 0.0
incorrectly calculated calculated from
from this pixel value this pixel value
EI  EITGT
Number of pixels

DI = -1.3

Correct
Values of Interest

Pixel Value
Incorrect Values of Interest 48

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Need to determine recommendations for repeats

• DI target is -2.0 to +2.0

• Check for noise. Consult with radiologist on need

for repeat if EI is  63% of target (DI -2)

• Investigate cause (do not repeat) if EI is between

160% and 200% of target (+2.0  DI  +3.0)

• Consult with radiologist (check for saturation) on

need for repeat and counsel of technologist if EI is
200% of target (DI  +3.0)

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IEC 62494-1: Target Exposure Index EIT

• EIT may depend on detector type, examination

type, diagnostic question and other parameters
• Establishing target exposure index values needs
medical knowledge – may be done by professional
societies
• EIT values should be provided as a data base in the
digital imaging system

Ulrich Neitzel
Project Leader,
Convenor IEC SC62B WG 43
50

25
 Caveats

• The EI does not describe patient dose

• EI is derived from detector signal (dose at the detector)

• The EI is not a dose measurement tool

• Dose calibration only valid at one radiation quality

• Images with same EI obtained on different digital

systems might not have similar image quality
• Influence of detector DQE, scattered radiation, beam
quality differences

Ulrich Neitzel
Project Leader,
Convenor IEC SC62B WG 43
51

Exposure Index & Deviation Index monitoring

• Collect EI and DI for every image and analyze

• By technologist
• Technique factors
• X-ray system
• Plate scanning unit (CR)
• Processing unit (CR - DR)
• Anatomical view

• Longitudinal studies
• Track performance over time
• Mean and Standard Deviation of EI and DI
• Watch for trends upward (Dose Creep)
52

26
Image Integration and Distribution
• RIS-PACS Integration
– Data Synchronization, Validation
– Interpretation & Results Reporting

• Modality Worklist (MWL)

– RIS-driven data transfer of exam information
– Aid the technologist for protocol and room setup

• Image Distribution (The Internet)

– Clinical Review, OR, Patients, Conferences
– Enterprise Integration - EMR
– Teleradiology

Communication Protocols
• TCP/IP
– Standard Communications Protocol
– The Internet

• HL7
– Health Level 7
– RIS / HIS

• DICOM 3.0
– Digital Imaging COmmunications in Medicine v3.0
– PACS

• HTTP
– Hyper-Text Transport Protocol
– The World Wide Web

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 A typical imaging solution

Typical PACS workstation configuration

•1536x2048
•10 bit
•Grayscale or
color
•400 Cd/m2
Navigation
Monitor(s)
1920x1080
color
Digital voice
dictation
support

28
 Basic Workstation Software Reqt’s
• Filters: sort studies by modality, location, time, etc.
• Worklist functionality: automate workflow
• Hanging protocols: arrange images and display
• Retrieving priors: pre-fetch or all spinning disk
• Graphic user interface: tool palette parameters
• Mechanical interface: keyboard, mouse, other
• User preferences: individual preferences for above

• American College of Radiology

• National Electrical Manufacturers Association
(NEMA)
• Established 1983, first published 1985
• Followup standards in 1988 (ACR-NEMA 2.0)
• 1993, DICOM 3.0 published and continuously
updated

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 What does DICOM do?
• Addresses 5 areas of functionality
– Transmission and persistence of complete objects
(images, waveforms, documents)
– Query & Retrieval of such objects
– Performance of specific actions (e.g. film printing)
– Workflow management (support of worklists)
– Quality and consistency of image appearance
(both display and print)

• Network configurations
– Application Entity (AE) title, IP address, TCP/IP port
number

What does DICOM do?

• DICOM storage
– e.g., CT image storage SOP class, CR image storage SOP class
• DICOM print
– Basic grayscale print management SOP class (SCU only)
• Query / Retrieve
– Poll a DICOM device for a list of studies or patients, then retrieve
one or more
• Worklist Management
– Download a list of “scheduled procedures” to the modality from
the RIS through a worklist management provider (PACS Broker)
• Modality Performed Procedure Step (MPPS)
– Modality tells RIS that the procedure has been performed

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 DICOM Metadata……

PACS capability & needs

• Hanging protocols—radiologist specific
• API – application program interface
• 3rd party add-ons
• Presentation State
• VOI LUT (Value Of Interest Look-up-table)
• De-identification / anonymization (HIPAA)
• Part 14 DICOM export
• ……… and so on…..

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 IMAGE DISTRIBUTION:
Web and the Internet and Teleradiology
Radiology Departments
Imaging
Centers CR MRI US CT
Hospital
PCs
Clinic
PCs Web Control Image
Servers Software Archive
Office (TB)
PCs
Home Review Review
PCs Remote Station Station
Radiologists
Radiologists
Courtesy of Dr. Keith Dreyer

PACS installation planning

• Location of server and major hardware
• PC requirements for workstations,
environment and power considerations
• “Mini-PACS” for ultrasound, nuclear medicine
– Color monitors
– Application specific workstation requirements
• Reading room
– Lighting
– Furniture

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 Challenges
• Integration of different systems

• IHE: Integrating the Healthcare Enterprise

– Addresses INTEROPERABILITY of systems
– Provides INTEGRATION PROFILES and a
framework for performing needed functionality and
workflow

• http://www.IHE.org

PACS quality control

• Interfaces
• Redundancy and emergency backup
• Software verification (distance accuracy
measurements, quantitative measurements)
• MONITORS
• Verification of correct data
• Display and viewing conditions
• Image compression & archiving
• Disaster Recovery and backup plans

33
 SUMMARY
Enterprise distribution of images is crucial
for implementation and application of technology

• Cassetteless, active detector radiography devices

(flat panel) are becoming the detectors of choice
• Proliferation of web-based PACS and unified
patient database (instead of Radiology centric
orientation) is here
• New opportunities
– Image acquisition and image processing tools
– Imaging technology innovation for diagnosis and
intervention

34