J Digit Imaging (2013) 26:38–52

DOI 10.1007/s10278-012-9522-2

ACR–AAPM–SIIM Technical Standard for Electronic

Practice of Medical Imaging
James T. Norweck & J. Anthony Seibert & Katherine P. Andriole &
David A. Clunie & Bruce H. Curran & Michael J. Flynn & Elizabeth Krupinski &
Ralph P. Lieto & Donald J. Peck & Tariq A. Mian

Published online: 20 September 2012

# Society for Imaging Informatics in Medicine and the American College of Radiology 2012

The American College of Radiology, with more than 30,000 members, is the principal organization of radiologists, radiation oncologists, and clinical
medical physicists in the United States. The College is a nonprofit professional society whose primary purposes are to advance the science of radiology,
improve radiologic services to the patient, study the socioeconomic aspects of the practice of radiology, and encourage continuing education for radiologists,
radiation oncologists, medical physicists, and persons practicing in allied professional fields.
The American College of Radiology will periodically define new practice guidelines and technical standards for radiologic practice to help advance the
science of radiology and to improve the quality of service to patients throughout the United States. Existing practice guidelines and technical standards will
be reviewed for revision or renewal, as appropriate, on their fifth anniversary or sooner, if indicated.
Each practice guideline and technical standard, representing a policy statement by the College, has undergone a thorough consensus process in which it
has been subjected to extensive review, requiring the approval of the Commission on Quality and Safety as well as the ACR Board of Chancellors, the ACR
Council Steering Committee, and the ACR Council. The practice guidelines and technical standards recognize that the safe and effective use of diagnostic
and therapeutic radiology requires specific training, skills, and techniques, as described in each document. Reproduction or modification of the published
practice guideline and technical standard by those entities not providing these services is not authorized .

Revised 2012 (Resolution 35)*

J. T. Norweck M. J. Flynn
Radiology Inc., Department of Radiology, Henry Ford Health Systems,
Huntington, WV, USA Detroit, MI, USA

J. A. Seibert E. Krupinski (*)

Department of Imaging, Department of Medical Imaging, University of Arizona,
University of California Davis health System, Tucson, AZ, USA
Sacramento, CA, USA e-mail: [email protected]

K. P. Andriole
R. P. Lieto
Department of Radiology, Brigham and Women’s Hospital,
Radiation Safety Office, St. Joseph Mercy Health System,
Harvard Medical School,
Ann Arbor, MI, USA
Boston, MA, USA

D. A. Clunie D. J. Peck
Comview Corporation, Department of Radiology, Henry Ford Health System,
Tarrytown, NY, USA Detroit, MI, USA

B. H. Curran T. A. Mian
Department of Radiation Oncology, Rhode Island Hospital, Medical Radiation Physics, Inc,
Providence, RI, USA Scottsdale, AZ, USA
J Digit Imaging (2013) 26:38–52 39

Preamble and images from ultrasound and magnetic resonance mo-

dalities. Research, nonhuman and visible light images (such
These guidelines are an educational tool designed to assist as dermatologic, histopathologic, or endoscopic images) are
practitioners in providing appropriate radiologic and radia- out of scope, though many of the same principles are
tion oncology care for patients. They are not inflexible rules applicable.
or requirements of practice and are not intended, nor should Increasingly, medical imaging and patient information
they be used, to establish a legal standard of care. For these are being managed using digital data during acquisition,
reasons and those set forth below, the American College of transmission, storage, display, interpretation, and consulta-
Radiology cautions against the use of these guidelines in tion. The management of these data during each of these
litigation in which the clinical decisions of a practitioner are operations may have an impact on the quality of patient
called into question. care.
The ultimate judgment regarding the propriety of any This technical standard is applicable to any system of
specific procedure or course of action must be made by digital image data management, from a single-modality or
the physician or medical physicist in light of all the circum- single-use system to a complete picture archiving and com-
stances presented. Thus, an approach that differs from the munication system (PACS) to the electronic transmission of
guidelines, standing alone, does not necessarily imply that patient medical images from one location to another for the
the approach was below the standard of care. To the con- purposes of interpretation and/or consultation.
trary, a conscientious practitioner may responsibly adopt a It defines goals, qualifications of personnel, equipment
course of action different from that set forth in the guidelines guidelines, specifications of data manipulation and manage-
when, in the reasonable judgment of the practitioner, such ment, and quality control and quality improvement proce-
course of action is indicated by the condition of the patient, dures for the use of digital image data that should result in
limitations of available resources, or advances in knowledge high-quality radiological care. A glossary of commonly
or technology subsequent to publication of the guidelines. used terminology (Appendix A) and a reference list are
However, a practitioner who employs an approach substan- included.
tially different from these guidelines is advised to document In all cases for which an ACR practice guideline or
in the patient record information sufficient to explain the technical standard exists for the modality being used or the
approach taken. specific examination being performed, that practice guide-
The practice of medicine involves not only the science, line or technical standard will continue to apply when digital
but also the art of dealing with the prevention, diagnosis, image data management systems are used.
alleviation, and treatment of disease. The variety and com- Digital mammography is outside the scope of this docu-
plexity of human conditions make it impossible to always ment. For further information, see the ACR–AAPM–SIIM
reach the most appropriate diagnosis or to predict with Practice Guideline for Determinants of Image Quality in
certainty a particular response to treatment. Digital Mammography.
Therefore, it should be recognized that adherence to these The goals of the electronic practice of medical imaging
guidelines will not assure an accurate diagnosis or a suc- include, but are not limited to:
cessful outcome. All that should be expected is that the
1. Initial acquisition or generation and recording of accu-
practitioner will follow a reasonable course of action based
rately labeled and identified image data.
on current knowledge, available resources, and the needs of
2. Transmission of data to an appropriate storage medium
the patient to deliver effective and safe medical care. The
from which it can be retrieved for display for formal
sole purpose of these guidelines is to assist practitioners in
interpretation, review, and consultation.
achieving this objective.
3. Retrieval of data from available prior imaging studies
to be displayed for comparison with a current study.
4. Transmission of data to remote sites for consultation,
Introduction
review, or formal interpretation.
5. Appropriate compression of image data to facilitate
This technical standard has been revised by the American
transmission or storage, without loss of clinically sig-
College of Radiology (ACR), the American Association of
nificant information.
Physicists in Medicine (AAPM), and the Society for Imag-
6. Archiving of data to maintain accurate patient medical
ing Informatics in Medicine (SIIM).
records in a form that:
For the purpose of this technical standard, the images
referred to are those that diagnostic radiologists would nor- (a) May be retrieved in a timely fashion
mally interpret, including transmission projection and cross- (b) Meets applicable facility, state, and federal regulations
sectional X-ray images, ionizing radiation emission images, (c) Maintains patient confidentiality
40 J Digit Imaging (2013) 26:38–52

7. Promoting efficiency and quality improvement. images being reviewed and understand the elements of
8. Providing interpreted images to referring providers. quality control of digital image management systems.2
9. Supporting telemedicine by making medical image 2. The physician must demonstrate qualifications as delin-
consultations available in medical facilities without eated in the appropriate ACR practice guideline or tech-
on-site medical imaging support. nical standard for the particular diagnostic modality
10. Providing supervision of off-site imaging studies. being interpreted.
11. Providing timely availability of medical images, image 3. The physician should have a working knowledge of
consultation, and image interpretation by: those portions of the digital image chain from acquisi-
tion to display that affect image quality and potential
(a) Facilitating medical image interpretations in on-
artifact production.
call situations
(b) Providing subspecialty support as needed. Qualified Medical Physicist
12. Enhancing educational opportunities for practicing
radiologists. A qualified medical physicist is an individual who is com-
13. Minimizing the occurrence of poor image quality. petent to practice independently one or more of the subfields
Appropriate database management procedures applicable in medical physics. The American College of Radiology
to all of the above should be in place. considers certification, continuing education, and experi-
ence in the appropriate subfield(s) to demonstrate that an
individual is competent to practice one or more of the
subfields in medical physics and to be a qualified med-
Qualifications and Responsibilities of Personnel ical physicist. The ACR strongly recommends that the
individual be certified in the appropriate subfield(s) by
Qualified personnel trained in the examination to be per- the American Board of Radiology, the Canadian College
formed must perform the imaging examination at the trans- of Physics in Medicine, or by the American Board of
mitting site. In all cases this means a physician, a licensed Medical Physics.
and/or registered radiologic technologist, a radiation thera- The appropriate subfields of medical physics for this
pist, a nuclear medicine technologist, or a sonographer. The standard are therapeutic medical physics, diagnostic medical
technologist, radiation therapist, or sonographer must be physics, and nuclear medical physics. (Previous medical
under the supervision of a qualified licensed physician. It physics certification categories including radiological phys-
is desirable to have a qualified medical physicist and an ics, diagnostic radiological physics, and diagnostic imaging
imaging informatics professional as a consultant. physics are also acceptable.)
A qualified medical physicist should meet the ACR Prac-
Physician tice Guideline for Continuing Medical Education (ACR
Resolution 17, 1996—revised in 2012, Resolution 42) and
1. Physicians using the image data management system for should include continuing education in radiation dosimetry,
official interpretation1 should understand the basic tech- radiation protection, and equipment performance.
nology of image acquisition, transmission, manipulation,
retrieval, and display, including the strengths, weak- Registered Radiologist Assistant
nesses, and limitations in the use of the image viewing
equipment. Where appropriate, the interpreting physician A registered radiologist assistant is an advanced level
must be familiar with the principles of radiation protec- radiographer who is certified and registered as a radiologist
tion, the hazards of radiation exposure to both patients and assistant by the American Registry of Radiologic Technol-
radiological personnel, and patient and personnel moni- ogists after having successfully completed an advanced
toring requirements. The physician performing the official academic program encompassing an ACR/American Socie-
interpretation must be responsible for the quality of the ty of Radiologic Technologists (ASRT) radiologist assistant

1
The ACR Medical Legal Committee defines official interpretation as 2
The ACR Rules of Ethics state: “It is proper for a diagnostic radiol-
that written report (and any supplements or amendments thereto) that ogist to provide a consultative opinion on radiographs and other
attach to the patient’s permanent record. In healthcare facilities with a images regardless of their origin. A diagnostic radiologist should
privilege delineation system, such a written report is prepared only by a regularly interpret radiographs and other images only when the radiol-
qualified physician who has been granted specific delineated clinical ogist reasonably participates in the quality of medical imaging, utili-
privileges for that purpose by the facility’s governing body upon the zation review, and matters of policy which affect the quality of patient
recommendation of the medical staff. care.”
J Digit Imaging (2013) 26:38–52 41

curriculum and a radiologist-directed clinical preceptorship. protocols, database management, internet protocols,
Under radiologist supervision, the radiologist assistant may and systems analysis methods and design.
perform patient assessment, patient management, and select-
ed examinations as delineated in the Joint Policy Statement A qualified imaging informatics professional is an indi-
of the ACR and the ASRT titled “Radiologist Assistant: vidual who is competent to practice independently in the
Roles and Responsibilities” and as allowed by state law. areas of informatics listed above and discussed in the section
The radiologist assistant transmits to the supervising radiol- on informatics workflow. He or she should have a minimum
ogists those observations that have a bearing on diagnosis. of a bachelor’s degree in computer science or equivalent,
Performance of diagnostic interpretations remains outside and continuing education and experience in imaging infor-
the scope of practice of the radiologist assistant (ACR matics to demonstrate that an individual is competent to
Resolution 34, adopted in 2006). practice as an Imaging Informatics Professional. Certifica-
tion through the American Board of Imaging Informatics
Radiologic Technologist can be used as validation of an individual’s qualification as a
qualified imaging informatics professional.
The technologist must:

1. Be certified by the appropriate registry and/or possess Equipment Specifications

unrestricted state licensure.
2. Meet the qualification requirements of any existing Specifications for equipment used in digital image data man-
ACR practice guideline or technical standard for acqui- agement will vary depending on the application and the indi-
sition of a particular examination. vidual facility’s needs; but in all cases, it should provide image
3. Be trained to properly operate those portions of the quality and availability appropriate to the clinical needs wheth-
image data management system with which he or she er that need be official interpretation or secondary review.
must routinely interact. This training should include as Compliance with the Digital Imaging and Communications
appropriate: in Medicine (DICOM) standard, the Integrating the Health-
care Enterprise (IHE) Radiology Technical Framework, and
(a) Image acquisition technology where applicable the IHE-Radiation Oncology Technical
(b) Image processing protocols Framework (IHE-RO) is strongly recommended for all new
(c) Proper selection of examination specific options equipment acquisitions, and consideration of periodic
(d) Image evaluation upgrades incorporating the expanding features of that standard
(e) Radiation dose indicators should be part of the ongoing quality control program.

Imaging Informatics Professional Acquisition or Digitization

The imaging informatics professional should be qualified to Initial image acquisition should be performed in accordance
assess problems and provide input to solutions, to initiate with the appropriate ACR modality or examination practice
repairs, and to coordinate system-wide maintenance pro- guideline or technical standard.
grams that will assure sustainable high image quality and 1. Direct image capture
system functioning. The responsibilities and experience of The image dataset acquired by the digital modality in
an imaging informatics professional include: the full spatial resolution (image matrix size) and pixel
Maintenance of the network for all informatics systems, bit depth should be transferred to the image manage-
e.g., radiology information system, PACS, speech recogni- ment system. It is recommended that the DICOM stan-
tion systems, computer servers, and desktops. dard be used.
2. Scanned radiographic films
1. Maintenance of the integrity of system databases to Films from prior patient studies may be digitized
ensure continuous and accurate operation of the infor- using modern film scanning systems. When used, the
matics systems. pixel pitch of the scanner should be small enough to
2. Coordination of the interaction/functionality of all data capture the limiting resolution of the film. For general
entry and management systems with the necessary radi- purpose radiographic films, a pitch of less than 200 μm
ology applications, programs and databases. (2.5 cycles/mm limiting resolution) should be used. For
3. Knowledge of computer systems using common oper- high-resolution film or mammography, a pitch of less
ating systems (Windows, Unix/Linux, Mac), data com- than 100 μm (5.0 cycles/mm limiting resolution) should
munications standards and equipment, network be used. The scanner should be capable of recording
42 J Digit Imaging (2013) 26:38–52

film optical densities up to at least 3.2 for general image. Irreversible compression may be used to reduce trans-
purpose radiographs and 4.0 for high-resolution radio- mission time or storage space only if the quality of the result is
graphs and mammograms. The digitization should have sufficient to reliably perform the clinical task. The type of body
at least 12 bits of precision (0–4,095) and produce either part, the modality, and the objective of the study will determine
DICOM presentation values or values proportional to the amount of compression that can be tolerated.
film density. In general, photographic cameras should The term diagnostically acceptable irreversible compres-
not be used to digitize films because of inherent distor- sion (DAIC) refers to mathematically irreversible compres-
tion and optical artifacts. sion that does not affect a particular diagnostic task [1].
3. Video digitizer acquisitions DAIC may be used under the direction of a qualified phy-
Traditional fluoroscopy systems have used video re- sician with no reduction in clinical diagnostic performance
cording cameras to acquire images from the output by either the primary image interpreter or decision makers
phosphor of an image intensifier. Recordings may be reviewing the images.
of individual spot exposures, pulsed fluoroscopic The ACR and this technical standard make no general
sequences, or continuous fluoroscopic frames. Analog statement on the type or amount of compression that is
video cameras produce a time-varying voltage signal appropriate to any particular modality, disease, or clinical
corresponding to a raster scan of the image. Analog to application to achieve the diagnostically acceptable goal.
digital conversion systems are used to convert these The scientific literature and other national guidelines may
signals to digital images formatted according to the assist the responsible physician in choosing appropriate
DICOM standard. These systems are susceptible to types and amounts of compression, weighing the risk of
degraded quality due to analog signal noise, timing, degraded performance against the benefits of reduced stor-
and drift. When used, the image quality should be age space or transmission time. The type and amount of
closely monitored. In general, the use of digital record- compression applied to different imaging studies transmitted
ing cameras with image intensifiers or direct digital and stored by the system should be initially selected and
fluoroscopy panels is preferred. periodically reviewed by the responsible physician to ensure
4. General requirements appropriate clinical image quality, always considering that it
may be difficult to evaluate the impact on observer perfor-
(a) At the time of patient imaging, the imaging modality mance objectively and reliably [2].
must have capabilities for capturing demographic as If reversible or irreversible compression is used, only
well as imaging information such as accession num- algorithms defined by the DICOM standard such as Joint
ber, patient name, identification number, date and Photographic Experts Group (JPEG), JPEG-LS, JPEG-
time of examination, name of facility or institution, 2000, or MPEG should be used, since images encoded with
type of examination, patient or anatomic part orien- proprietary and nonstandard compression schemes reduce
tation (e.g., right, left, superior, inferior), amount and interoperability, and decompression followed by recompres-
method of data compression, and total number of sion with a different irreversible scheme (such as during
images acquired in the study. (In some cases, the migration of data) will result in significant image quality
total number of images may not be known if the degradation [1]. The DICOM standard does not recommend
modality sends images as they are acquired.) This or approve any particular compression scheme for any par-
information must be associated with the images ticular modality, image type, or clinical application.
when transmitted with a modality-specific informa- The US Food and Drug Administration (FDA) requires
tion object descriptor. These fields should be format- that when an image is displayed, it be labeled with a mes-
ted according to the DICOM standard. It is desirable sage stating if irreversible compression has been applied and
to obtain this information using the DICOM modal- with approximately what compression ratio [3]. In addition,
ity work list services that communicate the correct the name or type of compression scheme used (for standard
information electronically. schemes such as JPEG, JPEG 2000, etc.) should also be
(b) The ability to capture the patient date of birth, sex, displayed, since this affects the interpretation of the impact
indications for the examination, and a brief patient of the compression. The DICOM standard defines specific
history is desirable. fields for the encoding of this information, and its persis-
tence even after the image has been decompressed.
Compression The FDA does not allow irreversible compression of
digital mammograms for retention, transmission, or final
Compression may be defined as mathematically reversible interpretation, though irreversibly compressed images may
(lossless) or irreversible (lossy). Reversible compression may be used for images from prior studies [4]. For other modal-
always be used, since by definition there is no impact on the ities, the FDA does not restrict the use of compression, but it
J Digit Imaging (2013) 26:38–52 43

does require manufacturers of devices that use irreversible without distortion. The flat panel surfaces are able
compression to submit data on the impact of the compression to absorb ambient light to minimize reflections and
on quantitative metrics of image quality (such as peak signal- glare. However, lower cost units using twisted
to-noise ratio) [3]. Since it is known that such simple metrics nematic (TN) pixel structures severely alter image
do not correlate well with human observer assessment of brightness, contrast, and color in relation to view-
quality or performance for diagnostic tasks [5], the claim of ing angle. TN devices should not be used. Several
the manufacturer that irreversible compression is satisfactory advanced pixel structures are now available to
may not be sufficient and the burden remains on the respon- provide improved viewing angle performance (ver-
sible physician to assure that the image quality is sufficient to tical alignment, in-plane switching, and dual do-
achieve a diagnostically acceptable goal. main structures). The viewing angle characteristics
of any LCD device should be evaluated using
Transmission contrast transfer test patterns prior to purchase.
(c) Graphic interface: LCD devices are inherently dig-
The environment in which the studies are to be transmitted ital with an internal buffer storing the data for each
will determine the type and specifications of the transmis- pixel in the rows and columns of the device. The
sion devices used. In all cases, for official interpretation, the interface between the graphic controller and the
digital data received at the receiving end of any transmission LCD device should transfer the image data using
must have no loss of clinically significant information. The a digital format such as DVI-D (either single-link
transmission system should have a bandwidth commensu- or dual-link) or display port. For optimal resolu-
rate with expected volumes in the ability to deliver images tion, the graphic controller device driver should
in a timely fashion. The transmission system must have always be set to the native rows and columns of
adequate error-checking capability. Only the appropriate the LCD device. An analog video interface signal
modality-specific DICOM service-object pair classes should such as VGA or DVI-A is not recommended since
be used for transmission and storage. the digital to analog conversion in the graphic
controller and the analog to digital conversion in
Display the LCD device can introduce image degradation.
(d) Image presentation size: The rows and columns of
The consistent presentation of images on workstations is the displayed image are typically different than the
essential for electronic imaging operations. Images seen by rows and columns of the acquired image. The
technologists during acquisition, by radiologists during inter- application software working in conjunction with
pretation, and by physicians as a part of patient care should the graphic controller interpolates from the ac-
have similar appearance. The spatial and contrast resolution of quired image data to get the displayed image data.
images displayed for interpretation is particularly important. For optimal image resolution, the interpolation of
The presentation of images is influenced by workstation soft- each displayed pixel, whether up- or down-sampling,
ware, graphic controllers, and display devices. should consider more than the closest four acquired
pixel values. Cubic spline and cubic polynomial
1. Workstation characteristics
interpolation algorithms are commonly used for high
(a) Graphic bit depth: The operating systems of most quality interpolation with the graphic controller pro-
workstations manage images with red, green, and viding acceleration so that images are presented with
blue channels having 8 bits (256 values). The num- negligible delay. When down-sampling noisy
ber of available gray levels where the red, green, images, the extended region considered in the inter-
and blue values are equal is thus 256. Systems with polation also helps reduce noise in the presentation.
increased bit depth such as 30 bit graphics with 10 (e) Presentation support features: The application soft-
bits per channel require support from the operating ware used to select and present images studies
system, workstation software, graphic card, and should provide features to allow rapid and easy
monitor. While subtle differences between 8- and review or interpretation of a study.
10-bit systems can be demonstrated using test pat-
terns, no evidence has been found to date that 1. Hanging protocols that address the selection of
diagnostic interpretations are affected by the use image series and display format should be flex-
of higher than 8-bit systems. ible and tailored to user preferences with proper
(b) Liquid crystal display (LCD) technology: Nearly labeling and orientation of images.
all workstation displays now use LCD panels. 2. Fast and easy navigation between new and old
Their discrete pixels offer excellent resolution studies should be feasible.
44 J Digit Imaging (2013) 26:38–52

3. Accurately associating the patient and study 4. Proper chairs with lumbar support and adjustable
demographic information with the images of height controls (including armrests) are recom-
the study performed is essential. mended to avoid injuries and excessive fatigue.
4. Window and level adjustment tools must be avail- 5. The workstation table should be height adjust-
able since the full dynamic range of most images able, and the keyboard, mouse, and monitors
cannot be displayed on most digital devices. Preset should be designed to maximize comfort and
window/level settings (e.g., bone or lung windows efficiency. The display devices should be placed
using set lookup table (LUT) transformations) are to maintain the viewers at an arm’s length from
recommended to increase the speed of user inter- the display (i.e., about 2/3 m or 60 cm).
action with the display device. 6. Dictation tools, internet access, and other refer-
5. Zoom (magnification) and pan functions capa- ence tools should be readily accessible and easy
ble of meeting guidelines for display at the to use during image interpretation.
originally acquired spatial resolutions (i.e., di- 7. Guidelines on the maximum number of accept-
rect presentation of acquired pixels on the dis- able pixel defects is specified by ISO 9241 as a
play pixels) are essential so that the display function of display class [7]. Documentation of
monitor does not limit the intrinsic spatial res- allowed pixel defects should be provided by the
olution of the image. For some applications, display manufacturer. Displays should be evalu-
the ability to present an image with anatomic ated for significant pixel defects initially and
structure having true size relative to the acquisi- periodically (at least annually is recommended).
tion is important.
6. Rotating or flipping the images must preserve the 2. Display characteristics
correct patient orientation labels.
(a) Luminance response
7. Calculating and displaying accurate linear meas-
The brightness and contrast of grayscale medi-
urements and pixel value determinations in values
cal images result from the luminance in relation to
appropriate for the modality (e.g., Hounsfield
the image gray level values [8].
units for CT images) are necessary, if those data
are available and can be calibrated to the acquisi- 1. Ambient luminance (Lamb): When the power to the
tion device. display device is off, the display surface will still
8. Prior application of irreversible compression ra- show some brightness due to diffusely reflected
tio, processing, or cropping on the image and/or room lighting. This is called the ambient luminance.
overlay should be indicated. The ambient luminance should be less than one
9. Clinically relevant technical parameters should fourth of the luminance of the darkest gray level.
be accessible with overlay information on the 2. Minimum luminance (Lmin): Since the contrast
display or with capabilities to view the DICOM response of the adapted human visual system is
header content. poor in very dark regions, the luminance of the
lowest gray value, Lmin, should not be extremely
(f) Ergonomic factors low. The minimum luminance including a com-
ponent from ambient lighting, L′min 0Lmin +Lamb,
1. Adequate air flow, optimal temperature, and hu- should be at least 1.0 cd/m2 for diagnostic inter-
midity control should be maintained in reading pretation and 0.8 cd/m2 for other uses.
areas. 3. Maximum luminance (Lmax): The perceived con-
2. Viewing conditions should be optimized to mini- trast characteristics of an image depend on the
mize eye fatigue by controlling reading room ratio of the luminance for the maximum gray value
lighting to eliminate reflections on the monitor (Lmax) to Lmin. This is the luminance ratio (LR),
and lowering the ambient lighting level as much which is not the same as the contrast ratio often
as is feasible without turning the lighting off com- reported by monitor manufacturers. Ideally, all
pletely (20–40 lx is recommended in the work display devices in a facility should have the same
space environment) [5]. Brighter ambient lighting LR so that the presentation is consistent for all
may be tolerable or even desirable so long as viewers of a study.
conformance with AAPM Task Group 18 specifi- 4. The LR must be large for good image contrast;
cations is maintained. [6]. however, an excessively large LR will exceed the
3. Noise from computer equipment and other devi- range of the adapted human visual system. A LR
ces should be minimized. of 350, which is equivalent to a film OD range
J Digit Imaging (2013) 26:38–52 45

from 0.20 to 2.75, is effective. For acceptable presented. The size of the active display region, in
contrast, LR should always be greater than 250. combination with pixel pitch, determines the num-
5. The Lmax of diagnostic monitors used for interpre- ber of pixels in the display device. While it has been
tation should be at least 350 cd/m2 with an L′min of common to classify monitors based on the number
1.0 cd/m2. For the interpretation of mammograms, of pixels (i.e., 1, 2, 3, or 5 megapixel), it is recom-
Lmax should be at least 420 cd/m2 with an L′min of mended that the pixel pitch and display size be used
1.2 cd/m2. The monitors used for other purposes when considering the capabilities of a particular
should have an Lmax of at least 250 cd/m2 device.
with an L′min of 0.8 cd/m2. For brighter moni-
tors, L′min, should be proportionately larger to 1. Pixel pitch: The pixel pitch of a monitor deter-
maintain the same LR. mines the maximum spatial frequency that can
6. Luminance versus gray level: In addition to hav- be presented in an image. Using the sampling
ing similar LR, the luminance of intermediate theorem, the maximum spatial frequency that
gray values between L′min and Lmax should fol- can be described by digital signals with a con-
low the same response function for all monitors stant pitch, P in millimeter, is 1/(2P) cycles/mm.
in a facility. It is recommended that the DICOM It is desirable to have the pixel pitch sufficiently
grayscale display function (GSDF) be used to set small so as to present all of the spatial frequen-
the intermediate gray values. cies that the human visual system can perceive.
7. Calibration: The luminance response, LR and At an arm’s length viewing distance (2/3 m,
GSDF, of some medical and professional 60 cm), the eye can perceive displayed spatial
graphics monitors can be selected using the mon- frequencies up to a maximum of 2.5 cycles/mm.
itor on screen display controls. Other medical/ For monitors used in diagnostic interpretation,
professional devices require software from the it is recommended that the pixel pitch be about
monitor manufacturer to load LUTs to the mon- 0.200 mm and not larger than 0.210 mm. For this
itor that set the luminance of each gray level. For pixel pitch, individual pixels and their substruc-
business class monitors used by technologists ture are not visible and images have continuous
and clinical care staff, the calibration can be tone appearance. No advantage is derived from
achieved by loading a LUT to the driver of the using a smaller pixel pitch since higher spatial
graphic control card. frequencies are not perceived.
8. Quality control: All display devices should be For the presentation of images with acquired
periodically checked to verify that the luminance detector element size different from the pixel
response is correct. Basic verification can be done pitch, zoom and pan display features should be
using a visual test pattern designed for evaluating used rather than moving closer to a display.
contrast response. Advanced tests, done on an Since the human visual system has maximum
annual or quarterly basis, measure the luminance contrast sensitivity at about 0.5 cycles/mm, im-
in relation to gray value and evaluate the contrast. age zoom with interpolation can often reveal
The contrast response of monitors used for diag- subtle detail not seen at true size.
nostic interpretation should be within 10 % of the Monitors used by technologists and clinical
GSDF over the full LR. For other uses, the con- care staff are often not viewed at a desk, and the
trast response should be within 20 % of the viewing distance is larger than for diagnostic
GSDF over the full LR. interpretation. For these monitors, a pixel pitch
9. White point: The color characteristics of a display of 0.250 mm (not larger than 0.300 mm) is
with respect to the presented color space are not appropriate.
considered in this technical standard. However, 2. Display size: When interpreting images, the at-
the white point associated with presentation of tention of the viewer is not limited to the center
grayscale images is important for medical imag- of the display but extends to the edges as well via
ing systems. It is recommended that monitors be peripheral vision. Good visualization of the full
set to a white point corresponding to the CIE scene is achieved when the diagonal display
daylight standard D65 white point. This corre- distance is about 80 % of the viewing distance.
sponds to a color temperature of about 6,500 °F. At 2/3 m, this corresponds to a diagonal size of
b. Pixel pitch and display size 53 cm (21 in.). Monitors with a pixel array size
The spacing of pixel structures, referred to as the of 1,500×2,000 and a pixel pitch of 0.210 will
pixel pitch, determines how much detail can be have a diagonal size of 52.5 cm.
46 J Digit Imaging (2013) 26:38–52

An aspect ratio, width to height, of 3:4 or 4:5 compliant with the IHE Portable Data for Imaging (PDI)
is well suited for the presentation of radiographic profile [9, 10]. PDI requires that DICOM images be
images. Such a portrait presentation requires im- recorded in a standard manner, and also permits addi-
age rotation from the graphic controller. Howev- tional “web content,” such as in the form of prerendered
er, the displays currently being manufactured JPEG images. Even if a facility has a means of sharing
typically have a wide format, 16:9 or 16:10. images over a network, standard physical media is re-
These can be used similar to a dual monitor quired for those recipients not able to use the network.
workstation if the application software can pres- Physical media containing proprietary formatted images
ent images in two regions with 8:9 or 8:10 aspect should not be used. Physical media may contain an
ratio. executable viewer. If present, an embedded viewer
should be capable of displaying the standard DICOM
Archiving, Retention, and Retrieval PDI images, and not depend on the presence of propri-
etary formats [9]. Each facility should comply with the
1. Digital imaging data management systems must provide recommendation of the American Medical Association
storage capacity capable of complying with all facility, Expert Panel on Medical Imaging, which put forward
state, and federal regulations regarding medical record the following statement that embodies the standard the
retention. Images stored by either a transmitting or medical imaging community must achieve: “All medi-
receiving site should meet the jurisdictional require- cal imaging data distributed should be a complete set of
ments of both the transmitting and receiving site. images of diagnostic quality in compliance with IHE-
Images interpreted off site need not be stored at the PDI.” The panel further stated that “this standard will
receiving facility provided they are stored at the trans- engender safe, timely, appropriate, effective, and effi-
mitting site or its designee. However, if the images are cient care; mitigate delayed care and confusion; enhance
retained at the receiving site, the retention period of that care coordination and communication across settings of
jurisdiction must be met as well. The policy on record care; decrease waste and costs; and, importantly, im-
retention should be in writing. prove patient and physician satisfaction with the medi-
2. Each examination data file must have an accurate cal imaging process.” The statement was signed by the
corresponding patient and examination database record American Medical Association, the American Associa-
that includes patient name, identification number, acces- tion of Neurological Surgeons, the Congress of Neuro-
sion number, examination date, type of examination, and logical Surgeons, the American Academy of Neurology,
facility at which the examination was performed. It is the American College of Radiology, the American
desirable that space be available for a brief clinical history. Academy of Orthopedic Surgeons, and the American
3. Current and prior examinations must be retrievable in a College of Cardiology.
time frame appropriate to the clinical needs of the facil- 2. Each facility should have a mechanism for secure image
ity and medical staff. sharing over the Internet. The network exchange of
4. Each facility should have policies and procedures for imaging information should be conducted in accordance
archiving and storage of digital image data equivalent to with the IHE Cross Document Sharing (XDS.b) profile
the policies that exist for the protection of hardcopy (and XDS-I.b for imaging objects) [10]. Depending on
storage media to preserve imaging records. the needs of the recipient, the images exchanged may be
5. For facilities practicing electronic radiology, quality pa- of original diagnostic quality, in which case DICOM PS
tient care depends on the stability and reliability of the 3.10 images are required, or may be prewindowed and
digital image data management system. Written policies prerendered. Every facility should have a mechanism
and procedures must be in place to ensure continuity of for providing both a full set of diagnostic quality
care at a level consistent with those for hard-copy imaging DICOM images and a subset of prerendered images of
studies and medical records within a facility or institution. the appropriate quality for this purpose, consistent with
They should include internal redundancy systems, backup the AMA’s recommendations for the analogous ex-
telecommunication links, disaster recovery, and business change on physical media.
continuity plan. 3. Each facility should have a mechanism for importing
images and associated information in standard DICOM
Image Sharing form from physical media and from the Internet, with
reconciliation of foreign identifiers, accession numbers
1. Each facility should have a mechanism for image shar- and procedure descriptions or codes, such that they do
ing on physical media, including CD, DVD, and USB not collide with local identifiers. Each facility should
media, and should be able to export and import data make it possible to display such foreign images with the
J Digit Imaging (2013) 26:38–52 47

same fidelity and side by side in the same user interface profile. This profile establishes the continuity and integ-
as locally acquired images. This allows for better patient rity of basic departmental imaging data, specifies trans-
care and fewer unnecessarily repeated studies (hence actions that maintain the consistency of patient and
avoiding the cost, inconvenience, and safety risk from ordering information, provides the scheduling and imag-
contrast and radiation of repeating a study). The impor- ing acquisition procedures steps, and makes it possible to
tation should be performed in accordance with the IHE determine whether images and other evidence objects
Import Reconciliation Workflow profile. associated with a particular performed procedure step
have been stored (archived) and are available to enable
Security, Privacy, Reliability, and Redundancy subsequent workflow steps, such as reporting. The SWF
profile may also provide central coordination of the com-
See the ACR–SIIM Practice Guideline for Electronic pletion of processing and reporting steps as well as noti-
Medical Information Privacy and Security. fication of appointments to the placer of the order.
Informatics Infrastructures and Workflow Processes 2. Correction of incorrect identification used during acqui-
sition should be performed in compliance with the IHE
Electronic practice of diagnostic radiology involves a number Patient Information Reconciliation (PIR) profile. PIR
of processes that should be coordinated by systems using the extends the SWF profile by providing the means to match
DICOM, HL7, IHE, and IHE-RO informatics standards to with the patient’s record, images, diagnostic reports, and
ensure that information associated with the imaging study other evidence objects acquired for a misidentified or
and patient record is accurate, that errors are minimized, and unidentified patient (for example, during a trauma case).
that the processes are efficient. These include: 3. In selecting a procedure, the ordering physician should be
assisted by an appropriateness criteria or decision support
& Patient demographic data should be obtained on admis- system.
sion (registration), rather than repeatedly reentered at 4. Standard terminology and codes for ordering should be
each step of the workflow. used, including:
& The appropriate modality and modality-specific imaging
protocol should be selected during scheduling. (a) Systematized Nomenclature of Medicine—Clinical
& The demographic and scheduling information should be Terms (see http://www.ihtsdo.org/snomed-ct).
communicated electronically to the modality in a stan- (b) RadLex—Lexicon for Uniform Indexing and Re-
dard form. trieval of Radiology Information Resources (see
& Complete and consistent demographic data should be http://www.radlex.org).
transferred across all systems. (c) Logical Observation Identifiers Names and Codes
& Relevant data about the acquisition should be included 5. Each facility should use a standard set of predefined image
in the electronic radiology report (preferably in an auto- acquisition protocols. Many image acquisition systems
mated and structured manner). (e.g., CT, MRI, NM) have complex protocols that need
& Relevant data about the acquisition should be made to be defined by the radiologist prior to the acquisition.
available for correct coding of the examination for bill- The appropriate protocol needs to take into consideration
ing, tracking and quality control. the order information (e.g., history, patient type), modality
& Relevant observations by the technical staff and inter- capabilities, and the technologist knowledge of the equip-
preting radiologist should be retained and distributed in ment/protocol. By requiring the definition of the appropri-
a standard form. ate protocol prior to the acquisition, the examination can
be optimized to use the lowest radiation dose sufficient to
The DICOM and HL7 [11, 12] standards provide the achieve the necessary image quality and the parameters
building blocks for such an infrastructure, and the IHE matched to the equipment and clinical needs of the patient.
Radiology Technical Framework [9] defines profiles for Evolving standards are being defined by professional
using those standards to implement the required processes. organizations to optimize the use of radiation dose for a
Some of the processes associated with diagnostic radiol- particular indication, for example in CT scanning [13].
ogy workflow and the standards that should be used are Using standard codes, such as those defined by the
given below. RadLex PlayBook [14], the choice of protocol should be
communicated to the acquisition modality using the IHE
1. Ordering and scheduling of procedures, performance Assisted Protocol Setting option to the SWF profile [9].
of the acquisition, and transfer of images and asso- 6. Each facility should store annotations made by staff on
ciated information to the PACS should be in com- images in a standard form as defined by DICOM in
pliance with the IHE Scheduled Workflow (SWF) presentation states, structured reports or structure sets.
48 J Digit Imaging (2013) 26:38–52

The IHE Consistent Presentation of Images profile speci- in a jurisdiction where the consulting radiologist is not
fies the use of DICOM presentation states. It also requires licensed. When interpreting images from a hospital,
that displays be calibrated according to the DICOM physicians should be credentialed and obtain appropriate
GSDF for the purpose of approaching consistency of privileges at that institution. Physicians providing do-
perceived grayscale contrast on different displays and in mestic and international teleradiology services should
different viewing environments (see also “Equipment consult with their professional liability carrier to ensure
Specifications” section). The IHE Simple Image and Nu- coverage in both the sending and receiving sites (state
meric Report specifies the use of the DICOM Structured or jurisdiction). The malpractice insurance coverage and
Report to store a simple structure consisting of a title, an claims jurisdiction should be determined by those con-
observation context, and one or more sections, each with a tracting to receive teleradiology services. Some states
heading, observation context, text, image references, and may require specific patient consent for telemedicine
coded measurements. Its use facilitates searches and consultation. Disclosing the use of international teleme-
serves as the input to the formal diagnostic report, thus dicine to the patient and referring physician should be
avoiding re-entry of information. considered if patient confidentiality is not assured by
the international provider. Physicians providing emer-
gency interpretations should be immediately available
Documentation for consultation. For non-emergent interpretations, the
physician should be available for consultation or have
Physicians officially interpreting examinations3 using digi- a method to communicate and authenticate his or her
tal image data management systems should render reports in findings.
accordance with the ACR Practice Guideline for Communi- Images stored at either site should meet the jurisdictional
cation of Diagnostic Imaging Findings. requirements of the transmitting site. Images interpreted off
If reports are incorporated into the data management site need not be stored at the receiving facility, provided
system, they should be retrievable with the same conditions they are stored at the transmitting site. However, if images
of timeliness and security as those for the imaging data. are retained at the receiving site, the retention period of that
jurisdiction should be met as well. The policy on record
retention should be in writing.
Licensing, Credentialing, and Liability

The interpreting physician is responsible for the quality

Radiation Safety in Imaging
of the images being reviewed.4 Physicians who provide
the official interpretation of images transmitted by tele-
Radiologists, medical physicists, radiologic technologists,
radiology should be familiar with the licensure require-
and all supervising physicians have a responsibility to min-
ments for providing radiologic or telemedicine service at
imize radiation dose to individual patients, to staff, and to
both the transmitting and receiving sites and obtain
society as a whole, while maintaining the necessary diag-
licensure as appropriate. Physicians practicing teleradi-
nostic image quality. This concept is known as “as low as
ology should conduct their practice in a manner consis-
reasonably achievable (ALARA).”
tent with the bylaws, rules, and regulations for patient
Facilities, in consultation with the medical physicist,
care at the transmitting and receiving site jurisdictions.
should have in place and should adhere to policies and
Regulations should not restrict the ability of radiologists
procedures, in accordance with ALARA, to vary examina-
to provide second opinion consultations when requested
tion protocols to take into account patient body habitus,
3
such as height and/or weight, body mass index or lateral
The ACR Medical Legal Committee defines official interpretation as
width. The dose reduction devices that are available on
that written report (and any supplements or amendments thereto) that
attach to the patient’s permanent record. In health care facilities with a imaging equipment should be active; if not; manual techni-
privilege delineation system, such a written report is prepared only by a ques should be used to moderate the exposure while main-
qualified physician who has been granted specific delineated clinical taining the necessary diagnostic image quality. Periodically,
privileges for that purpose by the facility’s governing body upon the
radiation exposures should be measured and patient radia-
recommendation of the medical staff.
4
The ACR Rules of Ethics state: “it is proper for a diagnostic radiol- tion doses estimated by a medical physicist in accordance
ogist to provide a consultative opinion on radiographs and other with the appropriate ACR Technical Standard. (ACR Reso-
images regardless of their origin. A diagnostic radiologist should lution 17, adopted in 2006—revised in 2009, Resolution 11)
regularly interpret radiographs and other images only when the radiol-
Exposures to patients from digital X-ray equipment (in-
ogist reasonably participates in the quality of medical imaging, utili-
zation review, and matters of policy which affect the quality of patient cluding projection radiography, fluoroscopy, angiography,
care.” and CT) should be recorded digitally by the modality in a
J Digit Imaging (2013) 26:38–52 49

standard form (such as the DICOM Radiation Dose Structured a spatial resolution test, at least 2.5 lp/mm, resolutions
Report [RDSR]) and transmitted and monitored using the IHE should be confirmed for official interpretation. As a test
Radiation Exposure Monitoring (REM) profile. Facilities of the display fidelity, TG18-QC pattern data files sized
should also contribute deidentified digital records of patient to occupy the full area used to display images on the
radiation exposure to the appropriate dose index registry (such monitor should be displayed. The overall SMPTE image
as the ACR’s Dose Index Registry component of the National appearance should be inspected to assure the absence of
Radiology Data Registry), for the purpose of establishing, gross artifacts (e.g., blurring or bleeding of bright dis-
maintaining, and comparing facility performance against na- play areas into dark areas or aliasing of spatial resolu-
tional Diagnostic Reference Levels. Facilities that have legacy tion patterns). All display monitors used for primary
technology not supporting standards such as DICOM RDSR interpretation should be tested at least monthly. As a
and IHE REM should employ tools using techniques such as dynamic range test, both the 5 % and the 95 % areas
Optical Character Recognition to extract the numeric expo- should be seen as distinct from the respective adjacent 0
sure information from modality manufacturer’s dose screens, and 100 % areas.
or other mechanisms, where possible. 3. Hardcopy imager accuracy and stability testing should
also be performed and documented.
Quality Control and Improvement, Safety, Infection 4. The view box luminance should be sufficient to meet
Control, and Patient Education the diagnostic needs of the imaging procedure and ap-
plicable industry standards and/or recommendations
Policies and procedures related to quality, patient education, should be followed when available.
infection control, and safety should be developed and imple- The use of digital imaging and digital image data man-
mented in accordance with the ACR Policy on Quality agement systems does not reduce the responsibilities for
Control and Improvement, Safety, Infection Control, and managing and supervising radiologic examinations. Loca-
Patient Education appearing under the heading Position tions and physicians providing remote imaging services
Statement on QC & Improvement, Safety, Infection Control, should participate in a documented ongoing quality assur-
and Patient Education on the ACR web site (http://www.a- ance program at least equivalent to that of the originating
cr.org/guidelines). facility. Summaries of the quality control monitoring should
Any facility using a digital image data management sys- be provided to the originating facility
tem must have documented policies and procedures for
monitoring and evaluating the effective management, safety, Acknowledgments This guideline was revised according to the pro-
and proper performance of acquisition, digitization, process- cess described under the heading The Process for Developing ACR
Practice Guidelines and Technical Standards on the ACR web site
ing, compression, transmission, display, archiving, and re- (http://www.acr.org/guidelines) by the Guidelines and Standards Com-
trieval functions of the system. The quality control program mittee of the Commission on Medical Physics in collaboration with the
should be designed to maximize the quality and accessibility AAPM and the SIIM.
of diagnostic information. Collaborative Committee—members represent their societies in the
initial and final revision of this guideline
ACR
1. Performance testing and monitoring of official or primary James T. Norweck, MS, Co-Chair
interpretation display devices should be performed in David A. Clunie, MB, BS
accordance with any relevant ACR modality accreditation Ralph P. Lieto, MS
AAPM
program quality control manual recommendations, the
Bruce H. Curran, MS, ME
equipment manufacturer specifications, applicable indus- Michael J. Flynn, PhD
try guidelines, and state and federal regulations. In the Donald J. Peck, PhD
absence of adequate manufacturer procedures, guidelines, SIIM
J. Anthony Seibert, PhD, FACR, Co-Chair
or standards, the recommendations for the performance Katherine P. Andriole, PhD
evaluation of display devices testing methods and fre- Elizabeth Krupinski, PhD
quencies contained in AAPM Task Group 18: Assessment ACR Guidelines and Standards Committee—Medical Physics—
of Display Performance for Medical Imaging Systems ACR Committee responsible for sponsoring the draft through the
process.
[15] should be followed.
Tariq A. Mian, PhD, FACR, Chair
2. As a minimum quality check for acquisition workstation Maxwell R. Amurao, PhD, MS
and secondary display devices, a test image such as the Chee-Wai Cheng, PhD
AAPM TG18-QC test pattern should be captured, trans- Laurence E. Court, PhD
Richard A. Geise, PhD, FACR
mitted, archived, retrieved, and displayed at appropriate
Nicholas J. Hangiandreou, PhD
intervals to test the overall operation of the system Bruce E. Hasselquist, PhD
under conditions that simulate its normal operation. As Ralph P. Lieto, MS
50 J Digit Imaging (2013) 26:38–52

Jeffrey P. Limmer, MSc 9. IHE Radiology Technical Framework, Volume 1: Integration

Janelle Lira Park, MD profiles. Feb. 18, 2011; http://www.ihe.net/Technical_Frame
Doug Pfeiffer, MS work/upload/IHE_RAD_TF_Rev10-0_Vol1_2011-02-18.pdf.
Christopher J. Watchman, PhD Accessed August 19, 2011.
Gerald A. White, Jr., MS, FACR 10. Mendelson DS, Bak PR, Menschik E, Siegel E: Informatics in
John W. Winston, MS radiology: image exchange: IHE and the evolution of image sharing.
James Hevezi, PhD, FACR, Chair, Commission Radiographics 28:1817–1833, 2008
Comments Reconciliation Committee 11. Health Level 7 International website. http://www.hl7.org/
Arun Krishnaraj, MD, MPH, CSC Co-Chair index.cfm?ref0nav. Accessed August 17, 2011.
Christopher G. Ullrich, MD, FACR, CSC Co-Chair 12. Digital Imaging and Communications in Medicine. DICOM
Katherine P. Andriole, PhD Standard. http://medical.nema.org. Accessed Aug. 19, 2011.
Kimberly E. Applegate, MD, MS, FACR 13. American Association of Physicists in Medicine (AAPM). CT
David A. Clunie, MB, BS Scan Protocols. http://aapm.org/pubs/CTProtocols/. Accessed
Bruce H. Curran, MS, ME August 19, 2011.
Howard B. Fleishon, MD, MMM, FACR 14. Radiological Society of North America (RSNA). RadLex
Michael J. Flynn, PhD Playbook information. http://www.rsna.org/Informatics/radlex_
James M. Hevezi, PhD, FACR playbook.cfm. Accessed August 19, 2011.
Elizabeth Krupinski, PhD 15. Samei E, Badano A, Chakaraborty, et al. Assessment of Display
Paul A. Larson, MD, FACR Performance for Medical Imaging Systems: American Associa-
Ralph P. Lieto, MS tion of Physicists in Medicine; 2005. AAPM On-Line Report
James T. Norweck, MS No. 3.
Tariq A. Mian, PhD, FACR
Debra L. Monticciolo, MD, FACR
Donald J. Peck, PhD
J. Anthony Seibert, PhD, FACR Appendix A
Julie K. Timins, MD, FACR

Glossary
References
1. Analog signal—a form of information transmission
1. Usability of irreversible image compression in radiological in which the signal varies in a continuous manner and
imaging. A position paper by the European Society of Radi- is not limited to discrete steps
ology (ESR). http://www.i3-journal.org/cms/website.php?id0/ 2. Archive—a repository for digital medical images in
en/index/read/image_compression.htm. Accessed August 19,
2011. PACS, typically with the specific purpose of provid-
2. Rockette HE, Johns CM, Weissman JL, Holbert JM, Sumkin ing either short- or long-term (permanent) storage of
JH, King JL, Gur D. Relationship of subjective ratings of images. Erasable or nonerasable media may be used
image quality and observer performance. Medical Imaging
1997: Image Perception Conference. Vol 3036. Newport Beach,
in an archive
Calif: SPIE; 1997. 3. Binary digit (bit)—the smallest unit of digital infor-
3. Center for Devices and Radiological Health. Guidance for the mation that a computing device handles. It represents
Submission of Premarket Notifications for Medical Image Man- off or on (0 or 1). All data in computing devices are
agement Devices. Rockville, Md: U.S. Department of Health and
Human Services; July 2000.
processed as bits or strings of bits
4. Mammography Quality Standards Act (MQSA) Policy Guid- 4. Bit depth—the number of bits used to encode the
ance Help System. http://www.fda.gov/Radiation-EmittingProd- signal intensity of each pixel of the image
ucts/MammographyQualityStandardsActandProgram/Guidance/ 5. Compression ratio—the ratio of the number of bits in
PolicyGuidanceHelpSystem/default.htm. Accessed August 19,
2011.
an original image to that in a compressed version of
5. Brennan PC, McEntee M, Evanoff M, Phillips P, O’Connor that image. For example, a compression ratio of 2:1
WT, Manning DJ: Ambient lighting: effect of illumination on would correspond to a compressed image with one
soft-copy viewing of radiographs of the wrist. AJR 188:W177–
half the number of bits of the original
W180, 2007
6. Chawla AS, Samei E: Ambient illumination revisited: a new 6. Computed radiography (CR)—a system that uses a
adaptation-based approach for optimizing medical imaging read- storage phosphor plate contained in a cassette instead
ing environments. Med Phys 34:81–90, 2007 of a film-screen cassette. A laser beam scans the
7. International Organization for Standardization. Ergonomics of
exposed plate to produce the digital data that is then
human-system interaction – Part 300: Introduction to electronic
visual display requirements. http://www.iso.org/iso/iso_catalogue_ converted into an image.
tc/catalogue_detail.htm?csnumber040096. Accessed September 7. Cathode ray tube (CRT)—an older technology
26, 2011. monitor or display device used for viewing digital
8. American Association of Physicists in Medicine (AAPM) Task
softcopy images. A CRT uses a controlled beam
Group 18. Assessment of display performance for medical imaging
systems. http://www.aapm.org/pubs/reports/OR_03.pdf. Accessed of electrons incident on a phosphor to generate a
January 4, 2012. luminous image
J Digit Imaging (2013) 26:38–52 51

8. Data communication—all forms of computer informa- size. Down-sampling–large matrix images are typi-
tion exchange. Data communication may take place cally sampled more coarsely than the acquired pixel
between two computers in the same building via a local spacing in order to decrease the number of rows and
area network (LAN), across the country via telephone, columns so that the full image area can be presented
or elsewhere by a wide-area network (WAN) 20. Irreversible compression—some permanent alter-
9. Data compression—methods to reduce the data vol- ation of digital image data. This is sometimes re-
ume by encoding it in a more efficient manner, thus ferred to as lossy compression
reducing the image processing and transmission 21. Liquid crystal display (LCD)—a modern monitor or
times and storage space required. These methods display device used for viewing digital softcopy
may be reversible (lossless) or irreversible (lossy) images
10. Digital Imaging and Communications in Medicine 22. Lossless compression—see reversible compression
(DICOM)—a standard for interconnection of medi- 23. Lossy compression—see irreversible compression
cal digital imaging devices, developed, and spon- 24. Monochrome monitor—a computer display in
sored by the American College of Radiology and the which an image is presented as different shades of
National Electrical Manufacturers Association, con- gray from black to white (see also grayscale)
sisting of a standard image format and a standard 25. Mouse—an input device that allows the computer
communications protocol user to point to objects on the screen and execute
11. Digital signal—a form of information transmission commands
in which the signal varies in discrete steps, not in a 26. PACS—Picture Archiving and Communication
continuous manner System
12. Digitize—the process by which analog (continuous 27. Phosphor—the coating on the inside of a CRT or
value) information is converted into digital (discrete monitor that produces light when it is struck by an
value) information electron beam
13. Direct image capture—the capture or acquisition of 28. Pixel (picture element)—the smallest piece of infor-
digital image data that have been acquired in digital mation that can be displayed on a CRT. It is repre-
format by an imaging modality. The image produced sented by a numerical code within the computer and
from the data, regardless of the modality that pro- displayed on the monitor as a dot of a specific color
duced it (CT, MRI, CR, US), should include the full or intensity. An image is composed of a large array
spatial resolution and bit depth of the original of pixels of differing intensities or colors
14. Dynamic range—the difference in signal intensity, 29. Protocol—a set of guidelines by which two different
or frequency, between the largest and smallest sig- computer devices communicate with each other
nals a system can process or display. Increasing the 30. Random access memory (RAM)—a type of tempo-
number of bits per pixel in a digital image increases rary memory in a computer in which programs are
the dynamic range of the image run, images are processed, and information is stored.
15. File—a set of digital data that have a common The amount of RAM that a computer requires varies
purpose, such as an image, a program, or a database widely depending on the specific application. Infor-
16. Grayscale—the number of different shades of levels of mation stored in RAM is lost when the power is shut
gray that can be stored and displayed by a computer off
system. The number of gray levels is directly related to 31. Resolution—spatial resolution is the ability to dis-
the number of bits used in each pixel: 6 bits064 Gy tinguish small objects at high contrast. It is related to
levels, 7 bits0128 Gy levels, 8 bits0256 Gy levels, 10 and in some cases limited by the pixel size. Contrast
bits01,024 Gy levels, and 12 bits04,096 Gy levels (grayscale) resolution is the ability of a system to
17. Hardware—a collective term used to describe the distinguish between objects of the same size having
physical components that form a computer. The different signal intensity. It is related to and in some
monitor, CPU, disk drives, memory, modem, and cases limited by the bit depth
other components are all considered hardware 32. Reversible compression—no alteration of original
18. Image matrix size—The size of an image described image information upon reconstruction. This is
as the number of rows and the number of columns of sometimes referred to as lossless
pixels 33. Secondary image capture—the capture in digital for-
19. Image sampling: up-sampling—Small matrix mat of image data that originally existed in another
images are typically sampled more finely than the primary format (e.g., a digital image data file on a CT
acquired pixel spacing in order to increase the num- scanner, or a screen-film radiographic film) through
ber of rows and columns and increase the presented the process of video capture or film digitization
52 J Digit Imaging (2013) 26:38–52

34. SMPTE—the Society of Motion Picture and Televi- Development Chronology for this Standard
sion Engineers 2007 (Resolution 13)
35. Software—a name given to the programs or sets of Amended 2009 (Resolution 11)
programs that are executed on a computer Revised 2012 (Resolution 35)
*Guidelines and standards are published annually with an
effective date of October 1 in the year in which amended,
revised or approved by the ACR Council. For guidelines and
standards published before 1999, the effective date was Janu-
Reprinted with permission of the American College of Radiology, the
ary 1 following the year in which the guideline or standard American Association of Physicists in Medicine and the Society for
was amended, revised, or approved by the ACR Council. Imaging Informatics in Medicine.