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pr.qxd 2/12/04 5:06 PM Page iii

PACS AND IMAGING

INFORMATICS
BASIC PRINCIPLES
AND APPLICATIONS

H. K. Huang, D.Sc., FRCR (Hon.)

Professor of Radiology and Biomedical Engineering,
University of Southern California, Los Angeles

Chair Professor of Medical Informatics

The Hong Kong Polytechnic University

Honorary Professor, Shanghai Institute of Technical Physics

The Chinese Academy of Science

A JOHN WILEY & SONS, INC., PUBLICATION

pr.qxd 2/12/04 5:06 PM Page iv

Copyright © 2004 by John Wiley & Sons, Inc. All rights reserved.

Published by John Wiley & Sons, Inc., Hoboken, New Jersey.

Published simultaneously in Canada.

No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form
or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as
permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior
written permission of the Publisher, or authorization through payment of the appropriate per-copy fee
to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400, fax
978-646-8600, or on the web at www.copyright.com. Requests to the Publisher for permission should
be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ
07030, (201) 748-6011, fax (201) 748-6008.

Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts
in preparing this book, they make no representations or warranties with respect to the accuracy or
completeness of the contents of this book and specifically disclaim any implied warranties of
merchantability or fitness for a particular purpose. No warranty may be created or extended by sales
representatives or written sales materials. The advice and strategies contained herein may not be
suitable for your situation. You should consult with a professional where appropriate. Neither the
publisher nor author shall be liable for any loss of profit or any other commercial damages, including
but not limited to special, incidental, consequential, or other damages.

For general information on our other products and services please contact our Customer Care
Department within the U.S. at 877-762-2974, outside the U.S. at 317-572-3993 or
fax 317-572-4002.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print,
however, may not be available in electronic format.

Library of Congress Cataloging-in-Publication Data:

Huang, H. K., 1939–
PACS and imaging informatics : basic principles and applications / H. K. Huang.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-471-25123-2 (alk. paper)
1. Picture archiving and communication systems in medicine. 2. Imaging systems in medicine.
[DNLM: 1. Radiology Information Systems. 2. Diagnostic Imaging. 3. Medical Records
Systems, Computerized. WN 26.5 H874pg 2004] I. Title: Picture archiving and communication
systems and imaging informatics. II. Huang, H. K., 1939– PACS. III. Title.
R857.P52 H82 2004
616.07¢54—dc22
2003021220

Printed in the United States of America.

10 9 8 7 6 5 4 3 2 1
pr.qxd 2/12/04 5:06 PM Page v

To my wife, Fong, for her support and understanding

and my daughter, Cammy, for her young wisdom
and forever challenging spirit.
pr.qxd 2/12/04 5:06 PM Page vi

Introduction
Chapter 1

Digital CT/MR/US/NM
Imaging Basics Compression
Radiography Light Imaging Hospital/Radiology
Chapter 2 Chapter 5 C/N
Chapter 3 Chapter 4 Information System
Chapters 7 & 12
Part 1 IMAGING PRINCIPLES
C/N

PACS Standards &

Fundamentals Protocols
Chapter 6 Chapter 7

Image/data C/N
Acquisition
Gateway
Chapter 8
C/N

PACS Controller
HIS/RIS/PACS
and Image C/N
Integration
Archive Server
Chapter 10 Chapter 12

C/N

Display Workstation Part 2

Chapter 11 PACS
FOUNDAMENTALS

Management and Image/Data WAN Telemedicine

Fault-Tolerant
Web-based PACS Security Teleradiology
Chapter 15
Chapter 13 Chapter 16 Chapter 14

Implementation/ Clinical Experience/

Evaluation Pitfalls/Bottlenecks
Part 3
Chapter 17 Chapter 18
PACS OPERATIONS

Medical Imaging Decision Support Education/

Application Servers
Informatics Tools Learning
Chapter 21
Chapter 19 Chapter 20 Chapter 22

Part 4 PACS-based Imaging Informatics

Enterprise PACS
Chapter 23 C/N: Communication Networks (Chapter 9)
Part 5 WAN: Wide Area Network
pr.qxd 2/12/04 5:06 PM Page vii

CONTENTS IN BRIEF

FOREWORD xxxi
PREFACE xxxv
PREFACE TO THE FIRST EDITION xxxix
ACKNOWLEDGMENTS xli
LIST OF ACRONYMS xliii

PART I MEDICAL IMAGING PRINCIPLES 1

1. Introduction 3
2. Digital Medical Image Fundamentals 23
3. Digital Radiography 49
4. Computed Tomography, Magnetic Resonance, Ultrasound, Nuclear Medicine,
and Light Imaging 79
5. Image Compression 119

PART II PACS FUNDAMENTALS 153

6. Picture Archiving and Communication System Components and Work Flow 155
7. Industrial Standards (HL7 and DICOM) and Work Flow Protocols (IHE) 171
8. Image Acquisition Gateway 195
9. Communications and Networking 219
10. PACS Controller and Image Archive Server 255
11. Display Workstation 277
12. Integration of HIS, RIS, PACS, and ePR 307

PART III PACS OPERATION 331

13. PACS Data Management and Web-Based Image Distribution 333
14. Telemedicine and Teleradiology 353
15. Fault-Tolerant PACS 381
16. Image/Data Security 409
17. PACS Clinical Implementation, Acceptance, Data Migration, and Evaluation 431
18. PACS Clinical Experience, Pitfalls, and Bottlenecks 463

PART IV PACS-BASED IMAGING INFORMATICS 485

19. PACS-Based Medical Imaging Informatics 487
20. PACS as a Decision Support Tool 509
21. ePR-Based PACS Application Server for Other Medical Specialties 539
22. New Directions in PACS Learning and PACS-Related Training 567

PART V ENTERPRISE PACS 589

23. Enterprise PACS 591

REFERENCES 611
GLOSSARY OF PACS CONCEPTS 633
INDEX 637

vii
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CONTENTS

FOREWORD xxxi
PREFACE xxxv
PREFACE TO THE FIRST EDITION xxxil
ACKNOWLEDGMENTS xli
LIST OF ACRONYMS xliii

PART I MEDICAL IMAGING PRINCIPLES 1

1. Introduction 3
1.1 Introduction 3
1.2 Some Remarks on Historical Picture Archiving and
Communication Systems (PACS) 4
1.2.1 Concepts, Conferences, and Early Research Projects 4
1.2.1.1 Concepts and Conferences 4
1.2.1.2 Early Funded Research Projects by the U.S.
Government 6
1.2.2 PACS Evolution 6
1.2.2.1 In the Beginning 6
1.2.2.2 Large-Scale Projects 7
1.2.3 Standards and Anchoring Technologies 8
1.2.3.1 Standards 8
1.2.3.2 Anchoring Techologies 9
1.3 What is PACS? 9
1.3.1 PACS Design Concept 9
1.3.2 PACS Infrastructure Design 10
1.4 PACS Implementation Strategies 11
1.4.1 Background 11
1.4.2 Five PACS Implementation Models 12
1.4.2.1 The Home-Grown Model 12
1.4.2.2 The Two-Team Effort Model 12
1.4.2.3 The Turnkey Model 12
1.4.2.4 The Partnership Model 13
1.4.2.5 The Application Service Provider (ASP) Model 13
ix
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x CONTENTS

1.5 A Global View of PACS Development 13

1.5.1 The United States 13
1.5.2 Europe 14
1.5.3 Asia 15
1.6 Examples of Some Early Successful PACS Implementation 15
1.6.1 Baltimore VA Medical Center 16
1.6.2 Hammersmith Hospital 16
1.6.3 Samsung Medical Center 16
1.7 Organization of This Book 17

2. Digital Medical Image Fundamentals 23

2.1 Terminology 23
2.2 Density Resolution, Spatial Resolution, and Signal-To-Noise
Ratio 25
2.3 Radiological Test Objects and Patterns 25
2.4 Image in the Spatial Domain and the Frequency Domain 28
2.4.1 Frequency Components of an Image 28
2.4.2 The Fourier Transform Pair 31
2.4.3 The Discrete Fourier Transform 34
2.5 Measurement of Image Quality 34
2.5.1 Measurement of Sharpness 35
2.5.1.1 Point Spread Function (PSF) 35
2.5.1.2 Line Spread Function (LSF) 36
2.5.1.3 Edge Spread Function (ESF) 36
2.5.1.4 Modulation Transfer Function (MTF) 37
2.5.1.5 Relationship Between ESF, LSF, and MTF 38
2.5.1.6 Relationship Between the Input Image, the
MTF, and the Output Image 39
2.5.2 Measurement of Noise 45

3. Digital Radiography 49
3.1 Principles of Conventional Projection Radiography 49
3.1.1 Radiology Work Flow 49
3.1.2 Standard Procedures Used in Conventional Projection
Radiography 51
3.1.3 Analog Image Receptor 51
3.1.3.1 Image Intensifier Tube 52
3.1.3.2 Screen-Film Combination 54
3.2 Digital Fluorography and Laser Film Scanner 57
3.2.1 Basic Principles 57
3.2.2 Video Scanner System and Digital Fluorography 58
3.2.3 Laser Film Scanner 59
3.3 Imaging Plate Technology 61
3.3.1 Principle of the Laser-Stimulated Luminescence
Phosphor Plate 62
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CONTENTS xi

3.3.2 Computed Radiography System Block Diagram and

Its Principle of Operation 63
3.3.3 Operating Characteristics of the CR System 63
3.3.4 Background Removal 66
3.3.4.1 What is Background Removal? 66
3.3.4.2 Advantages of Background Removal in
Digital Radiography 66
3.4 Full-Field Direct Digital Mammography 69
3.4.1 Screen-Film and Digital Mammography 69
3.4.2 Full-Field Direct Digital Mammography:
Slot-Scanning Method 70
3.5 Digital Radiography 72
3.5.1 Some Disadvantages of the Computed Radiography
System 72
3.5.2 Digital Radiography 72
3.5.3 Integration of Digital Radiography with PACS 73
3.5.4 Applications of DR in Clinical Environment 77

4. Computed Tomography, Magnetic Resonance, Ultrasound,

Nuclear Medicine, and Light Imaging 79
4.1 Image Reconstruction from Projections 79
4.1.1 The Fourier Projection Theorem 79
4.1.2 The Algebraic Reconstruction Method 81
4.1.3 The Filtered (Convolution) Back-Projection Method 82
4.1.3.1 A Numerical Example 82
4.1.3.2 Mathematical Formulation 83
4.2 Transmission X-Ray Computed Tomography (XCT) 84
4.2.1 Conventional XCT 84
4.2.2 Spiral (Helical) XCT 84
4.2.3 Cine XCT 86
4.2.4 Multislice XCT 87
4.2.4.1 Principles 87
4.2.4.2 Some Standard Terminology Used in
Multislice XCT 89
4.2.5 Four-Dimensional (4-D) XCT 90
4.2.6 Components and Data Flow of an XCT Scanner 90
4.2.7 XCT Image Data 90
4.2.7.1 Slice Thickness 90
4.2.7.2 Image Data Size 90
4.2.7.3 Data Flow/Postprocessing 92
4.3 Emission Computed Tomography 92
4.3.1 Single-Photon Emission CT (SPECT) 92
4.3.2 Positron Emission CT (PET) 94
4.4 Advances in XCT and PET 95
4.4.1 PET/XCT Fusion Scanner 95
4.4.2 Micro Sectional Images 96
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xii CONTENTS

4.5 Nuclear Medicine 97

4.5.1 Principles of Nuclear Medicine Scanning 97
4.5.2 The Gamma Camera and Associated Imaging System 98
4.6 Ultrasound Imaging 98
4.6.1 Principles of B-Mode Ultrasound Scanning 99
4.6.2 System Block Diagram and Operational Procedure 100
4.6.3 Sampling Modes and Image Display 101
4.6.4 Color Doppler Ultrasound Imaging 102
4.6.5 Cine Loop Ultrasound Imaging 102
4.6.6 Three-Dimensional US 102
4.7 Magnetic Resonance Imaging 104
4.7.1 MR Imaging Basics 104
4.7.2 Magnetic Resonance Image Production 104
4.7.3 Steps in Producing an MR Image 105
4.7.4 MR Images (MRI) 106
4.7.5 Other Types of Images from MR Signals 106
4.7.5.1 MR Angiography (MRA) 106
4.7.5.2 Other Pulse Sequences 109
4.8 Light Imaging 112
4.8.1 Microscopic Image 113
4.8.1.1 Instrumentation 113
4.8.1.2 Motorized Stage Assembly 113
4.8.1.3 Automatic Focusing Device 115
4.8.1.4 Resolution 115
4.8.1.5 Contrast 116
4.8.1.6 The Digital Chain 116
4.8.1.7 Color Image and Color Memory 116
4.8.2 Endoscopy 117

5. Image Compression 119

5.1 Terminology 119
5.2 Background 120
5.3 Error-Free Compression 121
5.3.1 Background Removal 122
5.3.2 Run-Length Coding 123
5.3.3 Huffman Coding 125
5.4 Two-Dimensional Irreversible Image Compression 127
5.4.1 Background 127
5.4.2 Block Compression Technique 127
5.4.2.1 Two-Dimensional Forward Discrete Cosine
Transform 129
5.4.2.2 Bit Allocation Table and Quantization 130
5.4.2.3 DCT Coding and Entropy Coding 130
5.4.2.4 Decoding and Inverse Transform 131
5.4.3 Full-Frame Compression 132
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CONTENTS xiii

5.5 Measurement of the Difference Between the Original and the

Reconstructed Image 133
5.5.1 Quantitative Parameters 133
5.5.1.1 Normalized Mean-Square Error 133
5.5.1.2 Peak Signal-to-Noise Ratio 134
5.5.2 Qualitative Measurement: Difference Image and
Its Histogram 135
5.5.3 Acceptable Compression Ratio 136
5.5.4 Receiver Operating Characteristic Analysis 136
5.6 Three-Dimensional Image Compression 140
5.6.1 Background 140
5.6.2 Basic Wavelet Theory and Multiresolution Analysis 140
5.6.3 One-, Two-, and Three-Dimensional Wavelet Transform 141
5.6.3.1 One-Dimensional 141
5.6.3.2 Two-Dimensional 142
5.6.3.3 Three-Dimensional 144
5.6.4 Three-Dimensional Image Compression with
Wavelet Transform 145
5.6.4.1 The Block Diagram 145
5.6.4.2 Mathematical Formulation of the Three-
Dimensional Wavelet Transform 145
5.6.4.3 Wavelet Filter Selection 146
5.6.4.4 Quantization 147
5.6.4.5 Entropy Coding 147
5.6.4.6 Some Results 147
5.6.4.7 Wavelet Compression in Teleradiology 148
5.7 Color Image Compression 148
5.7.1 Examples of Color Image Used in Radiology 148
5.7.2 The Color Space 150
5.7.3 Compression of Color Ultrasound Images 150
5.8 DICOM Standard and Food and Drug Administration (FDA)
Guidelines 151
5.8.1 FDA 151
5.8.2 DICOM 152

PART II PACS FUNDAMENTALS 153

6. Picture Archiving and Communication System Components and

Work Flow 155
6.1 PACS Components 155
6.1.1 Data and Image Acquisition Gateway 155
6.1.2 PACS Controller and Archive Server 156
6.1.3 Display Workstations 157
6.1.4 Application Servers 158
6.1.5 System Networks 158
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xiv CONTENTS

6.2 PACS Infrastructure Design Concept 159

6.2.1 Industry Standards 159
6.2.2 Connectivity and Open Architecture 159
6.2.3 Reliability 160
6.2.4 Security 160
6.3 A Generic PACS Work Flow 161
6.4 Current PACS Architectures 162
6.4.1 Stand-Alone PACS Model 162
6.4.2 Client/Server Model 164
6.4.3 Web-Based Model 166
6.5 PACS and Teleradiology 166
6.5.1 Pure Teleradiology Model 166
6.5.2 PACS and Teleradiology Combined Model 167
6.6 Enterprise PACS and ePR with Images 168

7. Industrial Standards (HL7 and DICOM) and

Work Flow Protocols (IHE) 171
7.1 Industrial Standards and Work Flow Protocol 171
7.2 The Health Level 7 Standard 171
7.2.1 Health Level 7 171
7.2.2 An Example 172
7.2.3 New Trend in HL7 174
7.3 From ACR-NEMA to DICOM and DICOM Document 175
7.3.1 ACR-NEMA and DICOM 175
7.3.2 DICOM Document 175
7.4 The DICOM 3.0 Standard 176
7.4.1 DICOM Data Format 176
7.4.1.1 DICOM Model of the Real World 176
7.4.1.2 DICOM File Format 179
7.4.2 Object Class and Service Class 179
7.4.2.1 Object Class 179
7.4.2.2 DICOM Services 181
7.4.3 DICOM Communication 182
7.4.4 DICOM Conformance 183
7.4.5 Examples of Using DICOM 183
7.4.5.1 Send and Receive 184
7.4.5.2 Query and Retrieve 185
7.4.6 New Features in DICOM 187
7.4.6.1 Visible Light (VL) Image 187
7.4.6.2 Structured Reporting (SR) Object 187
7.4.6.3 Content Mapping Resource 187
7.4.6.4 Mammography CAD (Computer-Aided
Detection) 187
7.4.6.5 Waveform IOD 187
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CONTENTS xv

7.5 IHE (Integrating the Healthcare Enterprise) 188

7.5.1 What is IHE? 188
7.5.2 The IHE Technical Framework and Integration Profiles 188
7.5.3 IHE Profiles 189
7.5.4 The Future of IHE 190
7.5.4.1 Multidisciplinary Effort 190
7.5.4.2 International Expansion 190
7.6 Other Standards 191
7.6.1 UNIX Operating System 191
7.6.2 Windows NT/XP Operating Systems 191
7.6.3 C and C++ Programming Languages 191
7.6.4 Structural Query Language 191
7.6.5 XML (Extensible Markup Language) 192

8. Image Acquisition Gateway 195

8.1 Background 195
8.2 DICOM-Compliant Image Acquisition Gateway 197
8.2.1 Background 197
8.2.2 DICOM-Based PACS Image Acquisition Gateway 198
8.2.2.1 Gateway Computer Components and
Database Management 198
8.2.2.2 Determination of the End of Image Series 202
8.3 Automatic Image Recovery Scheme for DICOM
Conformance Device 204
8.3.1 Missing Images 204
8.3.2 Automatic Image Recovery Scheme 204
8.3.2.1 Basis for the Image Recovery Scheme 204
8.3.2.2 The Image Recovery Algorithm 205
8.3.2.3 Results and the Extension of the Recovery
Scheme 207
8.4 Interface of a PACS Module with the Gateway Computer 208
8.4.1 PACS Modality Gateway and HI-PACS Gateway 208
8.4.2 Image Display at the PACS Modality Workstation 209
8.5 DICOM Conformance PACS Broker 210
8.5.1 Concept of the PACS Broker 210
8.5.2 An Example of Implemention of a PACS Broker 210
8.6 Image Preprocessing 211
8.6.1 Computed Radiography (CR) and Digital
Radiography (DR) 211
8.6.1.1 Reformatting 211
8.6.1.2 Background Removal 212
8.6.1.3 Automatic Orientation 212
8.6.1.4 Lookup Table Generation 214
8.6.2 Digitized X-Ray Images 215
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xvi CONTENTS

8.6.3 Digital Mammography 215

8.6.4 Sectional Images—CT, MR, and US 215
8.7 An Example of a Gateway in a Clinical PACS Environment 216
8.7.1 Gateway in a Clinical PACS 216
8.7.2 Clinical Operation Conditions and Reliability:
Weaknesses and Single Points of Failure 216

9. Communications and Networking 219

9.1 Background 219
9.1.1 Terminology 219
9.1.2 Network Standards 220
9.1.3 Network Technology 222
9.1.3.1 Ethernet and Gigabit Ethernet 223
9.1.3.2 ATM (Asynchronous Transfer Mode) 225
9.1.4 Network Components for Connectivity 226
9.2 Cable Plan 226
9.2.1 Types of Networking Cables 226
9.2.2 The Hub Room 227
9.2.3 Cables for Input Sources 228
9.2.4 Cables for Image Distribution 228
9.3 Digital Communication Networks 230
9.3.1 Background 230
9.3.2 Design Criteria 231
9.3.2.1 Speed of Transmission 231
9.3.2.2 Standardization 231
9.3.2.3 Fault Tolerance 231
9.3.2.4 Security 232
9.3.2.5 Costs 232
9.4 PACS Network Design 232
9.4.1 External Networks 232
9.4.1.1 Manufacturer’s Image Acquisition Device
Network 232
9.4.1.2 Hospital and Radiology Information Networks 233
9.4.1.3 Research and Other Networks 233
9.4.1.4 The Internet 233
9.4.1.5 Imaging Workstation Networks 233
9.4.2 Internal Networks 233
9.5 Examples of PACS Networks 234
9.5.1 An Earlier PACS Network at UCSF 234
9.5.1.1 Wide Area Network 234
9.5.1.2 The Departmental Ethernet 234
9.5.1.3 Research Networks 235
9.5.1.4 Other PACS External Networks 235
9.5.1.5 PACS Internal Network 235
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CONTENTS xvii

9.5.2 Network Architecture for Health Care IT and PACS 235

9.5.2.1 General Architecture 235
9.5.2.2 Network Architecture for Health Care IT 237
9.5.2.3 Network Architecture for PACS 237
9.5.2.4 UCLA PACS Network Architecture 238
9.6 Internet 2 238
9.6.1 Image Data Communication 239
9.6.2 What is Internet 2 (I2)? 241
9.6.3 Current I2 Performance 241
9.6.4 Enterprise Teleradiology 247
9.6.5 Current Status 247
9.7 Wireless Networks 248
9.7.1 Wireless LAN (WLAN) 248
9.7.1.1 The Technology 248
9.7.1.2 Performance 249
9.7.2 Wireless WAN (WWAN) 251
9.7.2.1 The Technology 251
9.7.2.2 Performance 251
9.8 Self-Scaling Networks 251
9.8.1 Concept of Self-Scaling Networks 251
9.8.2 Design of the Self-Scaling Network in the Health Care
Environment 253
9.8.2.1 Health Care Application 253
9.8.2.2 The Self-Scalar 253

10. PACS Controller and Image Archive Server 255

10.1 Image Management Design Concept 256
10.1.1 Local Storage Management via PACS Intercomponent
Communication 256
10.1.2 PACS Controller System Configuration 257
10.1.2.1 The Archive Server 257
10.1.2.2 The Database System 258
10.1.2.3 The Archive Library 259
10.1.2.4 Backup Archive 259
10.1.2.5 Communication Networks 259
10.2 PACS Controller and Archive Server Functions 259
10.2.1 Image Receiving 260
10.2.2 Image Stacking 260
10.2.3 Image Routing 261
10.2.4 Image Archiving 262
10.2.5 Study Grouping 262
10.2.6 RIS and HIS Interfacing 262
10.2.7 PACS Database Updates 263
10.2.8 Image Retrieving 263
10.2.9 Image Prefetching 263
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xviii CONTENTS

10.3 PACS Archive Server System Operations 264

10.4 DICOM-Compliant PACS Archive Server 264
10.4.1 Advantages of a DICOM-Compliant PACS Archive
Server 264
10.4.2 DICOM Communications in PACS Environment 265
10.4.3 DICOM-Compliant Image Acquisition Gateways 265
10.4.3.1 Push Mode 265
10.4.3.2 Pull Mode 265
10.5 DICOM PACS Archive Server Hardware and Software 266
10.5.1 Hardware Components 267
10.5.1.1 RAID 267
10.5.1.2 DLT 268
10.5.2 Archive Server Software 268
10.5.2.1 Image Receiving 269
10.5.2.2 Data Insert and PACS Database 269
10.5.2.3 Image Routing 269
10.5.2.4 Image Send 270
10.5.2.5 Image Query/Retrieve 270
10.5.2.6 Retrieve/Send 270
10.5.3 An Example 270
10.6 Backup Archive Server 271
10.6.1 Backup Archive Using an Application Service Provider
(ASP) Model 271
10.6.1.1 Concept of the Backup Archive Server 271
10.6.2 General Architecture 272
10.6.3 Recovery Procedure 273
10.6.4 Key Features 273
10.6.5 General Setup Procedures of the ASP Model 274

11. Display Workstation 277

11.1 Basics of a Display Workstation 277
11.1.1 Image Display Board 278
11.1.2 Display Monitor 279
11.1.3 Resolution 280
11.1.4 Luminance and Contrast 281
11.1.5 Human Perception 281
11.1.6 Color Display 282
11.2 Ergonomics of Image Workstations 282
11.2.1 Glare 282
11.2.2 Ambient Illuminance 283
11.2.3 Acoustic Noise Due to Hardware 283
11.3 Evolution of Medical Image Display Technologies 284
11.4 Types of Image Workstation 285
11.4.1 Diagnostic Workstation 285
11.4.2 Review Workstation 287
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CONTENTS xix

11.4.3 Analysis Workstation 287

11.4.4 Digitizing and Printing Workstation 288
11.4.5 Interactive Teaching Workstation 288
11.4.6 Desktop Workstation 289
11.5 Image Display and Measurement Functions 289
11.5.1 Zoom and Scroll 289
11.5.2 Window and Level 290
11.5.3 Histogram Modification 290
11.5.4 Image Reverse 292
11.5.5 Distance, Area, and Average Gray Level Measurements 292
11.5.6 Optimization of Image Perception in Soft Copy 293
11.5.6.1 Background Removal 293
11.5.6.2 Anatomical Regions of Interest 293
11.5.6.3 Gamma Curve Correction 293
11.5.7 Montage 293
11.6 Workstation User Interface and Basic Display Functions 296
11.6.1 Basic Software Functions in a Display Workstation 296
11.6.2 Workstation User Interface 297
11.7 DICOM PC-Based Display Workstation 300
11.7.1 Hardware Configuration 300
11.7.1.1 Host Computer 300
11.7.1.2 Display Devices 300
11.7.1.3 Networking Equipment 301
11.7.2 Software System 301
11.7.2.1 Software Architecture 301
11.7.2.2 Software Modules in the Application Interface
Layer 303

12. Integration of HIS, RIS, PACS, and ePR 307

12.1 Hospital Information System 308
12.2 Radiology Information System 308
12.3 Interfacing PACS with HIS and RIS 311
12.3.1 Workstation Emulation 311
12.3.2 Database-to-Database Transfer 311
12.3.3 Interface Engine 311
12.3.4 Reasons for Interfacing PACS with HIS and RIS 312
12.3.4.1 Diagnostic Process 312
12.3.4.2 PACS Image Management 313
12.3.4.3 RIS Administration 313
12.3.4.4 Research and Training 314
12.3.5 Some Common Guidelines 314
12.3.6 Common Data in HIS, RIS, and PACS 314
12.3.7 Implementation of RIS-PACS Interface 315
12.3.7.1 Trigger Mechanism Between Two Databases 315
12.3.7.2 Query Protocol 317
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xx CONTENTS

12.3.8 An Example—The IHE Patient Information

Reconciliation Profile 317
12.4 Interfacing PACS with Other Medical Databases 318
12.4.1 Multimedia Medical Data 318
12.4.2 Multimedia in the Radiology Environment 320
12.4.3 An Example—The IHE Radiology Information
Integration Profile 320
12.4.4 Integration of Heterogeneous Databases 321
12.4.4.1 Other Related Databases 321
12.4.4.2 Interfacing Digital Voice with PACS 321
12.5 Electronic Patient Record (ePR) 323
12.5.1 Current Status of ePR 323
12.5.2 Integration of ePR with Images—An Example 324
12.5.2.1 The VistA Information System Architecture 324
12.5.2.2 VistA Imaging 325

PART III PACS OPERATION 331

13. PACS Data Management and Web-Based Image Distribution 333

13.1 PACS Data Management 333
13.1.1 Concept of the Patient Folder Manager 334
13.1.2 Online Radiology Reports 334
13.2 Patient Folder Management 335
13.2.1 Archive Management 336
13.2.1.1 Event Triggering 336
13.2.1.2 Image Prefetching 336
13.2.1.3 Job Prioritization 337
13.2.1.4 Storage Allocation 338
13.2.2 Network Management 338
13.2.3 Display Server Management 338
13.2.3.1 IHE Presentation of Grouped Procedures
(PGP) Profile 339
13.2.3.2 IHE Key Image Note Profile 340
13.2.3.3 IHE Simple Image and Numeric
Report Profile 341
13.3 Distributed Image File Server 341
13.4 Web Server 343
13.4.1 Web Technology 343
13.4.2 Concept of the Web Server in PACS Environment 344
13.5 Component-Based Web Server for Image Distribution and
Display 345
13.5.1 Component Technologies 345
13.5.2 The Architecture of Component-Based Web Server 347
13.5.3 The Data Flow of the Component-Based Web Server 347
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CONTENTS xxi

13.5.3.1 Query/Retrieve DICOM Image/Data Resided

in the Web Server 348
13.5.3.2 Query/Retrieve DICOM Image/Data Resided
in the PACS Archive Server 348
13.5.4 Component-Based Architecture of Diagnostic Display
Workstation 349
13.5.5 Performance Evaluation 350

14. Telemedicine and Teleradiology 353

14.1 Introduction 353
14.2 Telemedicine 354
14.3 Teleradiology 355
14.3.1 Background 355
14.3.1.1 Why Do We Need Teleradiology? 355
14.3.1.2 What is Teleradiology? 356
14.3.1.3 Teleradiology and PACS 357
14.3.2 Teleradiology Components 358
14.3.2.1 Image Capture 359
14.3.2.2 Data Reformatting 359
14.3.2.3 Image Storage 359
14.3.2.4 Display Workstation 359
14.3.2.5 Communication Networking 359
14.3.2.6 User Friendliness 360
14.3.3 State-of-the-Art Technology 361
14.3.3.1 Wide Area Network—Asynchronous Transfer
Mode (ATM), Broadband, DSL, Internet 2,
and Wireless Technology 361
14.3.3.2 Display Workstation 362
14.3.3.3 Image Compression 364
14.3.3.4 Image/Data Privacy, Authenticity, and Integrity 364
14.3.4 Teleradiology Models 365
14.3.4.1 Off-Hour Reading 365
14.3.4.2 ASP Model 365
14.3.4.3 Web-Based Teleradiology 366
14.3.5 Some Important Issues in Teleradiology 366
14.3.5.1 Teleradiology Trade-Off Parameters 366
14.3.5.2 Medical-Legal Issues 367
14.4 Telemammography 367
14.4.1 Why Do We Need Telemammography? 367
14.4.2 Concept of the Expert Center 368
14.4.3 Technical Issues 368
14.5 Telemicroscopy 369
14.5.1 Telemicroscopy and Teleradiology 369
14.5.2 Telemicroscopy Applications 371
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xxii CONTENTS

14.6 Real-Time Teleconsultation System 372

14.6.1 Background 372
14.6.2 System Requirements 373
14.6.3 Teleconsultation System Design 373
14.6.3.1 Image Display Work Flow 373
14.6.3.2 Communication Requirements During
Teleconsultation 373
14.6.3.3 Hardware Configuration of the Teleconsultation
System 374
14.6.3.4 Software Architecture 375
14.6.4 Teleconsultation Procedure and Protocol 376
14.7 Trends in Telemedicine and Teleradiology 378

15. Fault-Tolerant PACS 381

15.1 Introduction 381
15.2 Causes of a System Failure 382
15.3 No Loss of Image Data 384
15.3.1 Redundant Storage at Component Levels 384
15.3.2 The Archive Library 385
15.3.3 The Database System 386
15.4 No Interruption of PACS Data Flow 386
15.4.1 PACS Data Flow 386
15.4.2 Possible Failure Situations in PACS Data Flow 387
15.4.3 Methods to Protect Data Flow Continuity from
Hardware Component Failure 387
15.4.3.1 Hardware Solutions and Drawbacks 387
15.4.3.2 Software Solutions and Drawbacks 388
15.5 Current PACS Technology to Address Fault Tolerance 389
15.6 Clinical Experiences with Archive Server Downtime:
A Case Study 390
15.6.1 Background 390
15.6.2 PACS Server Downtime Experience 390
15.6.2.1 Hard Disk Failure 391
15.6.2.2 Motherboard Failure 391
15.6.3 Effects of Downtime 391
15.6.3.1 At the Management Level 391
15.6.3.2 At the Local Workstation Level 392
15.6.4 Downtime for Over 24 Hours 392
15.6.5 Impact of the Downtime on Clinical Operation 392
15.7 Concept of Continuously Available PACS Design 392
15.8 CA PACS Server Design and Implementation 393
15.8.1 Hardware Components and CA Design Criteria 393
15.8.1.1 Hardware Components in an Image Server 393
15.8.1.2 Design Criteria 394
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