Contemporary Issue

Radiology Image Management in a Teaching Hospital

Network Scenario : Initial Experience
Surg Cdr IK Indrajit*, Surg Cdr J D Souza+, Lt Col Rajvir Singh#, Lt Anjanish Shekar**

Abstract
INHS Asvini has the distinction of emerging as the first Armed Forces Hospital with networked radiology images, sourced
principally from a recently installed Digital Substraction Angiography (DSA) machine (Siemens Polystar Top 1000 MA). In
recent times, newer imaging machines offer digital images that are in DICOM format. DICOM denotes ‘Digital Imaging and
Communications in Medicine”. Image management at INHS Asvini, involves transfer of DSA images in DICOM format, their
conversion into Joint Photographic Experts Group (JPG) format and subsequent transmission of JPG images through a robust
networking system that connects all departments/OPD/Wards, facilitating direct access of images to a variety of specialists and
specialities. Clearly, this encouraging outcome is a small but useful step heralding the concept of ‘anytime anywhere’ images,
and has the scalable expansibility of including CT and MRI images in future.
MJAFI 2003; 59 : 234-238
Key Words : DICOM; Hospital network; Image management

Introduction Material and Methods

I NHS Asvini is the principal Command Hospital of

the Indian Navy with a 825 bed teaching facility. It is
presently undergoing modernization, underscored by the
The DSA system
The Department of Radiodiagnosis and Imaging averages
125 diagnostic and interventional radiology procedures per
rapid induction of ‘state of art’ medical equipment along year. The newly installed Siemens Polystar Top DSA 1000
with continual computerization and networking of MA machine enables diagnostic and interventional radiology
various Departments, Wards and OPD. The Department procedures such as cerebral, peripheral vascular and renal
of Radiodiagnosis and Imaging at INHS Asvini has donor angiography, carotid and renal angioplasty,
recently acquired a modern DSA machine. By the percutaneous vascular stenting, antegrade ureteric stenting
presence of a most up-to-date networking system, the and biliary stenting, to be done.
DSA images are transferred, albeit at no extra cost, from The DSA is the principal image source at the moment.
the Department of Radiodiagnosis and Imaging to In the main digital system of the DSA machine, the images
various specialists, OPD and wards, thereby enhancing are digitized and archived incorporating the Digital
the capabilities of the network as well as exploring newer Communications in Medicine (DCM) format. The digitized
DCM images possess a file size ranging from 900 K to 2300
frontiers in health care delivery. An overview of the
K. Typically, a patient file name is referred as 1.2.592.
Image Management at INHS Asvini is given as Table 1. 300036.9116.2.2.2.1862616180.961732103.121216. This
This paper dwells on the practical issues of Image series of numbers contains data for a precise investigation
management in the network scenario at INHS Asvini. on a particular patient on a given date with unique procedure
and machine attributes.

Table 1
The overview of image management at INHS Asvini

Image management strategy Hardware/Software components Location

Image source Siemens Polystar DSA DSA Room

Radiology information systems Siemens Leonardo Workstation Central Workstation
DICOM image conversion E Film Dicom Converter/Viewer Central Workstation
Transmission TCP/IP Protocol Central Workstation
Network ISDN Entire Hospital
Hospital information System Radiology Image Folders Individual Client Computers
DICOM image viewer Irfan Dicom Viewer Individual Client Computers

*+
Classified Specialist (Radiodiagnosis and Imaging), #Officer-in-charge (Medical Informatics), **
Deputy Officer-in-charge (Medical
Informatics), INHS Asvini, Colaba, Mumbai - 400 005.
Radiology 235

Digital Imaging and Communications in Medicine RIS) to the modality [3].

(DICOM)
The Central Work Station
The importance of digital medical image processing has
Located at the Department of Radiodiagnosis and
increased since the introduction of Computed Tomography
Imaging is the central workstation, which performs two
as the first digital modality in the 1970s. In an effort to
important roles in the image management. Firstly, the DSA
develop a standard means by which users of different digital
source images in DCM format at Siemens DSA Leonardo
medical imaging equipment (CT, MRI, DSA) could interface
Workstation, needs conversion to JPG format. Secondly,
display or other devices to these machines, the American
the DSA images require transfer to a Network computer
College of Radiology (ACR) and the National Electrical
and thereafter to the Hospital’s Network. To achieve this,
Manufacturers Association (NEMA) formed a joint
two diverse computers are present, one representing the
committee early in 1983. The result was the advent of a
image source from Siemens Leonardo Workstation, and the
standard format called DICOM (Table 2). Today, DICOM
other nominated as X-ray 2 representing the Hospital
is the ubiquitous standard in radiology and imaging industry
Network. The images at Siemens DSA Leonardo
for the exchange and management of images and image
Workstation are in DCM format, while the Network are in
related information [1]. Importantly, DICOM is also used
JPG format.
in other image related medical fields, such as pathology,
endoscopy, dentistry, ophthalmology and dermatology. Specifically, the first task focuses on DICOM conversion
Table 2
to JPG. The DCM image from Siemens Leonardo
History of digital imaging and communications in medicine (DICOM) Workstation is transferred to X-ray 2 computer. The X-ray
2 computer acts as an intermediary, converting the images
Year Event from DCM to JPG. The second task is accomplished by a
1983 American College of Radiology (ACR) and National Electrical TCP/IP protocol (Transmission control protocol/Internet
Manufacturers Association (NEMA) develop an exchange protocol) between the two computers. Two Network cards
standard
in the X-ray 2 computer, support distinctly separate
1985 ACR-NEMA standard Version 1.0 published
connections to the Siemens DSA Leonardo Workstation and
1988 ACR-NEMA Version 2.0 published
Asvini Information Management System (AIMS) Network
1993 The DICOM standard developed creating an open
(vendor independent) platform for the communication of
at 10/100 Mbps. This enables transfer of images from
medical images Siemens DSA Leonardo Workstation to the X-ray2 computer
1993 DICOM Version 3.0 published and on to the AIMS Network. At central workstation, the
images are placed in X-ray 2 computer of the Network
The DICOM standard facilitates the exchange and Neighbourhood, within the Radiology Images folder, under
processing of vendor independent medical images in digital various referring specialities and specialists. The folders
form. Image acquisition devices, image archives, hardcopy are password protected and updated periodically.
devices and imaging workstations from different vendors
Dicom Converters
can be connected into a common information infrastructure
and integrated with other information systems (eg. HIS or Dicom Converters are software programmes that assist
Hospital Information System and RIS or Radiology in DCM to Joint Photographic Experts Group/Tagged Image
Information Systems). The DICOM standard achieves this File Format/Windows Bitmap/ (JPG/TIFF/BMP) conversion.
by creating a DICOM image that consists of a list of data The need for image conversion arises because a typical PC
attributes of image related information : patient (name, sex, with a Windows operating system or MS Word/Power Point
identification number), modality and imaging procedure programme is unable to handle DCM images while easily
(device parameters, calibration, radiation dose, contrast supporting viewing JPG/TIF/BMP images. Today, JPG
media), image (resolution, windowing). DICOM also offers format is a popular choice because of the tremendous
Network Services that are based on the client/server concept compression ratios (1:20) applied on images without
[2]. sacrificing perceived image quality. This is advantageous,
since native diagnostic quality images are of large file size.
In addition to the most basic DICOM service, image
A comparison of image data and digital file size is given as
transmission, there are number of advanced services, for
Table 3. Moreover, the JPG format allows preservation of
example : (a) DICOM image archive service (query/retrieve
both 24 bit color (“true” color) as well as “17 million” color
service class) that allows searching of images in Picture
(“diagnostic” quality color). As a result of these significant
Archiving and Communication System (PACS) by certain
advantages any significant lesion on a DSA/CT/MRI image
criteria (patient, time of creation of the images, modality
can be demonstrated with diagnostic quality, in less than
etc.) and downloading of images from the archive, (b)
100K, by today’s standards. Illustrating this point, a mosaic
DICOM print service (print management service class) that
of sample image in DCM/JPG/TIF/BMP formats is shown
permits access to laser cameras or printers over a network,
in Table 4.
so that multiple modalities and workstations can share
printers, (c) DICOM modality worklist service that facilitates Hospital Network
automatically download up-to-date worklist including the The Hospital Network is the highway, facilitating the
patient demographic data from the information system (HIS/ transfer of images. Originating from AIMS Data Centre at
MJAFI, Vol. 59, No. 3, 2003
236 Indrajit, et al

Table 3
Image data and comparison of digital file size
(Adapted from reference: Going digital: Image preparation for biomedical publishing Michael P Schenk*, Richard J Manning, Mark H Paalman. The
Anatomical Record Volume 257, Issue 4, 1999) Note : dpi denotes (dots per inch resolution)

Subject Resolution (dpi)

800 600 400 200 100 72

B/W photograph of MRI (head region) 3 ½" x 4 ½" 2.6 MB 1.5 B 728 K 243 K 117 K 97 K
B/W photograph of human brain (brainstem) 5" X 6" 3.4 MB 1.9 MB 922 K 291 K 146 K 97 K

Table 4
A mosaic of image in DCM, JPG/TIF/BMP formats

Biliary stenting images in current popular formats and file sizes (shown in clockwise direction from right top corner) : Tagged image file format (TIF) image
873 K; Joint Photographic Experts Group Format (JPG) 117 K; Windows Bitmap files (BMP) 1026 K and Digital Communications in Medicine (DCM) 913
K

DCM TIF
(Digital (Tagged
Communications Image
in Medicine) File Format)
913 K 873 K

BMP JPG
(Windows (Joint
Bitmap Photographic
Files) Experts Group
1026 K Format)
117 K

the Department of Medical Informatics in the OPD block, various hardware channels is given as Table 5 [5]. The
four multimode fibreoptic backbone-networking cables begin main information system (AIMS) is of Client-Server
and run through the hospital connecting nearly 150 stand- Architecture, established on Oracle 8 database on Solaris
alone client computers. 2.6 Operating System and based on Developer 2000 of
Supporting this fibre optic backbone network are full Windows 2000. The entire information system is powered
duplex managed switches. Besides, the network has by the presence of two Sun Ultra II Enterprise Servers.
structured semicentralised cabling type of architecture, based Image Viewing
on international standards defined by Krone. The fibre optic
The real power of Radiology images in the INHS Asvini
backbone Local Area Network forms the critical part of the
Network is realized, once they are available on the Network.
Hospital Network system with a data transfer rate of 100
The advantages that emerge range from simple viewing of
Mbps [4]. A tabulated data on network transfer speeds for
MJAFI, Vol. 59, No. 3, 2003
Radiology 237

Table 5 and lossy compression). Keeping these fundamental

Network transfer speeds doctrines at the core of its functioning are a set of
(Adapted from http://www.lumisys.com/support techref
network_speeds.html)
specialised image software called as DICOM Converters
and DICOM Viewers. Table 6 is a list of DICOM
Bandwidth table
Converters and Viewers such as E Film, Irfan Viewer
Bit Byte Time
Hardware/Channel transfer rate transfer rate 1MB file and Osiris, all freely downloadable from the Internet.
Gigabit LAN adapter 1.0 Gb/s 125 MB/s 8 ms Advantages
DS4 (T4) 274 Mb/s 34.2 MB/s 29 ms Concerning the advantages of image management, a
100Mb LAN card 100 Mb/s 12.5 MB/s 80 ms
key starting point, is the convenience factor. DSA
DS3 (T3) 44.7 Mb/s 5.6 MB/s 179 ms
Cable modem 10 Mb/s 1.25 MB/s 800 ms
derived images are available for all specialists at any
10 Mb LAN card 10 Mb/s 1.25 MB/s 900 ms computer, manifestly facilitating the delivery of quality
DS2 (T2) 6.3 Mb/s 789 KB/s 1.3 sec health care. Moreover, the images can be accessed at
DS1 (T1) 1.54 Mb/s 193 KB/s 5.2 sec any time for a relook or closer examination. The speed
ISDN - 2B 128 Kb/s 14.2 KB/s 70 sec of image transmission and image retrieval is
DS0 (ISDN) 64 Kb/s 8.0 KB/s 2.08 min instantaneous by virtue of the presence of a fast network.
56K modem 56 Kb/s 7.0 KB/s 2.38 min In addition, the images can be utilized for training and
CME presentation at individual departments,
Table 6 notwithstanding the ease of incorporation into slides for
Few DICOM software viewers and converters presentation at departmental lectures, auditorium and
Name Dicom URL and location clinical meetings. Besides, there is a potential
Capabilities infrastructure that can accommodate the creation of a
E Film Dicom http://www.efilm.ca filmless department with a Picture Archiving System
Converters University Health Network and Mount Sinai (PACS) at Department of Radiodiagnosis and Imaging
Hospital in Toronto, Canada
MRIcro Dicom http://www.psychology.nottingham.ac.uk
in the future [6].
Converters staff/crl/mricro.html
Difficult Areas
School of Psychology, Nottingham
University Data redundancy and security are two areas of
Osiris Dicom http://www.expasy.ch/UIN/html1/projects/ perceived difficulty. Data redundancy is an area of
Converters osiris/DownloadOsiris.html
University of Geneva concern, presently addressed by periodic erasing after
AccuImage Dicom http://www.accuimage.com archiving of data. Once an image is transmitted from
Lite Viewers the central workstation, it is placed in the Network for
ImageJ Dicom http://rsb.info.nih.gov/ij/ at least four months, until it is erased after obtaining a
Viewers ImageJ developed by Wayne Rasband
CD archive of all image files. Security issues have been
Irfan Dicom http://www.irfanview.com
Viewers Irfan View developed by Irfan Skiljan addressed in several ways. The DICOM 3.0 compliant
systems using classes to authenticate each modality, each
images to advanced applications such as copying and pasting server and each user, prevents unauthorized hosts from
images in a variety of applications such as MS Word, MS accessing the DSA machines or scanners or servers
Power Point etc. Other inherent advantages include the directly via the DICOM protocol. Similarly, the Network
ability of referring specialists to view any specific images, server employs both host level security and username-
from any computer in the Network. All this makes possible password authentication. However, this level of security
the retrieval of images “anywhere anytime” by the referring is inadequate when a PACS network is connected to the
specialities and specialists. Internet [7]. Therefore, the AIMS Network is not
Discussion connected to the Internet at the moment, providing more
There are four areas of practical importance tight control and access.
concerning image management in a network scenario : Future
firstly, the DSA/CT/MRI vendor source images need to Inherent to the aforementioned concepts and based
be viewed by remote computers, secondly, though the on the success of DSA images in the INHS Asvini
vendors are different, the digitized source images are Network, CT and MRI images have been chosen as the
standardized DCM format, thirdly, the file size of image next DCM sources for our image management project.
during conversion should not be larger than the original With the availability of cine-run in all the three
image, which will determine image transmission speeds modalities, it is expected that the Network will handle
in a network; fourthly, the image should not lose useful more real-time online color video with better image
information during conversion (the notion behind lossless
MJAFI, Vol. 59, No. 3, 2003
238 Indrajit, et al

quality. It has also been proposed to incorporate image administration and accommodates increasingly scalable
retrieval from the newer imaging modalities such as expansion by the inclusion of CT and MRI images.
DSA, CT and MRI directly from servers in the References
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