II.

Medical Image Data

1. Medical Image, Image Quality, and Data Formats

2. Medical Imaging Modalities
3. Medical Image Digitalization and Acquisition Gateway

2. Medical Imaging Modalities

Medical imaging modalities, for example, includes magnetic resonance imaging (MRI), ultrasound,
medical radiation, angiography and computed tomography (CT) scanners. In addition, to several
scanning techniques to visualise the human body for diagnostic and treatment purposes.

Medical imaging modalities, for example, includes magnetic resonance imaging (MRI), ultrasound,
medical radiation, angiography and computed tomography (CT) scanners. In addition, to several
scanning techniques to visualise the human body for diagnostic and treatment purposes. Also, these
modalities are very useful for patient follow-up, with regards to the progress of the disease state, which
has already been diagnosed, and/or is undergoing a treatment plan. The vast majority of imaging is
based on the application of X-rays and ultrasound (US). These medical imaging modalities are involved
in all levels of hospital care. In addition, they are instrumental in the public health and preventive
medicine settings as well as in the curative and further extending to palliative care. The main objective is
to establish the correct diagnoses.

Medical radiation

Medical imaging modalities in a clinical setting is a vital contribution to the overall diagnosis of the
patient and help in the decision of an overall treatment plan. The utilisation of imaging techniques in
medical radiation is increasing with new technological advances in medical sciences. Therefore, in the
spectrum of a broad range of imaging modalities are the specialities of nuclear medicine, positron
emission tomography (PET), magnetic resonance imaging (MRI) and ultrasound. Overall, imaging for
medical radiation purposes involves a team of radiologists, radiographers and medical physicists.

X-rays

Medical imaging modalities involve a multidisciplinary approach to obtain a correct diagnosis for the
individual patient with the aim of providing a personalised approach to patient care. These imaging
techniques can be applied as non-invasive methods to view inside the human body, without any surgical
intervention. They can be used to assist in diagnosis or treat a variety of medical conditions. Medical
imaging techniques utilise radiation that is part of the electromagnetic spectrum. These include imaging
X-rays which are the conventional X-ray, computed tomography (CT) and mammography. To improve X-
ray image quality, a contrast agent can be used, for example, in angiography examinations.

Medical imaging modalities

Furthermore, imaging utilised in nuclear medicine and angiography can be attributed to several
techniques to visualise biological processes. The radiopharmaceuticals used are usually small amounts of
radioactive markers: these are used in molecular imaging. Other non-radioactive types of imaging
include magnetic resonance imaging (MRI) and ultrasound (US) imaging. MRI uses strong magnetic
fields, which do not produce any known irreversible biological effects in humans. Diagnostic ultrasound
(US) systems use high-frequency sound waves to produce images of internal body organs and soft tissue.
Several medical imaging modalities use radiation uses X-ray beams that are projected onto the body.
When these X-ray beams pass through the human body some are absorbed, and the resultant image is
detected on the other side of the body.

Some types of medical imaging do not use radiation such as MRI, angiography and ultrasound

MRI angiography

Angiography

Some types of medical imaging function without using ionising radiation; for example, magnetic
resonance imaging (MRI), angiography, ultrasound imaging and have significant applications in the
diagnosis of disease. Medical imaging modalities include single-photon emission computed tomography
(SPECT), positron emission tomography (PET) and hybrid imaging systems such as PET/CT. Alternatively,
other systems use the application of positron emission mammography (PEM) and radio-guided surgery
(RGS). In addition, there is the application of short and long-lived radioisotopes for the research and
development of new imaging agents and associated targeted therapies. Other techniques include
computed tomography (CT), magnetic resonance imaging (MRI), ultrasound imaging and planar X-ray
(analogue, portable and digital) systems.

The special resolution required to elucidate detailed images of various structures within the human
body is the main practical limitation of current medical imaging modalities. However, the rate of image
acquisitions has increased over the last decade; this does not allow for the sensitivity required in order
to express anatomical structure and function which is limited by the radiation dose amongst other
factors.

Spatial resolution of medical imaging modalities

Imaging modality Spatial resolution (mm)

Animal Clinical

PET 1-2 6-10

SPECT 0.5-2 7-15
OPTICAL 2-5 (Visible to IR)
MRI 0.025-0.1 0.2
US 0.05-0.5 0.1-1
CT 0.03-0.4 0.5-1

Medical imaging modalities will not be dictated by the advancements in imaging quality, but more likely
the objective will be to reduce the cost and scanning time including exposure to radiation. These
technical innovations allow for the rational conclusion that medical radiation dose, scanning speed,
image resolution and sensitivity including cost per patient will all be elements of personalised medicine
in the future.

Consequently, the medical physicist will play a pivotal role to further these challenges: especially to
extend knowledge and understanding of the effect of which signals used to construct 3-D time-
dependent images.

In particular, it is important to account for the physical and biological factors that modulate the
behaviour of different energy forms within the human body. Moreover, to understand how to interpret
images and derive more crucial information regarding the patient’s disease state in order to formulate a
treatment plan which is personal to the patient.

As with the continual development and improvements in imaging, it is essential to understand the
specific biological episode associated with each specific disease state. It would be crucial to design
medical imaging modalities that can recognise a ‘fingerprint’ that can be attributed to a specific disease
state.

Furthermore, new imaging modalities would be used to evaluate changes in tissue composition resulting
from a disease like fibrosis. In this case, the physiological parameter would be the reduction of blood
flow in arteries according to angiography. Other techniques could evaluate the change in conductivity or
magnetic susceptibility of brain tissue. All of these improvements could help in the understanding of the
contrast mechanisms in several medical imaging modalities.

In essence, it is important to make use of the data within digital images to develop more quantitative
tissue characterisation from these anatomical scans. For example, functional magnetic resonance
imaging (fMRI) has transformed the understanding of the construction of the brain.

This imaging technique has provided the exact relationship between the MRI signals used to map neural
activity. However, fundamental neurochemical and electrophysiological processes are not well defined.

Diagnostic imaging tools provide powerful techniques to locate biological processes within the human
body. This includes spatial heterogeneity and related changes to the different regions within the
anatomical structure’s fine detail.

Advancements in medical imaging modalities will contribute to an overall personalised treatment plan
for each patient. This can only be guaranteed by continuing translational research in the design of novel
radiopharmaceuticals and biomarkers in order to increase the efforts to devise robust personalised
treatment plans for individual patients.

====================================
3. Medical Image Digitalization and Acquisition Gateway

Image Acquisition Gateway

The image acquisition gateway computer (gateway) with a set of software programs is used as a buffer
between image acquisition and the PACS server. In this chapter the terms acquisition gateway
computer, gateway computer, acquisition gateway, and gateway have the same meaning.

This chapter covers the digital imaging and communications in medicine (DICOM) interface: the DICOM
compliant gateway, the automatic image recovery scheme for DICOM conformance imaging devices,
interface with other existing picture archiving and communication system (PACS) modules, and the
DICOM broker.

When the acquisition gateway has to deal with DICOM formatting, communication, and many image
pre-processing functions, multiple-level processing with a queuing mechanism is necessary. The image
acquisition gateway computer with a set of software programs is used as a buffer between image
acquisition and the PACS-based multimedia imaging informatics servers. The chapter shows the
positions of the PACS server and archive, hospital information system (HIS), radiology information
system (RIS), and Web-based electronic patient records (ePR) server in the generic PACS components
data flow. Ultrasound (US) images can be shown with other modality images in the PACS general display
workstations for cross modality comparisons.
BACKGROUND

Several acquisition devices (modalities) can share one gateway. The gateway has three primary tasks:

(1) it acquires image data from the radiological imaging device,

(2) it converts the data from manufacturer data format specifications to the PACS image data standard
format (header format, byte-ordering, matrix sizes) that is compliant with the DICOM data formats, and

(3) it forwards the image study to the PACS server or directly to the PACA workstations (WSs). Additional
tasks in the gateway are some image pre-processing, compression, and data security.

An acquisition gateway has the following characteristics:

1. It preserves the image data integrity transmitted from the imaging device.

2. Its operation is transparent to the users and totally or highly automatic.

3. It delivers images timely to the PACS server and WSs.

4. It performs some image preprocessing functions to facilitate image display.

Among all PACS major components, establishing a reliable gateway in PACS is the most difficult task for
a number ...

Computers in Radiology, William W. Boonn MD, in Radiology Secrets Plus (Third Edition), 2011

What is DICOM?

DICOM stands for Digital Imaging and Communications in Medicine. DICOM is a standard that
establishes rules that allow medical images and associated information to be exchanged between
imaging equipment from different vendors, computers, and hospitals. A computed tomography (CT)
scanner produced by vendor A and a magnetic resonance imaging (MRI) scanner produced by vendor B
can send images to a PACS from vendor C using DICOM as a common language. In addition to storing
image information, other DICOM standard services include query/retrieve, print management,
scheduling of acquisition and notification of completion, and security profiles.

Components and implementation of a picture archiving and communication system in a prototype

application

Introduction

Picture archiving and communication systems (PACS) have become one of the most popular health care
systems between 2003 and 2008.1,2 During this period, archiving media and interpretation media
changed from film based to digital imaging, which was considered as a big breakthrough, where digital
image acquisition devices have become more famous than the classic radiology conventional systems.
Therefore, once a digital image of the chest is captured, it can be processed directly by the computer.3

The digital imaging PACS is a combination of hardware and software hybrid system that is used to
acquire, store, deploy and retrieve medical images using Digital Imaging and Communications in
Medicine (DICOM) standard. The images and reports are transmitted digitally via PACS by integrating
the system with the radiology information system (RIS) and hospital information system (HIS).2 This
integration of PACS–RIS–HIS would eliminate the need to manually store, retrieve and display film
jackets. Earlier, the majority of health care systems were adopting the conventional way of storing and
displaying patients’ data in hospitals, which delayed the time from imaging to reporting of the
interpretation. Providing medical stuff with information in a short period of time is an important step in
the current medical systems. Therefore, PACS is becoming a vital step and should be included in
hospitals to speed up doctors’ mission in curing patients.

The PACS was first embodied in mid 1970s.4 Professor Jean-Raoul introduced DIOGENE, a medical
information display system at the Geneva University Hospitals in Switzerland. This system was later
modernized to form PACS. Currently, PACS has been adopted in many hospitals and medical institutes.
By digitizing the medical images, institutes were able to minimize costs in data management and storage
and to reduce time consumption in data transportations.2 Images, as it is widely known, are the basis in
teaching medical imaging. Therefore, it is vital to provide the students of medical imaging with high-
quality images in order to improve the ability of analyzing images.5 Depending on this fact, a study was
established to combine the current PACS with the medical imaging teaching method to design a better
way of imaging teaching systems in higher institutes.5

Before PACS, the examination cycle of a radiology department usually flows in the following steps as
illustrated

 a patient is directed to the ward of physicians for medical checkup;

 the responsible physician may refer the patient to the X-ray laboratory for imaging;
  after imaging, the films will be taken manually to the reading room to be printed out and
analyzed by the radiologists in the radiology department;
 the radiologist will direct the analysis of X-ray images manually to a clerk to type out the report
 the radiologist’s report will manually reach the same physician as the first step to decide;
 the report might also reach outside clinics, other hospital departments, emergency room (ER) or
intensive care unit (ICU).

The examination cycle of a radiology department before PACS.

1. This turnaround time of examination cycle may vary from hours to days, and this cycle might
consume much time to get imaging reports which can delay the decision making about the
condition of patients.
2. The major limitations of the conventional examination radiology cycle are as follows:
3. time consuming – decision making of diagnostic results may not be obtained in a timely manner;
4. high possibility of losing the examination data of patients – implying examination retake;
5. physical retrieval of films from library and then from ER may take minutes to hours;
6. decision making by referring physician(s) varies from hours to days;
7. digitizing the films is necessary to save a copy of the images.
8. After PACS installation, the examination workflow is in the following steps:
9. technician takes digital images in the X-ray laboratory;
10. a few seconds later, the exposure was adjusted at the modality workstation (display
workstation);
11. images are then sent to digital archive;
12. images are immediately available to radiologist(s), referring physician(s) office, and anywhere in
the medical institute.
13. Therefore, with a smaller and more efficient file room, the health care is improved with more
physician’s satisfaction. Figure 2 briefly presents the workflow after PACS installation.

The examination workflow of a radiology department after PACS.

Materials and methods

This section discusses the main PACS components followed by introduction of the HL7 and DICOM
standards and the proposed prototype of WebXA application.

PACS components

PACS consists of four major components:

a) image acquisition devices (imaging modalities),

b) communication networks,
c) PACS archive and server, and integrated display workstations (WS)
PACS can be further connected to RIS and HIS health care systems via PACS communication networks

PACS basic components and workflow.

Image acquisition devices

The imaging acquisition devices are composed of the devices of imaging modalities and acquisition
gateway computers. Imaging modalities include magnetic resonance imaging, computed tomography,
PET, X-ray angiography, echocardiography and others. These modalities are interfaced with the PACS
server via acquisition gateway computers. The major roles of using acquisition gateway computers are
to acquire images from the imaging modalities, convert the format of the images data from
manufacturer’s specification to the PACS standard format, which is called DICOM, and to perform some
preprocessing functions on the data such as resizing, background removal and orientation calibration.6

The two common methods of image acquisition are digitization of films and direct digital acquisition.
The digitization of plain films is a vital method to convert the radiology projections (films) into digital
images, because computers can process only digital images. This can be achieved using film/image
digitizers such as laser scanner or charge coupled device (CCD). The second method of image acquisition
is the capturing of direct digital images, which can be done using the currently developed X-ray devices.
These devices can acquire digital images without the need of imaging plates used in conventional
radiography. Therefore, digital images are obtained from 30% of image acquisition devices such as
magnetic resonance imaging, computed tomography, ultrasound, and digital subtraction angiography.

Communication networks

The PACS communication network is the way of moving the medical data between the components of
PACS themselves and other systems and to remote locations. Similar to other computer networks, PACS
network provides a path to communicate between imagine modalities, gateway computers, PACS
server, display and review WSs, HIS/RIS systems and any other remote medical locations. The factors of
PACS networks are the network topology, line capacity and workflow assignments. The topology of
communication networks refers to the physical or logical way of designing these networks, whereas two
or more nodes connect to a link and then two or more links can form a network topology. The five main
topologies used in the medical environments are Ring, Star, Tree, Bus and Mesh.

Theoretically, three main types of networks are used to transfer the medical data of radiology:

 LAN network within one medical department to link imaging modalities, archive and data
storage and the display WSs;
 LAN network to link different departments in a hospital (intra-hospital);
 Tele-radiology network to transfer medical data to other remote hospitals in that region.

PACS Archive and server

All the patients’ information and imaging examination are sent to the PACS server for archiving. The
data are sent to PACS server from the acquisition gateway computers and from HIS/RIS systems. The
PACS server, which is the heart and engine of PACS, has two main components: storage media
(database) and archive system. The archive system of PACS needs two levels for archiving: short term
and long term. The data (images) from the short-term level are retrieved in 2 seconds, whereas those
from the long-term level are retrieved in £3 minutes.6

Examples of the storage media used for archiving are as follows:

 (RAID) redundant array of inexpensive disks for prompt access of current images;
 magnetic plates for speedy recovery of reserved images;
 erasable magneto-optical plates for impermanent long-haul archive;
 (ROM) read only memory in the optical plate library, which constitutes the changeless
document;
 recently created advanced flexible plates (DVD-ROM) for ease changeless document;
 the advanced straight tapes for reinforcement.

PACS servers have many significant functions, of which some of them are listed below:

 gets images from examinations through securing portals,

 extracts content data depicting the accepted examination from the DICOM image header;
 updates the database administration framework;
 determines the display WSs to which recently created examinations are to be sent;
 automatically recovers important correlation images from recorded examinations;
 store stockpiling or long-haul library file framework;
 automatically revises the introduction of registered or advanced radiography pictures;
 determines ideal complexity and brightness parameters for displaying images.

Display WSs

The display WS is a very important component of the PACS network, which plays a vital role in the
clinical acceptance of PACS. It is the hardware component that replaces the Alternator or the manual
light box of radiology system. Today, most radiologists analyze films in a perusing room utilizing light
boxes or alternators. The light boxes are lighted boards on which ~12 films may be hung at once for
review and physically turn about 8 of 200 films of a patient into position for diagnosing purposes. Simple
image preparing operations such as zooming using an amplifying glass and annotation of films are
performed utilizing the alternators. Display WSs help radiologists make primary diagnosis and hence
they are also named as diagnostic WSs. These WSs are composed from local storage database, network
connection for communications, resource management, display, and processing software. Display WSs
provide some of the basic image processing functions such as access, manipulation, evaluation, and
documentation.

HL7 and DICOM standards

Transmission of images and reports between different medical institutes is a hard mission for two
reasons: first, information systems utilize various machine platforms, and second, the medical images
and information are created from different imaging modalities by distinctive producers.
With the growing medical standards, Health Level 7 (HL7) and DICOM, incorporation of heterogeneous,
different restorative images and information into a composed system is made feasible. Interfacing two
medical systems requires two elements: a normal data format and a correspondence protocol. HL7 is a
standard text-based information format, and DICOM incorporates data format and correspondence
protocols. In compliance with the HL7 standard, DICOM is conceivable to exchange medicinal
information such as HIS, RIS and PACS. By adjusting the DICOM standard, the medical images created
from an assortment of modalities and manufacturers might be interfaced as an incorporated health care
system.

HL7, introduced in March 1987, was sorted out by a client–vendor board to create a standard for
electronic information trade in health care environments, particularly for hospital provisions. HL7
standard alludes to the highest level, the provision level, in the seven communication levels of Open
Systems Interconnection (OSI). The main objective is to improve the interface execution between PC
provisions from different manufacturers. This standard confirms exchanging data among health care
systems, for example, HIS, RIS and PACS. On the other hand, DICOM is a significant standard which has
been developed as a consequence of the starting exertions by ACR and NEMA joint council shaped in
1993 to push correspondence of computerized image data regardless of gadget producer. This standard
encourages the advancement and development of PACS to interface with different systems of healing
center data in a similar way. In addition, DICOM permits the making of indicative databases that could
be cross-examined by a wide assortment of gadgets conveyed geologically.

A work in 2008 discussed the integration of a research called content-based image retrieval with RIS and
PACS. This work aimed to improve the workflow of radiological daily routine. The importance of this
integration comes from making all the PACS archive available for radiologists to find an accurate
diagnosis for the current study of patients. In this article, the integration between RIS and PACS is
achieved in WebXA where all patients’ studies (images and information) are saved in the database of the
server, and WebXA can call any study using the name of the patient and number of the study. Specialist
can then illustrate the images of a specific study and analyses for better diagnosing from the current
study.

ACR–NEMA, officially known as the American College of Radiology and the National Electrical
Manufacturers Association, established a committee to create a set of benchmarks to serve as a
common background for different therapeutic medical imaging vendors. The main objective was that
recently created instruments have the capacity to impart and partake in imparting therapeutic image
data, specifically, inside PACS domain. The committee, which focused primarily on issues concerning
data exchange, interconnectivity, and communications among the health care systems, started work in
1982.6

WebXA prototype application

WebXA is the PACS prototype application which has the same structural design of client-server except
that the software for the client and server is Web-based application. Extra advantages of Web-based
design server over the client-server are as follows: first, the customer WS equipment might be hardware
independent as long as the Web software is underpinned. Second, the Web-based software is totally
movable, ie, the Web-based application might be utilized on any location as long as an Internet
connection is provided. The disadvantage of Web-based application is that its functionality and
performance are limited compared to the client server. One of the most important purposes of using
Web-based viewers and applications in health care systems is the real-time telecommunication or
teleconsultation. However, what is the teleconsultation process? and is there any application(s) to
support it? In this paper, we explained this process and tested a Web-based prototype application to
support the teleconsultation tool.

The teleconsultation is addressing different scenarios in the health care institutes. Let us consider the
following scenario: when a doctor in the physician department wants to consult with a radiologist in the
reading room about a written report of a patient in the checking room. This consultation process should
occur without leaving, both specialists, their wards and walk all the way to each other’s departments.
Therefore, the teleconsultation is a circumstance in which two or more specialists located in various
departments need to discuss and consult about a patient’s results without leaving their departments.
Earlier, there were few results of teleconsultation tools, such as Televideo, NetMeeting which is a
sharing software from Microsoft, Proshare from Intel, and PCAnywhere from Symantec. However, most
of these applications lack for convincing applicability of image processing functions which are becoming
necessary in the health care environments.

In this paper, a Web-based viewer application, called WebXA, has been created and tested on the PACS.
This application is established for viewing and primary diagnostic purposes only where the medical
imaging software is integrated with the communication facilities to develop a remote viewing and
consultation tool using the TCP/IP protocol.

Results

WebXA is to retrieve, store and display the angiography images on a web browser anywhere as long as
an Internet connection is provided. A real-time text exchanging property is added to WebXA application
to make it easy for specialists to exchange comments and consult about patients’ reports and results, as
shown in Figure 4. WebXA viewer provides:

 Easy and friendly GUI contains buttons to stop the moving frames of angiography and to move
forward or backward.
 Text exchange view that can be used by the specialists to exchange comments about the
medical images or the primary diagnostic of patients’ data.
 Client/PACS server communications via TCP/IP.
 Software functions such as save, open and print.

Few open-source PACS servers and DICOM viewers, such as K-PACS v1.6.0, ConQuest v1.4.17, ONIS
v2.5.1.6 and ClearCanvas v7.1, have been used in this study to test the workflow of PACS components. .
A prototype application for DICOM viewing and teleconsultation purposes application has been
developed in this study, where this application (WebXA) can store, display, download, send and print the
angiography images via Internet explorers. Since exchanging information of patients among specialists
who are located in different geographically area is a vital process, a comment box has been added to
WebXA viewer to give the ability to medical doctors and radiologists to discuss medical reports and
results of patients.

The proposed WebXA application mimics the functionality of PACS discussed above where it stores,
retrieves and illustrates coronary angiography images for radiologists and surgeons directly on their
mobile phones anytime and anywhere in order to save time and efforts of diagnosing. This is a very
important step for the medical doctors. The application is tested with its initial/preliminary results by a
heart surgeon, and he was greatly satisfied for being able to use his personal mobile phone to check his
patients’ data anywhere and anytime in the hospital or even outside.