See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/14242068

Radiology Information and Image Management System: New Approach to PACS

with Hypermedia Capabilities of Personal Computers

Article  in  Radiographics · April 1996

DOI: 10.1148/radiographics.16.2.8966298 · Source: PubMed

CITATIONS READS

8 85

7 authors, including:

Marco Marsella Valeria Panebianco

Food and Agriculture Organization of the United Nations Sapienza University of Rome
10 PUBLICATIONS   8 CITATIONS    248 PUBLICATIONS   2,917 CITATIONS   

SEE PROFILE SEE PROFILE

Andrea Laghi Vincenzo Campanella

Sapienza University of Rome 30 PUBLICATIONS   119 CITATIONS   
562 PUBLICATIONS   8,303 CITATIONS   
SEE PROFILE
SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Apple LAN at INFN View project

Multi detector CT scanning View project

All content following this page was uploaded by Andrea Laghi on 20 May 2014.

The user has requested enhancement of the downloaded file.

Radiology Information
and Image Management
System: New Approach to
PACS with Hypermedia
Capabilities of Personal
1
Paolo Pavone, MD #{149} Marco Marsella, MS EE #{149} Valeria Pane-
bianco, MD #{149} Carlo Catalano, MD #{149} Andrea Laghi, MD #{149} Vito
Campanella, RT #{149} Roberto Passariello, MD

A system for archiving patient data and images was developed, installed, and
evaluated in a radiology department. The system was developed with a rela-
tional database program for use with commercially available computers linked
with an Ethernet network. The main options of the system arc those of a con-
ventional radiology information system: scheduling, registration, examination
execution, reporting, archives and statistics, and system administration. How-
ever, the main feature of the system is the image archiving capability. Images
are associated with patient records after capture by direct acquisition of the
video signal or by scanning. Only relevant pathologic images are archived and
a commonly employed compression algorithm is used, reducing the total
mcniorv requirenlent for each case to 200-600 kbytes. The diagnosis is still
made by reading the original images. The low-resolution images stored in the
system have an important role in teaching and consultation and as a first-line
archive. Good resthlts have been obtained with this system, which is used by
medical and nonmedical staff without any special training.

. INTRODUCTION
Iim radiology departnments, nmany alpimanunmeric data and inmages are prodticed daily and
imeed to) be managed witlm information systenms. Traditionally, time nmain purpose of a ra-
diologv infornmatioim system (RIS) is managenment of alpimanunmeric data. whereas a pie-
ture archiving and coninmtinication systenm (PACS) deals mostly witlm images ( I ,2).
Timese two systenms have been conimected by using software, altimougim time results are
still not completely satisfactory (3-7).
A PACS is designed to store and process images and represents a high-teclm approach
to nmaimaging radiologic information. PACS imave been installed in few clinical research

Abbreviations: ll(; = (liSt ‘hotograpluc Experts (roup. l’AO :5 = ictrir’ archiving iitd cI)ntntuntcatu)n svstent. RlS =

radiology intorniation ‘.teni

index terms: 0(ttStl)tit(-r, Picture

#{149} archiving ittd conttuLlnicatlotl stcni 0 PAOS) Radu)k)g
#{149} and radiologo.o.. depart
nu.#{149}ntal ntanagenicnt Radnlog
#{149} reporting .stentr

RadioGraphics 1996: l( i2l-i2

I irOns tltt.’ l)&-parttn&-tit of Rarlulogv II. I nivcrsit of Ronse l.i Sapien/a. l)ltclIi1i(() I ntl)t.-rto I. V Ic Rt.-gtn.t FE-itt
0(0 I 6 I Rome. tab Prc.-s-nted o. an iii/oR.l) exhibit at the I 99 i RSN scientific ;is,enthlv RecLis ed \1.iich I . I 90S. rc
.Ion r(-ciu1-t&-(i .Jont- 28 atl rect-ived November 1 : accepted November 1 1). Address reprint requests to P P

. i0S\.. lt)90

421
 Figure 1. l)iagram shows how the
netwo)rk serves all areas o)f time de-
partment.

centers, and so-called mini-PACS are aimed at sonal computers in a multimedia environnment.
solving the connection and storage problems of We believed that diagnostic images cotild also
only a few diagnostic sections and not the be evaluated with these inexpensive comput-
whole department. Acceptance of PACS by the ers. Therefore, we developed an RIS database
radiologic community and diffusion of the PACS in which a few selected images could be dis-
technique to a large number of hospitals have played along with the report in a multinmedia
been redticed for various reasons, including the environment.
inadequacy of the hardware available up till In this system, a new approach is used in
now (8-10). management of images with the RIS. Time RIS is
An RIS represents a more convenient ap- not a pointer toward the images contained in
proach to daily routine management of radiol- the PACS; instead, the RIS itself is a multimedia
ogy departments. Although an RIS is satisfactory database in which images are archived together
as far as alphanumeric data are concerned, it with the reports. The system does not lmave the
does not represent the ideal solution, since im- characteristics of a PACS, since all of time images
age archiving is not performed (10-14). generated in the department are not archived.
An interface between a PACS and an RIS has On the contrary, only a few selected images are
been achieved in PACS installations by pointing archived in a compressed form in connection
tO RIS data from the PACS interface. To our with the report. This choice was made to re-
knowledge, there is no system in which the RIS duce the memory requirements of the database.
manages the images in addition to the alphanu- Future conversion to a full PACS approach is
meric information. planned (15).
New advances in computer technology al- This article describes the structure and soft-
low management of highly detailed digital im- ware of the system, together witim time restilts of
ages on commercially available, low-cost per- almost 2 years of clinical use.

. SYSTEM STRUCTURE
The system has been implemented on a net-
work of computers in our department and has
been routinely used since jantiai-y 1994.

422 #{149}
infoRAD Volume 16 Number 2
 Us MR CT DIG. ANGLO

Figure 3. Diagram slmows peripheral radiologic 5cr-

vices co)nnectcd to) the system. CT = computed to-
mography, DEPT = departnment.
DEFT. PERIPIIFJIAI.
WORKSTATIONS
PRINTERS

Figure 2. I)iagram shows connections to the net- access to the images and better performance of
work. CT = conmputed tomography, I)EPT = depart- the compression algorithm. All of the comptit-
ment. 1)1G. AAT(;I() = digital -angiograpimy, MR = mag- ers can also be used for other purposes, such as
netic reso)lmalmce, (IS = ultrasound. word processing, data analysis, and filing; it is
easy to switch from one activity to another.
Images are associated with patient records
. Hardware after capture by direct acquisition of the video
The systenm runs on a network of Macintosh signal (ultrasound [US] and magnetic resonance
computers (Apple Conmputer, Cupertino, Calif). [MR] imaging) or by scanning (conventional ra-
The network is an Ethernet 1OBASE 2 with a diography, angiography, and computed tomog-
star topology serving all areas of the depart- raphy ICTD. To digitize images, two linear,
ment (nmaximum-speed transmission, 10 Mhit/ charge-coupled device scanners (RSU I ; Rayven
see; real-speed transmission, 2-3 Mbit/sec) (Fig X-ray Scanner, Torrance, Calif) with a resolti-
1). Time server is a Macintosh Quadra 900 (64- tion of 1 ,024 x 1 ,024 x I 1 bits are connected
Mbyte random-access memory [RAM], 50()- to the network. Five laser printers and two dot
Mbyte hard disk). Up till now, the hard disk has matrix printers are also connected (Fig 2).
been sufficient; in fact, by tising time compres-
sion algoritimm, the results of 32,000 exanmina- . System Distribution
tions occupied
have 90 Mbytes of storage. The system is connected to the radiologic pe-
Time network is conmposed of 25 computers, ripheral sections located in the surgical depart-
all of whiclm run the management software. Ten ments. The connection to the distant units is
of these conmputers are also used for administra- through the optic fiber network of the hospital.
tive and secretarial purposes (Macintosh II vx We also plan to connect six other peripheral ra-
[8-Mbyte randonm-access memory, 1 60-Mbyte diologic services of our multiclinic hospital (Fig
hard diskj), and 15 are used for frequent access 3).
to the images (Macintosh Qtiadra 650 or 700
I 1 2-Mbyte random-access memory, 220-Mbyte
hard diskj). The iatter computers allow fitster

March 1996 Pavone et al #{149}

RadioGraphics #{149}
423
 Bookinge j 11 TC
Universit#{225} degji Studi di Roma .
I2 Sa}3IeflZa S-
, - , -
Policlinico Umbto I #{149}wI!j:ii. Uoic
dio1ogiaC1e(t.L1997O276)
c::: u !c

p I
_t#{149} I - ,-.

Eas. LaicuDsu I 3S32

-, I :r=
Iitrets I i_

States I WuSINN

thIpssPItsts I
0 PvIM Sss ‘#{149} -‘=, . =k- ...

ft. t.qis.at I - I sss’*a’j

ti.c j .s*lN.m.J
mit I RenivnSlti Os..
- RADIO Assistant 2.2 ernsriss.a11j1J Itas.

4. 5.

Reporting . .. -. oe- Archives&Statistic8 I

pStSt LR
NSIPIKRIttM bIUSIPPI I -.- . A I eq5
P#{149}UOflP

#{149}rta.L!_ 0 1 I 9J .
h#{149}$$. Ss

#{149}sss(i t URRi IA j .. Or LP Ponp5fln IssrI Ii’ -p-n

#{149}s(i ( I ( II I - I

,
Psilsal I
htss..ss.m

j
psd : 1acItSdS .J #{149}i_OO DO 00
. .. I J”’ #{149}aasc*1 -I
Os..d
. . :.- -- -., - :. ‘-‘#{149}#{149}‘: . #{149}f. . 1 ._J #{149}Srt 15ooii::oo I isa
-3 #{149}U #{163}.sIII Lass. tSISj ]
: r :.- : OPSSr K$C. lio.,t I
.--
.--... ,
.:., .
.. -
., ..
,.
-, :. :-- .. , .
:., .. -
: . .
. .
- Osssm I
,: .. ,- -...- . . . - . - -$ ‘ .. - -: ..--
TitsI kIs SRI
- Al
. . . - - I I-n-1,4mQ.
S..&is.s/RSIISIt*th t.aI sI
.
PN bau
c SI$SI UsaSRI
. . cJ i I _________________
IM#{149}_ISStS l I

I1 iJ= - -
6. 7.
Figures 4-7. (4) (onmputer screetm shows time main optio)ns o)f time systenm. (5) Colmmputer screeim simo)ws a list
of schmeduled patielmos and the exanminatio)ns to he perfornmed. Time l)LtieImts departnmelmt and time examination
co)de arc also shown. (6) (omputer screen simows a compiled medical report witim am Anmerican College of Radi-
ology (.4(R) co)de selectio)Im. (7) (onmputer screeim shmows several optioims for trchmives almd statistics. Time wilmdow
shmows am example of a researclm case selected by nmeans of the American College o)f Radiology (4CR) code.

. SYSTEM SOFTWARE stipported (Fig 4); owing to tiser-friendly htlt-

The nmultimedia software was prepared witim tons, use 0)f the svstenm is straigimtforward, traiim-
time 4th l)inmension development environment ing needs are minimal. operation is fast, and the
(A(;I I IS, Ctipertino, (ahif). The software has user experience is lmighly successful. A power-
i)eeIm imanmed RAI)I() Assistant. Aithotigim RAI)I() ful, easy to use, flexible scimeduhing 5ul)systeflm
Assistant is currently operating on Macintosim assists users in efficieimt allocation of room time.
conmputers, the generic personal co)mputer ver- The registration progranm works for scheduled
sion of 4dm l)inmension has been released and as well as enmergencv patients (Fig 5). Report
tested by the atitlmors. writing is fitcilitated by user-custonmized glossa-
ries (Fig 6). Archived reports can he retrieved
. The System as an MS with a wide array of searcim criteria; each conm-
Radio Assistant is first of all a powerful RIS. The i)lete immeo..lical record is available for reading at
activities of the department in all its aspects are any time. Inventory nmanagement is offered for
all kinds of materials and prodticts used in time
radiology departmeimt. RAI)IO Assistaimt stores a

424 #{149}
info RAD Volume 16 Number 2
 ..- NN#N2i I log-in name, a password, a set of privileges, and
Isa.sLsLtszzS SRI4TINS PSflsISItILISRUU.IU

Us..lSjOLsaIs
US1RI5IS5-SS-IR4S 1
1 iI-”’ J a start-tip
expire after
environment.
a given amount
Passwords can
of tinme or a tiser
he set to)

I*ou,t. n sIt.
log-in can be disabled after a given number of
- log-in attempts; log-ins can he assigned a time
frame of validity so that each user can access
the system only during the authorized hours.
Specific hardware devices such as card readers
can he used to offer even more sectiritv.

. Image Management
I/l The basic assumption made in RAI)I() Assistant
-
_______ ImpIIIF
ss__
1;:pJ concerning image management is that low-reso-
htition images for reference, consultation, and
Figure 8. Computer screen slmo)ws the inmage-inm- training in an inexpensive, fast, efficient RIS can
porting capability of the system. he a good method of image distribution to small
consultation workstations in time department.
The diagnosis is made by reading time o)riginal
complete set of information that is exploited inmages on the view box or by reading images
for management support by means of an exten- on the main workstations if -a PACS is available.
sive set of statistical and reporting functions Acquisition of images from sections connected
(Fig 7). on-line is possible (Fig 8).
All of these functions are tightly integrated While developing the project, we abandoned
to produce an efficient tool fur complete de- the idea of archiving all images at full quality.
partmental organization. Multiuser operation al- Archiving only selected images at low resolu-
lows natural task distribution among time work- tion greatly redtices the memory requirement
stations for optimal efficiency and cost. Scalahil- and allows image archiving witim personal
it)’ allows tailoring of a RADIo Assistant instal- computer-based networks. To) reduce the
lation from a simple system with a few stations amount of data to he stored, we decided to se-
and no image management to a full-scale iiospi- lect a limited nunmher of images and to conm-
tal department with several sections and mul- press them with commercially available soft-
tiple users. ware. The images are i)resented in the sanme
The huimman interface is one of time main ad- screen as time alpimanumeric data to reduce the
vantages of the system. RADIo Assistant offers cO5t o)f imardware acquisitio)n.
full graphic interaction, hut instead of cram- ‘rime alphanumeric data and time images are
flung the screen with lots of tiny, colorful, and managed witlm the same multimedia software
confusing icons, it focuses on the task at hand. (4th I)imension), and storage is done on the
In place of icons, large buttons witim clear labels same svstenm (curreimtly a 400-Mbyte hard drive
are used. Similarly, at any given moment, a of the server hacked tip O)fl a digital atidiotape
single window is opened with time possibility of [DAT)). (;ontrar’ to PACS, in whicim arcimive
only one activity. Commands and codes never consultation requires expensive workstations
lmave to he renmenmhered by time user because cv- and some waiting tinme, selected images be-
en’ option is clearly shown on the screen. Fur- come available at lh’sicians’ desktops almost
timerniore, although novice users are assisted instantaneously on lo)w-cost, connected per-
during operation, experienced tsers are offered sonal conmptiter workstations.
a wide range o)f shortcuts to) streanmline time in-
teraction witim RAI)I() Assistant.

S Security
Security is controlled by a sophisticated pass-
word-based mecimanism. Eacim user is given a

March 1996 Pavone et al U RadioGraphics #{149}

425
 - -
umun#{248}Iw#{149}i...J
(od. Rn. ___ ;.ii.i--. .:nf.*:tt:i.!I
Oat.
f
Sezlonsl

Repsatof oni

$r---- -it sasats Usfsats

a. b.
Figure 9. Arcimived inmages. (a) (omputer screen shows only three inmages, althouglm it is possible to) store up
to) six images. (b) Computer screen shows a magnified image.

Image Selection-Images are included in our with a raw size of 256 khytes is reduced to 90
RIS for teaching and consultation purposes kbytes after lossless compression and to 13
oniy. Therefore, we decided to perform a pre- kbytes afterJPEG compression. Aithotigim
liminary selection of the relevant images to be lossless compression does not degrade image
archived. Normal images (eg, a normal chest ra- quality, lossy compression (eg, JPEG conmpres-
diograph) are generally not stored. In examina- sion) can reduce image quality . However, our
tions with a large ntimber of images (ie, CT and experience suggests that a compression factor
MR imaging examinations), only images on of 20: 1 produces images nearly indistinguish-
which disease is evident are archived (Fig 9). able from the originals when displayed on corn-
Such clinical selection allows us to dramatically puter screens.
reduce the amount of data to he archived. We With clinical andjPEG compressioim, time to-
refer to this selection process as “ clinical com- tal amount of storage needed becomes much
pression.” more manageable. The images are not intended
to be used for diagnostic purposes, but they are
Digital Compression-Images in RADIO As- perfectly adequate for reference, consultation,
sistant are of impressive quality, although the teaching, and preparation of conference mate-
niernory required is irrelevant owing to the rial.
Joint Photographic Experts Group UPEG) corn-
pression, which is used to reduce memory re- . Image Evaluation in Clinical Prac-
quirements and improve overall system perfor- tice
mance. JPEG compression parameters can be No major drawbacks were seeim dtiring opera-
configured for each section to obtain optimal lion for clinical purposes. In fact, the images
image quality relative to memory requirements. have a consistent resolution for the goal that
No special hardware is required to perform im- we intended to achieve (a first-line arcimive for
age compression and decompression even on consultation and teaching) . Moreover, having
low-cost computers. The display time is ap- the screen occupied by an image reduces the
proximately 2-5 seconds for an x-ray image potential problems related with opening of nmui-
(less for IJS and MR images). tiple windows. Each task must he finisimed he-
Memory requirements are greatly reduced fore the next is started.
with JPEG compression: An x-ray image with a As far as the clinical acceptance of the sys-
raw size of 1 2 Mbytes is reduced to 4 Mbytes af- tern in our department, RAI)I() Assistant was
ter lossless conmpression. Moreover, a US image considered to improve the ro)utilme clinical work
by acting as a first-line archive and allowing
easy consultation with clinicians, who appreci-
ate the selection of pathologic images and no)t

426 #{149}
infoRAD Volume 16 Number 2
 having to scroll through a large number of 3. Bakke SJ, Smith HJ, Smevik B. Modular imple-
them. However, teaching appears to be the mentation of PACS: preliminary results of the
most interesting application of the system. Se- RiskPACS project-consequences for x-ray de-
partment and clinicians. EurJ Radiol 1992; 16:
lection of cases that contain images of a certain
64-65.
organ or pathologic condition can be quickly
4. Bakker AR. HIS and RIS and PACS. Comput
performed. The system allows scrolling through
Med Imaging Graph 1991; 15:157-170.
all of the cases and exporting relevant images 5. Cannavo MJ. Fitting the PACS technology into
to other files. The images can then be exported the hospital of tomorrow. Diagn Imaging 1988;
to other software programs for slide prepara- 10:188-190.
tion. 6. Mosser H, Urban M, I)urr M, et al. Integration
We have also prepared a specific teaching of radiology and hospital information systems
file with the same configuration as the main (RIS, HIS) with PACS: requirements of the radi-
RIS. This teaching file allows one to archive ologist. EurJ Radiol 1992; 16:69-73.

clinical data, the diagnosis, and other informa- 7. tJkovich W, Bravar D, Cuttin-Zernich R, Ct al.
An experimental evaluation of the impact of a
tion along with relevant images imported from
PAC system on the operations of a radiology
the RIS.
department. In: Lemke HU, Rhodes ML, Jaffe
CC, Felix R, eds. Computer assisted radiology.
U CONCLUSIONS Berlin, Germany: Springer-Verlag, 1989; 537-
Our experience with this software has shown 540.
its validity in time management of our radiol- 8. I)alla Paima L, Ukovich W, Stacul F, et al.
og)’ department. The
use of image archiving Sistema PACS a progetto modulare. I. Esperi-
has proved to be very valuable, and all of the enza operativa prehiminare. Radiol Med 1990;
radiologists have routine access to images for 80:9-17.

consultation and teaching purposes. Having 9. Daila Palma L, Ukoviclm W, Stacul F, et al.
reached this goal, we are flOW ifl the process of Sistema PACS a progetto modulare. II. Esperi-
enza chinica prehiminare. Radiol Mcd 1990; 80:
expanding toward a PACS approach, in which
18-23.
our system will still represent the informatic
10. Romeo MA, Skrtich P. AlexanderJ. An imag-
backbone.
ing department for the 90’s: 3 year experience.
Our next goal is to develop a true PACS ap-
EurJ Radiol 1992; 15:286-288.
proach with complete digital acquisition, 11. LissnerJ, Fink U. Digital imaging and picture
archiving, and display of all images generated in archiving and communication systems. Curr
the department; the images will be stored on an Opin Radiol 1991; 3:267-274.
optic disk and archived with a memory juke- 12. Gartner C, WeberJ, Nissen-Meyer S. et ai.
box. A few PACS workstations will be present Modern RIS designed from a radiologist’s view.
in our department in the future, but the work- Berlin, (;crnman)’: Springer-Verlag, 1991 : 496-
station of the system we have developed will 498.
13. Gur D, Straub WH, Lieherman RH, et al. Cli-
still be the informatic core of the department.
nicians’ access to diagnostic imaging informa-
In fact, access to images archived in the PACS
tion at an academic center: perceived impact
will still be possible with RADIO Assistant,
on patient management. AJR 1992: 158:893-
althotigh only for selected images in a corn- 896.
pressed form. Such access will allow the spread 14. Pinzani A, Faggian U, (ongolo A, Raccanehlo N,
of small, low-cost workstations in the depart- Ravasini R. Informatizzazione integrale in un
ment and in other departments connected to 5CfViZiO) di radiologia: espericnza di 5 anni in
ours. un sistema centralizzato. Radioi Med 1993; 86:
763-770.
. REFERENCES 15. Horii S, Mun 5K. Radiology operations with a
1 . Lcmke HIJ, Osteatix M. PACS and digital im- large scale diagnostic network. Presented at
aging: new directions (editorial). Eur J
Radiol the seventh EuroPACS conference, Brussels,
1993; 17:1-2. Belgium, 1989.
2. Racoveanu NT. Benefits of coordinated ac-
tiO)fl in PACS evaluation. Int J
Biomed Comput
1992; 30:295-300.

March 1996 Pavone et al #{149}

RadloGrapbics #{149}
427

View publication stats