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Medical Imaging Workstations –
What’s Missing and What’s Coming
(How to avoid $1+M mistakes)
Michael W. Vannier, M.D.
University of Chicago Medical Center
Outline
Introduction:
Medical Imaging
Surgical (image guided therapy) Workstations
1.
2.
3.
4.
Motivation, interfaces, workflow and standards
Workflow and Automation
DICOM and IHE
Where to get more information
Learning Objectives
1. To understand types of medical imaging
workstations, their motivation, interfaces, workflow
and standards
2. Identify sources of information and software that
help introduce technology and aid decision making
3. To appreciate what other medical specialties have
done to implement and standardize interoperability
and workflow across vendors: DICOM and IHE
Medical Imaging Workstations
Thick Client – expensive, with substantial
local processing capability
Thin Client – small, portable &
accessible throughout enterprise
Analogy – Medical
Workstation and Gaming
Platform
≈
Analogy – Portal and Website
≈
Imaging Portal
Surgical Workstations
BrainLab™
StealthStation™
“Neuronavigation”
(Proprietary Systems)
DICOM in Radiotherapy
(1998)
www.sgsmp.ch/bull983b.htm
Schweizerische Gesellschaft für Strahlenbiologie und Medizinische Physik
Société Suisse de Radiobiologie et de Physique Médicale
Società Svizzera di Radiobiologia e di Fisica Medica
Swiss Society of Radiobiology and Medical Physics
Imaging for the Simulation
and Treatment Process
D.Jaffray, Princess Margaret Hosp.
U Toronto
Patient and
Disease
Model
Auto-segmentation Tools for Data Handling
*Model-based image segmentation is a work in progress.
Courtesy
of Todd
McNutt,Hosp.
PhilipsUMedical
D.Jaffray,
Princess
Margaret
Toronto
Generalized Patient:
Diseased and
Normal Tissues
Model
Simulation and
Treatment
Process
CT
CT/PET
MR
Specific Patient
;
D.Jaffray, Princess Margaret Hosp. U Toronto
Need for information systems in the OR
AR in
microscope
Navigation data
Display of Models
System monitoring
US-Display
Tracked USprobe
Modern, complex surgical interventions are strongly
dependant on the availability of information.
Computer Assisted Digital OR Suite for Endoscopic MISS
Problems: Image guided vs. n-D model guided therapy
Video Endoscopy
Monitor
Image Manager Report
C-Arm Images
MD’s
Staff
RN, Tech
EEG Monitoring
MRI Image PACS
C-Arm
Fluoroscopy
Left side of OR
Laser
generator
Image view
boxes
EMG
Monitoring
Digital endoscopic OR suite facilitates MISS
Teleconferencing
- telesurgery
Courtesy of Dr. John Chiu
DICOM = Digital
Communications in Medicine
• What is it?
– Voluntary standards adopted by industry in
cooperation with users and academia
• How does it work?
– Extensively used for PACS to facilitate
interoperability of modalities (CT, MR, US, …) with
archives and workstations
• Is this only for diagnostic radiology?
– NO! There are DICOM standards for radiation
therapy, cardiology, dentistry, and other
disciplines…
URL: medical.nema.org
Definitions
• WORKFLOW = Sequence of steps
needed to accomplish a complete task /
procedure
– For example, a surgical workflow may
delineate all of the steps needed to
accomplish an appendectomy
• WORKGROUP = A collection of experts
from industry, academia and users who
collaborate with the DICOM organization
to develop specific standards in a focused
area
Hospital Workflows
© Oliver Burgert
Patient Workflow
Patient e-Health-Record Workflow
Physical Patient Workflow
Diagnostic Workflow
Radiology Workflow
Administrative Workflow
OR-Workflow
Image Processing
Workflow
Surgical Workflow
Information
Flow
Surgical
Processes
Material Workflow
Anaesthesia
Workflow
Sample Case – Surgical Planning
Humeral Non Union
„Best Practice“ Workflow Repository
Reference expert knowledge
Peer Expert I
Peer Expert II
Repository of workflow
Generic models and
patient-spec. models
reference models (WFs, SIPs)
for medical techniques, WF graph
operating instructions,
Peer Expert III
etc.
Peer Expert IV
etc.
Example of
WorkFlow
in repository
Integration of Surgical
Workstations
• To some extent, surgical workstations
have already been integrated:
– HIFU = High intensity focused ultrasound
– DaVinci Surgical Robot
– And many others….
Da Vinci Robot
& Workstation
MISS = Minimally Invasive Spine
Surgery
Chair for Computer Aided Medical Procedures
& Augmented Reality
IHE and Radiology
(IHE = Integrated Healthcare
Enterprise)
CT Scan – No. exams per year
CT Image Volume Per Year
8000000
7000000
Images
6000000
5000000
4000000
Images
3000000
2000000
1000000
0
1994
1996
1998
2000
2001
2002
Year
AJR Nov. 2006; 187:1160-1165
The Perfect Storm?
• Increasing demand (no. of exams)
• Increasing complexity of exams (no. of
images and post-processing)
• Same number of personnel & work hours
• In many institutions, there was –
– Same number of CT scanners
– With newer (faster) systems
Objective
• In 2000, a severe shortage of diagnostic
radiologists existed in the United States.
• We seek to explain how the shortage
eased greatly by 2003, despite the fact
that the total imaging workload
usually grows much faster than the
number of radiologists in practice,
which would be expected to intensify the
shortage.
AJR Nov. 2006; 187:1160-1165
Conclusion
• Increased productivity is the
predominant explanation of how the
radiologist shortage eased. The
contribution of other factors was, in
comparison, small or even in the opposite
direction.
AJR Nov. 2006; 187:1160-1165
What happened?
• PACS – electronic image distribution and
soft copy interpretation
• Improved IT infrastructure (paperless)
• DICOM adoption allowed interconnection
of innovative new systems
– Imaging workstations
– Post-processing (advanced visualization)
– Web-based access to images throughout the
enterprise
Sample IHE “Success Story”
Why IHE?
Sources of Images
•
•
•
•
•
Radiology
Pathology
Cardiology
Ophthalmology
Radiation Oncology
• Dilemma: disparate image management
systems (e.g., PACS) for each
department?
Standards
• Like electrical plugs and voltages;
plumbing; tires; CD’s and DVD’s;
telephone; …
• Enable interoperability of items from
different manufacturers
• Benefits are many – to the user and
manufacturer
• Antithesis of standard is proprietary
• Computer equipment was connected via
proprietary interfaces in the past
– IBM standard; DEC standard; AT&T standard
– Now we have industry standards; MIL
standards
Need for
Standards
DICOM
• Version 3 is data format standard
• ACR & NEMA – drafted standards,
reviewed and published them,
developed a certification process,
continued evolution
• Incompletely developed and only
partially implemented
• “Flavors” of DICOM
DICOM
IHE
Room Layout
Plug & Play
Interface
House Wiring Diagram
What is IHE?
Standards-based,
Global Initiative
generating
Real-world Implementations
in patient care
“Defining, testing, and implementing standardsbased interoperability for EHR’s”
Why IHE?
1970’s—Mainframe Era--$100,000 per interface
1990’s—HL7 2.x--$10,000 per interface
2000’s—IHE Implementation Profiles—
Cheaper than a new phone line!
How? IHE Eliminates Options found in
Published Standards
IHE brings reality to workflow
Who is IHE?
IHE is a joint initiative among:






American College of Cardiology (ACC)
Radiological Society of North America (RSNA)
Healthcare Information Management Systems Society (HIMSS)
College of American Pathologists - SNOMED Terminology Solutions
American Society of Ophthalmology
American College of Physicians (ACP)
 American College of Clinical Engineering (ACCE)
 And many more….
Began in 1997 in Radiology (RSNA) and IT (HIMSS)
International effort: IHE- Europe and IHE-Asia
Additional sponsors for Cardiology including ASE, ESC, ASNC,
SCA&I, HRS and more
IHE – Nine Active Domains
Over 100 vendors involved world-wide, 5 Technical Frameworks
37 Integration Profiles, Testing at Connectathons
Demonstrations at major conferences world-wide
15 Active national chapters on 4 continents
Electronic Health Record
Radiology
Cardiology
14 Integration Profiles
4 Integration Profiles
IHE
IT Infrastructure
Laboratory
5 Integration Profiles
Patient Care
Coordination
1 Integration Profile
13 Integration Profiles
Future
Domains
Patient Care
Devices
Pathology
Eye Care
Oncology
IHE Standards-Based Integration Solutions
Professional Societies Sponsorship
Healthcare Providers & Software Developers
Healthcare IT Standards
General IT Standards
HL7, DICOM, etc.
Internet, ISO, etc.
IHE
Process
Interoperable Healthcare IT
Solution Specifications
Interoperable Healthcare IT
IHE Integration
Profile Specifications
Solution
Interoperable Healthcare IT
IHE Integration
Profi
le Specifications
Solution
Interoperable Healthcare IT
IHE Integration
Profile Specifications
Solution
IHE Integration Profile
IHE Integration Profiles
Scheduled Workflow
P
a
t
i
e
n
t
I
n
f
o
r
m
a
t
i
o
n
Charge
Posting
-
R
e
c
o
n
c
i
l
i
a
t
i
o
n
Presentation
of Grouped
Procedures
Consistent
Presentation
of Images
PostProcessing
Workflow
Evidence
Documents
Reporting
Workflow
Key Image
Notes
Access to Radiology Information
Basic Security
Simple
Image and
Numeric
Reports
IHE Technical Frameworks
Department System
Scheduler/
Order Filler
Order
Placer
ADT
Image
Manager/
PPS Manager
Acquisition
Modality
Register J.Doe
Patient
Registration [RAD-1]
Placer Order
Management–
New [RAD-2]
One or the
other methods
of creating an
order is used
Filler Order
Management New [RAD-3]
Schedule
Procedure
Procedure
Scheduled [RAD-4]
Query Modality Worklist [RAD-5]
Filler Order
Mgmt - Status
Update [RAD-3]
Patient Reconciliation
J.Doe ->
J.Smith
ADT
Pt. Registration [RAD-1] 
Patient Update [RAD-12] 
DSS/ Order Filler
Patient Update/
Merge [RAD-12]
 Pt. Registration [RAD-1]
 Patient Update [RAD-12]
 Placer Order Management [RAD-2]
 Filler Order Management [RAD-3]
 Modality PS in Progress [CARD-1]
 Modality PS Completed [RAD-7]
Filler Order
Mgmt - Status
Update [RAD-3]
Modality Procedure
Step In Progress
[CARD-1]
Modality Procedure
Step Completed
[RAD-7]
Modality Procedure
Step In Progress
[CARD-1]
Modality Procedure
Step Completed
[RAD-7]
Patient Update/
Merge [RAD-12]
Order Placer
 Procedure Scheduled [RAD-4]
 Patient Update [RAD-12]
 Procedure Updated [RAD-13]
 Instance Availability Notification [RAD-49]
Evidence
Creator
 Modality PS in Progress [CARD-1]
 Modality PS Completed [RAD-7]
Detailed standards implementation
guides
Performed
Procedure
Step Manager
Storage 
Commitment
[CARD-3]
Image Display
 Modality Image/Evidence
Stored [CARD-2]
Image
Manager
Image
Archive
 Modality PS in Progress [CARD-1]
 Modality PS Completed [RAD-7]
Storage
Commitment 
[CARD-3]
Modality Image/Evidence
Stored [CARD-2]
 Modality PS in Progress [CARD-1]
 Modality PS Completed [RAD-7]
 Query Modality Worklist [RAD-5]
Acquisition
Modality
 Query Images [RAD-14]
 Retrieve Images/Evidence [CARD-4]
Perform
Acquisition
(82 pages)
(41 pages)
IHE Connectathon
•300+ participants, 120+ systems
•60+ systems developers
•Four Domains: Cardiology, IT Infrastructure,
Patient Care Coordination, Radiology
•2800+ monitored test cases
5 Things you can do to create
problems for yourself and
others
1. Buy proprietary systems and lock yourself
into one vendor’s products
2. Buy the best-in-class system based on last
year’s rating (e.g., ignore the users)
3. Buy the first of anything
4. Believe vendor’s promises, even when
they’re written down
5. Expect the vendor to be interested in your
problem after the last payment is made
A sobering thought…
Remember what happens to ALL
of the computer systems that you
use…
Yesterday’s Workstations
And where do you think that
Google and Wikipedia
and enterprise computing
is done?
Server
Farms
Strategy for web hosting
• Reduce costs by consolidating services
onto the fewest number of physical
machines
http://www.vmware.com/img/serverconsolidation.jpg
Some places to look for
more information…
www.klasresearch.com
http://www.pacsnet.org.uk/
Open Source Software
For Medical Imaging
http://www.osirix-viewer.com/
ImageJ
rsb.info.nih.gov/ij/
Wayne Rasband
NIH
itk
Insight Journal - http://insight-journal.org/
BioimageXD
NIH Initiatives:
Grid(s)
caBIG – Cancer Biomedical Informatics Grid
http://cabig.cancer.gov/
caBIG Pathology
Workspace
http://apiii.upmc.edu/
SIIM
Society for Imaging Informatics in
Medicine
http://www.siimweb.org/
Conclusion
• Medical imaging workstations and integration
of information technologies are in a rapid
state of evolution.
• It is challenging to follow and understand
these trends, but decisions must be made
soon.
• Those who successfully integrate and use
these tools will prosper, and those who do
not face marginalization and peril.
TRANSFORMING PATHOLOGY:
Emerging technology driving practice innovation