Henry Ford. Michael Flynn Department of Radiology. Health System

Transcription

1 Henry Ford Health System RADIOLOGY RESEARCH PACS, HIS, and RIS What Does a Physicist Need to Know? Michael Flynn Department of Radiology mikef@rad.hfh.edu

2 Outline Or rather, What might a Physicist want to know. Radiological Terminology Workflow Improvement Network Architecture Storage Technology AAPM

3 Part 1. Radiological Terminology Radiology has evolved a highly standardized lexicon of terms to describe the body parts and procedures used in medical imaging examinations. AAPM

4 DICOM Part 16 PS Digital Imaging and Communications in Medicine (DICOM) Part 16: Content Mapping Resource Published by National Electrical Manufacturers Association 1300 N. 17th Street Rosslyn, Virginia USA Copyright Pages AAPM

5 3.16 Context ID tables Context ID 6103 Abnormal Context Lines ID Finding 6011 or Feature Calcification Context ID 18 Type: Context Extensible Types ID 7Version: from BI-RADS Note: Original Isotopes Type: Ultrasound source Context in Extensible Radiopharmaceuticals of ID terms 4012 Version: Context ID 4010 Beam is Path [Fraser and Pare]. Note: From Projection BI-RADS Type: Extensible Context Eponymous Third Version: Edition Type: Extensible DX ID View 4009 Version: Name Coding (0008,0102) Scheme Type: DX Context Extensible Code Anatomy ID (0008,0100) 4 Version: Value Code Type: Extensible Version: Images (0008,0104) Meaning Coding (0008,0102) Scheme Code (0008,0100) Value Code (0008,0104) Meaning Coding (0008,0102) Scheme Type: Anatomic Extensible Code (0008,0100) Version: Region Value Code (0008,0104) Meaning Coding (0008,0102) Scheme Coding Scheme Type: Extensible Code (0008,0100) Code Version: Value Value Code (0008,0104) Meaning (0008,0102) (0008,0100) Code (0008,0104) Meaning Coding (0008,0102) Scheme SNM3 DCM Code (0008,0100) Value C-111A Code (0008,0104) Meaning ^18^Fluorine Air-fluid level (0008,0102) SNM3 DCM (0008,0100) G-A1A (0008,0104) Trans-hepatic Corona radiata Coding Scheme Code Value Code Meaning DCM Reticulonodular pattern SRT F Dystrophic calcification SRT F Eggshell calcification Coding Scheme SNM3 SNM3 Code Value Code Meaning SNM3 SRT R C-114A4 Caldwell ^123^Iodine (0008,0102) SNM3 (0008,0100) (0008,0104) SNM3 SNM3 SNM3 DCM G-A1B2 F R T R-1026A C-114A Trans-gastric Punctate lateral Bronchus Camp-Coventry ^125^Iodine Honeycomb calcification pattern oblique SNM3 SRT SNM3 R lateral-medial SNM3 SNM3 SNM3 SNM3 DCM G-A1A5 F T T R C-114B Trans-pleural Calcified Breast Larynx Grashey ^131^Iodine Kerley B skin lineof breast SNM3 SRT SNM3 R medial oblique SNM3 SNM3 SNM3 SNM3 DCM G-A1B3 F-0176A Trans-mural SNM3 T T-D3300 R C-122A Calcified G-A1A8 Wrist Mediastinum Judd^133^Barium Reticular suture pattern material SRT F-0176B SNM3 R right joint Trans-orbital Vascular calcification lateral SNM3 SNM3 SNM3 SNM3 SNM3 T T R C-131A2 G-A1A6 Ankle Heart Merchant ^67^Gallium SNM3 R right joint Trans-pancreatic oblique SNM3 SNM3 SNM3 T T-D1600 R-102AB Nose NeckTowne SNM3 R left lateral SNM3 SNM3 T T Larynx Sternum SNM3 T Trachea AAPM

6 3.16 Normative References (selected) SNOMED The Systematized Nomenclature of Medicine Clinical Terms, 1999 College of American Pathologists (CAP). BI-RADS BI-RADS Third Edition, Addendum 3.1 (lexicon of Mammography screening terminology and Nomenclature), American College of Radiology. Fraser and Pare Terms Used in Chest Radiology and Terms For CT of the Lungs, from Fraser and Pare s Diagnosis of Diseases of the Chest, Fourth Edition, Volume I ACR Standards Performance of Pediatric and Adult Chest Radiography Perf. of CT for Detection of Pulmonary Embolism in Adults AAPM

7 Consistent Terminology Consistent terminology allows studies to be accessed based on database entries derived from the DICOM object. Newer DICOM objects require the code value in addition to the meaning for terms associated with a context ID. The availability of these code values facilitates database management. However, the persistence of older DICOM objects that do not have standardized terminology prevents consistent access to prior studies. AAPM

8 A database alternative At HFHS, when an imaging study is received by the PACS archive, the accession number is used to match the study with the order. DCM-Image ACC# NAME DOB MRN Body Part.. RIS-Orders ACC# ORBITS A table of Body Part, Modality, and Workgroup (BMW table) versus order code is then used to consistently assign the anatomical region to the imaging study. Order AAPM ORBITS CTORBW MRORBW RIS-BMW BodyPart ORBIT ORBIT ORBIT Mod CR CT MR Workgrp Neuro Neuro Neuro

9 HFHS Body Part Terms All body part terms in the RIS database table are derived from DICOM PS 3.16 terminology Database Terms DICOM PS (Image Suite) DX Anatomy Imaged (Snomed terms, SNM3) Code Val. Code Meaning Code (4) Term (10) HAND Hand T-D8700 Hand FING Fingers T-D8800 Finger ELBO Elbow T-D8300 Elbow HUME Humerus T Humerus SHOU Shoulder T-D2220 Shoulder ARM Arm T-D8200 Arm CLAV Clavicle T Clavicle AAPM

10 Part 2. Workflow Optimization Information technologies offer opportunities to alter the work processes used in Radiology and improve productivity. AAPM

11 Radiology Meta-Processes Players : Care givers Receptionists Technologists Radiologists Transcriptionists Physicists Informaticists Objects: Forms Cassettes Films Computer files Images Reports Values Diagnostic Radiology practice involves a small number of well understood meta-processes ORDER SCHEDULE EXAMINE PATIENT REPORT INTERPRET CREATE IMAGE RECORDS AAPM

12 IHE profiles IHE defines specific profiles for improving workflow by integrating image and information systems in Radiology ORDER SCHEDULE EXAMINE PATIENT REPORT INTERPRET CREATE IMAGE RECORDS IHE Radiology Technical Framework Integration Profiles : (SWF) Scheduled Workflow (CPI) Consistent Presentation of Images (KIN) Key Image Note (PIR) Patient Information Reconciliation (ARI) Access to Radiology Information (SINR) Simple Image and Numeric Rpt. (CHG) Charge Posting (RID) Retrieve Information for Display AAPM

13 IHE The Integrating the Healthcare Enterprise (IHE) initiative defines a consensus effort and framework for integrating information systems in a healthcare environment. Joint effort: Radiological Society of North America (RSNA) Healthcare Information and Management Systems Society (HIMSS) Since 2000, the IHE has demonstrated progress at the RSNA and HIMSS annual meetings. AAPM

14 Modality Communication Processes HFHS DICOM Supported Services Modality Worklist All modalities Patient oriented accession # Image Send RIS Radiology RIS-PACS RPT PAC Not Supported PPS complete PPS commit Key Img Note Query LIST IMG 90 Modalities AAPM

15 DICOM MWL The MWL services on both the modality and the server must be consistently configured Patient oriented query Worklist oriented query MWL Query Keys W (0040,0001) ae Scheduled Station AE Title W (0040,0002) ae Scheduled Procedure Step Start Date W (0040,0003) e Scheduled Procedure Step Start Time P (0040,0010) e Scheduled Station Name P (0008,0050) ae Accession Number (0010,0010) ae Patient s Name, last^first P (0010,0020) ae Patient ID WP (0008,0060) ae Modality (0040,0006) a Scheduled Performing Phys. Name AAPM

16 MPPS and KIN DICOM Modality Performed Procedure Step (MPPS) Modality to RIS transactions Modality Procedure Step in Progress Modality Procedure Step Completed DICOM Key object selection document Modality to PACS transaction IHE Key Image Note (KIN) profile Example: Technologists attaches a note to a chest 2 view study indicating that the patient has an amputated arm and the stub appears in the lateral view. AAPM

17 HIS Communication Processes 550 Clinical HIS Stations REG HFHS IS EMR ADT Report Images RIS-PACS HL7 Registration, ADT Report text RIS Query RPT LIST PAC IMG WEB Images Reports AAPM Modalities 17

18 RAD Communication Processes HFHS IS 51 RAD Reading 550 Clinical HIS Stations REG EMR ADT Report Images RIS-PACS List Radiology Reading Stations Exam List Images VR report RIS Query RPT LIST PAC IMG Images VR Rpt AAPM Modalities 18

19 Order Entry Processes HFHS IS 51 RAD Reading 550 Clinical HIS Stations REG EMR ADT Report Images RIS-PACS Order RIS RPT PAC List Images Complete VR Rpt Query LIST IMG RIS Stations RIS Orders AAPM Modalities 19

20 Order Entry Processes HFHS IS 51 RAD Reading 550 Clinical HIS Stations REG EMR ADT Report Images RIS-PACS Order RIS RPT PAC List Images Complete VR Rpt Query LIST IMG HIS - Orders AAPM Modalities 20

21 Part 3. Network Architecture The design and performance of computer networks has significantly changed over the last 10 years. AAPM

22 Technology Gartner #1 Gartner analysts list of 10 predictions that will impact enterprise businesses. 1. Bandwidth will be more cost effective than computing Network capacity will increase faster than computing, memory and storage capacity to produce a major shift in the relative cost of remote versus local computing. Cheap and plentiful bandwidth will catalyze a move toward more centralized network services, using grid computing models and thin clients. Ten predictions to shake your world By Dan Farber, Tech Update AAPM 2004 October 10,

23 Enterprise Network Architecture WAN ARCHIVE DATABASE Disaster recovery Central Storage Integrated RIS On-demand access ARCHIVE DATABASE HIS CT MR CR HFH LAN AAPM

24 HFHS Wide Area Network (PACS) OC3 150 Mbps IP 100 PACS DS3 45 Mbps Voice,IPX DS3 45 Mbps PACS 2 T1 3 Mbps PACS LIV WBL Corp. IT LKS STH FRL 1FP TAY DNW HFH All large centers are directly connected to the Main Campus HFH PACS facility using synchronous optical network (SONET) service. Alternative communication channels through the corporate IT facility provide are utilized if the direct channel fails. AAPM

25 Stentor isyntax (Dynamic Transfer Syntax) Dicom processors convert modality data to compressed coefficients that are stored in cache units while migrating to the central archive. D D TAY LIV C D D FRL D D D D Dnw D DICOM Proc. C Cache Store S Archive Store C D D WBL C C S S S D STH C D D LKS S HFH AAPM

26 Suburban Network Configuration S Multiservice Switch R Building Router PACS Radiology router OC3 S R OC3 100 Mb/s PACS 1 Gb/s The large suburban clinics use a dedicate router for Modalities, Workstations, and Storage units The PACS router is connected using dual fiber to the building router that similarly connect to the switch servicing the OC3 connection. AAPM

27 Main Campus Network OC3 OC3 Redundant fiber connected routers. S R PACS modalities and work stations PACS 16 PACS Routers OC3 Fiber Cluster 1G/100M AAPM

28 Network management Nodes: servers, workstations, routers, switches, hubs etc. SNMP is the Internet standard protocol developed to manage nodes on an IP network. SNMP enables network administrators to manage network performance, find and solve network problems, and plan for network growth. Numerous commercial and public domain software applications and toolkits are available. MSU Radiology switch traffic graphed updated every 5 minutes using MRTG AAPM

29 Phys. Rev. Letters Jan 2004 Argollo recently evaluated internet traffic dynamics in relation to other natural processes to demonstrate a unique scaling law that relates fluctuations to average flux. AAPM

30 Phys. Rev. Letters Jan 2004 Fig 1a (a) Time dependent traffic on three Internet routers of the Mid- Atlantic Crossroads network, whose activity is monitored by the Multi Router Traffic Grapher software (MRTG). The figure shows the number of bytes per second for each of the routers in 5 min intervals for a two day period. AAPM

31 Phys. Rev. Letters Jan 2004 Fig 1b (b) Streamflow, measured in cubic feet per second, on three rivers in the U.S. river basin, based on data collected by the U.S. Geological Survey in AAPM

32 PACS performance Facility Net MB/s Sec/CR PACS apps. monitor the total network data rate from a modality to the storage server and from the server to a workstations Main Campus Fairlane W. Bloomfield Lakeside Sterling Hts. Taylor Livonia Detroit N.W. LAN OC3 OC3 OC3 DS3 2 T1 2 T1 2 T Acquisition and Radiology Display. Acquisition and Clinical Display. AAPM

33 Part 4. Storage Technology Similarly, rapid change in the design and performance of storage devices impacts our approach to long term image archival and disaster recovery. AAPM

34 Technology price of storage x ½ per yr IBM, Grochowski, Almaden Dec Jul IDE DRIVEs $ 1, USD/TB $.0006 $.0015 USD/MB SCSI RAID5 $6,250 $10,000 USD/TB $.0062 $.0100 USD/MB AAPM

35 Computers: 1982 to years 1/30 th the cost 500 times more disk storage 250 times more memory 900 times faster processor Circa 1982 VAX 11/780 Purdue Univ.* $250,000 3 x 300 MB disks 8 MB memory 5 Mhz VAX Circa 2002 IBM xseries 345 HFHS Radiology $8,000 6 x 73 GB disks 2 GB memory 2 x 2.2 Ghz Xeon * Purdue University AAPM 2004 Tech. Report TR-EE

36 Hans Moravec Robotics Institute Carnegie Mellon University Intro computer power/cost AAPM

37 Technology Gartner #6 Gartner analysts list of 10 predictions that will impact enterprise businesses. 6. Moore's Law continues to hold true through this decade Gartner gives Moore's Law, which says that cpu power doubles every 24 months, a 70% chance to continue through Gartner projects that the typical desktop computer in 2008 will have: 4 to 8 CPUs running at 40 GHz, 4 to 12 gigabytes of RAM, 1.5 terabytes of storage, and 100Gbit LAN technology. By GHz CPUs and have 6 TB of storage. Ten predictions to shake your world By Dan Farber, Tech Update AAPM 2004 October 10,

38 Technology Gartner 9 & 10 Gartner analysts list of 10 predictions that will impact enterprise businesses. 9. Business units, not IT, will make most application decisions Gartner says that business units, rather than centralized IT departments, will make decisions on applications. By 2007, this trend has a 70 percent probability of governing purchasing in 65 percent of enterprises. 10. Pendulum swings back from centralized to decentralized Gartner predicts the focus on more centralized IT during this time of economic contraction will shift by 2004 to a more decentralized model. Ten predictions to shake your world By Dan Farber, Tech Update AAPM 2004 October 10,

39 Technology change Continuous rapid improvement in price/performance makes computerized technology markedly different than other technologies. Developers, purchasers, and operators of medical PACS system must understand and plan for technology change Porsche L Turbo 300 hp 260 km/hr 2001 Porsche L Turbo 415 hp 305 km/hr AAPM

40 Outline What might a Physicist want to know. Radiological Terminology Workflow Improvement Network Architecture Storage Technology AAPM