Medical Imaging Workstations Whats Missing and Whats Coming

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Medical Imaging Workstations – What’s Missing and What’s Coming (How to avoid $1+M mistakes)

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. Motivation, interfaces, workflow and

Outline Introduction: Medical Imaging Surgical (image guided therapy) Workstations 1. Motivation, interfaces, workflow and standards 2. Workflow and Automation 3. DICOM and IHE 4. Where to get more information

Learning Objectives 1. To understand types of medical imaging workstations, their motivation, interfaces, workflow

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

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 – Medical Workstation and Gaming Platform ≈

Analogy – Portal and Website ≈ Imaging Portal

Analogy – Portal and Website ≈ Imaging Portal

Surgical Workstations Brain. Lab™ Stealth. Station™ “Neuronavigation” (Proprietary Systems)

Surgical Workstations Brain. Lab™ Stealth. Station™ “Neuronavigation” (Proprietary Systems)

DICOM in Radiotherapy (1998) www. sgsmp. ch/bull 983 b. htm Schweizerische Gesellschaft für Strahlenbiologie

DICOM in Radiotherapy (1998) www. sgsmp. ch/bull 983 b. 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

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

Auto-segmentation Tools for Data Handling *Model-based image segmentation is a work in progress. Courtesy of Todd Mc. Nutt, Hosp. Philips. U Medical D. Jaffray, Princess Margaret Toronto

Generalized Patient: Diseased and Normal Tissues Model Simulation and Treatment Process CT CT/PET MR

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

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

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

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

URL: medical. nema. org

Definitions • WORKFLOW = Sequence of steps needed to accomplish a complete task /

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 Diagnostic Workflow OR-Workflow Image Processing Workflow Surgical Workflow Information

Hospital Workflows © Oliver Burgert Diagnostic Workflow OR-Workflow Image Processing Workflow Surgical Workflow Information Flow Surgical Processes Material Workflow Anaesthesia Workflow

Sample Case – Surgical Planning Humeral Non Union

Sample Case – Surgical Planning Humeral Non Union

„Best Practice“ Workflow Repository Reference expert knowledge Peer Expert II Repository of workflow reference

„Best Practice“ Workflow Repository Reference expert knowledge Peer Expert II Repository of workflow reference models (WFs, SIPs) for medical techniques, WF graph operating instructions, etc. ph ra WF g Peer Expert III Peer Expert IV Generic models and patient-spec. models etc.

Example of Work. Flow in repository

Example of Work. Flow in repository

Integration of Surgical Workstations • To some extent, surgical workstations have already been integrated:

Integration of Surgical Workstations • To some extent, surgical workstations have already been integrated: – HIFU = High intensity focused ultrasound – Da. Vinci Surgical Robot – And many others….

Da Vinci Robot & Workstation

Da Vinci Robot & Workstation

MISS = Minimally Invasive Spine Surgery Chair for Computer Aided Medical Procedures & Augmented

MISS = Minimally Invasive Spine Surgery Chair for Computer Aided Medical Procedures & Augmented Reality

IHE and Radiology (IHE = Integrated Healthcare Enterprise)

IHE and Radiology (IHE = Integrated Healthcare Enterprise)

CT Scan – No. exams per year AJR Nov. 2006; 187: 1160 -1165

CT Scan – No. exams per year AJR Nov. 2006; 187: 1160 -1165

The Perfect Storm? • Increasing demand (no. of exams) • Increasing complexity of exams

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

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.

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

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”

Sample IHE “Success Story”

Why IHE?

Why IHE?

Sources of Images • • • Radiology Pathology Cardiology Ophthalmology Radiation Oncology • Dilemma:

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; …

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

Need for Standards

DICOM • Version 3 is data format standard • ACR & NEMA – drafted

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

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,

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—HL 7 2. x--$10, 000 per interface

Why IHE? 1970’s—Mainframe Era--$100, 000 per interface 1990’s—HL 7 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

IHE brings reality to workflow

Who is IHE? IHE is a joint initiative among: Ø Ø Ø American College

Who is IHE? IHE is a joint initiative among: Ø Ø Ø 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) Ø American College of Clinical Engineering (ACCE) Ø 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

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

IHE Standards-Based Integration Solutions Professional Societies Sponsorship Healthcare Providers & Software Developers Healthcare IT

IHE Standards-Based Integration Solutions Professional Societies Sponsorship Healthcare Providers & Software Developers Healthcare IT Standards General IT Standards HL 7, 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 Profile Specifications Solution IHE Integration Profile

IHE Integration Profiles Scheduled Workflow P a t i e n t I n

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 Post. Processing Workflow Evidence Documents Reporting Workflow Key Image Notes Access to Radiology Information Basic Security Simple Image and Numeric Reports

IHE Technical Frameworks Detailed standards implementation guides

IHE Technical Frameworks Detailed standards implementation guides

(82 pages) (41 pages)

(82 pages) (41 pages)

IHE Connectathon • 300+ participants, 120+ systems • 60+ systems developers • Four Domains:

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

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

A sobering thought… Remember what happens to ALL of the computer systems that you use…

Yesterday’s Workstations

Yesterday’s Workstations

And where do you think that Google and Wikipedia and enterprise computing is done?

And where do you think that Google and Wikipedia and enterprise computing is done?

Server Farms

Server Farms

Strategy for web hosting • Reduce costs by consolidating services onto the fewest number

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…

Some places to look for more information…

www. klasresearch. com

www. klasresearch. com

http: //www. pacsnet. org. uk/

http: //www. pacsnet. org. uk/

Open Source Software For Medical Imaging

Open Source Software For Medical Imaging

http: //www. osirix-viewer. com/

http: //www. osirix-viewer. com/

Image. J rsb. info. nih. gov/ij/ Wayne Rasband NIH

Image. J rsb. info. nih. gov/ij/ Wayne Rasband NIH

itk

itk

Insight Journal - http: //insight-journal. org/

Insight Journal - http: //insight-journal. org/

Bioimage. XD

Bioimage. XD

NIH Initiatives: Grid(s)

NIH Initiatives: Grid(s)

ca. BIG – Cancer Biomedical Informatics Grid http: //cabig. cancer. gov/

ca. BIG – Cancer Biomedical Informatics Grid http: //cabig. cancer. gov/

ca. BIG Pathology Workspace

ca. BIG Pathology Workspace

http: //apiii. upmc. edu/

http: //apiii. upmc. edu/

SIIM Society for Imaging Informatics in Medicine

SIIM Society for Imaging Informatics in Medicine

http: //www. siimweb. org/

http: //www. siimweb. org/

Conclusion • Medical imaging workstations and integration of information technologies are in a rapid

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

TRANSFORMING PATHOLOGY: Emerging technology driving practice innovation