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(Radiographics. 2002;22:217-221.)
© RSNA, 2002

infoRAD

Development of a Teaching File by Using a DICOM Database1

Randy D. Ernst, MD, Bruce R. Baumgartner, MD, Eric P. Tamm, MD and William E. Torres, MD

1 From the Department of Radiology, University of Texas Medical Branch at Galveston, 301 University Blvd, G09, Galveston, TX 77551 (R.D.E.); the Department of Radiology, Emory University, Atlanta, Ga (R.D.E., B.R.B., W.E.T.); and the Department of Diagnostic Radiology, University of Texas M.D. Anderson Cancer Center, Houston, Tex (E.P.T.). Presented as an infoRAD exhibit at the 2000 RSNA scientific assembly. Received January 9, 2001; revision requested February 13 and final revision received May 31; accepted June 18. Address correspondence to R.D.E. (e-mail: rernst@massmed.org).


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Conclusions
 References
 
A teaching file of Digital Imaging and Communications in Medicine (DICOM) images was developed. Selected computed tomographic, magnetic resonance, angiographic, nuclear medicine, and ultrasonographic images were transferred to a personal computer (PC) with a 75-GB hard drive. The database created from the DICOM header information was modified to include American College of Radiology (ACR) Learning File categories. Database modification allowed cases to be searched by diagnosis, by findings, and by patient age, sex, and demographics. Technologists inputted ACR codes into the DICOM headers before the images were acquired, thereby reducing database maintenance time. Images were manipulated and reviewed and were used for case presentations, board review, and conferences. Selected images were transferred via a hospital network to workstations for consultation, saving time for referring clinicians. The teaching file is reliable, cost-effective, and easy to install and takes advantage of recent technologic advances in computer hardware and software. Rapid cost reductions and increases in PC storage capacity allow maintenance of the teaching file in DICOM format without intermediate steps involving automation or manual conversion. This setup rivals any of the proprietary software currently available from other vendors.

© RSNA, 2002

Index Terms: Computers • Computers, educational aid • Computers, multimedia • Digital imaging and communications in medicine (DICOM)


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Conclusions
 References
 
Many articles on the creation of digital teaching files have been published (1–7). These articles document techniques for creating files that provide better organization, wider availability, and greater compactness than is afforded by conventional film teaching files. Although the prominence of computers in work areas used by residents, technologists, students, and physicians and the widespread availability of the Internet and Intranet allow data to be rapidly and widely disseminated, many of these digital radiology filing systems are time-consuming to maintain and cumbersome and expensive to implement. Some of these teaching files involve transferring and converting images from Digital Imaging and Communications in Medicine (DICOM) sources to common Joint Photographic Experts Group (JPEG), tagged image file (TIF), or graphical interchange formats (1,3,4,6,8). Although they require less storage capacity, images in these formats are 8-bit images without headers; they are not DICOM images and contain only the user-determined window width and level that existed at the time of transfer (1,2,6). JPEG images obtained with lung windowing can no longer be viewed with soft-tissue windowing. Transfer back to the workstation for postprocessing is not an option with these images.

Even in departments that are almost filmless, saving digital images for slides and presentations may involve a digital camera and a light box, and use of digital cameras for capturing and transferring radiologic images can be time-consuming (2). We believe that our digital teaching file is a better alternative.

The purpose of our project was to develop a low-cost DICOM teaching file that would be easy to update and modify with commercially available hardware and cost-effective software programs that were available throughout the radiology department. Most contemporary radiology equipment is now DICOM-compatible. Rapid cost reductions and increases in personal computer (PC) storage capacity now allow maintenance of the teaching file in DICOM format without intermediate steps involving automation or manual conversion. Advances from Microsoft (Redmond, Wash) and other manufacturers have improved the quality, functionality, and affordability of commercially available software and hardware (4,9). Improved network capacity with widespread availability of fiber-optic, cable modem, and asymmetric digital subscriber line (ADSL) network connections allows these cases to be shared in uncompressed DICOM format over the Internet or Intranet. Our project significantly reduces the time required for organization by having the technologist input American College of Radiology (ACR [Reston, Va]) codes into the DICOM headers before the images are acquired. We found the text version of the ACR code to be more helpful than the numeric code. Studies can be sorted later using these codes. The database (eFilm Version 1.5.2, developed at the Department of Medical Imaging at the University Health Network and Mount Sinai Hospital in Toronto, Ontario, Canada) automatically created from the DICOM data can be manually corrected with Microsoft Access, and further information or a final diagnosis can be added. The additional information can be viewed and sorted with the eFilm viewer.

With our teaching file, images can be transferred back to the workstation for postprocessing with three-dimensional multiplanar volume reconstruction, maximum intensity projection, and shaded surface display. Virtual colonography, endoscopy, and angioscopy can then be performed with these postprocessed images. Reformatting of computed tomographic (CT) and magnetic resonance (MR) angiograms is often helpful for teaching purposes, and research projects such as virtual colonography can benefit from maintaining raw data in a readily available form.

In this article, we describe the materials and methods we used to develop our digital radiology teaching file and discuss some of the advantages it affords.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Conclusions
 References
 
The eFilm program was downloaded free of charge from the eFilm site on the World Wide Web (http://www.efilm.ca) and can read, receive, and send DICOM images. The program bundle contains a database file that was written with Access 2000 (Microsoft) and works well with the bundled database. However, with the use of Access software, additional functions (eg, searching, field modification, Web-based input tables) become available.

DICOM images were transferred from MR imaging, CT, ultrasonographic (US), angiographic, and computed radiographic equipment to GE workstations (GE Medical Systems, Milwaukee, Wis). The primary review and postprocessing software used in our department is Advantage Windows Version 3.1 (GE Medical Systems), running on a Unix-based UltraSPARC 2 (Sun Microsystems, Mountain View, Calif). However, images were also transferred from GE US and CT scanners, Marconi Omnipro workstations (Marconi Medical Systems, Cleveland, Ohio), Philips MR imagers (Philips Medical Systems, Best, The Netherlands), Philips Easy View workstations and computed radiography units, AGFA workstations (AGFA-Gevaert, Mortsel, Belgium), and an AGFA redundant array of inexpensive disks (RAID) workstation (AGFA IMPAX). The teaching file database was created by transferring selected images from our review station to the teaching file workstation. The database, which could be viewed with eFilm and Access, was automatically populated with the following data: patient’s medical record number and name, modality, study date, referring physician, anatomic study description, subanatomic location, accession number, and patient history (Fig 1).



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  		Figure 1.   Editing Web page for the Access database.

 
In our department, the information flow would begin when a referring physician requested an examination from the radiology department by means of a written order that included patient information and clinical indication. A radiologist noted the protocol for each examination and usually indicated ACR descriptors on the written order. The technologist manually typed the information into the scanner, and during the examination the scanner added more information about the type of examination being performed. At this point, the information in the DICOM headers was complete. Studies were then transferred to the workstation for review and dictation. A radiologist selected interesting images and transferred them to the teaching file in DICOM format, including the header information. There was a one-to-one relationship between the data in the DICOM header and those in the Access file. The Access program allowed additional editing and provided sorting capabilities. In addition, the radiologist could add the requisite ACR descriptors and the diagnosis to the teaching file. Both Access and eFilm functionality are available in the teaching file.

The DICOM header contains many fields or categories important to case management, but if a field has little significance for a particular examination, the technologist may leave it blank. If film is the end product of the scan, little more than the patient’s name and medical history is included in the final record. If cases are reviewed electronically, more detailed header information is available. The entering of DICOM header information was encouraged to facilitate research projects and teaching file organization. Technologists were instructed to use ACR anatomy codes for the "Exam Description" field and ACR pathology codes for the "Refer" (ie, referring physician’s name) field. Technologists were also asked to be as descriptive as possible when inputting patient history (Figs 1, 2).



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  		Figure 2.   Data input screen shows information provided by the technologist for a patient undergoing MR imaging.

 
We chose the dedicated DICOM header field "Accession Number" for inputting the final diagnosis as suspected from the initial clinical history. Many examinations were performed as routine follow-up for complications of known disease processes. Most of the ACR coding was done prior to the examination. In cases in which the diagnosis was not entered and the radiologist did not remember the case, pathologic findings and postoperative reports provided the final diagnosis. All examinations were coded, but only relevant teaching cases were transferred to the teaching file. When information is changed in the eFilm teaching database, the actual DICOM headers imbedded within the images remain fixed. Use of the rebuild function on the DICOM database would cause all changes and the final diagnosis to disappear.

The hardware platform consisted of a Dell Precision 420 dual processor–capable workstation (Dell, Round Rock, Tex). The workstation included dual monitors, a Pentium 900-MHz microprocessor (Intel, Santa Clara, Calif), 256 MB of RAM, and a 75-GB small computer system interface (SCSI) hard drive. A removable 80-GB integrated drive electronics (IDE) hard drive was also available for backup. Software running on our workstation included eFilm as well as Windows 2000 and Access 2000. The ACR index for radiologic diagnosis on compact disk–read-only memory (CD-ROM) was also available and was useful in accumulating ACR codes. An ACR code could then be copied and pasted into any Windows program using the "Paste" command from the program’s "Edit" menu.

Over 3,000 cases have been stored on removable 30–80-GB hard drives; 1,066 studies with approximately five images in each study occupy 20.5 GB of storage on a 31.4-GB backup disk (Fig 1). As a hard drive reached capacity, it was backed up to a removable drive of the same or larger capacity. Tape storage with 30–50-GB compressed capacity was achieved with On Stream tape drives (Philips Medical Systems).


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Conclusions
 References
 
Use of DICOM header data that were typed by requesting physicians or clerks reduced database maintenance time. Technologists helped by entering ACR pathology and anatomy codes. When technologists were asked to be as descriptive as possible when inputting patient history, we found that this history was often identical to the final diagnosis. Because the technologists inputted ACR pathology and anatomy codes prior to the examination, editing time for the final diagnosis was markedly reduced. New functionality in the Access database allowed rapid editing, inputting of ACR codes, and writing of text reports at the time of interpretation via a Web interface.

The Access database allowed sorting by all the DICOM header fields as well as by edited final diagnosis fields. Access 2000 was site licensed to Emory University and was available to help edit the DICOM database at no additional cost.

The eFilm software allowed referring physicians, faculty, technologists, residents, and medical students to access the teaching file. This software was used for storage review, windowing, and so on. Additional proprietary software (at additional expense) was not necessary.

The entire faculty in the Division of Body Imaging at the University of Texas Medical Branch at Galveston now have eFilm on their office PCs. Many other faculty members are using eFilm to store images in preparation for talks and research projects. Conference presentations are made with a liquid crystal display (LCD) projector and the eFilm viewer (Fig 3). LCD projectors are available in our main hospital conference room, resident conference room, and medical student radiology classroom. Each year, residents provide the faculty with feedback on presentations made at conferences. The ratings from the residents this year were excellent, and the computerized files were noted as being helpful.



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  		Figure 3.   Screen shows the eFilm graphical user interface, which allows sorting of DICOM columns and viewing of the images in the database. Images can be exported in TIF or JPEG format for PowerPoint (Microsoft) presentations.

 
Maintaining the teaching file in DICOM format allowed research projects (eg, virtual colonography) and three-dimensional reformatted images to be reloaded onto workstations for postprocessing. A study of Egyptian mummies presented at the 86th Scientific Assembly and Annual Meeting of the Radiological Society of North America in 2000 and featured in an RSNA 2000 Explore News Release made use of the postprocessing features (http://pcipr.com/RSNA /N%20mummy.htm).


   Conclusions
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Conclusions
References
 
Our teaching file takes advantage of the reliability, accessibility, and ease of installation of eFilm and of technologic advances from Microsoft. This setup rivals any of the proprietary software currently available from other vendors. Rapid cost reductions and increases in PC storage capacity allow maintenance of the teaching file in DICOM format without intermediate steps involving automation or manual conversion. Our project reduced much of the weekend time required for database editing by having the technologist input ACR codes into the DICOM headers before the images were acquired.


   Footnotes
 
Abbreviations: ACR = American College of Radiology, DICOM = Digital Imaging and Communications in Medicine, JPEG = Joint Photographic Experts Group, PC = personal computer


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Conclusions
 References
 

  1. Tran TH, Roach NA, O’Kane PL, Thune M. Creating a digital radiographic teaching file and database using a PC and common software. AJR Am J Roentgenol 2000; 175:325-327.[Abstract/Free Full Text]
  2. Maldjian JA, Listerud J. Automated teaching file and slide database for digital images. AJR Am J Roentgenol 2000; 175:1249-1251.[Abstract/Free Full Text]
  3. Zaidel M, Hopper K, Iyriboz T. Interactive web-based radiology teaching file. J Digit Imaging 1999; 12:203-204.[Medline]
  4. Wendt GJ. Using commercially available off-the-shelf software and hardware to develop an Intranet-based hypertext markup language teaching file. J Digit Imaging 1999; 12:122-123.[Medline]
  5. Honeyman JC. Information systems integration in radiology. J Digit Imaging 1999; 12:218-222.[Medline]
  6. Chin H, Klepac D, Ernst RD, et al. Digital photography of digital imaging and communications in medicine: 3 images from computers in the radiologist’s office. J Digit Imaging 1999; 12:192-194.[Medline]
  7. Ernst R, Kawashima A, Tamm E, Sandler CM. A high-quality, low-cost, Internet/Intranet-based digital imaging database. RSNA EJ/RadioGraphics 1997; 1:Available at http://ej.rsna.org/EJ_0_96 /0056-97.fin/tfile1.htm.
  8. Tellis WM, Andriole KP, Avrin DE, Arenson RL. Web technology in the integration of a digital teaching file at the diagnostic workstation. J Digit Imaging 1998; 11:117-119.[Medline]
  9. Ernst R, Le VT, Kawashima A, et al. A picture archiving and communications system featuring multiple monitors using Windows98. J Digit Imaging 1999; 12:106-108.[Medline]



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