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DOI: 10.1148/rg.226025058
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(Radiographics. 2002;22:1567-1577.)
© RSNA, 2002

infoRAD

Integration of a Multimedia Teaching and Reference Database in a PACS Environment1

Antoine Rosset, MD, Osman Ratib, MD, PhD, Antoine Geissbuhler, MD and Jean-Paul Vallée, MD, PhD

1 From the Department of Radiology, Hôpital Cantonal Universitaire de Genève, Rue Micheli-du-Crest 24, 1211 Geneva 14, Switzerland (A.R., A.G., J.P.V.); and the Department of Radiology, University of California, Los Angeles (O.R.). Presented as an infoRAD exhibit at the 2001 RSNA scientific assembly. Received March 18, 2002; revision requested May 20; final revision received July 22; accepted July 24. Supported by grant PL7512 from the Geneva Health Department. Address correspondence to A.R. (e-mail: rossetantoine@bluewin.ch).


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Conclusions
 References
 
In one radiology department, a computerized authoring and editing environment was developed and integrated with the picture archiving and communication systems (PACS) for creation of image-based electronic teaching files to replace a collection of printed film images. This multimedia database and authoring environment allows physicians to create reference databases for teaching and research directly from clinical cases being reviewed on PACS diagnostic workstations. The database engine allows users to generate stand-alone CD-ROMs (compact disks, read-only memory) and World Wide Web–based teaching files. The system is fully compliant with the Digital Imaging and Communications in Medicine (DICOM) standard and supports a large number of standard multimedia image file formats. The focus of the development was on convenience and ease of use of a generic system adaptable to all users. The software was integrated on the PACS workstations to allow users to add new cases to the database at any time and anywhere in the department. A pilot system was implemented in clinical operation, with a central server and several client units.

© RSNA, 2002

Index Terms: Computers, educational aid • Images, storage and retrieval • Picture archiving and communication system (PACS)


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Conclusions
 References
 
With the introduction of the picture archiving and communication system (PACS) in radiology, classic teaching files based on printed film images are becoming rapidly obsolete and incompatible with the digital environment of modern radiology departments (1). With the recent developments in PACS (2) and the emergence of new standards such as Digital Imaging and Communications in Medicine (DICOM) (3), the development of a digital teaching files system is facilitated, allowing the radiologist to benefit from the advantages of digital imaging technology in editing and sharing image collections: access anywhere and anytime, online or offline access (Internet, CD-ROM [compact disk, read-only memory]), quick and easy data replication of multimedia data sets, and an interactive environment that provides powerful and convenient tools for query and data retrieval.

A digital teaching files authoring environment should include three main functions, on which will depend its success: importing images from different sources, editing images and the associated description, and finally sharing and consultation of image collections. These three functions represent a chain of events that must allow the author to work efficiently, then allow the users easy and convenient access to the collections.

No satisfactory commercial solution is available today. Existing software programs for creating collections of images often do not support the DICOM imaging standard and are often not designed to coexist with an existing clinical PACS. This is why we elected to develop our own system. This system is designed as a generic image database–authoring tool and is based on the integration of commercially available software components running on any personal computers.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Conclusions
 References
 
For the development of our digital teaching files authoring and storage system, we chose a commercially available relational database development environment: 4th Dimension by ACI, version 6.7.1 (4,5). This software was installed in a client/server mode on a Macintosh computer (Apple Computer, Cupertino, Calif) (G4 800-MHz processor, 372-Mbyte random-access memory [RAM], 80-Gbyte hard disk), with MacOS 10.1 as the operating system. The database structure was defined in four relational tables (author-collection-case-image) with a One-To-Many relation between them. For each table, we defined a list of specific fields (Table).


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  		Tables and Fields of the Teaching Files Relational Database

 
Images are saved as individual files in a separate folder in order not to overload the index file of the database and affect its performance. Images are stored in the JPEG file format (6) for still images and in the QuickTime file format (7) for dynamic sequences. We use the lowest compression rate for JPEG files to minimize image deteriorations due to compression (8–10) and MPEG (Moving Picture Experts Group) compression (11) for QuickTime files. File size is limited to 10 Mbytes for reasons of performance. We did not set any limitation to the size and spatial resolution of the images.

The database server is the core of our system (Fig 1). Users can connect to the central database in a client/server mode. The client software is also developed with the 4th Dimension environment. It can run on the MacOS and Windows operating systems and connects to the server through a standard TCP/IP (Transmission Control Protocol/Internet Protocol).



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  		Figure 1.  Architecture of the digital teaching files system. Win = Windows (Microsoft, Redmond, Wash).

 
Data Importing
The first function to be offered by our system is the ability to import images from our PACS or from any digital source directly into the image database. In our department, we have been using a commercial DICOM-based PACS from ImageDevice (12) for 2 years, in which the images from all modalities are saved and retrieved for clinical interpretation. We developed two ways to import DICOM images into our digital teaching files system:

1. From a DICOM file: We developed a 4th Dimension plug-in that converts a DICOM file to a JPEG file. It allows the user to select a custom window level and width before the conversion. This plug-in uses our own DICOM C/C++ software library, Papyrus 3.0 (13). The Papyrus toolkit, developed at the University of Geneva, is available in the public domain (14). It is written in ANSI C (American National Standard for Information) (15) and is thus compatible with most C/C++ compilers.

2. With the DICOM communication standard protocol: We installed "DICOM listener" software on our server, which we developed in the Java programming language. This Java DICOM listener is also available in the public domain (16). It allows any user of our PACS to send a DICOM data set directly to our digital teaching files system (17). The images are then converted from the DICOM format to JPEG with our Papyrus plug-in software (13).

Since some images do not come from our PACS but can, for example, be scanned from a hard copy or film, we also support most standard multimedia file formats (JPEG, TIFF [Tagged Image File Format], BMP, Photoshop [Adobe Systems, San Jose, Calif]) by using two commercial plug-ins for 4th Dimension: Qpix and Qmedia (18). These plug-ins convert all of these multimedia file formats to JPEG and handle QuickTime files.

Finally, our system supports a copy/paste function: Our PACS interpretation software allows the user to copy the image displayed onto the clipboard. The user can then simply paste the image from any viewing application into the server database (19) (Fig 2). Depending on the application from which images are copied, this function can be limited by the display resolution and thus may require high-resolution displays for copying high-resolution images like projectional radiographs.



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  		Figure 2.  4th Dimension user interface for case input to the teaching and reference database running on a PACS workstation.

 
Data Editing
Once the images are imported into the database, the user can edit all text data as well as the images in the client software environment (Fig 3). The text data can also be edited in a word processing program to benefit from grammatical and spelling corrections and then pasted back into the image database. The client software also includes simple image editing functions, such as change of spatial resolution, cropping, and contrast/brightness setting (Fig 4). Using the copy/paste function, the user can also copy images from the database to any image editing software to make more complex changes to the images, such as applying special filters, removing part of the image, or adding arrows or legends to an image.



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  		Figure 3.  Graphical user interface of the client software used to edit image collections.

 


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  		Figure 4.  Image editing capabilities of the client software.

 
Data Sharing
For review of the collection stored in the database, the system offers two modes of data sharing, allowing users to access and review the teaching files anywhere and anytime:

1. A Web server (HyperText Transfer Protocol [HTTP]) allows any Web browser to consult our collections (Fig 5) through any standard Web browser without the need for any special software.



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  		Figure 5.  Graphical user interface of the Web server.

 
2. Offline hybrid CD-ROMs (MacOS and Windows) containing selected cases exported from the database can be displayed and reviewed on any personal computer with a CD-ROM drive. Each CD-ROM contains a run-time version of our 4th Dimension client software, thus avoiding the need for any preinstalled application on the computer. The advantage of CD-ROMs is that they can be replicated in a large number of copies to be distributed to users or students at a relatively low cost (20).


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Conclusions
 References
 
The use of our digital teaching files system was rapidly adopted by many members of the department, who successfully developed large collections of images. All radiologists in our department have access to the database with their own personal collections. This tool is now part of our standard resources for teaching and training students and residents, and faculty members are assigned to maintain and update official pre- and postgraduate teaching collections, such as magnetic resonance imaging of muscle tumors, bone disease, Doppler ultrasonography, emergency neuroradiology, and tumors in neuroradiology. After about 1 year of operation, over 9,000 images had been entered in about 2,000 teaching file cases. At the current stage of the project, users add about 200 images per week in our system. We also published three CD-ROMs for students and residents and presented them at international meetings and conferences.


   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Conclusions
 References
 
The transition from traditional film images to PACS is a challenging and often difficult path. In an academic environment, the transition to the digital world is not limited to the clinical implementation of a PACS but also significantly affects the teaching and academic role of a radiology department. The benefit of using a PACS in the clinical routine is to provide better tools supporting the teaching and training tasks that are part of the academic mission of a university hospital (1). This extension of PACS functionality usually cannot be achieved at the same time as the migration to a digital PACS environment: Most current commercial PACS do not offer the necessary tools for creation of teaching files of selected clinical cases.

In clinical PACS, the search for examination results is mostly performed by using the patient’s demographic data, not keywords or ACR codes. It is usually not possible to index or retrieve specific pathologic conditions in a conventional PACS. In most clinical settings, there are also limitations and constraints imposed by security and confidentiality requirements: It is often difficult to share the same software and database environment used clinically simply by restricting access to the patient’s demographic data for teaching purposes.

The selection of a PACS should always consider the needs and requirements of academic and research tasks, which often require an in-depth evaluation of the needs and functions that the system must have to support sharing clinical data for teaching and education purposes while maintaining full compliance with policies and regulations on patient confidentiality and data security (21).

Advantages of a Digital Teaching Files System
Advantages of a digital environment for teaching files compared with a film-based environment are numerous:

1. The most important advantage is the cost-effectiveness of a digital system. Although such a system requires expensive computer equipment, it is possible to limit the cost by sharing the same computers for software dedicated to the PACS and for software for the digital teaching files system. The cost will then be limited to the software and its maintenance. On the other hand, traditional film-based collections generate continuous and increasing costs with increasing size of the collection: Duplication of a film costs approximately $1 per film, compared with a recordable CD-ROM that costs less than $1 but can store up to 2,000 JPEG images (if images are stored at a medium resolution of 800 x 800 in the highest-quality mode). Film collections also require significant storage space and are hard to transfer from one location to another. For large image collections that exceed a few thousand images, the financial advantage goes to the digital system (22).

2. Another advantage of digital image collections is the ability to duplicate the data very easily without any loss of quality and information. A digital collection can thus be duplicated and distributed to other institutions at relatively low cost.

3. Transfer of a digital collection is extremely easy compared with transfer of a film-based collection. In our system, we have two modes of digital transfer: (a) transfer by digital network, which allows the user to transfer more important volumes of data from one site to another (23) without any physical transportation; and (b) transfer by CD-ROM, which allows the user to move more than 2,000 radiologic images on a low-cost medium that can easily be sent by mail (9).

4. With a digital system, it is possible to add some interactivity to the teaching files (24). The user benefits from powerful searching functions with logical operators (AND, OR, IF) and from the possibility to search targeted fields such as "anatomy" or "ACR codes." The interactivity also allows self-evaluation tests and quizzes to be incorporated.

5. A digital system greatly facilitates the task of preparation and creation of a teaching database. On the other hand, creation of a film-based collection is a complex and time-consuming task that requires several steps: Once an image is chosen, it is necessary to have a copy made by a technician, to dictate the case comments to a secretary, and finally to gather these components and classify the case in a library. A digital system simplifies these steps into a single step: The radiologist selects an image directly from the PACS and copies it into the digital system (25). The user can also enter comments, legends, and annotations directly with the database authoring software. Thanks to a client/server architecture, every newly created case is immediately available on the network for other users to review (26).

Choice of Technology
The choice of technology is one of the keys to success for a digital system. First of all, it is important to choose an adequate database management system (DBMS). Using the generic functions of a DBMS, the user will be able to search, sort, and classify data according to the preset fields and tables. However, the DBMS must be able to perform these functions without performance limitations and with large volumes of data. The DBMS represents the core of the system around which fundamental functions of importing, editing, and sharing are developed, and its choice is key for the implementation of a successful system.

Many characteristics of the digital system depend on the choice of DBMS: (a) its ease of use through a simple graphical user interface, (b) its compatibility with other systems through its ability to import and export data, (c) its adaptability to be cross-platform and system-independent, and (d) its sharing capacities through the support of Internet Protocol.

A large number of database programs exist today: simple DBMS software like FileMaker from Apple Computer or Access from Microsoft or more powerful DBMS software like 4th Dimension from ACI or Oracle from Oracle (Redwood Shores, Calif). We elected to use 4th Dimension because it was found to best support the requirements listed earlier: It has a robust database engine with no limits on the data size; it can manage images and animated sequences with the help of plug-ins; it functions in a transparent way with MacOS or Windows; it offers a programming language for the development of specific functions like the DICOM support; it includes a powerful tool for creation of the graphical user interface; it includes an HTTP (HyperText Transfer Protocol) server for data sharing on the Internet; and finally it functions in a transparent way in client/server mode for use in a network and in local mode for creation of stand-alone CD-ROMs. The whole system is developed with the same tool, thus avoiding problems of interfacing between several different software packages. Use of a single tool also provides the most optimal performance and facilitates transfer of the data from one site to another.

System Development
Based on the 4th Dimension DBMS, the development of import functions, editing tools, and data sharing functions took approximately 6 months for a full-time software developer. The first stage of the development was definition of the four relational tables (Table). These four tables represent the four hierarchical levels in which the data are structured.

The highest level is the "administrator" table. This table contains information about each person with access to the system (password, telephone number, e-mail address, and department). This table has a relation with one or more "collection" tables. A "collection" table represents a whole collection; it is defined by the name of the collection, the type of the collection (teaching, search, and personal), and so on. Each "collection" table then has a relation with one or more "case" tables. The "case" table contains all of the medical data: patient name, clinical presentation, description of images, commentary, references, ACR codes, pathologic condition, and so on. Finally, each "case" table has a relation with one or more "image" tables, which are defined by the image name, specific commentaries about the image, and the link with the image file.

Definition of the tables and fields is an important stage and must be accomplished with input from the users. The users cannot modify these tables once they have been created. Any changes in these tables generate new development and reprogramming of the database. Moreover, if fields are added or modified while data are already present in the database, the risk of losing data consistency is quite high. For example, the new fields will not be filled in with the old data, and the modified fields will not correspond to the data already present.

After defining the database structure, we developed the necessary import functions to allow integration with our PACS. It was important for our project that the system allow a complete integration with the PACS infrastructure and allow importing of image data from the PACS with a limited number of steps. To achieve such an integration, we installed the client software (the proprietary client developed with 4th Dimension) on each PACS diagnostic workstation in our department. The advantage of having the PACS software and the teaching files software on the same computer used for clinical interpretation is that it avoids unnecessary "double browsing" to retrieve the image data: When the user sees an interesting case during interpretation work, he or she can quickly copy and paste the images with the proper window level and window width settings (Fig 2) (19,29). This eliminates the need for searching for this case subsequently with different software to retrieve and transfer the images. Simplicity and rapidity of this step is key to success and acceptability by the users, as it motivates users to add new cases to the digital teaching files system on a regular basis (27).

In addition to this easy copy/paste function, the user can also perform a standard "DICOM Send" function from the PACS software to our Java DICOM Listener installed on our digital teaching files server. In that mode, the user must then set the window level and width in the client software, and the DICOM image will then be converted into the JPEG format at the original resolution of the DICOM image. This method requires more steps than the copy/paste function but allows one to send image sets from any DICOM-compliant source. As all images do not necessarily originate from our PACS, it was equally important to support additional standard file formats: It is therefore possible to import an image in the JPEG, TIFF, or BMP format.

We elected to store images in the JPEG file format for several reasons: JPEG allows a very advantageous quality/size ratio with a compression ratio of about 90% (10) and few image distortions in high-quality mode (8); its use is ubiquitous, supported by all multimedia software (PowerPoint [Microsoft], Photoshop); it is the image standard format that is widely used for the Internet and World Wide Web applications (28); and finally, it does not contain "hidden" confidential data, unlike DICOM files, which can contain the patient’s specific metadata (29). The JPEG file format is actually the standard most widely used for teaching files systems (8–10,19, 23,25,26,28,30). A disadvantage of JPEG is that the pixel depth is only 8 bits, allowing only 256 shades of gray in gray-scale images. Therefore, it is not possible to change the window level and window width defined by the author once the image is in the database. A solution to this problem could be to use an alternative format like the more recent PNG (Portable Network Graphics) file format provided its use spreads as much as that of the JPEG file format in the general consumer market (8).

After the import functions, we developed the editing functions for images and textual data. We used the graphical user interface tool of 4th Dimension: the client software, which allows communication and interaction with the central database server. This client software takes advantage of a user-friendly graphical user interface that offers the full set of standard features, such as buttons, pop-up menus, hierarchical lists, drag-and-drop functions, and icons. It was designed to be very intuitive. The user sees all cases and images stored in the database as small thumbnail images. The user can edit all the different fields and tables of the database simply by pointing and clicking in the given field. For certain fields (eg, anatomy, ACR codes), we added the possibility of using predefined lists with the most frequently used values (19). The user can also edit and modify the images with the basic image processing functions (zoom, crop, contrast/brightness). Our experience showed that these basic functions are sufficient for most cases. If a user wants to do more complex image processing and editing, he or she can transfer any image to more advanced commercially available image processing software programs.

The last component of our system was the development of data sharing functions. Data sharing is the final and most important stage of a teaching files system. An image collection is useful only if it can be easily shared and reviewed by the greatest number of users. We used two characteristics of 4th Dimension for facilitating data sharing: The first is the ability to create a stand-alone application that runs on either MacOS or Windows. The second mechanism uses the feature of sharing the database on the Internet with the integrated Web server.

The stand-alone applications allow us to generate CD-ROMs of specific collections. This sharing mode on CD-ROM is complementary to online Internet access. It offers the advantages of easy transfer of a very large data volume (650 Mbytes) on a small and affordable medium. Offline media such as CD-ROMs also offer better performance compared with online access over the Web, which can be relatively slow, depending on the bandwidth of the network access.

However, access to the data online allows continuous updating of the database collection and real-time access to the newly updated cases. Every new case entered in the database becomes available immediately to other users to review. The convenience and flexibility of data sharing over the Internet are unmatched by any other technology (30,31). Access to databases through Web pages by using standard HTML (HyperText Markup Language) allows users to retrieve and review images from the database using standard Web browsers. The graphical user interface for the Web pages is simple and uses the same principle as the client software developed with 4th Dimension (32): The user navigates in the collections with small thumbnail images (Fig 5).

Security
Security and data protection depend on two basic requirements: (a) It is necessary to maintain patient confidentiality by protecting access to the patient’s demographic data. (b) It is necessary to prevent other persons from modifying or altering the data. For these two reasons, our system required the setting up of a user identification procedure with a password (19). Only the author is able to see the patient’s demographic data of a case being edited. It is important that the system stores patient identification to allow subsequent updates of the cases with additional examination results and images that may be acquired at a later time. Authors must also be careful to remove any patient name that appears on an image, like an ultrasound "screen shot." With the identification procedure, the system authorizes data modification only by the owner and author of that case. The system also authorizes an anonymous login without access to the patient demographic data.

To increase the security of patients’ data, we have set up an independent Web server for Internet distribution of teaching databases. This Internet server is located outside our intranet network, without a link to the intranet database server. All collections that are accessible through the Internet are copied manually after extraction of all patient demographic data.

Keys to Success
The creation and maintenance of a teaching files database often represent additional work on top of the radiologist’s clinical activity. The success of such projects depends mainly on the motivation of the users (26). This motivation depends on questions such as the following: Can I make effective use of an image collection and generate a publication or a scientific paper out of data extracted from a collection? Is there a possibility of publishing a collection as a teaching file or a reference image database? Will I learn something in doing it? Are there some users interested in this collection?

The digital teaching files system cannot answer these questions, but it certainly can facilitate and support the user’s motivation to achieve these goals. The author should see in the system a practical and powerful tool, not a succession of incomprehensible and complex procedures. The system must minimize the number of steps required to create and store a case. Authors’ creativity and motivation are inversely proportional to the complexity and awkwardness of a system (21). The system must also be accessible from everywhere at any time. Thanks to the client/server architecture and the cross-platform compatibility, access to our system is possible from any computer in our department. The author can therefore select images on the PACS stations, then edit the selected cases from his or her desktop computer. This ease of access adds to the convenience of creating teaching files and the motivation for doing so, which often tends to be exhausted after the initial enthusiasm for creation of a complete collection.

Outlook
We are currently evaluating several improvements to the system. First of all, we would like to add options that allow marking regions of interest and annotations on the images. Concerning data security, we are also evaluating the use of watermarking technologies to label the images, to provide image traceability and prevent illegal use of images without the author’s agreement. Finally, we are investigating content-based image retrieval (CBIR) algorithms as an extension of our teaching files database query mechanisms.


   Conclusions
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusions
References
 
A digital teaching files system is vital for an academic radiology department equipped with a PACS. Existing commercial solutions for creating image collections are often not suitable for radiologic applications. These systems are usually difficult to integrate with a PACS. For these reasons, we developed our own digital teaching files system and image collection database system. We chose a database development tool that allows rapid design and development of multimedia, user-friendly authoring programs supporting Web-based as well as stand-alone applications. With this software, we developed the three main functions of our system: (a) a data import function fully integrated with our PACS workstations, as well as compatibility with other standard multimedia image formats (JPEG, TIFF, BMP, etc); (b) data editing by means of simple and powerful client software, which is connected to the database server remotely; and (c) data sharing and distribution with the creation of stand-alone and multiplatform CD-ROMs and with a Web server for online access by using any Web browser, such as Internet Explorer (Microsoft) or Navigator (Netscape Communications, Mountain View, Calif).

The system, implemented in a clinical setting, was rapidly adopted by all of our faculty members, and the rapid growth of database content was clear evidence of the success and acceptance of the system by the users. Storage of selected interesting cases in the image databases became a natural and common trend among our radiologists during their daily clinical routine. They particularly appreciated the convenience of doing so from the PACS workstations while reviewing images for clinical diagnosis. The ability to generate online teaching files as well as offline CD-ROMs motivated numerous members of our department to add comments and complete collection of cases in specific domains to generate comprehensive collections that were edited and distributed in large numbers to other institutions and at international meetings and conferences.


   Footnotes
 
Abbreviations: ACR = American College of Radiology, CD-ROM = compact disk, read-only memory, DICOM = Digital Imaging and Communications in Medicine, JPEG = Joint Photographic Experts Group, PACS = picture archiving and communication system


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusions
 References
 

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