DOI: 10.1148/rg.252045061
RadioGraphics 2005;25:543-548
© RSNA, 2005
Informatics in Radiology (infoRAD)
Integrating MIRC-compliant Semiautomated Teaching Files into PACS Work Flow1
Pattanasak Mongkolwat, PhD,
Pankit Bhalodia, MS,
Arnon Makori, MD,
James A. Gehl, BBA,
Alexander Kogan, BS and
David S. Channin, MD
1 From the Department of Radiology, Northwestern University, Feinberg School of Medicine, 448 E Ontario St, Suite 300, Chicago, IL 60611. Presented as an infoRAD exhibit at the 2003 RSNA Scientific Assembly. Received April 2, 2004; revision requested June 30 and received August 13; accepted September 10. All authors have no financial relationships to disclose.
Address correspondence to D.S.C. (e-mail: dsc{at}radiology.northwestern.edu).
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Abstract
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A Medical Image Resource Center (MIRC)–compliant teaching file system was created that can be integrated into a picture archiving and communication system (PACS) environment. This system models the three-step process necessary for efficient teaching file creation in a PACS environment: (a) identifying and transferring a case quickly and easily during primary interpretation, (b) editing and authoring the case outside of primary interpretation time, and (c) publishing the case locally and via MIRC standard–based mechanisms. Images from interesting cases are e-mailed to the teaching file system from either the PACS workstation or the radiologist’s personal computer. Notes and clinical information may be included in the e-mail text to prompt the recollection of case details. Images are automatically extracted from the e-mail and sent to an image repository, and text fields are captured in a database. The World Wide Web–based authoring component provides tools for final authoring of cases and for the manipulation of existing cases. Authors designate access levels for each case, which is then made available locally and, potentially, to the entire MIRC-compliant community. Although this application has not yet been implemented as a departmental solution, it promises to improve and streamline medical education and promote better patient care.
© RSNA, 2005
Abbreviations: ACR = American College of Radiology, DICOM = Digital Imaging and Communications in Medicine, FTP = file transfer protocol, HTTP = hypertext transfer protocol, JPEG = Joint Photographic Experts Group, MIRC = Medical Imaging Resource Center, PACS = picture archiving and communication system
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Introduction
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A collection of teaching files is an important resource for medical education and the dissemination of knowledge in radiology. It is also a requirement for radiology residency programs. Traditionally, film-based teaching file systems have been used to meet this need; however, problems exist with creating, managing, tracking, storing, and sharing cases in film-based systems.
The digital transformation of radiology presents many opportunities for digitally producing and disseminating teaching files. Indeed, dozens if not hundreds of electronic teaching file systems have been described. Yet, numerous teaching file programs cannot be seamlessly integrated into the clinical work flow, making teaching file creation a disruptive and time-consuming act. Even in a picture archiving and communication system (PACS) environment, creating a teaching case can be labor intensive. A radiologist must write down patient and study information as a reminder of the case. In addition, he or she may have to "screen scrape" a PACS workstation display or use World Wide Web PACS viewing tools to save images to a local folder.
Working in a PACS environment presents work flow and efficiency challenges that can be affected adversely by poorly integrated teaching file creation. In a busy clinical practice, the identification and transfer of selected interesting images must be accomplished on the PACS workstation as part of routine work flow and must not significantly degrade the radiologist’s throughput. If these criteria cannot be met, case creation, and therefore educational opportunities, will take a back seat to the pressures of clinical work flow.
Our GE Centricity PACS (GE Healthcare, Mt Prospect, Ill) allows radiologists to create personal folders in which to store radiology cases for teaching purposes. However, restrictions on who can view cases, a lack of proper text annotation tools, and difficulties in exporting these folders make their use suboptimal. Because teaching cases remain on the PACS, one must use a PACS workstation to access them, which further reduces the availability of workstations.
In this article, we describe an approach that exploits an e-mail functionality of our existing PACS to integrate teaching file creation into a busy PACS clinical work flow. The system facilitates case identification and rapid extraction of cases from the PACS with minimal impact on clinical work flow. It allows radiologists to complete teaching file creation at a later time and provides an e-mail notification when a case has been submitted to the teaching file system from either the PACS or the radiologist’s personal computer. The teaching file system was also designed to participate in the Medical Imaging Resource Center (MIRC) community to maximize the educational value of this repository.
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Medical Imaging Resource Center
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MIRC (1) represents an initiative by the Radiological Society of North America (RSNA) to promote standards in the creation and exchange of teaching file cases and serves as an excellent reference point for the radiology community. MIRC provides three alternatives for individuals and organizations wishing to participate in the dissemination of teaching cases: (a) installing MIRC software developed by the RSNA, (b) implementing MIRC storage and query services adhering to specifications created by RSNA MIRC (2), or (c) accessing a complete index of all cases from a repository to the RSNA MIRC site using a MIRC-defined index card format (3).
The RSNA hosts the central MIRC site using the same set of software it developed and distributes to the public. RSNA MIRC software, specifications, and documentation can be obtained free of charge at http://mirc.rsna.org. The software, which runs as a stand-alone MIRC server, can be installed on a variety of computer platforms, including Linux, Mac OS X (Apple Computer, Cupertino, Calif), and Windows (Microsoft, Redmond, Wash), and can serve as either a private teaching file repository or a departmental solution, providing case storage and query mechanisms. There are two primary ways to create a teaching case. MIRCat, provided by the RSNA, is an easy way to author and submit new teaching cases to the MIRC server. It is also possible to develop a program that will create a teaching case and submit the case to the MIRC server on the basis of the MIRCdocument schema (4).
A site that already has a repository of teaching cases can also be integrated into the MIRC community by accepting and returning MIRCquery and MIRCqueryresult, respectively (2). As an alternative to developing a program to communicate with MIRC, a catalog of teaching case indexes can be created on the basis of MIRCsite-index and MIRCdocument (3,4) and submitted to the RSNA MIRC site.
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Methods
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Currently, there are four possible methods of exporting images from our GE Centricity PACS workstation: Digital Imaging and Communications in Medicine (DICOM) Store, e-mail, file transfer protocol (FTP), and the "save to disk" function. DICOM Store simplifies image management and delivers full-fidelity DICOM images, but images can be exported to DICOM destinations only, and there is no mechanism for identifying the individual sender or owner of a case. This solution also mandates the maintenance of DICOM entities and communication infrastructure and does not allow the inclusion of dictated reports or reminder notes. We disabled FTP and save-to-disk functionality for security reasons. We prohibit users of our system from sending radiology cases with patient information to a nonsecured and nonauthorized FTP site. Although the GE Centricity PACS strips patient information from cases sent via e-mail or FTP, we allow this sensitive information to be sent to departmental servers only. Hence, we adopted the e-mail solution as the means for radiologists to export cases from the PACS. As a security precaution and to comply with Health Insurance Portability and Accountability Act (HIPAA) regulations, messages can be sent only from the PACS to the departmental e-mail server.
We have integrated our application into the MIRC community by accepting MIRC queries and returning query results that conform to the specifications outlined by RSNA MIRC.
Our software development environment consists of JBuilder IDE (Borland, Scotts Valley, Calif), along with Java J2SE 1.3.x, Java Servlet, and JavaScript (Sun Microsystems, Mountain View, Calif). E-mail services come from Netscape Messaging Server (Sun Microsystems). E-mail is processed by our Java program. We use MS SQL 2000 (Microsoft) as the database and Tomcat 4.1 (Apache Software Foundation, Forest Hill, Md) for Web services. We developed our own MIRC storage and query services based on the reference implementation available from the RSNA (2).
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Teaching File System
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A teaching case can be e-mailed directly to the teaching file system from a PACS workstation—in our case, with just five or fewer mouse clicks on GE Centricity workstation 2.0 during the course of the radiologist’s clinical work flow. The system allows radiologists to send all images in the study, significant images only, or manually selected images only. Possible image formats include Joint Photographic Experts Group (JPEG), tagged image file format (eight and 16 bits), portable network graphics, or DICOM. GE Centricity PACS and workstations do not have the ability to export images in JPEG 2000. At this point, the client-size DICOM image viewer on the Microsoft Internet Explorer browser has not been implemented. Exported images are captured at screen resolution, and any image manipulations such as window width and level, zoom, and annotations that are applied to selected images will be captured along with images when they are converted to any of the aforementioned image formats except DICOM. The message authoring component on the PACS workstation has an area for the radiologist to add comments or to copy and paste radiology report information if a report exists. Radiologists can also send images and textual reports from an e-mail client program directly to the teaching file system.
Our teaching file system (Fig 1) receives e-mail from the departmental e-mail server as teaching cases are sent from the PACS workstation. The system immediately processes the e-mail by checking to see if the sender is a valid user, to determine the author of the case and protect against e-mail spamming. If the message comes from an authorized user, both textual information and attached images are extracted from the e-mail. The message text is sent to a parsing program to retrieve information relevant to the teaching case. The parser references configurable lists of accepted and rejected keywords to determine which information should be included in the teaching case. Information in the message body that is immediately adjacent to acceptable keywords is mapped to corresponding fields in database tables and will be stored for inclusion in the teaching case. Information that is adjacent to rejected keywords is discarded. Patient-identifying information is immediately and permanently discarded to ensure confidentiality. Any attached images are extracted one by one and stored in a unique folder. The location of the folder is stored in the database for retrieval purposes.
After the initial parsing and image extraction, a confirmation e-mail message is automatically sent to a user-defined e-mail address to notify the user that his or her case has been submitted. Users can send teaching cases from multiple e-mail addresses (other than their PACS e-mail address) and can designate a primary e-mail address at which they will receive their notifications. The e-mail body contains a URL (uniform resource locator) link to the submitted case. After clicking on the link, the user must authenticate him- or herself and is automatically directed to a Web page containing unfinished teaching cases. If the user has previously been authenticated with the teaching file system, he or she will be redirected to the specific case based on the URL.
The three sections of the teaching file system user interface are designed to limit unnecessary navigation, pop-up windows, and required number of clicks. The first section at the top of the Web page contains links to navigate to our external and internal departmental Web sites, along with links to navigate the teaching file system, including "department cases," "my collection [of cases]," "my unfinished cases," "add new case," and "utilities." The second section of the case-authoring page contains textual information related to the case, including the case title, American College of Radiology (ACR) code, abstract, history, findings, and so on. The last section contains the imaging functionality, including thumbnail images, image description, type of image (ie, modality used), image order, and delete and upload operations (Fig 2).
In addition to the authoring component of our teaching file system, a personalized folder system was developed that can be customized by the user. This architecture provides a personalized organizational framework for the user. The framework is stored in the database with pointers to the appropriate cases and images, which are stored on the teaching file server.
The "department cases" page contains links to teaching cases classified by radiology subspecialty according to ACR categories. It also has search-able fields (similar to RSNA MIRC) to allow users to search for available cases in our teaching file system on the basis of several parameters. The "my collection" and "my unfinished cases" pages contain links to users’ completed or unfinished cases. All of the teaching case authoring pages ("add new case," "my collection," and "my unfinished cases") have the same page structure and information. The difference between the complete and unfinished pages lies in the state of the case, which can be "unfinished," "department," "MIRC," or "private." The "utilities" page allows users to add up to three e-mail addresses and to create and manage folders to categorize their teaching cases.
Our teaching file system can accept a MIRC-query (1,2) and return query results to the requester. Compatibility with RSNA MIRC software versions T12 and T16 has been confirmed (5). The MIRC software sends a MIRCquery via hypertext transfer protocol (HTTP) POST transaction to our Web server. The request invokes a Java servlet that extracts information from the MIRCquery based on the MIRCdocument (4) XML (extensible markup language) schema. The extracted information is used to formulate an SQL (structured query language) query to retrieve relevant teaching cases from our database. Once a result from the database is returned, a Java servlet constructs a MIRCquery-result for the Web server to return to the requester via an HTTP response.
A teaching case from our system can be viewed with Microsoft Internet Explorer 5 or above. A user must have an account to view cases. Once authenticated, the user can view the "department cases" Web page. Only the owner of a case can modify it and change its state. Cases that are assigned MIRC status can be queried via a MIRCquery interface.
Although we have designed and developed our teaching file system to be compatible with our GE Centricity PACS, the system is viable in any PACS environment that supports standard e-mail protocols.
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Discussion
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Radiology teaching files are an invaluable resource for education and research. Creation and communication of these teaching files constitute an integral part of medical education and promote better patient care. The digital transformation of radiology and the ensuing work flow changes pose many challenges to the teaching file creation process, including a limited ability to export digital images from commercially available PACS and a lack of built-in teaching file authoring tools. Available teaching file programs cannot be easily integrated into the clinical work flow, making file creation a disruptive and time-consuming act. In addition, many teaching file viewing applications are not optimally designed, having a complex, nonintuitive user interface. It is evident that new strategies must be considered when designing a teaching file system to be integrated into a digital clinical work flow.
Our highest priority was designing a teaching file system that would reduce the amount of time spent creating teaching cases and could be seamlessly integrated into radiologists’ clinical work flow. Teaching case creation with our system takes a fraction of the time it would take with the labor-intensive process described earlier and provides radiologists with the flexibility to either create their own teaching case text or recycle the text in the dictated report. As familiarity with the system increases, radiologists will become even more adept at using the keyword parsing system, thereby saving even more time in case creation by reducing manual text entry. In effect, all that is required of a radiologist to create a teaching case is to (a) identify the case on the PACS workstation, (b) send the relevant images and text to the teaching file system via e-mail, (c) wait for a notification e-mail from the system that his or her case is ready for review, (d) log on to the teaching file system to make the desired changes, and (e) classify the case in one of the predefined states.
This teaching file application has been developed and tested in a laboratory environment but has not yet been implemented as the departmental solution. Consequently, usage data and statistics are not yet available. However, the need for this tool is substantiated by the disparate procedures that faculty use to obtain images and create teaching cases from the PACS. The only solution provided within the GE Centricity PACS environment is a private collection of teaching cases, which does not promote availability of cases to anyone other than the creator.
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Conclusions
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We consider our case creation method via e-mail from the PACS to be a temporary solution until DICOM standard–based mechanisms for exporting teaching file references are developed by the IHE (Integrating the Healthcare Enterprise) initiative. In the meantime, this e-mail–based strategy models the three-step process necessary for efficient teaching file creation in a PACS environment.
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TAKE-HOME POINTS
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Identification of cases for inclusion in teaching files must be a core part of the routine radiology workload.
Standards for identifying these cases are currently being developed.
Once created, teaching files can be shared using the MIRC standard.
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References
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- A technical overview of MIRC community. Revision 1.0. Oak Brook, Ill: Radiological Society of North America, February 27, 2002.
- The MIRCquery and MIRCqueryresult schemas. Version 18. Oak Brook, Ill: Radiological Society of North America, September 13, 2003.
- The MIRCsiteindex schema. Version 3.0. Oak Brook, Ill: Radiological Society of North America, February 27, 2002.
- The MIRCdocument schema. Version 9.7. Oak Brook, Ill: Radiological Society of North America, October 28, 2003.
- The RSNA MIRC Software Release T16. Oak Brook, Ill: Radiological Society of North America, November 15, 2003.
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A. W. C. Kamauu, S. L. DuVall, R. J. Robison, A. P. Liimatta, R. H. Wiggins III, and D. E. Avrin
Informatics in Radiology (infoRAD): Vendor-Neutral Case Input into a Server-based Digital Teaching File System
RadioGraphics,
November 1, 2006;
26(6):
1877 - 1885.
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Abstract
Introduction
