- Email: [email protected]
Masking Personal Health Information on Real-time Echocardiographic Images
Masking Personal Health Information on Real-time Echocardiographic Images Roxann Rokey, MD, FACC, FASE, and G. Wesley Vick III, MD, PhD, FAAP, FACC, Marshfield, Wisconsin, and Houston, Texas
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rovisions of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 ensure patient confidentiality for all health care–related information. The requirements of HIPAA apply to any person or group storing and/or transmitting patient-identifiable information on electronic media. This affects physicians in the field of echocardiography, particularly when echocardiographic real-time images are shown for educational purposes. Identifying information needs to be masked or deleted. Frequently, real-time echocardiographic images shown in Power Point presentations for educational purposes are adjusted so the identifying information is extended beyond the field of view. In addition to containing identifying information, even unseen, this type of adjustment runs the risk of inadvertent exposure of identifying information. Although some digital imaging companies and software vendors provide the capability to mask or delete identifying information, not all do. Furthermore, videotaped images converted from analog to digital format also need to be stripped of identifying information (Figure 1). We report a relatively simple method to mask personal health information contained in real-time echocardiograms. This can be done on an office or home desktop or laptop computer using:
Figure 1 Static images of real-time echocardiogram movie with personal information and other data (left) and finished product with information hidden by separate video track masks (right).
RAM and 64 megabytes or more dedicated video RAM. Minimum computer configuration for an Apple Macintosh® is a 500-MHz G3 Power personal computer with 256 megabytes of RAM. Optimal computer configuration for a Macintosh
1. Echocardiographic real-time images saved in audio video interleave (AVI) format 2. Desktop or portable computer Most computers purchased in the past 2 to 3 years should work well. Minimum computer configuration for a Windows® Operating System personal computer should be a 700-MHz Pentium III with 256 megabytes of random access memory (RAM). Optimal configuration is a 2-gigahertz or above Pentium IV with 512 megabytes or more From the Marshfield Clinic, Department of Cardiology (R.R.), and Division of Cardiology, Texas Children’s Hospital, Department of Pediatrics, Baylor College of Medicine. Reprint requests: Roxann Rokey, MD, FACC, FASE, Marshfield Clinic, Department of Cardiology, 1000 N Oak Ave, Marshfield, WI 54449 (E-mail: [email protected]). J Am Soc Echocardiogr 2005;18:970-978. 0894-7317/$30.00 Copyright 2005 by the American Society of Echocardiography. doi:10.1016/j.echo.2004.12.016
970
Figure 2 Making mask to cover personal health information. Black rectangle is created using software drawing program and saved in BMP or JPEG format for future use in current session and for subsequent sessions on other days. In this example, 1-in ⫻ 0.5-in mask is made.
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is a 1-gigahertz or better G4 or G5 Power personal computer with 512 megabytes or more RAM and 64 megabytes or more dedicated video RAM. 3. Quick Time Pro from Apple Computer Quick Time Pro software is selected for several reasons a. The Pro version, which is required to produce the masked digital movies, is inexpensive (⬍ $50) b. It runs well on both Windows and Macintosh personal computers c. Editing of the digital movies with Quick Time Pro is simple and intuitive, with selection, cut, and paste operations analogous to those used in word processing d. The masked movies produced can be viewed effectively by any of a number of free display programs, such as Windows Media Player or the standard version of Quick Time. Furthermore, the produced movies are easily imported into Power Point presentations. 4. Any software program capable of providing BMP or JPEG image for use as a mask
OVERVIEW The process of producing a masked study requires 4 steps: (1) make the mask and import it into Quick Time Pro; (2) import the real-time echocardiographic study into Quick Time Pro; (3) add the mask to the real-time echocardiogram; and (4) export the masked echocardiogram. Making the Mask and Importing it into Quick Time Pro The mask creation. Create a 1-in ⫻ 0.5-in black rectangle using any software drawing program and save in JPEG or BMP format (Figure 2). Store in a file that is easily accessible. This will be used for masking all future real-time echocardiographic studies. Importing the mask into Quick Time Pro. Open Quick Time Pro. Select “File” and pull down to “Import. . .” (Figure 3, A). This will open a window that allows selection of the mask just created/saved (Figure 3, B). After selection, click on “Open.” The mask will appear in new Quick Time Pro window (Figure 3, C). Copying the imported mask. Next, the imported mask will need to be copied. Do this by selecting “Edit” from the toolbar. Under “Edit,” scroll to “Select All” and then to “Copy” (Figure 4, A and B). This copied mask can be pasted repeatedly to identifying information on the real-time echocardiographic study during the masking procedure (see
Figure 3 Importing mask into Quick Time Pro.
next section). It can also be saved in Quick Time Pro format for use in subsequent sessions so the initial steps of creating and importing the mask to Quick Time Pro are not necessary. Importing the Real-time Echocardiographic Study into Quick Time Pro The next step is to import the real-time echocardiographic image into Quick Time Pro. The instructions for this are similar to that for importing the mask. On the original Quick Time pro window, select “File”
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Figure 4 Selecting and copying mask imported into Quick Time Pro for subsequent addition to real-time echocardiographic movie.
Figure 5 Importing the real-time echocardiogram into Quick Time Pro. Description of how real-time echocardiographic movie saved originally in AVI format is imported into Quick Time Pro. Window is separate from one used to import mask. Real-time echocardiogram is now movie contained in video track 1.
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Rokey and Vick 973
Adding the Mask to the Real-time Echocardiogram This step will allow addition of the mask to the real-time movie. Select the window containing the real-time echocardiographic image. Choose “Edit” on the toolbar and scroll to “Add Scaled” (Figure 6, A). This will add the copied mask (done earlier; see Figure 4) to the upper left-hand portion of the window containing the real-time echocardiographic image (Figure 6, B). Resizing the mask to cover personal health information. Once the masked is added, select “Movie”
on the menu bar and scroll to select “Get Movie Properties” Figure 7, A. This will open another window with left and right drop-down selection options (Figure 7, B). On the left box, scroll to “Video Track 2” (video track 1 is the original realtime movie). Then on the right box, scroll to “Size.” Then click “Adjust” (Figure 7, C). This will allow the mask added on “Video Track 2” to be resized. Click on the mask and adjust to cover the desired information (Figure 7, D). When completed, select “Done” (Figure 7, E). Play the movie (Figure 7, F). Resizing additional masks to cover personal health information. The procedure of adding the
mask and resizing the mask to cover information can be repeated as many times as needed. It is important to remember that, if another mask is added, another video track will be added. The new video track needs to be selected to resize the newly added mask (Figure 8, A-F). Exporting the Masked Echocardiogram
Figure 6 Adding mask to real-time echocardiogram movie. Steps describe how copied mask in separate Quick Time Pro window (Figure 4) is added to real-time echocardiographic movie.
on the toolbar and pull down to “Open Movie in New Player” (Figure 5, A). Open the desired realtime echocardiogram that is saved as a movie in AVI format (Figure 5, B). The movie with identifying information now appears in Quick Time Pro on video track 1 (Figure 5, C).
If the echocardiogram just completed is to be played in Power Point, or on devices that do not have Quick Time, then the study needs to be converted to a format that is easily recognized by many programs. At the current time, AVI files are most easily imported into Power Point and other media. We describe below the means to complete the conversion. Preparing for exporting. Select “File” from the Quick Time Pro menu and scroll to “Export” (Figure 9, A). The “Save exported file as:” window will appear (Figure 9, B). Pick the appropriate folder to save the echocardiographic image file. If using the same folder where the original study resides, use another name for the file so the original is not overwritten. Be sure to add the extension .avi to the file name. Next, to “Export” scroll “Movie to AVI.” Next to “Use,” scroll and select “Most Recent Settings.” Then select “Options.” As explained in the next section, the “Options” tab will allow choice of compression algorithm and other important features that enhance viewing of the finished product. Once the compression settings are chosen, the “Most Recent Settings” will default to the compression
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Figure 7 Steps to resize mask added to real-time echocardiographic movie. Mask just added to real-time echocardiographic movie is automatically assigned to video track 2. Its size can be adjusted to cover personal health information. D, Mask is lengthened horizontally at top of movie to cover patient name and procedure date.
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Figure 8 Procedure of adding and resizing additional masks is similar to steps described in Figures 6 and 7. Each new mask added will have its own separate video track. Appropriate video track needs to be chosen when resizing mask. D, Additional mask is moved to right, lengthened vertically, and widened. F, Image without identifying information.
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settings selected for all future studies during the session. Selecting compression settings. Most computers today will have a choice of several compression algorithms. When “Options” is chosen, the “AVI Settings” window will open. Check “Video” and choose “Settings. . .” (Figure 10, A). The “Compression Settings” window will open (Figure 10, B). In the top window, scroll to “Cinepack” to select this compression algorithm. Choose “Millions of Colors” from the “Depth” setting. Select “Medium Quality” and 29.97 frames/s. “Key frame every” and “Limit data rate to” should not be checked. Select “OK.” The “AVI Settings” window will appear again (Figure 10, C). Be sure the compression settings just chosen are reflected, and then select “OK.” This will bring back the “Save exported file as:” window (Figure 10, D). Exporting the AVI file. The window depicted in Figure 10, D, will be used to save the masked study. Select the “Save” key (Figure 11, A). This process should take several seconds to minutes, depending on the speed of the computer. Once completed, the new image should be present in the folder to which it is saved (Figure 11, B). The masked study then can be used for placement into presentations such as Power Point or other compatible image display programs.
Cautions and Suggestions
Figure 9 Preparation for exporting completed study. Movie needs to be converted to format that is easily recognized by many programs. Study is prepared for exporting (A). “Save exported file as:” window will appear (B). File name different from original is used and AVI extension should be added to that file name. Additional selections in “Save exported file as:” window are made as described in text.
Selection of compression settings can be one of the most problematic steps in producing or displaying any produced movie. When using the compression settings described above, the produced images can be played on most computers. Although there are many other codecs (compression/decompression algorithm) available, “Cinepak” is the most widely compatible with other systems. If needed, the “Depth” selection can be altered to “256 Grays” if only grayscale video is desired. The “Quality” setting that is most desirable is dependent on the type of computer on which the study is to be played. “Medium” quality is a safe choice with most currently operative computers. If the playback computer is powerful, however, the “High” or “Best” quality settings can be used. The “Key frame every” box is typically unchecked. However, if the operator plans frequent stops or freeze frames during the presentation of the produced video elsewhere, it may be helpful to check the box and enter “30.” Normally, the “Limit data rate to” box is also unchecked. However, if the resultant video does not play smoothly, it may be helpful to check the box and limit the data rate to somewhere between 300 and 700 Kbytes/s, depending on the speed of the playback computer.
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Figure 10 Selecting compression settings. Compression algorithm is accessed by choosing “Options” key as described in Figure 9, B. The “AVI Settings” window will appear where video box and settings tab are selected (A). “Compressions Settings” window will appear. In window, at top, “Cinepack” video compression algorithm is selected (B). Depth, quality, frame rate, and other parameters are selected (B) (also see “Cautions and Suggestions”). When completed, select “OK.” Settings are confirmed in C and then “OK” is chosen. “Save exported file as:” reappears and now contains chosen compression settings. File is now ready to be exported (D).
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Conclusion The method described easily allows personal health information to be masked in real-time echocardiographic images. The process is relatively easy, rapid, and ensures patient confidentiality. Once the initial real-time echocardiogram is masked, subsequent additional studies in a current session and those of future sessions are easier to do, because the mask is saved and appropriate compression settings are selected. The technique described is routinely used to make real-time masked echocardiographic movies for free display programs and Power Point at the local and national level.
Figure 11 Once settings for compression and exportation are confirmed, study is saved (A). This may take several seconds or minutes to render depending on speed of computer and file size. Once file is exported, location is confirmed (B). Masked study can then be used in presentation software such as Power Point or other compatible image display programs (C).
P
rovisions of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 ensure patient confidentiality for all health care–related information. The requirements of HIPAA apply to any person or group storing and/or transmitting patient-identifiable information on electronic media. This affects physicians in the field of echocardiography, particularly when echocardiographic real-time images are shown for educational purposes. Identifying information needs to be masked or deleted. Frequently, real-time echocardiographic images shown in Power Point presentations for educational purposes are adjusted so the identifying information is extended beyond the field of view. In addition to containing identifying information, even unseen, this type of adjustment runs the risk of inadvertent exposure of identifying information. Although some digital imaging companies and software vendors provide the capability to mask or delete identifying information, not all do. Furthermore, videotaped images converted from analog to digital format also need to be stripped of identifying information (Figure 1). We report a relatively simple method to mask personal health information contained in real-time echocardiograms. This can be done on an office or home desktop or laptop computer using:
Figure 1 Static images of real-time echocardiogram movie with personal information and other data (left) and finished product with information hidden by separate video track masks (right).
RAM and 64 megabytes or more dedicated video RAM. Minimum computer configuration for an Apple Macintosh® is a 500-MHz G3 Power personal computer with 256 megabytes of RAM. Optimal computer configuration for a Macintosh
1. Echocardiographic real-time images saved in audio video interleave (AVI) format 2. Desktop or portable computer Most computers purchased in the past 2 to 3 years should work well. Minimum computer configuration for a Windows® Operating System personal computer should be a 700-MHz Pentium III with 256 megabytes of random access memory (RAM). Optimal configuration is a 2-gigahertz or above Pentium IV with 512 megabytes or more From the Marshfield Clinic, Department of Cardiology (R.R.), and Division of Cardiology, Texas Children’s Hospital, Department of Pediatrics, Baylor College of Medicine. Reprint requests: Roxann Rokey, MD, FACC, FASE, Marshfield Clinic, Department of Cardiology, 1000 N Oak Ave, Marshfield, WI 54449 (E-mail: [email protected]). J Am Soc Echocardiogr 2005;18:970-978. 0894-7317/$30.00 Copyright 2005 by the American Society of Echocardiography. doi:10.1016/j.echo.2004.12.016
970
Figure 2 Making mask to cover personal health information. Black rectangle is created using software drawing program and saved in BMP or JPEG format for future use in current session and for subsequent sessions on other days. In this example, 1-in ⫻ 0.5-in mask is made.
Journal of the American Society of Echocardiography Volume 18 Number 9
Rokey and Vick 971
is a 1-gigahertz or better G4 or G5 Power personal computer with 512 megabytes or more RAM and 64 megabytes or more dedicated video RAM. 3. Quick Time Pro from Apple Computer Quick Time Pro software is selected for several reasons a. The Pro version, which is required to produce the masked digital movies, is inexpensive (⬍ $50) b. It runs well on both Windows and Macintosh personal computers c. Editing of the digital movies with Quick Time Pro is simple and intuitive, with selection, cut, and paste operations analogous to those used in word processing d. The masked movies produced can be viewed effectively by any of a number of free display programs, such as Windows Media Player or the standard version of Quick Time. Furthermore, the produced movies are easily imported into Power Point presentations. 4. Any software program capable of providing BMP or JPEG image for use as a mask
OVERVIEW The process of producing a masked study requires 4 steps: (1) make the mask and import it into Quick Time Pro; (2) import the real-time echocardiographic study into Quick Time Pro; (3) add the mask to the real-time echocardiogram; and (4) export the masked echocardiogram. Making the Mask and Importing it into Quick Time Pro The mask creation. Create a 1-in ⫻ 0.5-in black rectangle using any software drawing program and save in JPEG or BMP format (Figure 2). Store in a file that is easily accessible. This will be used for masking all future real-time echocardiographic studies. Importing the mask into Quick Time Pro. Open Quick Time Pro. Select “File” and pull down to “Import. . .” (Figure 3, A). This will open a window that allows selection of the mask just created/saved (Figure 3, B). After selection, click on “Open.” The mask will appear in new Quick Time Pro window (Figure 3, C). Copying the imported mask. Next, the imported mask will need to be copied. Do this by selecting “Edit” from the toolbar. Under “Edit,” scroll to “Select All” and then to “Copy” (Figure 4, A and B). This copied mask can be pasted repeatedly to identifying information on the real-time echocardiographic study during the masking procedure (see
Figure 3 Importing mask into Quick Time Pro.
next section). It can also be saved in Quick Time Pro format for use in subsequent sessions so the initial steps of creating and importing the mask to Quick Time Pro are not necessary. Importing the Real-time Echocardiographic Study into Quick Time Pro The next step is to import the real-time echocardiographic image into Quick Time Pro. The instructions for this are similar to that for importing the mask. On the original Quick Time pro window, select “File”
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Figure 4 Selecting and copying mask imported into Quick Time Pro for subsequent addition to real-time echocardiographic movie.
Figure 5 Importing the real-time echocardiogram into Quick Time Pro. Description of how real-time echocardiographic movie saved originally in AVI format is imported into Quick Time Pro. Window is separate from one used to import mask. Real-time echocardiogram is now movie contained in video track 1.
Journal of the American Society of Echocardiography Volume 18 Number 9
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Adding the Mask to the Real-time Echocardiogram This step will allow addition of the mask to the real-time movie. Select the window containing the real-time echocardiographic image. Choose “Edit” on the toolbar and scroll to “Add Scaled” (Figure 6, A). This will add the copied mask (done earlier; see Figure 4) to the upper left-hand portion of the window containing the real-time echocardiographic image (Figure 6, B). Resizing the mask to cover personal health information. Once the masked is added, select “Movie”
on the menu bar and scroll to select “Get Movie Properties” Figure 7, A. This will open another window with left and right drop-down selection options (Figure 7, B). On the left box, scroll to “Video Track 2” (video track 1 is the original realtime movie). Then on the right box, scroll to “Size.” Then click “Adjust” (Figure 7, C). This will allow the mask added on “Video Track 2” to be resized. Click on the mask and adjust to cover the desired information (Figure 7, D). When completed, select “Done” (Figure 7, E). Play the movie (Figure 7, F). Resizing additional masks to cover personal health information. The procedure of adding the
mask and resizing the mask to cover information can be repeated as many times as needed. It is important to remember that, if another mask is added, another video track will be added. The new video track needs to be selected to resize the newly added mask (Figure 8, A-F). Exporting the Masked Echocardiogram
Figure 6 Adding mask to real-time echocardiogram movie. Steps describe how copied mask in separate Quick Time Pro window (Figure 4) is added to real-time echocardiographic movie.
on the toolbar and pull down to “Open Movie in New Player” (Figure 5, A). Open the desired realtime echocardiogram that is saved as a movie in AVI format (Figure 5, B). The movie with identifying information now appears in Quick Time Pro on video track 1 (Figure 5, C).
If the echocardiogram just completed is to be played in Power Point, or on devices that do not have Quick Time, then the study needs to be converted to a format that is easily recognized by many programs. At the current time, AVI files are most easily imported into Power Point and other media. We describe below the means to complete the conversion. Preparing for exporting. Select “File” from the Quick Time Pro menu and scroll to “Export” (Figure 9, A). The “Save exported file as:” window will appear (Figure 9, B). Pick the appropriate folder to save the echocardiographic image file. If using the same folder where the original study resides, use another name for the file so the original is not overwritten. Be sure to add the extension .avi to the file name. Next, to “Export” scroll “Movie to AVI.” Next to “Use,” scroll and select “Most Recent Settings.” Then select “Options.” As explained in the next section, the “Options” tab will allow choice of compression algorithm and other important features that enhance viewing of the finished product. Once the compression settings are chosen, the “Most Recent Settings” will default to the compression
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Figure 7 Steps to resize mask added to real-time echocardiographic movie. Mask just added to real-time echocardiographic movie is automatically assigned to video track 2. Its size can be adjusted to cover personal health information. D, Mask is lengthened horizontally at top of movie to cover patient name and procedure date.
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Figure 8 Procedure of adding and resizing additional masks is similar to steps described in Figures 6 and 7. Each new mask added will have its own separate video track. Appropriate video track needs to be chosen when resizing mask. D, Additional mask is moved to right, lengthened vertically, and widened. F, Image without identifying information.
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settings selected for all future studies during the session. Selecting compression settings. Most computers today will have a choice of several compression algorithms. When “Options” is chosen, the “AVI Settings” window will open. Check “Video” and choose “Settings. . .” (Figure 10, A). The “Compression Settings” window will open (Figure 10, B). In the top window, scroll to “Cinepack” to select this compression algorithm. Choose “Millions of Colors” from the “Depth” setting. Select “Medium Quality” and 29.97 frames/s. “Key frame every” and “Limit data rate to” should not be checked. Select “OK.” The “AVI Settings” window will appear again (Figure 10, C). Be sure the compression settings just chosen are reflected, and then select “OK.” This will bring back the “Save exported file as:” window (Figure 10, D). Exporting the AVI file. The window depicted in Figure 10, D, will be used to save the masked study. Select the “Save” key (Figure 11, A). This process should take several seconds to minutes, depending on the speed of the computer. Once completed, the new image should be present in the folder to which it is saved (Figure 11, B). The masked study then can be used for placement into presentations such as Power Point or other compatible image display programs.
Cautions and Suggestions
Figure 9 Preparation for exporting completed study. Movie needs to be converted to format that is easily recognized by many programs. Study is prepared for exporting (A). “Save exported file as:” window will appear (B). File name different from original is used and AVI extension should be added to that file name. Additional selections in “Save exported file as:” window are made as described in text.
Selection of compression settings can be one of the most problematic steps in producing or displaying any produced movie. When using the compression settings described above, the produced images can be played on most computers. Although there are many other codecs (compression/decompression algorithm) available, “Cinepak” is the most widely compatible with other systems. If needed, the “Depth” selection can be altered to “256 Grays” if only grayscale video is desired. The “Quality” setting that is most desirable is dependent on the type of computer on which the study is to be played. “Medium” quality is a safe choice with most currently operative computers. If the playback computer is powerful, however, the “High” or “Best” quality settings can be used. The “Key frame every” box is typically unchecked. However, if the operator plans frequent stops or freeze frames during the presentation of the produced video elsewhere, it may be helpful to check the box and enter “30.” Normally, the “Limit data rate to” box is also unchecked. However, if the resultant video does not play smoothly, it may be helpful to check the box and limit the data rate to somewhere between 300 and 700 Kbytes/s, depending on the speed of the playback computer.
Journal of the American Society of Echocardiography Volume 18 Number 9
Rokey and Vick 977
Figure 10 Selecting compression settings. Compression algorithm is accessed by choosing “Options” key as described in Figure 9, B. The “AVI Settings” window will appear where video box and settings tab are selected (A). “Compressions Settings” window will appear. In window, at top, “Cinepack” video compression algorithm is selected (B). Depth, quality, frame rate, and other parameters are selected (B) (also see “Cautions and Suggestions”). When completed, select “OK.” Settings are confirmed in C and then “OK” is chosen. “Save exported file as:” reappears and now contains chosen compression settings. File is now ready to be exported (D).
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Conclusion The method described easily allows personal health information to be masked in real-time echocardiographic images. The process is relatively easy, rapid, and ensures patient confidentiality. Once the initial real-time echocardiogram is masked, subsequent additional studies in a current session and those of future sessions are easier to do, because the mask is saved and appropriate compression settings are selected. The technique described is routinely used to make real-time masked echocardiographic movies for free display programs and Power Point at the local and national level.
Figure 11 Once settings for compression and exportation are confirmed, study is saved (A). This may take several seconds or minutes to render depending on speed of computer and file size. Once file is exported, location is confirmed (B). Masked study can then be used in presentation software such as Power Point or other compatible image display programs (C).