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The Use of a Picture Archiving and Communication System to Catalogue Visible-Light Photographic Images
The Use of a Picture Archiving and Communication System to Catalogue Visible-Light Photographic Images James E. Silberzweig, MD, Azita S. Khorsandi, MD, Tarek El-Shayal, MD, and Michael M. Abiri, MD
The purpose of this study was to demonstrate that anatomic visible-light photographs can be catalogued using a system primarily intended for viewing radiographic images. One hundred four patients from April 2004 through November 2005 were evaluated for lower extremity venous insufficiency, lower extremity varicose veins, and/or telangiectasias. All consultation reports, duplex ultrasound reports with images, and lower extremity photographic images were archived in the radiology department’s picture archiving and communication system. The picture archiving and communication system provides an electronic alternative to using a conventional, manual, or analog method of storing photographic images. Use of a picture archiving and communication system for the archiving of photographic images can be a valuable tool for an interventional radiologist’s vein practice. J Vasc Interv Radiol 2007; 18:577–579 Abbreviations: DICOM ⫽ Digital Imaging and Communications in Medicine, HIPPA ⫽ Health Insurance Portability and Accountability Act, JPEG ⫽ Joint Photographic Experts Group, PACS ⫽ picture archiving and communication system, TIFF ⫽ Tagged Image File Format
RECENT developments in the percutaneous treatment of venous insufficiency have allowed evaluation and management of lower extremity varicose veins/venous insufficiency to become a significant component of many interventional radiology practices (1,2). Typically, the documentation of an initial clinical evaluation of a patient with lower extremity venous insufficiency includes a consultation report, a lower extremity venous duplex ultrasound, and photographs of the lower extremities. Data may be stored in a hard-copy file folder or in a computer database. Among the limitations
From the Department of Radiology, St. Luke’s-Roosevelt Hospital Center, 1000 Tenth Avenue, New York, NY 10019 (J.E.S., T.E-S., M.M.A.); and the Department of Radiology, Beth Israel Medical Center, New York, NY (A.S.K.). Received July 24, 2006; final revision received January 22, 2007; accepted February 4, 2007. Address correspondence to J.E.S.; E-mail: [email protected] None of the authors have identified a conflict of interest. © SIR, 2007 DOI: 10.1016/j.jvir.2007.02.005
enforced by maintaining a hard-copy system are the inadequate capabilities of image backup and redundancy, high image developing expenses, and the inability to access patient data from any remote site, if needed. Nowadays, most modern radiology departments use an enterprise picture archiving and communication system (PACS) for radiographic image and report viewing and historical archival. Nevertheless, the use of radiology department PACS tools can be extended beyond conventional radiology imaging to include secondary document acquisition, such as scanned documents and prescriptions, as well as the archival of photographic (visible-light) images. The purpose of this study was to demonstrate our experience with the use of a conventional PACS primarily intended for radiographic images for viewing and archiving of visible-light images.
MATERIALS AND METHODS Between April 2004 and November 2005, 104 patients (92 women, 12 men; mean age, 44 years) were evaluated for
lower extremity venous insufficiency, lower extremity varicose veins, and/or telangiectasias. Clinical evaluations were performed in a freestanding outpatient interventional radiology facility. The clinical evaluation documentation consisted of a consultation report, venous duplex sonogram, and photographs of the lower extremities. Photographs were taken using a commercially available digital camera (Canon PowerShot G5; Canon, Lake Success, NY) as JPEG (Joint Photographic Experts Group) files. All images were taken using the standard automatic focus and exposure camera functions with 5-megapixel JPEG settings on fine resolution (the highest available for the camera). A neutral-colored background was used. Automatic flash was employed with standard overhead fluorescent room lighting. Photographs were taken an average of 2 m from the patient. Typically, photographs of the patient’s lower extremities included four views: anterior, posterior, lateral right, and lateral left. An assistant positioned the patient’s hard-copy file folder (listing the patient’s name and
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April 2007
Use of PACS to Catalogue Visible-Light Photographic Images
JVIR
DISCUSSION
Figure. Screenshot demonstrating photographic image on PACS of a 33-year-old woman with right lower extremity venous insufficiency/varicose veins. The screen includes the photographic image as well as demographic information and date.
medical record number next to the patient) to be included in each photograph. The consultation report and duplex ultrasound reports with images were archived in the radiology department PACS. The images and reports were archived using a method similar to the method used to process any other type of radiology study (ultrasound, computed tomography, magnetic resonance imaging, nuclear medicine, mammography, etc). After that, the photographic images were transferred from the camera to a conventional desktop personal computer (Dell, Inc., Round Rock, TX) as a JPEG file format using a USB card reader. The images were then manipulated (rotated and cropped) as needed using Microsoft Office Picture Manager (Microsoft, Redmond, WA). The images were thus transferred back from the desktop computer to a USB 2.0 flash drive (PNY Technologies, Parsippany, NJ) and then uploaded to the PACS using the tools of a dedicated PACS workstation (Horizon Review Station, version 4.6.1; McKesson Medical Imaging, Vancouver, BC, Canada). The PACS system encapsulated the JPEG images with a wrapper. The wrapper created Digital Imaging and Communications in Medicine (DICOM) objects from the non-DICOM JPEG
files. The photographic image files were archived with each patient’s clinical consultation report and sonogram. This retrospective Health Insurance Portability and Accountability Act (HIPAA)-compliant study was performed after the institutional review board deemed the study to be exempt from review and not to require patient informed consent.
RESULTS The photographic images for all 104 patients were uploaded to the PACS as images associated with the clinical consultation. Subjectively, the JPEG images displayed on a color computer monitor linked with the PACS were of comparable quality with the images displayed on a conventional desktop computer monitor. The PACS display included the photographic image along with the demographic information including the patient’s name, date, medical record number, exam type, and patient’s age (Figure). Images could also be subsequently exported to a compact disc (CD) or a USB 2.0 flash drive for transfer to a computer linked to a paper color printer.
The location and extent of venous disease is documented by written description in the consultation report, duplex sonogram, and with photographs. Findings including varicosities, telangiectasias, skin color changes, and ulcerations are readily demonstrated in photographs. Photographic documentation can be used as a guide to evaluate treatment progress for both the treating physician and the patient. Additionally, insurance carriers may request photographic documentation. In our practice, prior to the implementation of photographic image transfer to PACS, all photographic images were transferred from the camera to a conventional desktop computer as JPEG files. The files were either stored in the computer hard drive with intermittent backup made onto CD or were printed on paper and filed in the patient’s hard-copy folder. These photographs were archived separately from the radiology department PACS data. Limitations of our previous photographic image archive system included the inability to access the photographs from a remote workstation, limited backup capability, and the requirement to access separate databases to evaluate a single patient’s clinical data. Additionally, a separately named computer file folder needed to be created for each patient. In our experience, the use of our PACS for photographic image storage has been quite reliable. The PACS has been widely used in our radiology department daily practice routine for the past 5 years. On a typical weekday, more than 1,200 radiology examinations are sent to the radiology department PACS. Modalities capable of sending images to PACS include computed tomography, magnetic resonance imaging, interventional radiology, sonography, nuclear medicine, computed radiography, and digital mammography. Image storage capacity with this system is virtually limitless. Data is stored in a series of network server hard-drives as a tier 1 archive. Another backup is stored in an offsite storage location. Additional data backup on tape is performed as the disaster recovery solution giving the site a three-tier redundancy of image archive.
Volume 18
Number 4
The use of PACS at other medical centers has been extended to manage all medical images acquired within the hospital including nonradiology imaging applications such as endoscopy and microscopy images in addition to photographic images obtained in dermatology and ophthalmology (3,4). Most PACS can import files from multiple formats including JPEG, Tagged Image File Format (TIFF), and DICOM. One report demonstrated experience with the ability of a PACS to integrate outside imaging studies on CD-R and transfer the data into a local PACS (5). We used the JPEG format for image acquisition and transfer to the PACS. In general, the major advantage for using TIFF over JPEG is that TIFF gives the best quality image because it is uncompressed (lossless). However, use of TIFF comes at the expense of large image size (6). Digital camera images of patients acquired in JPEG format have been shown to be reliable
Silberzweig et al
for plastic surgery and vascular surgery (7,8). Photographic image import to a PACS can be a valuable tool for an interventional radiologist’s vein practice. Secondary capture of JPEG files is a feature that should be considered when purchasing or upgrading a PACS. A PACS provides access to a reliable, secure, HIPAA-compliant, virtually limitless image and clinical data archive offering the clinician a complete, chronological view of the patient clinical record. References 1. Min RJ, Khilnani N, Zimmet SE. Endovenous laser treatment of saphenous vein reflux: long-term results. J Vasc Interv Radiol 2003; 14:991–996. 2. Merchant RF, Pichot O; Closure Study Group. Long-term outcomes of endovenous radiofrequency obliteration of saphenous reflux as a treatment for superficial venous insufficiency. J Vasc Surg 2005; 42:502–509. 3. Kuzmak PM, Dayhoff RE. The use of digital imaging and communications in
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7.
8.
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579
medicine (DICOM) in the integration of imaging into the electronic patient record at the Department of Veterans Affairs. J Digit Imaging 2000;13:133–137. Bandon D, Lovis C, Geissbuhler A, Vallee JP. Enterprise-wide PACS: beyond radiology, an architecture to manage all medical images. Acad Radiol 2005; 12:1000 –1009. van Ooijen PM, Guignot J, Mevel G, Oudkerk M. Incorporating out-patient data from CD-R into the local PACS using DICOM worklist features. J Digit Imaging 2005; 18:196 –202. LaBerge JM, Andriole KP. Digital image processing: a primer for JVIR authors and readers: part 1: the fundamentals. J Vasc Interv Radiol 2003; 14:1223– 1230. Galdino GM, Vogel JE, Vander Kolk CA. Standardizing digital photography: it’s not all in the eye of the beholder. Plast Reconstr Surg 2001; 108:1334 –1344. Murphy RX Jr, Bain MA, Wasser TE, Wilson E, Okunski WJ. The reliability of digital imaging in the remote assessment of wounds: defining a standard. Ann Plast Surg 2006; 56:431– 436.
The purpose of this study was to demonstrate that anatomic visible-light photographs can be catalogued using a system primarily intended for viewing radiographic images. One hundred four patients from April 2004 through November 2005 were evaluated for lower extremity venous insufficiency, lower extremity varicose veins, and/or telangiectasias. All consultation reports, duplex ultrasound reports with images, and lower extremity photographic images were archived in the radiology department’s picture archiving and communication system. The picture archiving and communication system provides an electronic alternative to using a conventional, manual, or analog method of storing photographic images. Use of a picture archiving and communication system for the archiving of photographic images can be a valuable tool for an interventional radiologist’s vein practice. J Vasc Interv Radiol 2007; 18:577–579 Abbreviations: DICOM ⫽ Digital Imaging and Communications in Medicine, HIPPA ⫽ Health Insurance Portability and Accountability Act, JPEG ⫽ Joint Photographic Experts Group, PACS ⫽ picture archiving and communication system, TIFF ⫽ Tagged Image File Format
RECENT developments in the percutaneous treatment of venous insufficiency have allowed evaluation and management of lower extremity varicose veins/venous insufficiency to become a significant component of many interventional radiology practices (1,2). Typically, the documentation of an initial clinical evaluation of a patient with lower extremity venous insufficiency includes a consultation report, a lower extremity venous duplex ultrasound, and photographs of the lower extremities. Data may be stored in a hard-copy file folder or in a computer database. Among the limitations
From the Department of Radiology, St. Luke’s-Roosevelt Hospital Center, 1000 Tenth Avenue, New York, NY 10019 (J.E.S., T.E-S., M.M.A.); and the Department of Radiology, Beth Israel Medical Center, New York, NY (A.S.K.). Received July 24, 2006; final revision received January 22, 2007; accepted February 4, 2007. Address correspondence to J.E.S.; E-mail: [email protected] None of the authors have identified a conflict of interest. © SIR, 2007 DOI: 10.1016/j.jvir.2007.02.005
enforced by maintaining a hard-copy system are the inadequate capabilities of image backup and redundancy, high image developing expenses, and the inability to access patient data from any remote site, if needed. Nowadays, most modern radiology departments use an enterprise picture archiving and communication system (PACS) for radiographic image and report viewing and historical archival. Nevertheless, the use of radiology department PACS tools can be extended beyond conventional radiology imaging to include secondary document acquisition, such as scanned documents and prescriptions, as well as the archival of photographic (visible-light) images. The purpose of this study was to demonstrate our experience with the use of a conventional PACS primarily intended for radiographic images for viewing and archiving of visible-light images.
MATERIALS AND METHODS Between April 2004 and November 2005, 104 patients (92 women, 12 men; mean age, 44 years) were evaluated for
lower extremity venous insufficiency, lower extremity varicose veins, and/or telangiectasias. Clinical evaluations were performed in a freestanding outpatient interventional radiology facility. The clinical evaluation documentation consisted of a consultation report, venous duplex sonogram, and photographs of the lower extremities. Photographs were taken using a commercially available digital camera (Canon PowerShot G5; Canon, Lake Success, NY) as JPEG (Joint Photographic Experts Group) files. All images were taken using the standard automatic focus and exposure camera functions with 5-megapixel JPEG settings on fine resolution (the highest available for the camera). A neutral-colored background was used. Automatic flash was employed with standard overhead fluorescent room lighting. Photographs were taken an average of 2 m from the patient. Typically, photographs of the patient’s lower extremities included four views: anterior, posterior, lateral right, and lateral left. An assistant positioned the patient’s hard-copy file folder (listing the patient’s name and
577
578
•
April 2007
Use of PACS to Catalogue Visible-Light Photographic Images
JVIR
DISCUSSION
Figure. Screenshot demonstrating photographic image on PACS of a 33-year-old woman with right lower extremity venous insufficiency/varicose veins. The screen includes the photographic image as well as demographic information and date.
medical record number next to the patient) to be included in each photograph. The consultation report and duplex ultrasound reports with images were archived in the radiology department PACS. The images and reports were archived using a method similar to the method used to process any other type of radiology study (ultrasound, computed tomography, magnetic resonance imaging, nuclear medicine, mammography, etc). After that, the photographic images were transferred from the camera to a conventional desktop personal computer (Dell, Inc., Round Rock, TX) as a JPEG file format using a USB card reader. The images were then manipulated (rotated and cropped) as needed using Microsoft Office Picture Manager (Microsoft, Redmond, WA). The images were thus transferred back from the desktop computer to a USB 2.0 flash drive (PNY Technologies, Parsippany, NJ) and then uploaded to the PACS using the tools of a dedicated PACS workstation (Horizon Review Station, version 4.6.1; McKesson Medical Imaging, Vancouver, BC, Canada). The PACS system encapsulated the JPEG images with a wrapper. The wrapper created Digital Imaging and Communications in Medicine (DICOM) objects from the non-DICOM JPEG
files. The photographic image files were archived with each patient’s clinical consultation report and sonogram. This retrospective Health Insurance Portability and Accountability Act (HIPAA)-compliant study was performed after the institutional review board deemed the study to be exempt from review and not to require patient informed consent.
RESULTS The photographic images for all 104 patients were uploaded to the PACS as images associated with the clinical consultation. Subjectively, the JPEG images displayed on a color computer monitor linked with the PACS were of comparable quality with the images displayed on a conventional desktop computer monitor. The PACS display included the photographic image along with the demographic information including the patient’s name, date, medical record number, exam type, and patient’s age (Figure). Images could also be subsequently exported to a compact disc (CD) or a USB 2.0 flash drive for transfer to a computer linked to a paper color printer.
The location and extent of venous disease is documented by written description in the consultation report, duplex sonogram, and with photographs. Findings including varicosities, telangiectasias, skin color changes, and ulcerations are readily demonstrated in photographs. Photographic documentation can be used as a guide to evaluate treatment progress for both the treating physician and the patient. Additionally, insurance carriers may request photographic documentation. In our practice, prior to the implementation of photographic image transfer to PACS, all photographic images were transferred from the camera to a conventional desktop computer as JPEG files. The files were either stored in the computer hard drive with intermittent backup made onto CD or were printed on paper and filed in the patient’s hard-copy folder. These photographs were archived separately from the radiology department PACS data. Limitations of our previous photographic image archive system included the inability to access the photographs from a remote workstation, limited backup capability, and the requirement to access separate databases to evaluate a single patient’s clinical data. Additionally, a separately named computer file folder needed to be created for each patient. In our experience, the use of our PACS for photographic image storage has been quite reliable. The PACS has been widely used in our radiology department daily practice routine for the past 5 years. On a typical weekday, more than 1,200 radiology examinations are sent to the radiology department PACS. Modalities capable of sending images to PACS include computed tomography, magnetic resonance imaging, interventional radiology, sonography, nuclear medicine, computed radiography, and digital mammography. Image storage capacity with this system is virtually limitless. Data is stored in a series of network server hard-drives as a tier 1 archive. Another backup is stored in an offsite storage location. Additional data backup on tape is performed as the disaster recovery solution giving the site a three-tier redundancy of image archive.
Volume 18
Number 4
The use of PACS at other medical centers has been extended to manage all medical images acquired within the hospital including nonradiology imaging applications such as endoscopy and microscopy images in addition to photographic images obtained in dermatology and ophthalmology (3,4). Most PACS can import files from multiple formats including JPEG, Tagged Image File Format (TIFF), and DICOM. One report demonstrated experience with the ability of a PACS to integrate outside imaging studies on CD-R and transfer the data into a local PACS (5). We used the JPEG format for image acquisition and transfer to the PACS. In general, the major advantage for using TIFF over JPEG is that TIFF gives the best quality image because it is uncompressed (lossless). However, use of TIFF comes at the expense of large image size (6). Digital camera images of patients acquired in JPEG format have been shown to be reliable
Silberzweig et al
for plastic surgery and vascular surgery (7,8). Photographic image import to a PACS can be a valuable tool for an interventional radiologist’s vein practice. Secondary capture of JPEG files is a feature that should be considered when purchasing or upgrading a PACS. A PACS provides access to a reliable, secure, HIPAA-compliant, virtually limitless image and clinical data archive offering the clinician a complete, chronological view of the patient clinical record. References 1. Min RJ, Khilnani N, Zimmet SE. Endovenous laser treatment of saphenous vein reflux: long-term results. J Vasc Interv Radiol 2003; 14:991–996. 2. Merchant RF, Pichot O; Closure Study Group. Long-term outcomes of endovenous radiofrequency obliteration of saphenous reflux as a treatment for superficial venous insufficiency. J Vasc Surg 2005; 42:502–509. 3. Kuzmak PM, Dayhoff RE. The use of digital imaging and communications in
4.
5.
6.
7.
8.
•
579
medicine (DICOM) in the integration of imaging into the electronic patient record at the Department of Veterans Affairs. J Digit Imaging 2000;13:133–137. Bandon D, Lovis C, Geissbuhler A, Vallee JP. Enterprise-wide PACS: beyond radiology, an architecture to manage all medical images. Acad Radiol 2005; 12:1000 –1009. van Ooijen PM, Guignot J, Mevel G, Oudkerk M. Incorporating out-patient data from CD-R into the local PACS using DICOM worklist features. J Digit Imaging 2005; 18:196 –202. LaBerge JM, Andriole KP. Digital image processing: a primer for JVIR authors and readers: part 1: the fundamentals. J Vasc Interv Radiol 2003; 14:1223– 1230. Galdino GM, Vogel JE, Vander Kolk CA. Standardizing digital photography: it’s not all in the eye of the beholder. Plast Reconstr Surg 2001; 108:1334 –1344. Murphy RX Jr, Bain MA, Wasser TE, Wilson E, Okunski WJ. The reliability of digital imaging in the remote assessment of wounds: defining a standard. Ann Plast Surg 2006; 56:431– 436.