Advanced DICOM Medical Imaging Software - Open Source ...

OSCC MAMPU OSS Case Study Awards 2010 A. Project OsiriX: Advanced DICOM Medical Imaging Software

B. Particulars Name: Professor Dr. Ibrahim Lutfi Shuaib (Professor of Radiology and Senior Consultant Radiologist) Government Agency/Institution: Advanced Medical and Dental Institute (AMDI), Universiti Sains Malaysia Full Street Address: Advanced Medical and Dental Institute, Universiti Sains Malaysia, No 4, Persiaran Seksyen 4/2, Bandar Putra Bertam, 13200 Kepala Batas, Pulau Pinang Full Postal Address: Advanced Medical and Dental Institute, Universiti Sains Malaysia, No 4, Persiaran Seksyen 4/2, Bandar Putra Bertam, 13200 Kepala Batas, Pulau Pinang Email: [email protected] Phone: +6019 4775174 Fax: +604 5793787 URL: http://www.amdi.usm.edu.my

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C. Awards Categories Group 2: Public Higher Education Institutions (IPTA)

D. Tell us about your agency, its mission, objectives, clientèle, number of employees Advanced Medical and Dental Institute (AMDI), Universiti Sains Malaysia Introduction AMDI was established on 16th October 2002 with grants from the Malaysian Government including the Ministry of Higher Education. AMDI is a post graduate research institute specializing in selected medical and dental areas including clinical services, collaborative research and post-graduate academic programs. AMDI also plays vital roles in producing competent medical and dental specialists who, among others are able to conduct clinical trails for patents in the northern region of Malaysia. To achieve this, AMDI is divided into clusters. They are Oncological Science; Cardiovascular Science; Integrative Medicine; Infectious Diseases; Brain Science; Behavioural Science; Immunological Science; Oral Science; Transfusion Medicine; Nuclear Medicine; Clinical Toxicology and Poisoning; and Healthy Life Style.

Vision Leading the world in new innovative discoveries towards sustainable and holistic healthcare deliveries.

Mission To develop state-of-the-art advanced research, conduct innovative postgraduate programmes and deliver tertiary healthcare services towards sustainable mankind.

Objectives 

To provide state-of-the-art research facilities to generate novel healthcare discoveries of great commercial values. 2



To disseminate research findings in the form of presentations and publications for the advancement of knowledge.



To achieve and maintain international standards of accreditation in management, laboratory and research facilities and services.



To be a leading referral centre providing state-of-the-art healthcare services and promoting healthy lifestyle.



To offer, upgrade, create, innovative and relevant postgraduate programmes in niche areas that meet global requirements.



To promote internationalization of healthcare services, academic and research activities.

Clientele Post-graduate students Patients Private companies in Research Collaborations Employees AMDI has 574 employees and 60 post-graduate students.

E. Principle Objectives of the Project 1. To provide affordable application and workstation in radiology and other departments throughout the hospitals 2. To create awareness, disseminate knowledge and provide skill using cost-effective archiving and distribution of medical imaging in USM, nation wide and in the region 3. To provide accessibility and improve delivery of health care in less specialized hospitals 4. To provide academic and research tool in medical imaging

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F. Who are the Key Partners (Please briefly describe the role of each partner) 1. University hospitals University hospitals are academic centers for training of professional post-graduate residency programs such as Master of Medicine. About 500 medical officers are trained in Malaysia each year. As OsiriX is in their daily activities of treating patients, once they graduated after four years, they will continue using their experience and train other medical officers in their respective hospitals where they are working.

2. Ministry of Health and Government Linked Company hospitals Many hospitals could not afford to buy multiple image processing workstations. The need of having four to five workstations is high as hospitals is staffed by about 6 to 8 radiologists each. Most hospitals only have one or two workstations and each cost about RM 250,000 to RM 350,000. OsiriX is free and high-end Apple Mac cost only RM 10,000. The cost is 25 to 35 times less as compared to

if

they

procure

most

high-end

vendor

workstations.

The

implementation of using OsiriX will be much easier when the policy and decision makers of these hospitals has seen the success and costeffective of the implementation.

3. Multimedia Development Corporation (MDeC) MDeC

is

government-owned

corporation,

established

to

facilitate the development and promotion of Multimedia Supercorridor Malaysia (MSC). Telehealth is one of the flagship project identified in MSC blueprint. By collaborating with MDeC, OsiriX is identified as a new initiative to provide an affordable health care solution for storage, distributing, viewing, reconstruction, transfer of images between hospitals and providing teleradiology services. MDeC is possible to provide grants to create awareness, education and training of health personnels in using OsiriX. MDeC is also possible to provide grants to 4

value-add OsiriX in the development of Radiology Management Conference System. A meeting was arranged between AMDI and Telehealth section of MDeC on 5 March 2010.

Summary of the

meeting is: a. AMDI will participate in Telehealth Education sessions. This was held on 30 July 2010 in USM, Pulau Pinang b. Participation in MDeC telehealth workshops c. Provision of grant for the implementation of nation wide OsiriX training 4. Centers for E-Health and Telemedicine in Southeast Asia (CETSEA) During the International Conference on Open Source Software in Healthcare (INCOSSH) successfully organized by AMDI from 23-25 November 2008 at Batu Feringghi, Penang, a Memorandum of Understanding was signed with one of the objectives is to share expertise in ICT in healthcare among the ASEAN countries. A few awareness and training programs of OsiriX has been planned. We hope to kick-start late this year or early next year in Manila.

G. What are the Primary OSS technologies? Why did you choose these technologies? Please describe them briefly 1. DCM4CHEE PACS Server – To function as Picture Archiving and Communication System (PACS) server, OsiriX has limitations. For more advanced features of more efficient storage and distribution, DCM4CHEE is the solution. It is a free open source and PACS server for OsiriX workstations to be connected to.

H. What are the design specifications? 

Standards Compliance OsiriX

uses

medical

imaging

Digital

Imaging

and

Communication in Medicine (DICOM) standards and other standards in healthcare such as HL7. Other protocols are also used that ensure 5

interoperability between OsiriX and other systems and technologies, while supporting existing workflows and tools. OsiriX also ensure interoperability conforming to Integrating the Healthcare Enterprise (IHE) technical framework. It has also participated in Connectathons, an event where companies test inter-operability capabilities of their healthcare ICT products to conform to the Telehealth and International standards organized by IHE. 

Web-based Interfaces OsiriX is as a workstation uses a client server approach. However, recently it has a built-in Web Server with Web Access to DICOM persistent Objects (WADO). WADO is to provide WEB access to DICOM object, so that any web browser could render the data. The purpose of WADO is to convert DICOM images to something displayable by any browser like JPG, PNG, Structured Report etc.

 Network server compatibility OsiriX has also the functionality of a DICOM server but with limited

capabilities as

primarily the

use

is for

viewing

and

reconstructing images. 

Client workstations compatibility OsiriX can only be operated using a Mac using Mac OS X



Network Architecture compatibility The greatest advantage of using OsiriX is its ability to run on any TCP-IP network.

I. What is the end client usage model (how are the systems used eg. on dept desktop, nationally via web browser and internet) The client usage can be: Desktop OsiriX only runs on Mac using Mac OS X. There are three types of Mac desktop, iMac, Mac mini and Mac Pro. OsiriX that is downloaded free has a 6

32-bit extension. This limits the use of multi-dimensional reconstruction up to 500 images of CT and MRI with the size of 250MB. To get the full advantage of rendering capabilities of OsiriX to reconstruct more than 500 images efficiently, it is advised to upgrade to 64-bit. The cost is about USD 200. The advantage is the memory (RAM) is fully used and address more than 32-bit limit of 4GB. Upgrade will make OsiriX run faster between 25 to 400%.

Assessment of better OsiriX 64-bit

Mobile Using notebooks, there are three types as well, Macbook air, Macbook and Macbook Pro. Since last year, OsiriX team has introduced new application also called OsiriX to be used with iPhone and this year to be used with iPad. The OsiriX application is not free and cost USD 19.99.

Web browsing Any computers with any operating system or mobile devices such as notebooks, tablets, PDAs that can do web browsing are able to view the studies. This is made possible as OsiriX can function as web server using WADO. Security using https and user authentication is available to ensure patient confidentiality. Below is an example of the image shown using the Camino web browser.

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A MRI image viewed using Camino web browser

J. Overview of hardware/software of system Software of system OsiriX is an application in medical imaging used in patient care and health research. It conforms to medical standard DICOM 3.0. It is used as multimodality and multi-dimensional DICOM Viewer and PACS workstation. OsiriX was conceived by Dr. Osman Ratib in 2003, and written by his colleague radiologist Dr. Antoine Rosset. It was developed into its present form by Rosset and Joris Heuberger, a computer scientist at University Hospital of Geneva, Switzerland. The users are worldwide who believe in an open, different and free future in imaging. It is released under a free software license and runs under Mac OS X. It uses Open Source architecture where the developers and users improve the application. It supports a complete plug-in architecture that allows one to expand the capabilities. The image processing application is dedicated to DICOM images produced by medical equipment (MRI, CT, PET, PET-CT, etc.) and confocal microscopy (LSM and BioRAD-PIC format). Besides that, it 8

also able to read many other file formats: TIFF (8,16, 32 bits), JPEG, PDF, AVI, MPEG and Quicktime. The development of OsiriX is based on Open-Source components : a. Cocoa (OpenStep, GNUStep, NextStep) b. VTK (Visualization Toolkit) c. ITK (Insight Toolkit) d. PixelMed (David Clunie) e. Papyrus 3.0 (Digital Imaging Unit) f. DICOM Offis g. OpenGL h. LibTIFF i.

Jasper

j.

LibJPEG

OsiriX is a unique software where it can function as a viewing application workstation, reconstruction of data to be multi-dimensional (3D, 4D, 5D), limited server capabilities for storage and distribution, web server and transferring images from Hospital A to Hospital B through internet cloud. 1.

Viewing application workstation It has an ultrafast performance with intuitive interactive user interface. Other features include: a. Thick Slab for multi-slices CT and MRI (Mean, MIP, Volume Rendering) b. ROIs: Polygons, Circles, Pencil, Rectangles, Point, etc Multi-Buttons and Scroll-wheel mouse supported c. Custom 3x3 and 5x5 Convolution Filters (Bone filters, etc) d. Image Fusion for PET-CT exams with adjustable blending percentage

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Fusion for PET-CT exams

e. Image subtraction for XA

Image subtraction in angiography

f. Plugins support for external functions g. Customizable Toolbars h. Custom CLUT (Color Look-Up Tables) i.

Bicubic Interpolation

10

2D viewer

It also support DICOM file, a. Read and display all DICOM Files (mono-frame, multiframes) b. Read and display the new MRI/CT multi-frame format (5200 group)

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Multi-frame viewer

c. JPEG Lossy, JPEG Lossless, JPEG2000, RLE d. Monochrome1, Monochrome2, RGB, YBR, Planar, Palettes, etc. e. Support custom (non-square) Pixel Aspect Ratio f. 8, 12, 16, 32, 64 bits g. Write 'SC' (Secondary Capture) DICOM Files from any 2D/3D reconstructions h. Read and display all DICOM Meta-Data i.

Read AND Write DICOM CD/DVD (DICOMDIR support)

j.

Export DICOM Files to TIFF, JPEG, Quicktime, RAW, DICOM, PACS

2. Reconstruction of data to be multidimensional (3D, 4D, 5D) Specifically designed for navigation and visualization of multimodality and multidimensional images 3D Viewer, 4D Viewer (3D series with temporal dimension, for example: 12

Cardiac-CT) and 5D Viewer (3D series with temporal and functional dimensions, for example: Cardiac-PET-CT).

Viewing of CT Cardiac-PET-CT

The 3D Viewer offers all modern rendering modes: Multiplanar reconstruction (MPR), Surface Rendering, Volume Rendering and Maximum Intensity Projection (MIP). All these modes support 4D data and are able to produce image fusion between two different series (for example: PET-CT).

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Orthogonal and Multi-planar reconstruction

14

3D Maximum intensity projection of MA angiography

3D Surface rendering of lower limb bones

3D volume rendering of abdominal arteries 15

3. Server capabilities for storage and distribution It is fully compliant with the DICOM standard for image communication and image file formats but has limited server capabilities. It is able to receive images transferred by DICOM communication protocol from any PACS or medical imaging modality (STORE SCP - Service Class Provider, STORE SCU Service Class User, and Query/Retrieve). It also support DICOM Network Support such as Store User (STORE-SCU, DICOM Send), Store Provider (STORE-SCP, DICOM Listener), C-FIND SCU/SCP, C-MOVE SCU/SCP: Query and Retrieve studies from/to a PACS workstation.

4. Web server for LAN and WAN viewing and teleradiology using browsers OsiriX has built-in web server with WADO server support. To ensure patient confidentiality, OsiriX has HTTPS encryption and ZIP export. The ability to customize the built-in Web server is highly appreciated.

5. Transferring images from Hospital A to Hospital B through internet cloud Using the DICOM send function, studies are send to selected hospitals for the transfer of images. Once the images are received, these DICOM images can be reconstructed to assist making diagnosis and plan further management.

16

Sending of images from Hospital A to Hospital B using DICOM send

Hardware of System OsiriX workstation only run on Mac using Mac OS X 1. Desktop Mac computers (iMac, Mac mini or Mac Pro) 2. Macbook, Macbook Air or Macbook Pro

Limited features if use web browser and internet 1. Any computers using any operating system

OsiriX mobile used only 1. iPhone with OsiriX application 2. iPad with OsiriX application

17

iPhone with OsiriX application

1. Desktop Mac computers (iMac or Mac Pro) and Macbook or Macbook Pro Minimum: Mac OS X 10.5 or higher Intel processor 2 GB of RAM For best performance: 6 GB of RAM if you plan to open more than 800 images (CT & MRI, PET-CT) 8 GB of RAM for more than 1500 images (multi-slice CT & PETCT) with OsiriX-64 bit extension 12 GB of RAM for more than 3000 images (cardiac or functional imaging) with OsiriX-64 bit extension As a limited Server for clients: Mac OS X 10.6 or higher Intel processor 8 - 16 GB RAM As a Web Server: Mac OS X 10.6 or higher Intel processor 18

8 GB RAM Broadband internet of minimum1MB bandwidth

System Architecture: OsiriX implementation The role of OsiriX can be as stand alone, in a small LAN, in a large LAN, in a wide enterprise environment, as a web server and transfer node from one hospital to another. The system architecture below shows how each role is implemented.

Figure 1: OsiriX as a workstation and storage in small department

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Figure 2: OsiriX as a workstation in a hospital PACS

Figure 3: OsiriX as a workstation multiple sites in LAN and internet cloud

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Figure 4: OsiriX transferring studies across hospital using internet cloud

K. Why did you choose OSS/Linux? lower cost, customisation requirements, security etc. The maintenance cost of the system is very low. Open source is inevitable and we are able to control the operations such as make changes, system customization, data retrieval test and also system deployment. By using proprietary system, we still have to depend on the vendors. Besides, open source system is growing and used extensively all over the world without any boundaries.

L. How and why did OSS solve the perceived need/problem? The problem that has been solved by using OSS:

a) Cost By using OSS, the cost for developing and maintaining the system is less compared to the proprietary system. For example, getting the fully functioning image processing workstation will cost not less than RM 21

400,000.00. By choosing OsiriX, we are able to save a lot of money.

Table 1, 2 and 3 show the study being made by AMDI before implementing OsiriX.

Table 1: OsiriX Cost Analysis

OsiriX OsiriX application

FREE

OsiriX 64-bit license

RM 500

Project Management Services

FREE

Implementation Services

FREE

  

OsiriX configurations Application/database testingtuning Testing/commissioning

Training & Consultation

RM 5000

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Table 2 : OsiriX - 5 Years Projection Cost for a radiology department with 5 workstations

ITEM

2009

2010

2011

2012

2013

TOTAL

SOFTWARE OsiriX Application, maintenance and training

RM10,000.00

RM0.00

RM0.00

RM0.00

RM0.00 RM10,000.00

OsiriX Maintenance

RM0.00

RM0.00

RM0.00

RM0.00

RM0.00

SUB TOTAL

RM10,000.00

RM0.00

RM0.00

RM0.00

RM0.00 RM10,000.00

Mac x 5 units

RM40,000.00

RM0.00

RM0.00

RM0.00

RM0.00 RM40,000.00

SUB TOTAL

RM40,000.00

RM0.00

RM0.00

RM0.00

RM0.00 RM40,000.00

TOTAL

RM50,000.00

RM0.00

RM0.00

RM0.00

RM0.00 RM50,000.00

RM0.00

HARDWARE

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Table 3 : Proprietary System – A mini PACS server with 5 workstations for 5 Years Projection Cost * for the purpose of this presentation, the proprietary name are anonymous

ITEM

Year 1

Year 2

Year 3

Year 4

Year 5

TOTAL

SOFTWARE Imaging Application x 5 RM2,000,000.00 Imaging Maintenance

RM0.00

RM0.00

RM0.00 RM80,000.00 RM80,000.00

RM0.00

RM0.00 RM2,000,000.00

RM80,000.00 RM80,000.00

RM320,000.00

OS1 (XXXXXX)* App.

RM14,000.00

RM0.00

RM0.00

RM2,800.00 RM2,800.00

RM19,600.00

OS2 (XXXXXX)* Database

RM14,000.00

RM0.00

RM0.00

RM2,800.00 RM2,800.00

RM19,600.00

OS3 (XXXXXX)* Web

RM14,000.00

RM0.00

RM0.00

RM2,800.00 RM2,800.00

RM19,600.00

RM150,000.00

RM0.00

RM0.00

RM30,000.00 RM30,000.00

RM210,000.00

RM56,000.00

RM0.00

RM0.00

RM11,200.00 RM11,200.00

RM78,400.00

Database (XXXX)* OS4 (XXXX)* 5 Clients

SUB TOTAL

RM2,667,200.00

HARDWARE Application

RM50,000.00

RM0.00

RM0.00

RM7,500.00 RM7,500.00

RM65,000.00

Database Server

RM50,000.00

RM0.00

RM0.00

RM7,500.00 RM7,500.00

RM65,000.00

Web Server

RM35,000.00

RM0.00

RM0.00

RM5,250.00 RM5,250.00

RM45,500.00

RM120,000.00

RM0.00

RM0.00

RM18,000.00 RM18,000.00

RM156,000.00

Client Server (5 units)

SUB TOTAL

TOTAL

RM331,500.00

RM2,998,700.00

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b) Health Standards Compliance OsiriX is built using the medical and health standards and protocols that ensure interoperability between OsiriX and other systems and technologies, while supporting existing workflows and tools. By using OsiriX, all the bibliographic data are in compliance with the required standard such as DICOM, HL7 and IHE.

c) Web-based Interfaces When used as web-based, OsiriX interfaces are based on standardscompliant World Wide Web technologies—WADO, XHTML, CSS and Javascript - making OsiriX a truly platform-independent solution.

M. What Innovation took place, if any? Business Process and Change Management a)

Choosing an Open Source application A few problems existed in the optimization of delivery of quality

healthcare in Malaysia. The cost of health has always been very expensive and takes a lot of budget from the public and private sector. A solution is looked for in the Open Source for viewing, reconstruction, storage, distributing within the local network and also across using the internet cloud. Although a few DICOM viewer software are available from OSS community, after getting information from the articles published in recognized journals and talking to several world leaders in imaging fraternity, everybody felt that OsiriX is the best and most advanced DICOM viewer. The only caveat is, it only uses Mac. OsiriX application has also won many awards:

i.

Two awards at the Apple Design Awards, Worldwide Apple Developers Conference in June 2005. The first is "Best OpenSource Application" and the second is "Best Scientific Computing".

ii.

Mobie Awards 2009: Winner - Best Medical Application

iii.

RSNA 2008: Excellence in Design 25

iv.

RSNA 2008: Certificate of Merit

In addition, the radiology and imaging fraternity has accepted and recognized OsiriX as one of the best OSS available. Every year, Radiological Society of North America Conference and European Congress of Radiology organize hands-on workshop on OsiriX since 2008.

b)

Creating awareness and training A careful planning was carried out in detail with a comprehensive

business process. The plan is detailed below starting from self-evaluation, deploying to AMDI institution, to the rest of USM, later to other universities and Ministry of Health (MOH) Hospitals and ultimately in all hospitals in Malaysia.

Road map of creating OsiriX awareness and training

The time-line for these activities started in year 2007 and has progressed to involve to all universities and MOH hospitals to date.

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Step approach implementation of OsiriX from personal to national level

AMDI has been recognized by OsiriX foundation as an OsiriX user.

AMDI accepted as an OsiriX user Two types of hands-on OsiriX training was organized by AMDI and a few is with collaboration with other institute. They are for Basic and Intermediate level and the other is Advance level.

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Training session in AMDI

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The summary is as below:

Level of training

Place

Date

Participants

AMDI, Kepala Batas AMDI, Kepala Batas HUSM, Kubang Kerian UIA, Kuantan

22 Jan 2008

35

2 May 2008

14

18 Aug 2008

40

6 Nov 2008

35

1st KL OsiriX Training Course 2009 AMDI, Kepala Batas AMDI, Kepala Batas AMDI, Kepala Batas

14 Feb 2009

25

31 Mar 2009 9 Apr 2009

12

27 Oct 2009

12

2008 Basic and Intermediate Basic and Intermediate Basic and Intermediate Basic and Intermediate 2009 Basic and Intermediate Basic and Intermediate Advance Advance

9

2010 Basic and Intermediate Basic and Intermediate Basic and Intermediate Basic and Intermediate

AMDI, Kepala 24 June Batas 2010 UPM, Serdang 28 June 2010 AMDI, Kepala 30 June Batas 2010 AMDI, Kepala 29 July Batas 2010

12 15 7 6

This brought a total of 222 people trained in OsiriX in Malaysia. The participants comprise of radiologists, medical officers, radiographers, ICT staffs and other interested people.

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Hands-on workshop in AMDI

OsiriX foundation sells a book called OsiriX: The pocket guide to help potential users and also users to start and familiarize using OsiriX and later becoming an expert user. This book is also used by us to prepare materials for our training sessions. There are other resources from the web such as Apple Seminar Online: OsiriX Tutorial and Wikipedia.

OsiriX: The Pocket Guide and Apple Seminar Online: OsiriX Tutorial used as training resources

c)

Support group A discussion group was formed by the developers with the following

objectives: learn OsiriX, give feedback, discuss with other users, ask for new features and find solutions to problems. In Malaysia, Professor Dr. Ibrahim Lutfi Shuaib has also formed and moderate a user group called osirixmalaysia with email [email protected] so that experiences can be 30

shared, problems and technical solutions can be looked into.

d)

Procurement of OsiriX workstations In radiology departments in university and MOH hospitals in Malaysia,

after have been convinced of the capabilities of OsiriX, a bold and wise decicion has been made. Everytime a new imaging system such as CT scan and MRI is procured, a few OsiriX workstations are also procured together. This is to increase the number of imaging workstations available for doctor’s use. Prior to the awareness of the availability of OsiriX workstations, only one workstation manage to be procured so limiting the patient care.

e)

Radiology Clinical Management Conference Radiology Clinical Management Conference is conducted a few times

every

week

to

promote

continuous

medical

education,

team

care

management of patients and post-graduate teaching in hospitals. Multidimensional images and movies are created to have better understanding of disease process. This is greatly appreciated by health care providers as decision made are easier. This will benefit and improve patient care.

3D segmentation image done using OsiriX on a child with a small right lung. This 3D image compared to 2D images is better appreciated and easier to understand by surgeons to facilitate surgical approach

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N. What impact did deployment have on local OSS ecosystem? As result of the deployment, OsiriX gives positive impacts to radiology services, research, academic and training. Among them are:

a)

Impact on the cost for the new system acquisition and maintenance No doubt that when we decided to implement OsiriX, the first priority to

be considered is the cost. Our organization decided to take this opportunity to use OSS to cut down expenses. As shown in Table 1, 2 and 3 earlier, our organization saves millions of ringgit by using OSS.

b)

Impact on radiology operations and services Before the deployment of this system, we are dependent on vendor

expensive workstations. These workstations came with the imaging systems such as MRI, CT and the number bought is only one per imaging modality and those workstations were too expensive to install in other departments. The hospital clinicians needed and wanted was a sophisticated analysis system that they could use in their own offices and conference rooms. Hospitals everywhere face the same problem. With OsiriX, clinicians in other departments also began pulling DICOM images from the hospital PACS and rendering them for 3D analysis. The maintenance, troubleshooting and problem solving was under the vendors. As there are more users to use the workstations, we have to find solutions in an affordable approach. Professor Dr. Ibrahim Lutfi Shuaib, a Senior Radiologist, personally tried using OsiriX after acquiring a Macbook. After using for six months, he is convinced about the ability of OsiriX meeting the

promises

of

an

advanced

multi-dimensional

and

multi-modality

workstation. More OsiriX workstations were bought and they never looked back.

32

c)

Impact on teaching medicine Usually the medical lecturers use images from textbooks, buy from companies or retrieve from the internet to teach anatomy. Through OsiriX, the medical students learn anatomy through 3D volumetric rendering, which is the way anatomy should be learned. But they also learn to use a radiology tool that they will use later in their clinical practice.

d)

Impact on research In hospitals, priority is towards is patient care. With limited number of

workstations, research is surely affected as sessions to use the workstations are limited. Data collection and analysis is important to research activities and availability of imaging workstations is important. OsiriX is not only developed for patient but also for research purpose. It is not only affordable but also developed for research use. When search with the word ―OsiriX‖ is given to Pubmed search engine on 6 August 2010, a total of forty articles were found.

Forty articles published using OsiriX in research using Pubmed

These are reputable papers that recognized OsiriX as a multidimensional and multimodality tool in research. In USM and UKM, OsiriX is also used by researchers. 33

Recently on 10 August 2010, Tan Sri Bernard Dompok visited AMDI, USM. OsiriX application as a research tool was shown.

Tan Sri Bernard Dompok visit to AMDI, USM

e)

Impact on Public AMDI successfully organized an International Conference on Open

Source Software in Healthcare, 23 - 25 November 2008 at Batu Feringghi, Penang. Professor Dr. Ibrahim Lutfi Shuaib gave a talk about OsiriX and the implementation in AMDI. The international conference was attended by participants from several higher learning institutions, government agencies and also from private agencies throughout Malaysia. It was also attended by forty participants from ASEAN.

34

Key speakers during opening ceremony

Director of AMDI presenting souvenir to a keynote speaker

35

Participants from ASEAN countries

f)

Impact on staff competencies and skills on OsiriX from AMDI to national and international level During deployment process, all imaging staffs are required to attend

one to two days training on OsiriX. This initiative gives them opportunities to improve their skills and competencies in OsiriX and its implementation. OsiriX able to produce images of rich in detail and could help them immensely in planning treatment. A step approach and road-map creating awareness of OsiriX and skill was planned in late 2007. The first OsiriX hands-on workshop was organized in AMDI on 22 January, 2008. Four workshops were organized in 2008, in AMDI and UIA. In 2009, four workshops were organized in AMDI and PPUKM and this year, till date four workshops were organized in AMDI.

36

Flyer of Basic and Intermediate OsiriX training in AMDI

37

Flyer of Advance OsiriX training in AMDI

Flyer of OsiriX training in PPUKM, Kuala Lumpur

38

Even though a total of 222 people are trained in OsiriX, unfortunately not all become users as a few hospitals unable to buy Mac or convince their management that OsiriX workstation is an affordable option.

A total of about 140 OsiriX users had been trained and by July 2010, the institutions involved were: Institution

Number of users

a. AMDI, USM

10

b. Hospital USM

40

c. UKM Medical Center

40

d. UM Medical Center

10

e. UIA, Kuantan

10

f. UPM, Serdang

15

g. Hospital Kuala Lumpur

5

h. Hospital Serdang

5

i.

Hospital Tuanku Jaafar

5

j.

Hospital Raja Perempuan Bainun, Ipoh

5

k. Hospital Melaka

5

l.

5

Hospital Tengku Ampuan Afzan, Kuantan

m. Hospital Sultanah Aminah, Johor

3

n. Hospital Sultanah Nur Zahirah, Kuala Terengganu

2

o. Hospital Kepala Batas

2

p. Hospital Pulau Pinang

6

q. Institut Jantung Negara

10

Total

138

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Professor Dr. Ibrahim Lutfi Shuaib doing a presentation during OsiriX training in Universiti Islam Antarabangsa, Kuantan

OsiriX training participants doing the 3D reconstruction

We had a few follow-up sessions either on site, by emails or during other occasions. This is to provide continuous support for those who had undergone hands-on training. Any difficulty, obstacle and inefficient implementation or using OsiriX were attended. We had visited UKM, Hospital Serdang, Hospital Melaka, Hospital USM and UIA to address these issues after their staff had OsiriX training. It was done from 18-19 June 2009. This is to get feedback and solve any issues and problems. Technical expertise of ICT staffs also increased in configuration of OsiriX preferences. During MyGOSSCON 2009, AMDI participated in the booth exhibition. We demonstrated OsiriX in action and the visitors were impressed with OsiriX 40

performance and the ability to show superb fantastic images.

OsiriX workstation demonstration at AMDI booth during MyGOSSCON 2009

A few foreign students have graduated from USM who have experience using OsiriX. They are now practicing radiologists in their own countries and OsiriX is being used there. The countries are Yemen, Iran and Iraq.

World map showing users where they had OsiriX training in Malaysia

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O. Any key experiences learned that you can share as result of experience? During the deployment, we gain a lot of experiences especially in:

a)

Solving the existing problems Before implementing OsiriX, we were worried about what would be the

solution of acquiring more image processing workstations. After evaluating the affordable OsiriX implementation, we were confident of the success of OsiriX implementation.

b)

Gaining customers’ confidence Being able to process the images in multi-dimensional format, the

confidence of making the diagnosis is increased, in turn gave an impact on patient care. The population will have more confidence in health care rendered by hospitals that have facilities of advanced multi-dimensional workstations.

c)

Storage of terabytes of image data OsiriX also functions as a storage server as it has a DICOM C-STORE

class. With the modern high-end technology of cross section imaging modalities, a large volume of data are churned in each study. d)

Distribution of radiology studies OsiriX has ability to do DICOM send and DICOM Query/Retrieve. This

is a basic function of distributing radiology studies with multiple modalities and workstations. e)

Transfer of images between hospitals using internet cloud The need of transfer medical studies across hospitals existed. For

example, a middle age man has sudden excruciating central chest pain with radial-femoral pulse delay in Hospital A. A diagnosis of dissection of thoracic aorta was made and an urgent CT angiography of aorta was planned. After performing the CTA, the diagnosis of dissection of thoracic aorta originate beyond the left subclavian artery was confirmed. The vascular team in 42

Hospital B was consulted and requested the studies to be sent to them. This will enable them to do reconstruction of the CTA to assist them to make further plan whether to transfer the patient to them or not. Using OsiriX, the 200MB data can be transferred using the internet cloud. The time taken will depend on the bandwidth of the broadband. f)

Web server to view images To quickly view the images by other users in another hospital can be

accomplished. For example, Hospital A has no neurosurgical service but provide CT scan service. A head injury patient in Hospital A had CT head done and the neurosurgical team in Hospital B was consulted. Without the images available to the neurosurgical team in Hospital B, this would be difficult for them to decide what further management to be instituted. The need to transfer the patient from Hospital A to B is difficult to make. The images can be made available by allowing them to view using a web browser.

P. What is the current status of the Project? Current status of the project 1. OsiriX has successfully been implemented in our organization (AMDI). There are five

workstations purchased

and used

extensively. They are also purchased and used in other university hospitals, Ministry of Health Hospitals and National Heart Institute. 2. Twelve awareness and training programs has been organized since January 2008 till date. They were well attended by radiology, cardiology and ICT fraternity. 3. AMDI has recently implemented teleradiology by web access of MRI studies in Hospital Kepala Batas. This will ensure continuum of excellent service to the patients in that hospital. 4. Osirix is used as teaching and research tools in Malaysia.

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Roadmap of OsiriX project

Q. Who can provide testimonials of the project – please provide details of their affiliation, designation, contacts, etc. Assoc. Prof. Dr. Mohd. Sobri Muda Consultant Radiologist Department of Radiology Pusat Perubatan UKM, Cheras +60 19 6685885 [email protected]

Dr Subramani Venugopal Head, Department of Diagnostic Imaging Hospital Tuanku Jaafar Seremban +60 6 762 3333 [email protected]

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Assoc. Prof. Dr. Mohd. Ezane Aziz Consultant Radiologist Department of Radiology Hospital USM Kubang Kerian +60 19 9389868 [email protected]

R. Please share any other relevant information. Based on our experience in deploying OsiriX in our organization, we have identified the key factors to the success of this project is the determination of all of our staffs. Their initiative and the willingness to learn new knowledge are the key to the future success. A strong leadership in the organization is also vital in making this dream a reality.

S. Can you share any knowledge products as a result of this experience (studies, presentations, reports, design documents etc?) Yes, we have training materials in DVDs, reports of status of implementation and training. We are also glad to provide any other information when requested.

T. Please cite any relevant URLs •

http://www.osirix-viewer.com/

•

http://en.wikipedia.org/wiki/OsiriX

•

http://tech.groups.yahoo.com/group/osirix/

•

http://www.seminars.apple.com/seminarsonline/osirixintro/apple/index.html

•

http://developer.apple.com/business/macmarket/osirix.html

•

http://www.apple.com/uk/business/osirix/

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