and Data Navigation Workstatio

Multimedia

Image

and Data Navigation Workstatio& Osman

Ratib,

PhD

Marianne

#{149}

Trayser,

PhD

MD,

Eng

Logean, #{149}

Denis

images,

extracted

package

called

images

PhD

#{149}

Christian

#{149}

Hochstrasser,

Christian

Girard,

Pro!,

Mascarini,

MSc

Gerhard

#{149}

MD

standards have been established for the transmission on medical information and records, including mcd-

from

Osiris

Ligier,

MSc

World Wide Web (WWW) of and remote consultation ical

Yves

#{149}

an

is being

in a hospital-based

existing

used

hospital

information

for the display

picture

archiving

system.

A software

and manipulation

and

of medical

communication

system.

Re-

cent extensions of Osiris, through the integration of WWW navigational tools, allow easy access to a variety of clinical data from patient records. A special interface allows access to radiologic images, laboratory results, and related textual information through public-domain software programs. These technologic advances

offer

made

medical

WWW

and

professionals

Internet

the

navigation

convenience

so popular

and in the

ease

of use

academic

that

have

community.

U INTRODUCTION One

of the

fords

major

advantages

to transmit

the

these images with cessibility of these cialists

in large

of digital

images

archiving

to multiple

of medical

locations

for

images

immediate

other medical data as part of a patient’s medical images is of great value to referring physicians

multidisciplinary

hospitals,

although

images

of a hospital

aspects.

Such

which as text

allows reports,

be one

of the

institutions

dated

information

major

“legacy”

ESQL OSF

language,

terms:

(PACS)

See

the

are

development on

different

not

suf-

view

of a unified

of all these

user

interface,

through various Such accessibility

types of data, such to data used to

of an integrated

HIS,

systems,

some

especially

of which

may

in

be

out-

= =

embedded Open

structured

Software

query

Foundation,

language, PACS

=

HIS picture

=

hospital

archiving

information and

system.

communication

HTML

=

system.

hypertext WWW

=

Computers,

multimedia

Images.

storage

and

retrieval

Picture

#{149}

archiving

and

communication

system

Workstation

#{149}

the

1997; Digital

17:515-521

Imaging

Geneva 14, Switzerland. 1996; revision requested c RSNA,

in the data

generally

acspe-

are not concurrently in databases separate Today, one of the main

an integrated

development

“browse” and images.

are

The

Web

RadioGraphics From

difficulties

is to provide the

it af-

to link

systems.

markup

Index

(HIS)

requires

to conveniently data, graphs,

different

Abbreviations: Wide

usually

physicians numerical where

World

system

integration

ability and

record (1). and consulting

alone

ficient if corresponding medical records (eg, laboratory results) available. In most institutions, images are stored and manipulated from those in which other aspects of patient records are stored. tasks

is the display

tJnit,

Department

of Radiology,

University

Presented as an infoRAD exhibit at the June 14 and received July 30; accepted

Hospital

of Geneva,

1995 RSNA scientific August 1 3. Address

24 rue

assembly. reprint

Micheli

Received requests

du

Crest,

February to OR.

121 1 29,

1997 commentary

by Greenes

and

Chang

following

this

article.

515

With

Wide

the

increasing

Web

widespread

the

popularity

(WWW) availability

trend

tools

and

of computer

has

been

for

exploring

standards

of World

navigational

the

browsers,

for developers

to usc

all types

of data-in-

WWW

Patient databases

cluding, of course, medical data, particularly where the need exists to access multimedia data consisting of images, numerical data, graphs,

and

textual

documents.

ers offer a convenient ing applications easily different

databases

of integration

WWW

brows-

way to customize for data extracted

while

viewfrom

maintaining

in a single-user

Image Archives

FTP transfer)

(me

Query program

a degree

‘I,

1%-

environment.

Query and retrieval of different types of data from multiple databases can be performed easily from

WWW

lished

The through

with

a well-estab-

paradigm

(Fig

1).

usc of WWW tools for navigating medical records is being explored

variety our

browsers

client-server

of applications. experience

In this

at the

article,

University

in a

we

report

Hospital

Figure

of

Geneva (Switzerland) with a new approach to providing a large number of users with convenient access to patient records. This system comprises

an integrated,

workstation

multimedia

environment

gational

tools

imaging

viewers.

combined

with

The

information

on

WWW

specific

software

related communication the advantages of the tional

medical

based

1.

medical

the

databases.

images

cation

architecture

and

The

GENEVA

tradition

are

FTP

ers

discussed.

HIS

Hospital

of Geneva

in developing

its own

has HIS,

a long

called

the

Diogene system (2). This system has constantly evolved since its inception and is currently based on a distributed architecture in which different parts of the medical records are located Ofl different databases linked together through a single

patient

years,

an

obtained

been

with

made

developed our

hospital,

ety of ology other ports)

management

increasing

system.

number

different

available

imaging

in digital

as an

extension

the

Diogene

In recent

of medical

images

modalities

form

of Diogene system

have

with

= file

record

are

sent

a study

to the

to display

transfer

of the

has been

user

and

selected,

a “helper”

and manipulate

appli-

the images.

protocol.

(3).

handles

gathered

by

different

servers.

(OSF)-Motif chines.

these

serv-

network,

they

as part

of a given

A distributed

chitecture different archived. Diogene software interface

At a vari-

Diogenc identified

are

linked

and

patient’s

medical history. The data arc stored in an INGRES database management system on different UNIX-based

a PACS

data, including all laboratory results, radireports, and discharge letters, as well as documents (eg, surgery procedure re(4). Although these different elements of

a patient’s

between

tools arc presented, and new system over conven-

systems

University

of the relationships

After

are

is used

uniquely

U THE

Schematic

the WWW browser and the various parts of the HISpicture archiving and communications system (PACS). Query is performed through a WWW interface to the standard PACS and radiology information

system navi-

OSIRIS viewer (helper application)

browser

www

X-terminal

Macintosh

available offices.

graphical setting

from

(Apple

computers

stations

emulators

applications

cians’

software

and

hardware

ar-

allows a progressive evolution of the parts of the medical record being For data retrieval and display, most applications rely on specially designed programs with an X-Window graphical with Open Software Foundation extensions running on UNIX ma-

This

arc

used

to access

PC-compatible

Computer,

and Calif) and physi-

Cupertino,

in clinical allows

wards

access

to the

same

user interface from both UNIX workand desktop personal computers. This requires that all applications developed

with

an X-Window

user

applications

graphical to be

interface

implemented

allow in a client-

server mode. One major exception to this concept in the Diogene system relates to the retrieval and display of medical images, for which

516

U

info

RAD

Volume

17

Number

2

a specially

designed

Osiris

developed.

was

directly

on the

files

must

tion

before

that

Osiris

be

they

downloaded can

be

image required

of hardware

software

nipulation

was

degree

and

needs

menus,

was

of physicians

sive

of customization.

features

computer

skills.

the generic nipulation,

adapted

and

The

windows,

does

to meet

not

Osiris

icon the

require

provides

exten-

some

of

tions,

inverse

tation,

image

necessary for basic image maas zoom and panning operavideo mode, magnifying glass, roprocessing, and color and contrast

adjustments.

The

designers

special

care

with

the

various

cessing

image

ways,

so that

familiar with of the program. and operation

design lytic

tools

dalities

Osiris

the

applicable is, to our

program

took

a consistent

approach

manipulation

and

(6). Different

tools

in similar

come tures

of the

to provide

tasks the

user

rapidly

lar.

the

Two

basic

the user

components

allow tools:

call-back

the

window

tools

to different

hcuge.ch/UIN/UIN.html.

can

be

can

be

to the

basic The

analysis

and

WWW

manufacturer-

and

in recent

modality-specific Recent developments in PACS have led manufacturers to design systems that can handle and display images from different modalities. However, little effort has been made to unify the different image analysis tech-

tas

niques

in a unique

it was

initially

The oriented

Osiris software programming

of the

WWW

.

ensures

a modular

structure.

gram made ous

Among

is written language and

the

easily main

features

of the

1997

program

tools.

in the objectC++, which

adaptable features

is its portability to different by different manufacturers

fled and customized needs. Most important,

March-April

of standard

can

can

among

OF WWW STANDARDS phenomenal development of the

set

Osiris

of charge and at http://expasy.

The

are

fea-

processing

U USE

that

be

mouse

these and

software.

software is distributed free be obtained on the Internet

can

in which

analysis

added

attributed.

results

Through

advanced

man-

manager. The dialog to create dialog wintypes of elements to

windows

is possible.

more

creation

dialog

manager,

in separate

system in particu-

the

the

operations

data

interaction

underlying

currently available commercial systems. Most manufacturers implement image processing and programs

to

platforms.

interface

ager and the data window manager makes it possible dows containing different

displayed

mo-

from

of system-independent

operation of all the feaThis consistency in the of a large variety of anaimaging

X-Window

of UNIX

graphical

tures,

unique

Win-

and OSF-Motif (extension environments to ensure its

a variety

be-

knowledge,

(both

of Technology

independent from

With

are performed can

library

which

pro-

as for

PC-compat-

95 versions). The UNIX with the X-1 1 (Massa-

developed

for

a van-

Osiris was designed as an extensible platform that allows new tools to be developed easily and integrated into the software. Because these tools must be portable for the different workstations supported by Osiris, it was important to provide the potential developer with a and

tools such

and

Windows

Windows

Institute

portability ma-

some

buttons,

was

for

as well

computers

running

3. 1 and

The

available

workstations

computers

analysis

applications.

is currently

graphical interface) X-1 1) windowing

to perform

of specific clinical

personal

chusetts

Washington).

designed

which

Macintosh

version

as Macrunning

tions

with

implementation specialized

software

such

and analysis of digital medical images be used in different clinical applica-

interface,

Osiris

dows

(5). It can user

for

ible

SOFFWARE

U 0511115

easy

tools

workstations

computers

Redmond,

low

ety of UNIX-based

worksta-

This

computers

(Microsoft;

Osiris

so that

on a variety

PC-compatible

Windows

runs

to the

UNIX-based

personal

and

called

program

displayed.

be available

desktop

Osiris

workstation,

including

intosh

package

The

local

first

platforms,

and

software

software of the

pro-

workstations (7). The varieasily

be

modi-

in the

domain

years

has

Internet

opened

of worldwide

data

new

vis-

exchange

and data communication. The rapid evolution of the “Web” has extended the possibility of communications among a large number of users far beyond the academic community to which confined. has

been

terfaces for viewing documents, including and

animation,

through

The

major

to offer

innovation

standardized

in-

and linking multimedia images, texts, sounds, standard

wide availability of software low display and manipulation of data on different hardware

protocols.

The

programs that alof various kinds platforms has

to meet different user Osiris is designed to al-

Ratib

et al

U

RadioGrapbics

U

517

made

the

exchange

universally which

makes

communication

and

attractive.

The

it possible

to link

document to other documents, ages and sounds, has opened navigate across the different dition,

WWW

trigger

different

browsers

of data

hypertext parts

the

JLJ

imto In ad-

capacity

for displaying

to

of data. Every time a new type of document is referred to, appropriate software can be added to the list of programs, often referred to as “helpers” or “viewers,” that can be triggered from the browsers to display the data. capability

is obviously

an

attractive

of displaying data such as medical documents. With a tool designed and manipulating medical images them to existing WWW browsers, to use

the

remote

existing

Web

consultation

This

new

for

technology

was

(Macintosh,

PC

the

documents. tion and

A large up-to-date

confidential

recently

(8).

imple-

UNIX),

exchange

amount medical

C, 15i

s

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9

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4u

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2. First WWW page for a PACS database query. This page allows the user to make selections with a simple set of search criteria.

able on different on any computer, used in private tion,

a special

tocol

was

cess

servers and since they practitioners’ proprietary

established

to patient

can be retrieved are now widely offices. In addi-

communication

to allow

data

such

pro-

confidential

as laboratory

acresults,

reports, images, and other graphics through the exchange of the corresponding files, which can be consulted further on any computer with use of the appropriate viewer linked to the WWW browser. This solution should prove superior to the tedious, older communication protocols that are often used to exchange data between different laboratories and clinics. Standardization

efforts

are

also

community to allow ments across different

being

the

made

in the

exchange platforms.

medical

of docu-

it is

ideally suited for use as a document viewer in the conventional Web architecture. Beyond just using the Web browsers inside the hospital for retrieving and viewing parts of the computerized medical record, the Internet also facilitates the exchange of medical documents on a much larger scale. We recently cxplored this technologic advance through the implementation of a public server that would provide convenient, low-cost access through the Internet to medical information and make possible

1* bs1..

of and

documents

Windows,

-

Figure

mented at our hospital, where the conventional PACS environment was replaced with a prototype of the WWW browser that directly triggers a specific program designed for displaying medical images from the conventional Netscape or Mosaic browsers-in our institution, Osiris. Before this modification, a user had to perform a tedious series of database queries and file transfers to retrieve images obtained of different patients. Now, to retrieve images, the user can work through a specially designed interface written in hypertext markup language (HTML) from any conventional WWW browser on any platform. In addition, because the Osiris program was written for different hardware platforms

-

ds

means

images or for displaying and linking it is possible

transmission

on medical

-

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differ-

ent types

This

Jiii

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of a text

including a new way sets of data.

have

programs

ro

concept,

of medical

of relevant informadata are also avail-

U CURRENT

IMPLEMENTATION

AND

FUTURE DEVELOPMENT To explore the possibilities and advantages of the WWW as an extension of the conventional PACS environment, we elected to use currently available navigational tools such as Mosaic and Netscape that are available on all hardware platforms (9). A special effort has been made to provide intuitive access to the data by developing programs written in languages such as PERt, CGI, and C. These programs can assist the user in accessing remote databases or information servers to retrieve and display the results

of a search.

One

major

advantage

of using

WWW facilities to access PACS databases is their ability to treat text, images, or movies in a similar way by selecting different viewers adapted to the type of data being retrieved. Data protection and access control may be among the most important features of a WWW-

518

U

infoRAD

Volume

17

Number

2

-

-

Figure

3. WWW query selected image. After the study and image set have

lected from the WWW images are downloaded workstation

and

cally with

page

query page, to the local

displayed

the Osiris

and a

appropriate been se-

automati-

image

analysis

software.

based PACS system. In our hospital, a selective control is used to allow user identification and checking of access rights as defined by our cxisting HIS to provide limited access to the data and adequate protection of confidentiality. User identifIcation is achieved through a simple interface (Fig 2) similar to that used for all other standard applications of our HIS. After the user’s tion

name

and

is made

password

are

by querying

the

given, central

concerning the rights owned by that given workstation. All the applications are described in the database, making sible

to allow

tion

accessible

user

may

images

be

and

access from allowed

reports

to only

part

the

servers

HIS

access

but

not

The second stage consists of choosing among the different examinations performed on the patient by clicking on one or more check box buttons. To help the user make a more selective choice, some information relative to each

identifica-

examination is shown next to each entry. The third and last stage consists of choosing the image files to be retrieved. Depending on what configuration of the WWW browser is

database

being

user at the rights it pos-

of the

informa-

(eg,

(Fig

a given

to the radiologic to the laboratory

re-

sults).

Image data arc accessed in a three-step procedure that mirrors the PACS database structure whereby the user selects a subset of images from the PACS database. First, the user is requested to complete several query fields to restrict the number of records being extracted from the database (Fig 2). These query fields indude the patient’s name, sex, and date of birth; the examination identification number; the interval during which the research will be carried out; the anatomic part (eg, chest); and the modality (eg, computed tomography). Once the selection fields are filled, the user can trigger the search process, activating a special program on the server machine that gathers all the information given by the user and translates it into embedded structured query language (ESQL) to transmit the query to the database and obtains the results of the search, which arc displayed HTML in the WWW browser window.

March-April

1997

used,

these

images

can

either

be

simply

downloaded onto the workstation local disk for temporary storage or directly displayed by launching the Osins software automatically 3).

At every stage, the user has the option of searching directly for the radiologic report associated with a given examination by clicking on the patient’s name. This action triggers a hyperlink that starts an ESQL query to the reports database, called Unidoc, to retrieve and display the chosen report. The Unidoc reporting system

has

system.

been

developed

as part

It was

designed

to archive

of the

Diogene

patients’

tex-

tual medical records, produced on a personal computer running Microsoft Word, into an INGRES database. All collected documents are structured paragraph by paragraph with an associated set of keywords for archiving and retrieval

purposes.

mation

regarding

database tion

number

and

In addition, patient

is related for

the

all detailed identification

to the patient

unique in the

inforis in the

identificaHIS.

in

Ratib

et al

U

RadioGraphics

U

519

jrj..LJ-I::I’I

U

I

i_,43CJ Figure 4. that allows tory results tabase.

Sequence the user directly

of query pages to gather laborafrom the HIS da-

Li:j---i-i=

-

-Th

t#{149}

.

a

I

I

.

U

1000 Figure

5.

Two

WWW

pages

show

information on a test (left) and a compilation of more detailed information

derived

from

the test (right).

The

I

,,..

user can retrieve ing the biochemical

pects suits.

of each

information regardand technical as-

test,

Laboratory

as well as test re-

are accessed through a 4). The user can select query criteria such as patient number, record number, or date of examination. The query is sent to a service of the HIS via a remote procedure call to retrieve the information collected similar

interface

by

laboratory

the

results

(Fig

database.

The

played on an HTML page that matically. Furthermore, these with hyperlinks to laboratory clinical information related to 6). A special hyperlink allows for the results of other radiologic undergone by the same patient.

results

arc

dis-

is generated autoresults are listed methods and each test (Figs the user to search examinations 5,

U CONCLUSIONS Recent studies demonstrate that the cost-effectiveness of a PACS should not be evaluated relative to the radiology department alone but relative to the entire hospital. The main benefit of a PACS accrues outside the radiology department,

520

U

infoRAD

where

clinicians

will

profit

access

to images

(Fig

7).

from more efficient Access to both images and related data such as the radiologic report, annotations, and results of laboratory analysis is a primary benefit of having a PACS in a clinical setting. Substantial added value is also derived from the image manipulation and processing features that the system provides to clinical uscrs outside the radiology department. Therefore, it is important to allow flexibility in the design

of such

tools

in customizing

the

work-

station software that must be adapted to meet different users’ needs. With these new tools, the PACS environment is made convenient and easy to use, allowing every clinician, even those who are unfamiliar with

computers,

to retrieve

pertinent

radiologic

images, reports, and even laboratory results. Connections between different parts of the computerized medical record can be achieved with hyperlinks and the rest of the WWW hypertext environment that links the Web to the existing distributed databases in an HIS. The use of these tools speeds up the development of software applications and allows developers

Volume

17

Number

2

U

_i

U

I

5SChESIGSI

P.iws

Map Plo. A4

woo 1

Figure

,

.

1

3.

Ratib

0,

#{149}#{149}=#{149} I ,II.,.

PACS.

a

-,.-

au

hoff 7th

4.

_l_

.

1 ‘

.

5.

Figure 7. Two pages from a WWW server that provides information to physicians and private practitioners outside the hospital. The page on the left is the main home page, with links to sources of rel-

exchange shown

6.

documents.

that

vary

Documents

according

dam, Ratib

7.

type.

Switzerland:

sociated on the

with design

Finally,

lated

their

recent

efforts

database consultation of the graphical user technologic

to videoconferencing

interactive

on software

communication

breakthroughs in the remote consultation.

areas

tasks

rather interface.

innovations

and

other

will

lead

as-

than

8.

re-

means

of

to new

of teleradiology

9. and

TE, Rien-

North-Holland

Ed Amster-

concepts.

diagnostic

In: Dc

imaging:

digi-

tal PACS in medicine. New York, NY: Elsevier, 1992; 293-318. Ligier Y, Ratib 0, Logean M, Girard C. OSIRIS: a medical image manipulation system. MD Comput 1994; 11:212-218.

Ligier

Y, Funk

M, Ratib

0, Perrier

interface In: Huang

G, eds.

Picture

R, Girard

for manipulating HK, Ratib 0,

archiving

system

(PACS)

in medicine.

vanced

Science

Institutes

Series.

many: Ligier

Springer-Verlag, Y, Ratib 0, Funk

C.

Bakker

and commu-

nication

Logean M. ware: what to concentrate

JF, Do H,

P, Piemme

1992; 781-787. 0. Evolution of PACS

AB, Witte

are

to data

G, Vuriod

image management in an integrated RIS and

In: Lun KC, Degoulet

The OSIRIS user medical images.

The page on the right shows the mailbox system that allows the

of medical as icons

H, Trayser Distributed storage

Valk JPJ, ed. Integrated

.

M

information. of a secure

biochemi-

0, eds. MEDINFO ‘92: proceedings of the World Congress on Medical Informatics.

Geneva, I.

evant output

Lemke

Scherrer JR. and hierarchical #{149}“#{149} ..

The complete

the map and retrieve additional data regarding that particular substrate from related WWW servers around the world.

___2-_

Ii

6

cal pathways are also displayed graphically on “maps” such as the one shown. The user can even select any biochemical substrate shown on

NATO

Berlin,

1991 ; 395-399. M, Perrier R, Girard

Portable image-manipulation is the extra development

Ad-

GerC,

softcost? J

Digit Imaging 1992; 5:176-184. Bitti M, Matta G, Tuveri M, et al. A WWWbased distributed system for medical data analysis and 3D reconstruction. In: Lemke HU, ed. CAR ‘96: Computer Assisted Radiology. Amsterdam, The Netherlands: Elsevier, 1996; 345-350.

Mascarini C, Ratib 0, Trayser G, Ligier Y, Appel R. In-house access to PACS images and related data through World 2711:531-537.

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Ratib

et al

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