TELEMETRY IN RADIOLOGY

Teleradiology have become increasingly important as our countrys healthcare delivery system gradually changes from fee-for-service to managed, capitated care. During the past several years, we have seen the trend of primary care physicians joining health maintenance organizations (HMOs). These HMOs purchase smaller hospitals and form hospital groups under the umbrella of HMOs. Also, academic institutions form consortia to compete with other local hospitals and HMOs. This consolidation allows the elimination of duplication and the streamlining of healthcare services among hospitals. As a result, costs are reduced, but at the same time because of the downsizing, the number of experts available for service also decreases. Utilization of telemedicine and teleradiology is a method to alleviate the diminishing of experts, streamline the diagnosis process, and save healthcare costs. Teleradiology is a subset of telemedicine operation focusing in remote diagnosis of medical images. Teleradiology utilizes computer, display, and telecommunication technologies for radiologists to make remote diagnosis from radiological images generated at distant examination sites. The diagnostic report is sent to the examination site where a primary physician can provide proper treatments to the patient immediately. Figure 1 shows a generic teleradiology set-up illustrating that teleradiology is not a single medical device or an instrument, instead, it is a system integration of various imaging devices using communication technology and system software connecting multiple imaging centers and expert centers together (13). Dependent on the required turn around time in obtaining the diagnosis from the examination site, the expert center has three reading modes: telediagnosis, teleconsultation, and telemanagement. These reading modes dictate the communication requirements of transmitting the images between the sites. Teleradiology operation can be very simple or extremely complicated. In the simple case, a radiology resident may send an image set from a CT (computed tomography) scanner using low quality teleradiology equipment and slow speed communication technology in the evening to the radiologists home for a second opinion. This type of teleradiology operation does not require highly sophisticated equipment. A conventional telephone and simple desktop personal computer with modem connection and display software are sufficient to perform the teleradiology operation. This type of application originated in early 1970. The complicated teleradiology operation can have different models starting from simple to complicated in ascending order. The complications occur when the current examination requires historical images for comparison, and when the radiologist needs information from the radiology information system (RIS) to make a diagnosis. In addition, complications arise when the images and the corresponding diagnosis report are required to be archived to the patient data file. Teleradiology is relatively simple to operate when neither retrieval nor archive of previous information and images is required. However, when both archive and retrieval are required, the operation becomes extremely complicated.

WHY DO WE NEED TELERADIOLOGY? The managed care trend in healthcare delivery expedites the formation of teleradiology expert centers. However, even without the healthcare reform, teleradiology is still an extremely important component in radiology practice for the following reasons: First, teleradiology secures images for radiologists to read so that no images will be accidentally lost in transit. Second, teleradiology reduces the reporting cycle time after the image is generated. Third, since radiology is subdivided into many subspecialties, a general radiologist requires a specialists second opinion on occasion. The availability of teleradiology will facilitate seeking a second opinion. Fourth, teleradiology increases radiologists income since no images would accidentally be lost and subsequently not reported. The healthcare reform adds two more reasons. It saves healthcare costs since an expert center can serve multiple sites reducing the number of radiologists required. It improves the efficiency and effectiveness of healthcare because the report turn-around time would be reduced and there would be no loss of image. TELERADIOLOGY COMPONENTS A generic schematic of teleradiology depicted in Fig. 1 shows teleradiology components and their connections. Modalities generating images in teleradiology applications include CT, MR, CR, DR, US, NM, DSAdigital fluorography (DF), and film digitizer.These acquisition devices are first generated from the examination site and then sent through communication networks to the expert center if they are already in digital format. Or, if these images are stored on films, then they need to be digitized by a film scanner at the examination site. IMAGE CAPTURE In image capture, if the original image data are on film, then either a video frame grabber or a laser film digitizer is used to convert them to digital format. A video frame grabber produces low quality digital images, but is faster and cheaper. On the other hand, laser film digitizers produce very high quality digital data, but take longer and cost more compared to the video frame grabber. During the past several years, direct Digital Imaging and Communication in Medicine (DICOM) standard output images from CR, DR, CT, and MR have been used extensively in teleradiology. DATA REFORMATTING After images are captured, it is advantageous to convert these images and related data to industry standards because multiple vendors equipment can be used in the teleradiology chain. The two common standards used in medical imaging industry are the DICOM (6) for images and Health Level 7 (HL7) (7) for textual data. The DICOM standard includes both the image format as well as the communication protocols based on the standard TCP/IP. Health level 7 is the standard for textual data, it uses the TCP/IP communication protocols.

IMAGE STORAGE At the expert center, a local storage device is used before images are displayed. The capacity of this device can range from several hundred megabytes to many gigabytes. A long-term archive, such as a small DLT (digital linear tape) library, is used for teleradiology applications that require historical images and diagnostic reports, related patient information, and current images and diagnosis. DISPLAY WORKSTATION For an inexpensive teleradiology system, a low cost 512- line single monitor can be used for displaying images. However, high resolution multimonitor display workstations are needed for the primary diagnosis. These state-of-the-art technology diagnostic workstations, use two monitors with over 2 GB of local storage, and can display images and reports from the local storage in 12 s. A 2000-line LCD monitor workstation costs from $20,000 to 30,000, and a 1,600 line costs from $15,000 to $20,000. User-friendly image display software is necessary for easy and convenient use by the radiologist at the workstation.

TELERADIOLOGY AND PACS Picture Arching and Communication System (PACS) is a hospital integrated imaging management system developed in the early 1990s (Fig. 3) (4). The infrastructure of PACS is shown in the upper three rows. Two types of servers in the bottom of the figure are for various PACS applications. When teleradiology service requires patients historical images as well as related information, technologies used in both teleradiology and PACS become very similar. Table 2 shows technologies used in teleradiology and PACS, the major differences are in image capture, communication, and storage. Some current teleradiology operations still use a film digitizer as the primary method of converting a projection film image-to-digital format, although the trend is moving toward direct digital capture.

In PACS, direct digital image capture using Digital Imaging Communication in Medicine (DICOM) standard format is mostly used. In networking, teleradiology uses slower speed wide area networks (WAN) compared with the higher speed local area network (LAN) used in PACS. In teleradiology, image storage is mostly short term, whereas in PACS it is long term. Teleradiology relies heavily on image compression, whereas PACS may or may not. PACS and teleradiology use medical images for radiologists to make diagnosis. In clinical applications, one examination is composed of many images of different views and anatomical emphasis, since a single image is generally not sufficient for making the proper diagnosis. In general, a typical examination generates between 10 and 20 MB, although some current CT and MR imaging modalities can generate up to 3000 images per examination.The high extreme is in digital mammography, which routinely requires 160 MB. To transmit 160 MB of images through WAN for teleradiology requires a very high bandwidth communication technology.