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Computers in Radiology |
1 Department of Radiology, CH-69, Children's Hospital and Regional Medical
Center, 4800 Sand Point Way N. E., Seattle, WA 98105.
2 Vivalog, 543 27th Ave., Seattle, WA 98122.
3 Department of Radiology, Children's Hospital Medical Center, Rm. 5031, 3333
Burnet Ave., Cincinnati, OH 45229.
Received December 27, 2001;
accepted after revision March 13, 2002.
Supported in part by National Institute of Mental Health grant
R43-MH61277-02.
Abstract
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CONCLUSION. We created MyPACS, a hosted teaching file authoring tool that allows easy uploading of images and descriptive information from any computer with Web access. Radiologists may designate their cases to be public or private (viewable only by the case author), and cases may be retrieved on searching for multiple parameters.
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When authoring a static Web site, the next step for the operator involves HTML construction, often performed with an HTML editor such as FrontPage (Microsoft, Redmond, WA). Each case is created as an HTML document that contains text, images, and presentation markup. The author then needs to update the collection index page by adding a labeled hyperlink to the new case document. Finally, the case document and updated index page are copied to the Web server's active directory, enabling it to become visible on the Web.
To facilitate automation of this process and to provide a more flexible retrieval interface, some institutions have developed database-driven teaching file repositories, in which case data are stored as records in a relational database, and Web pages are generated dynamically in response to browser requests. These sites allow cases to be retrieved by keyword search or by specifying attributes such as pathology or anatomic location. Although these systems are advantageous for supporting large collections of teaching files, deploying them in-house requires a significant investment in software development and maintenance costs. Furthermore, inserting new cases into the database requires knowledge of the underlying schema and data manipulation interface and requires access to the computer on which the software resides, effectively limiting the range of contributors to a few individuals. Radiologists who want to put their own teaching files online must participate in a complex workflow process that typically involves submitting their cases to a third party and waiting for approval. A user-friendly tool is needed that will empower radiologists to create and maintain their own database-driven collections of teaching-files.
In response to this need, we developed a hosted Web application that allows radiologists to create teaching file collections through their Web browsers. The goal of this effort was to allow radiologists to create online teaching files from any computer connected to the World Wide Web, regardless of platform, requiring no software other than a standard Web browser.
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The user can append images to a case at the time of case submission or at any later time. The image upload form provides a folder navigation interface that allows a file to be selected from the local hard drive and uploaded over the Internet to the MyPACS.net server. The order of images presented can be easily changed. One of the strong features of MyPACS is that the user does not have to be involved in changing image formats or image size. In many electronic teaching files that currently exist, the image that is displayed is the image that was entered into the teaching file. Thus, if an image is captured electronically, a CT scan with a pixel size of 512 x 512 will be displayed four times larger than an MR image with a pixel size of 256 x 256. This can result in the user's having to manipulate the images so that they have a uniform appearance. MyPACS takes care of this issue by allowing the uploading of images in any of more than 60 recognizable formats. So that images may be viewed on the Web, MyPACS converts them into the browser-friendly JPEG format, but an image can always be retrieved in its original format. At the time of a search request, MyPACS converts each image into three standard image sizes so that each teaching file case has a uniform look and can be optimally displayed depending on the user's monitor and desired resolution (Fig. 3). A smooth transform algorithm preserves image quality during enlargement or reduction. With the appropriate plug-in software installed in the browser, cases can be augmented with audio or video files.
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Teaching files may be retrieved by searching on any combination of parameters, including date, title, pathology, and anatomy, or by searching the full text of the findings in the case. Designed for simplicity, the search function has a toggle between a simple and an advanced search interface.
The author of a teaching file retains ownership of the images and case studies that he or she enters into the system and has complete control over how they are used. For each teaching file, the author may choose from two levels of access regulation: public and private. Public files can be accessed by any user, whereas private files are accessible by the author alone. A notes field that is accessible only to the owner of the case can be used to store additional information or coding, allowing the owner his or her own defined search parameters.
Cases may be viewed in the "images-only mode," which hides the history, findings, discussion, and reference text, and places a dark border around the images for improved viewing. This mode enhances the presentation of cases in conferences and other formal teaching settings.
The folder interface (Fig. 4) allows users to organize cases into folders according to their own preferences. Folders are particularly useful for saving search results and aggregating cases for conference presentation. Another feature is the posted notes, which allows users to add public or private notes to any case—even those they have not authored.
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Cases are stored on a professionally hosted, high-bandwidth Web server, where they are backed up daily and are always online. To adhere to patient privacy regulations, cases stored in MyPACS.net are not allowed to include patient identifiers such as name or medical record number. Each case stored in MyPACS.net is assigned a unique case number, however, and case authors may choose to keep track of the mapping between patient identifiers and case numbers. Alternatively, to enable patient identifiers to be stored in the case without potentially violating the regulations of the Health Insurance Portability and Accountability Act, the MyPACS server can be installed on an institution's local intranet. Locally hosted teaching files are accessible from any Web browser within the institution's firewall or from any PC that participates in the institution's virtual private network. In addition to avoiding the issue of storing patient data on a third-party system, locally hosted teaching files exhibit faster response times because data do not have to travel over the Internet. Furthermore, the server can be configured for tighter integration with the institution's PACS (picture archiving and communication system), either through a direct DICOM interface or by prefetching images that have been saved to a local file repository, eliminating the need to upload images into the teaching file as a separate step. Local hosting of the MyPACS server is particularly useful for institutions that want to create many teaching files for internal use. In one hospital in which the MyPACS server was installed, more than 700 cases were entered into the database in the first 4 months.
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WIRM implements Web applications using the Common Gateway Interface (CGI) protocol, a standard for interfacing external software with Web servers. WIRM works with any Web server, preferably the free Apache server (Apache Software Foundation, Forest Hill, MD) running on Linux. In our experience, Linux is the most cost-effective and reliable of all server environments, although WIRM can be easily ported to other UNIX platforms or to Windows (Microsoft, Redmond, WA). Regardless of the server environment, WIRM clients are platform-independent and compatible with any Web browser.
WIRM derives its power by leveraging free, open-source software, including ImageMagick (ImageMagick Studio, Landenberg, PA) for manipulating images, the MySQL database (MySQL AB, Uppsala, Sweden) for storing records, and the CGI module (Cold Spring Harbor Laboratory, Cold Spring Harbor, NY) for generating Web-based user interfaces. Although these free software packages are readily available, they often go untapped by the domain experts who need them most because these packages are aimed at Linux developers who have the expertise to understand their details and tie them together with a custom code. WIRM integrates these different components into a coherent framework, providing visual interfaces and high-level abstractions suitable for use by scientists, clinicians, and educators.
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The role of MyPACS expands beyond that of the traditional cut-film teaching file. For example, MyPACS can be used as a tool during intra- and interdepartmental conferences. In one institution, a weekly intradepartmental "interesting case conference" is given directly from a folder created in MyPACS; presenting residents and fellows enter cases into the teaching file as they prepare for the conference. After each conference, conference folders remain in the teaching file so that those wishing to review cases are able to do so at their leisure.
MyPACS can also be used to store, organize, and retrieve cases for upcoming publications and presentations. The flexible text fields, advanced search features, anatomic and pathologic subcategories, folder structuring, and comments fields included with MyPACS simplify the task of locating and copying relevant images and text. These features makes lecture and publication preparation far more efficient.
In summary, MyPACS enhances access to useful images in everyday clinical practice. By making instructive images more accessible, MyPACS enhances the ability to teach, while decreasing the time it takes to locate, organize, and display quality images. This enhanced access can be invaluable as institutions work to fulfill their educational mission in the face of ever-increasing clinical demands.
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