Robert G. Leckie

Lessons learned and two years clinical experience in implementing the Medical Diagnostic Imaging Support (MDIS) System at Madigan Army Medical Center

The Medical Diagnostic Imaging Support System at Madigan Army Medical Center has been operational in a phase approach since March 1992. Since then, nearly all image acquisition has been digital with progressively increasing primary soft copy diagnosis utilized. Nearly four terabytes of data will have been archived in compressed form by the two year anniversary including more than 300,000 Computed Radiography images.

Evolution of teleradiology in the defense medical establishment.

The Medical Diagnostic Imaging Support (MDIS) System is a four-year contract to install large-scale picture archival and communications systems (PACS) and teleradiology in Army and Air Force medical treatment facilities. MDIS specifications were based on the results of three years of tri-service research and development through the Digital Imaging Network Systems Project and the Tactical Air Command Teleradiology Project. At the time of the governments request for proposals, MDIS functional specifications represented the most comprehensive understanding of the requirements for large-scale PACS and teleradiology complied by a composite team of radiologists, physicists, clinical engineers, hospital administrators, technologists, and computer systems engineers. As MDIS sites become operational, a better understanding of the capabilities and limitations of teleradiology is emerging. This paper reviews functions and subsystems common to all teleradiology systems, MDIS specifications for teleradiology, installation planning, and the status of Army and Air Force Teleradiology with special emphasis on early installations that validate routine teleradiology operations.

Optimization and quality control of computed radiography

Computed radiography (CR) is a relatively new technique for projection radiography. Few hospitals have CR devices in routine service and only a handful have more than one CR unit. As such, the clinical knowledge base does not yet exist to establish quality control (QC) procedures for CR devices. Without assurance that CR systems are operating within nominal limits, efforts to optimize CR performance are limited in value. A complete CR system includes detector plates that vary in response, cassettes, an electro-optical system for developing the image, computer algorithms for processing the raw image, and a hard copy output device. All of these subsystems are subject to variations in performance that can degrade image quality. Using CR manufacturer documentation, we have defined acceptance protocols for two different Fuji CR devices, the FCR 7000 and the AC1+, and have applied these tests to ten individual machines. We have begun to establish baseline performance measures and to determine measurement frequencies. CR QC is only one component of the overall quality control for totally digital radiology departments.

MDIS workstation: an update of performance after nearly two years of clinical use

The medical diagnostic imaging support workstation has been in clinical use at selected military medical centers since March 1992. The workstation is a critical component in picture archiving and communications systems representing the interface between the system and the end user. The workstation has undergone several software changes over the last year based on feedback from end users. The present performance of the workstation in terms of image manipulation and navigation, response time, database, and reliability is emphasized. Discussion includes clinical acceptance, lessons learned, and future enhancements.

Medical diagnostic imaging support early experience and efficacy of wide-area intercontinental teleradiology

Intercontinental teleradiology is a newly implemented operational environment for the Medical Diagnostic Imaging Support (MDIS) system project, with phased teleradiology implementation at five sites coming on-line on the Korean peninsula, and four sites being phased in on the island of Oahu, Hawaii, between September 1993 and November 1994. Early implementation and testing efforts began between McConnell Air Force Base, Kansas, and the MDIS Project Office, Fort Detrick, Maryland, in the Summer of 1993. Emphasis is on explaining lessons learned and technical considerations for improving patient care on a global basis. Data on system speed, reliability, image quality, image interpretation and report turn-around is presented. The discussion will cover lessons learned on setting up an intercontinental teleradiology system and various configuration requirements for global teleradiological imaging, diagnosis, and reporting. The scope of the MDIS teleradiology implementation includes U.S. based Picture Archival Communications Systems at major medical treatment facilities which will do consultative and primary diagnostic reading of radiological images sent to them from smaller facilities all over the world.

Clinical Experience with Teleradiology in the U.S. Military

The U.S. military through the Medical Diagnostic Imaging Support (MDIS) system is installing teleradiology at multiple medical treatment facilities throughout the US and abroad. The goals are to improve patient care, maximize limited resources, and realize cost savings. This presentation reviews early experience with clinical use of the MDIS teleradiology configuration. Emphasis is on lessons learned in the areas of image quality, speed of image transmission, communication between sites, and the advantages of the MDIS two-way teleradiology configuration. The data is accumulated from the combined experience of the authors at multiple different sites within the continental US, Hawaii, and Korea.

Evaluation of Specific PACS Equipment Components Operational and Maintenance Experience

Through the Medical Diagnostic Imaging Support (MDIS) Program, the U.S. military has installed picture archiving and communication systems and teleradiology systems in three medical centers. The primary image acquisition modality for these systems is computed radiography. This presentation reviews the distribution of downtime for the computed radiography devices at the three PACS based hospitals and at one non-PACS based medical center. Data on both the Fuji AC1+ and the Fuji Digiscan 7000 is included. Reported downtime is divided into four categories; user induced, hardware, software, and preventive maintenance. Analysis of the distributions of these four categories in the context of the equipments operational environment points out the impact of workload, interface complexity, preventive maintenance, and human factors upon both the number of equipment failures and the reason for the failures.

Digital imaging access library

The ability to access a vast array of radiological and pathologic diagnoses through computer searches of local medical facility databases is a by-product of the continued development of filmless imaging systems. The Department of Defense (DoD) Medical Diagnostic Imaging Support initiative is expanding through the addition of on-line systems at several DoD health care facilities. Madigan Army Medical Center, as the initial site, will soon be 90% filmless, with over one million images archived. Multiple other DoD medical centers are under installation. The eventual goal is an interconnected network of PACS systems of DoD medical centers and their supported medical facilities throughout the United States. To access this potential pool of medical information requires a centralized database capable of acting as a diagnostic index system. The establishment of a multi-center film library index begins with an initial analysis of issues regarding data storage and access, indexing, cross-coding with pathological files, communication formats, cost sharing, and patient confidentiality. In initiating these first steps to developing this telecommunications library these issues and their implications are discussed. The final implementation of this system will facilitate markedly improved research and teaching capabilities in both radiological and pathological fields.

Image processing of storage phosphor musculoskeletal radiographs: a comparison of the AGFA and Fuji bone algorithms

Storage phosphor radiography of the musculoskeletal system offers significant advantages for most potential diseases of the skeleton. Proper use of the system is however essential if its value is to equal or exceed that of conventional screen film radiography. There are two competing storage phosphor imaging commercial systems currently designed to accommodate musculoskeletal images. The Fuji and the AGFA systems. The image processing methods for the Fuji and AGFA machines differ substantially from each other and there are advantages and disadvantages of each system.

Conceptual plan to link nuclear medicine and the MDIS radiology PACS

The Medical Diagnostic Imaging Support System (MDIS) is a project to install PACS systems at several medical sites in the military. The configuration calls for links to nuclear medicine in the near future but to date no definite system has been devised. This presentation describes a scenario in which a nuclear medicine department acts as a mini-PACS system with a direct link to the larger parent PACS system. The advantage of this approach is that it allows greater specialization at the workstation than is presently configured into the MDIS PACS system. Also large data sets can be reviewed and manipulated without slowing down the flow of images in the parent PACS. Only processed and formatted images are sent to the parent PACS system. Several problems exist in interfacing a nuclear medicine service with the MDIS PACS system and these are discussed.