Friday, June 28, 2013

CARS 2013 - OR Systems Design and Applications

Ratib and Amato discussed about intelligent design in the OR. They state that intelligence in workflow and data management will drive future diagnostic and treatment platforms...from Patient models... To intelligent patient models. They stated that in intelligent design the BIM (building intelligent model) should be used allowing integration of simulation into a 3D model. This concept is already used in other areas and should be introduced in the design of facilities in healthcare integrating the patient specific model into the design. There is too much technology in the OR, the future paradigm should be to move the technical stuff outside the OR. On the other side, imaging is entering the OR and new technologies are coming fast.

Five other presentations were given touching different aspects of developments in the OR. Generally it was discussed that a lot of information is available during surgery from different systems on different computer screens and that intelligent systems are required to optimalize the data rich OR environment.
This requires a new vision on how the data should be presented to the surgeon. Decreasing the number of screens by integration of the sources on one switchable display is one of the presented solutions. A group from Leipzig showed how they perform this switching automatically using a roadmap of the OR workflow for the procedure currently performed. Huang discussed a currently running and tested integrated OR setup. Other topics covered were the standardization of robotic interfaces for image guided surgery using OpenIGTLink, and experiences with IP based systems in the OR.

The main direction presented by most is to move to more intelligent systems and infrastructures. Possible direction is by employing machine learning.

CARS 2013 - Cardiovascular and Angiographic Imaging

The first presentation in this session was by Tuncay on segmentation of the aortic valve area on CT. They have deviced a novel method to semi automatically segment the opening area of the aortic valve. They created an adaptive grayscale image to get the boundaries more clear and an adaptive algorithm to remove the calcium from the image. The technique proved effective and more reproducible in 21 patient datasets.

The second presentation by Haase was on Model based 3D registration of a CS catheter: application to single X-ray projections from a rotational angiographic sequence. They use a model of the catheter and combine this with the recorded Xray data to obtainna 3D representation of the orientation and movement of the catheter in 3D. They showed high accracy in the tracking in a simulated phantom setup. In clinical datasets also a high accuracy was obtained. Overall accuracy was 0.33 mm in 2D and 2.04 mm in 3D.

The third and final presentation by Masuda was on full automatic calculation of ejection fraction of left ventricle from either of short-axis view by processing succesive ultrasound images. The aim of their study was to design a method that does not require any initial input of the user. They envision to include this algorithm into a portable echography device for use in emergency situations. They demonstrate an interactive real-time detection of the LV cavity during the acquisition of the ultrasound. A subjective scoring by sonographers showed a high level of correct segmentation. Their algortihm was succesfull both in two and four chamber view. Good correlation was shown of the EF based on the new and conventional method.

Thursday, June 27, 2013

CARS 2013 - Image Processing Workflow and Management in Clinical Practice

Regge gave an interesting presentation on getting from bench to desktop with image processing illustrated with his own example on CT colonography. His take home points are that an Imaging lab should be embedded in a cliinical unit, should be cautious with industrial partners, and must start from a clinical problem and build the software on that problem.

Glinkowski presented about what information the clinician really needs. The questions a clinician asks are: what? Where? How? Decision making - what to do? In answering these question the clinicians are heavily depending on imaging an Radiology is essential in answering many of the questions a clinician may have in a muti disciplinary collaborative effort to get the optimal outcome for the patient.

Where we stand on costs and reimbursements of image processing was the topic of a presentation by Turchetti. He started to show that the total healthcare expenditure in Europe and the US is increasing. First cause of this increase is innovation because of growing indications and applications of the innovations, growing area of treatable conditions, increasing use of technologies for the same conditions with less discomfort, broadening definition of diseases and life extending effects. Note that all issues are positive: we live longer and better... Most countries try to tackle these issues with increasing efficiency, redesign of the supply side (closing hospitals, reducing beds, etc), regulation of price and/or quantity of services, and the reduction of the services granted for free and introduction of higher level of co-payment.
The reimbursement mechanism could stimulate efficiency and reduce the opportunistic behavior of hospitals. But if not used properly it could impede the transfer of innovation to the clinical practice.
Studies to calculate real cost of procedures should be promoted and reimbursement should be defined accordingly. Define for which indications the image processing is approriate from a clinical point of view and from a cost effectiveness point of view. Cost and reimbursement should be properly aligned.

In the next presentation Fatehi discussed the composition of the image processing research team including the clinician, radiologist, radiographer, computer scientist, biomedical engineers, and ... He stated that image processing reeserach is done to answer a clinical need, to refine engineering methods and to support management. As stated already many times during the conference he also stresses that imaging research should be a multi-disciplinary effort. The cooperation should include the following topics.

Clinical to Technical:

  • Defining the clinical question

  • Defining the components of the applications

  • Providing the most relevant datatsets

  • Defining the workflow before and after the image processing

  • Validating the test protocol

  • Improving the user interface

Technical to clinical:

  • Specify potential methods to achieve the clinical goal

  • Specify technical limitations of implementing the application development

  • Provide a comparative list of already tested methods in the literature

  • Translating the clinical workflow into an engineering language with technical block diagrams

  • Keeping engineering standards in the final product/application

  • Taking care of the integration issues

  • Taking care of the licensing issues

  • Providing information about open source to avoid high costs.

Finally, Schilling presented on bridging the radiology/surgery gap. He advocated the introduction of new visualization protocols with higer dimension imaging with direct interaction with the data using easy to use devices. They want to have intuitive 2D and true 3D. Clinical efficacy and worflow can both be optimal using true 3D.

CARS 2013 - PACS Workflow

In a presentation from the Neterlands, Jorritsma discussed the necessity to introduce usability to the PACS selection process. He stated that in PACS replacement functionality is regarded but not usability, while this should be a major criterion in the PACS selection process. Subjective measures should be complemented with objective usability data to be valuable in the selection process.

Next, Procida from Italy presented on 'PACS independent and IHE-like approach method for the analysis of PACS in a healthcare enterprise'. they noticed that the hospital had over 100, high cost, workstations connected to the PACS. However, the usage of these systems is unknown and many of them might be used only for a small part of the time. The display on/off status was recorded in a database and provided the possibility to record system usage. This method was limited by the fact that the displays had a delay of 10 min inactivity before they turned off automatically. The IHE ATNA (Audit Trail Node Authentication) profile was utilized to determine the exact use of the workstations since information about each exam view was recorded with the user information. A more accurate status was obtained with this second method about the workstation usage per workstation. This allowed reallocation and discontinuation of underused, high cost, workstations. Proposals are made to the IHE to adopt the ATNA profile to fully support this non-intended but very interesting use.

Final presentation was from Japan, presented by Ito on the improvement of clinical workflow of thoracic surgeons in distant hospitals by interactive teleconference using open source software. They used Osirix, VNC, Voice Chatter (voice communication software) and Wireshark (packet analyzer) to setup teleconference with only open source software. Using this they setup a four hospital teleconference system using VPN connection. Instead of travelling up and down they now upload anonymized DICOM data to the university hospital and do the consultation using the teleconference method saving hours of travelling time.

CARS 2013 - Image Distribution and Cloud Computing

Aryanto presented on an institutional DICOM data distribution system called RadTransceiver. They have built an environment to distribute DICOM data throughout the health enterprise using a webbased, standards based, environment. The setup allows easy distribution using different protocols either with or without anonymization.

Mahmoudi touched the topic of medical image annotation and retrieval. This group from Belgium uses CBIR to support a decision support system by providing similar previous exams based on a query image.

A zero footprint application of mobile devices in radiolgy was presented by dr. Engelmann. He showed that starting early this century the developments of mobile devices for medical image review has progressed steps until their now marketed product that is device independent and available from CHILI as CHILI/Mobile.

Final presentation by Kondoh on development of hybrid medical record sharing system, EPR and PACS of each hospital on cloud technology plus XDS and XDS-I on cloud technology.

CARS 2013 - Content based retrieval from DICOM images

In a very interesting presentation, dr. Caramella stated that making full use of PACS content goes beyond the images and involves teaching files, content based retrieval, dose information extraction both regarding radiation and contrast media use, and proactive quality assurance.

Dr. Kozuka showed image based retrieval in a clinical database of lung CT images. They defined image features in the lung CT scans with a new approach to dynamically assign weights to image features for each query by also using written findings descriptions to extract information from the database. They showed higher succes rates with their weighted method (71%) when compared to the conventional method (61%).

The next presentation was about user interface design to enhance human interpretation of content based image retrieval by dr. Kubar. Using 8 literature based UI requirements and recommendations. Their novel approach is a graph showing a representation of the data by providing anatomical region nodes and tumour region nodes and the connection between the node that define their relationship. The nodes are linked to the images allow the user to utilize the nodes to jump to the correct image. A full paper on the presenation can be found in the Int. journal of CARS.

Bastião from Portugal presented on analyzing of efficiency and service quality of digital imaging laboratories. They use DICOM (meta)data to perform knowledge extraction to get quality indicators and evaluate performance. They used a DICOM data mining tool called dicoogle available at which permits extraction of DICOM meta data allowing a variety of analyses based on the DICOM header information.

CARS 2013 - PACS-CAD Integration

This session contained four presentations on PACS-CAD integration.

Dr. Regge gave an outlook of a radiologist on how to use the CAD in the clinical workflow. He discussed the problems with double reading with increased recall rate of patients for biopsy and the cost involved in requiring two experts to review all datasets. This provides a good incentive to start using CAD as a second reader. Studies have shown similar performance with increased recall rates but also with reduced cost of the diagnostic process because of having only one reader and the decrease in reading time. Controversies are that radiologists might reject true positive polyps defined by CAD and the influence of CAD on the reading process. Inconclusion CAD is coming to maturity and can be used but still is controversial and the clinical value still needs to be assessed.

Dr. Suárez Cuenca presented on an integration of CAD into the PACS environment using a wide computing infrastructure. They aim to build a sytem for a whole region in Spain to make CAD assessable for multiple hosptials utilizing different PACSs and clinical workstations. They build a standards based platform with which users can request a CAD service and receive the results in their local PACS. The process is running through a webinterface that allows sending their (anonymized) data to the CAD service and receiving a DICOM object with the result.

Next a presentation on Enhancing clinical use of CAD systems in PACS with automation and open-source tools by dr. Summers. They built a system that allows a better integration of CAD into the normal workflow utilizing the clinical information already available in the PACS to automate the utilization of CAD in three different scenario's. Either all studies are processed automatically based on their properties (8 minutes per case), a radiologist selects a specific case and requests processing (6 min per case), or a list of cases is predefined in PACS and processed automatically with notification of completion to the radiologist by email or text message (9 min per case). This method allows non disruptive integration with the ability to utilize the full capabilities of the PACS workstation, such as direct comparison with older data.

The final presentation by dr. Behlen was entitled 'an unexamined assumptionnis not worth assuming: imaging data quality exposed in data migration'. this talk was about PACS data migration by Laitek, a company specializing in this area. They presented figures showing exceptions ranging from almost 0 to 35%. Majority of the migrations will only have 1-2% of exceptions. Many problems occur related to interpretation of the DICOM standard. One of the problems is the utilization of annotations, where everybody is implementing in a different way resulting in difficulties to transfer them from one to another PACS environment.

CARS 2013 - Medical Imaging Informatics Simulators

After a short introduction and welcome by prof. Neri, prof. Huang presented a tutorial on Medical Imaging Informatics Simulators. In this tutorial a Medical Imaging Informatics Infrastructure was introduced together with its simulator environment. The simulators are plugged into the MIII layers which integrates with PACS/RIS/ePR/HIS/etc. The simulators can be built in different forms for a variety of applications utilizing different components. They use the actual 'live' information to provide a simulated environment for training and testing. The other simulators described by prof Huang are systems setup to achieve the standards based integration of different components within one single workflow enabling easy acces to and deployment of those different components. After a proven implementation in the simulator environment, the simulators can be moved into patient care.

Wednesday, June 26, 2013

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CARS 2013 - Opening Lectures

Three keynotes were presented during the opening ceremony.

Dr. Ringertz presented about histopathology using integrated diagnostics where many modalities are used to gather diagnostic data. The emergence of molecular imaging has reduced the impact of imaging scale. Knowledge from radiology resulted in a study on workflow and IT solutions for efficient digital pathology. The main goal is to Design the optimal workflow of a digital pathology department utilizing the synergies between the imaging modalities in radiology and pathology. Dr. Ringertz showed that although many actions in pathology are still done manually and non-digital this will move to a more digital environment using IT possibilities based on the experience already gained in Radiology. A major problem is the data explosion when digitizing imaging modalities in pathology where a multitude of the data of radiological modalities like CT is produced. He concluded that digitization has started in pathology and that radiology can help the process. Furthermore, the role of pathology in the diagnosis will increase. This requires standardized referral, computerized order entry and structured reporting.

Dr. Satava presented on 'how much radiology do you need in surgery'. He stressed that this requires disruptive visions because we went from the industrial to the information age. He showed an increase of the use of different tools in treatment (ablation) and robotics. This requires a combination of radiology and surgery and the need for these new techniques will increase to about 90% of the surgeries within 25 years. The Interventional Radiology and non-invasive surgery are moving into a new dimension where surgeons need to move towards radiology or cooperate, which also holds for the digital operating room. The fundamental change is from tissue and instruments to information and energy. Its about exploiting the electromagnetic spectrum (energy) and utilizing the information flow. Dr. Satava stated that it is all about controlling energy and building intelligent sytems.

Finally, dr. Fenster presented on 'Dynamics of medical and technical disciplines towards a multi-disciplinary approach to digital driven healthcare and research'. He presented on the way they setup a small lab which developed into a leading center in Canada. One of the priorities he defined is a multi-disciplinary approach is crucial within a lab although many barriers may exist. Another priority is the focus on diseases and translation instead of on technology, which in itself also helps the creation of a multi-disciplinary approach.

Tuesday, June 25, 2013

CARS 2013

The coming days I will be attending the CARS 2013 in Heidelberg, Germany. I will mainly focus my attendence of scientific sessions to the EuroPACS part and the digital OR developments. For more information keep a look on this blog for the coming days.

CARS is running from June 26-29, 2013. For more information visit their website.

Tuesday, June 11, 2013

Microsoft's Robot Touch Screen Lets You Palpate a Brain

Microsoft is working on haptic feedback integrated into a touch display. So when going to a stack of slices from a CT or MR haptic feedback can be provided based on the image displayed.

Microsoft's Robot Touch Screen Lets You Palpate a Brain