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Elizabeth A. Krupinski, PhD Arizona Telemedicine Program Ovitt, et al . Intravenous angiography using digital video subtraction: x-ray imaging system. AJR 135(6):1141-4, 1980.

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elizabeth a krupinski phd arizona telemedicine program
Elizabeth A. Krupinski, PhD

Arizona Telemedicine Program

slide2

Ovitt, et al.Intravenous angiography using digital video subtraction: x-ray imaging system.AJR 135(6):1141-4, 1980.

An x-ray imaging system, using digital subtraction techniques, has been developed. The system requires: (1) high output generation equipment; (2) an image intensifier capable of receiving high output exposures, 1 mR (2.58 X 10(-7) C/kg) at the face of the intensifier, without loss of either contrast or resolution; (3) a precision digital video camera; (4) processing computer with sufficient storage capacity; and (5) digital image storage. With this system it is possible to visualize the major arteries after intravenous contrast injection.

slide3
Capp et al.

The digital radiology department of the future.

Rad Clin N Am 23(2):349-55, 1985.

The boom in microelectronics, including cost-effectiveness, has

now allowed us to consider the use of these objects to store

digital images. There remains much research, development,

And clinical evaluation to be done in receptor technology.

Further improvements in image processing, optical laser disk

storage, & optical transmission and further commercial

Development of display technology must take place. All of

These developments are occurring simultaneously. Within 5 to

10 years, radiology departments will most likely be totally

electronic, probably cost-effective, and, it is hoped, more

diagnostically accurate.

slide5

Oldest established TM application

  • Well integrated in numerous settings
  • Facilitated by co-evolution PACS
  • Few to no reimbursement issues
  • Only interventional radiology currently less amenable to teleradiology applications
  • Little/no differences between teleradiology & on-site radiology
slide6

ACR-NEMA development DICOM

  • Continual updates of DICOM
  • Development of standards & practice guidelines that explicitly include teleradiology
  • http://medical.nema.org/
  • http://deckard.duhs.duke.edu/~samei/tg18.htm
slide10
Key is the human-computer interface
  • Series of observer performance studies designed to optimize the digital reading room environment
  • Performance metrics
    • Diagnostic accuracy (ROC)
    • Search efficiency (eye position)
  • Human Visual System Modeling
slide12

Softcopy display parameters

    • Luminance
    • Calibration (tone scale)
    • Type of phosphor
    • CRT vs LCD
    • MTF
    • Viewing angle
    • Number of displays
    • Ambient lighting
    • Compression
    • Role of color

P45

P104

slide13

Spatial & contrast resolution limitations require radiologists to search images. The UVF is about 2.5 deg radius. Probability of target detection falls off as a function of target eccentricity from axis of gaze.

slide14

Total viewing time shorter

  • Time to first hit shorter
  • Total time on lesion shorter
  • Fewer returns to lesion
  • Total path length shorter
  • Overall = more EFFICIENT
slide17

Med Student

Resident

Pathologist

slide18

Display & Interface

20% fixations fell outside diagnostic image

slide19
Hospital/MC
  • Clinics
  • Mobile van
    • Mammo
  • Dedicated
    • PET clinic
    • THH
    • UASA
  • Public Health
  • Battlefield
  • Hand-held
slide23
Medical Imaging Consultants -> ?
    • Data acquisition & archiving
  • RadWorks (GE) -> Siemens/Fuji
    • Viewing station
  • 35% of department’s reading volume
  • 25% department’s income
    • Reading only & reading + archiving
    • $/case & $/set volume
slide24
68% sites using AHSC hub for TM services use TR service
  • TR typically 1st service requested
    • 79% of sites with TR use only TR
    • 21% started with TR & added services
  • TR specialty with most volume
slide25

Time from mammography to consult with oncologist ~ 28 days

    • Screening mammography
    • Diagnostic mammography
    • Biopsy
    • Pathology processing & report
    • Oncology consultation
  • THIS IS TOO LONG!
slide27

DS3 (45 Mbps) backbone

    • ATM protocol
  • T1 (1.5 Mbps) links
  • 65 direct link sites
  • ~ 85 with affiliated
    • NARBHA
    • DOC
    • IHS
  • RT & SF applications
  • ~ 55 sub-specialties
  • Teleradiology core app.
slide28

Started in 2001 to rural sites

  • 7/28 telerad sites send mammo
  • Mostly use GE system
  • Directly to TBC for reading
  • Some archive some do not
  • Contracts specify 30-45 min TAT
  • > 26,000 telemammography
slide30

Quick Processing

Milestone Medical Systems RHS-1-30

Vacuum Histoprocessor

slide31

Telepathology

DMetrixTM -40 Slide Scanner System

slide34

Telepathology report sent S&F to oncologist

  • Oncologist connects RT videoconference to rural location
  • Discuss pathology results
  • If necessary discuss treatment options and plan of action
the future of tr pacs
The Future of TR & PACS
  • MI = prevention, detection, diagnosis, treatment & therapy
  • Acquisition & display technology continually changes
  • Clinician shortages are not easing
  • Rapidly expanding types & number images
    • Multi-modality & fusion complimentary information sources is becoming common
    • Anatomy & function gross & molecular levels
    • Merging specialties
slide40

Clarke et al. Validation if Tumor Burden Measurements

Using 3D Histopathology. In: Digital Mammography 2008.

Springer-Verlag.

the future of tr pacs41
The Future of TR & PACS
  • Image Display, Analysis & Processing are key links in the imaging chain
  • Need to present data to the clinician in the most efficient & informative manner
  • Taking into account perceptual & cognitive capabilities of human observer
  • Ultimate goal = facilitate decision-making process & enhance patient care
  • Related goal = improve workflow & the reading environment
slide42

Stereo vs Traditional

  • Az 0.85 to 0.94
  • 23% increase TPs
  • 105% increase calcs
  • 46% decrease FPs

Getty et al. Stereoscopic Digital Mammography:

Improved Accuracy of Lesion Detection in Breast Cancer Screening.

In: Digital Mammography 2008. Springer-Verlag.

slide46

50 DR chest images (PA) : 1/2 solitary pulmonary nodule verified CT; 1/2 nodule free

  • 6 radiologists (3 sr residents, 3 board-certified)
  • 3MP Barco color medical-grade display (BarcoCoronis MDCC-3120-DL) vs COTS color 2MP monitor (Dell 2405)
  • Calibrated (DICOM GSDF ) to luminance corresponding to backlight aging 1-year time
    • Max Barco 500 cd/m2 min 0.77 cd/m2
    • Max Dell COTS 342 cd/m2 min 0.376 cd/m2
color vs color
Color vs Color

F = 4.1496, p = 0.0471

Sensitivity = 0.91 vs 0.86

Specificity = 0.93 vs 0.92

color vs color48
Color vs Color

F = 3.38, p = 0.067

color vs color49
Color vs Color

No significant differences

TN significantly different

slide51

Carpal tunnel syndrome

  • Elbow & shoulder (cubital tunnel)
  • Neck, back & shoulder strains
  • Computer vision syndrome
    • Eye strain
    • Dry eyes
    • Glaucoma
    • Headaches
    • Corneal erosion and abrasions
    • Contact lens problems
slide52

Reader Fatigue

BLURRED VISION

slide56

TR has made a significant impact on patient care over the past 20 years

  • Advances in technology will further change MI & interpretation of medical data by more clinicians
  • Costs can increase & decrease
  • Optimizing observer accuracy while maintaining efficiency & comfort are critical to continued success
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