PACS (PowerPoint) by chin1981

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powerpoint about picture archiving and communication system.

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A picture archiving and communication system
(PACS) is a comprehensive computer system that is
responsible for the electronic storage and
distribution of medical images in the medical

To   replace conventional analogue film, paper clinical request forms and
reports - with a completely computerized electronic display whereby
digital images are viewed on monitors in conjunction with the clinical
details of the patient and the associated radiological report displayed in
electronic format.
Must  replace functions of traditional X ray film i.e. image acquisition,
storage, transportation and display
Must   improve upon a film based system in a cost–neutral manner
  The PACS Project Team

Most PACS decisions take upwards to two years from initial
planning through contract negotiations and employs a team of
people from:

     Radiology- Radiologists, Techs
     Information Systems- I/S support, networking, etc.
     Administration (CIO, CFO, VP, etc.)
     Purchasing
     Staff Physicians and Nursing staff
     Outside Consultant
Key components of PACS
   Digital acquisition devices
   Network
   Database server
   Archival system
   RIS
   Soft-copy display workstations
   Remote access
    PACS & Its Components
    (1) Acquisition (2) Storage                    (3) Display
        DICOM Modality

                               DICOM Server

                                                      Diagnostic WS

         CT, MR

                                                      Clinical WS

        DSA, CR, DR, RI
                                                                           Laser Imager
                                Storage &
                                                          Printer Server

               Video Acq. WS
      US, ES                                                               Laser Imager

7     Non-DICOM Modality                    (4) Network

To   acquire- digital DICOM compatible acquisition devices

To   display- bright monitor

To   transport- fast network

To   store- large archive and database (efficient data management)
 Digital Imaging

 Digital   imaging is a broad term.

 Term   was first used medically in 1970s in computed
 tomography (CT).

 Digital   imaging is defined as any image acquisition process
 that produces an electronic image that can be viewed and
 manipulated on a computer.

 In   radiology, images can be sent via computer networks to a
 variety of locations.
An electronic digital image is made up of a matrix of tiny
Picture elements called as Pixels
Bit depth for a pixel

   Each pixel is represented by a digital value.
   This value in turn corresponds to a specific colour or a shade
   of gray.

   Bit depth 1     =      only black and white shade

   Bit depth 8     =      256 shades of color

   Bit depth 24    =      16 million colors

 Resolution - number of pixels
 Color shade info - Bit depth
 Image file size - depends on the above two factors
  expressed in KB or MB
 Image file format -Bitmap, Gif, Jpeg, Tiff, DCM

 Uncompressed or compressed
Resolution of an image
Dots   per inch (DPI)
Also described in pixels per image of a given size e.g. 800x600 pixels.
More number of pixels per image of a given size means a greater resolution.

800x600                   10.5‖x8‖                         76 DPI

1024x768                  10.5‖x8‖                         96 DPI
Calculation of Image file size

800x600                    x8       = 469kB > 0.469 MB

76   DPI2 * 10.5‖x8‖                x 8

       BMP (Windows Bitmap)
       TIFF (Tagged image file format)
       GIF (Graphic interchange format)
       JPEG (Joint photographic experts group)
Images on monitors

  Monitors also have a defined ability to
  reproduce shades of colour or gray tone.

   -monochrome CRT (1bit)
   -CGA (16 colour- 4 bit)
   -VGA (256 colour - 8 bit)
   -SVGA (16 million colours - 24 bit)
   The amount of the image that can be displayed at once depends on the
    relationship of the image’s pixel dimensions (or dpi) to the monitor’s
    desktop setting.
   Suppose an image has 800*600 pixel resolution. And this is being
    displayed on a monitor set to 640*480 pixel resolution. Then only part of
    that image covered by these many pixels will be displayed resulting in
    incomplete display.
   The percentage of an image displayed can be increased several ways, by
    increasing the screen resolution and/or by decreasing the image resolution
   Dimensional fidelity
   This can be achieved when digital image resolution equals the monitor’s
    resolution (dpi)
Comparative image sizes from different

 modality        matrix       Bit depth      Image size
 mammograph      4000*6000    12             50 MB
 Radiography     2500*2000    10 or 12       10 MB
 Digital fluro   1000*1000    8 or 10        1 or 2 MB
 Digital Cine    1000*500     8 or 10        1 MB
 CT              512*512      16             524 KB
 MRI             256*256      16             131 KB
 USG             512*512      8              262 KB
 Nuclear med     64*64        16             8 KB

  1 k image = 1024*1024 and 2k = 2048*2048

3 methods

Digitizing   conventional analogue film

Photostimulable phosphor plate technology,
computed radiography (CR)

Direct   digital radiography (DR)

 Time   consuming process that requires skilled operators

         image retains intrinsic limitations present in the
 Digitized
 analogue film

 Not   practical on a large scale

 Necessary in a PACS environment- to allow analogue films
 acquired at a non-PACS institution to be entered onto the PACS

   Commonest means of acquiring plain radiographic images in a
    digital format

   Phtostimulable phosphor plates replace conventional
    film/screen combination

   Phosphor plates are reusable (thousand or more exposures)

   Can be used with standard X-ray equipment

   CR is suitable for mobile radiographic work

               Digital Cassette reader

   Flatter, more linear, optical density versus radiation exposure response
    curve than the classic sigmoid-shaped curve of the conventional
    film/screen combination

   Greater latitude of exposure - useful under challenging circumstances e.g.
    in ICU , and in the area behind the cardiac silhouette and the lung vessels,
    or the soft tissues of the neck and the cervico-thoracic junction

   Reduction in number of repeat images

   Lower spatial resolution (2.5 line-pairs/mm) ) than that of film
    (approximately 5 line-pairs per mm),

   Superior contrast resolution

   Amorphous silicon is used with a digital detector

   Detectors- caesium iodide or rare earth scintillators which
    emit light photons or selenium which produces an electrical
    signal (i.e. direct digital signal)

   Detector plates are heavy, fragile and fixed

   Only very recently been adapted for use in mobile direct DR
    apparatus ( much more expensive than the phosphor plate
        X-ray photons                        X-ray photons

  Caesium Iodide

Amorphous silicon                      Amorphous silicon
Photodiode/Transistor array            Photodiode/Transistor array
                        electrons                             electrons

Read out electronics                  Read out electronics

       Digital signal                      Digital signal

   Spatial resolution of DR equals that of film

   DR has better detective quantum efficiency (DQE) thus allowing
    dose reduction/exposure and better contrast resolution

   Produces direct digital signal and there is no manual processing
    of plates

   High cost

1.   Primary diagnostic workstations- imaging

2.   Review workstations- rest of the hospital
     including OT, OPDs

Diagnostic      Workstations
     2, 3 or 4 Monitor Workstations
     2, 3 or 5 Megapixel Displays
     Combination
         2 (3 or 5 Mpixel Monitor for Reporting)
         1 (1280 X 1024 Monitor for RIS, Mail, Voice Recognition etc.)
     Flat vs CRT
Clinical    / Orthopedic Workstations
     1 or 2 Monitor Workstations
     Flat vs CRT
Web   Client Workstations
     1 or 2 Monitor Workstations
     Flat vs CRT

Resolution -

   A digital chest radiograph(plain radiography) requires a monitor :

   3 megapixels (for spatial resolution)

   Greyscale, not colour

   Other images (e.g. CT, MR, US, NM, angiography or fluoroscopy) -
    1 megapixel monitor

   Digital mammograms - a 5 megapixel monitor

   Brightness- 10 times less than conventional view box.
   B/W monitors- brighter than colour monitors, greater range of grey scale,
   Colour monitors- doppler, nuclear medicine, PET, post processed images
Ambient lighting - dark (black or navy) blackout blinds fitted to the windows,
 and dimmer switches fitted to the room lighting.
   Monitors should not be placed opposite a window
   On the wards, the workstations should be sited off the main ward .
   new hardware development is the manufacture of dual-monitor computers
    (with one central processing unit (CPU), one graphics card and one
    two chest radiographs from the same patient could be compared
    simultaneously, at large size, one on each monitor.

   Cost one-half to one-third as a      Preferable
    comparable LCD.                      Medical LCDs are brighter than
   Can be viewed from a wide             medical CRTs.
    angle - several users view the       Flat-panel monitor -the amount of
    image at the same time.               desk space required is
   Luminosity degrades relatively        substantially less.
    quickly- need to be replaced         A fixed geometry - aspect ratio
    more often                            never changes.
   Curved screen causes                 Capacity to dynamically change
    distortion of the image               their luminosity so that the
   The aspect ratio (the ratio of        perceived brightness is constant
    height to width can be varied.        .
   images may appear too tall or
    too wide if deviated from its
    calibration settings

   Screen layout and computer
    tools presented to the user

   Contrast width and level

   CT density value

   Greyscale inversion

   Image orientation

   Magnification

   Annotation
‘PACS workstations’ versus ‘web browsers’

The   only difference is their software.
‗PACS  workstation‘ refers to a high-specification computer that runs
proprietary sophisticated software dedicated to image diagnosis and
 ‗PACS web browser‘ depends upon a public domain web browser
(usually Internet Explorer) to display images for review purposes, and can
be loaded on any off-the-shelf computer.
PACS web browser can also perform numerous other functions (e.g.
making slides, writing documents, accessing the Internet etc.) depending
upon which software packages have been loaded onto it

   Proprietary, and vendor specific

   Sophisticated PACS software is essential to the radiologist to allow the PACS
    to be used efficiently.

4 main software concepts

   Prefetching or Preloading

   Worklists and folders

   Default display protocols or hanging protocols

   Reporting/dictation macros or worklists

   Retrieval of previous images of a patient from the long term
    archive onto the short –term storage device, prior to new
    imaging examination on that patient

   Prefetch algorithms- Software programs that automatically
    retrieve historical examination results and reports for
    correlation with the current study

   Prefetching algorithms rely upon connections with HIS and

   Subdividing the vast amount of imaging data acquired onto
    the PACS into clinically relevant, easily accessible subgroups

   Worklists- work that has to be done

   Folders- grouping of reported examinations in different ways
    (eg. by body part or by referring clinician)
   Depending upon the nature of the workflow in a particular
    institution - worklists and folders will differ

   Software for displaying the images of current and related
    previous examinations in a predetermined arrangement on
    the workstation monitors as per the wish of radiologist or
   Based on the anatomic region, examination type, technique,
    and pathologic condition; customized and made user specific
    (based on login) and user configurable
   Save user time – images not to be rearranged on the
    monitors prior to reporting or viewing.

Software   that enables the radiologist to work through a reporting worklist
in a efficient and time saving manner
Minimizing   the number of commands necessary to accomplish various
Automatically  skips displaying the next exam in the reporting worklist if
it has already been opened in reporting macro mode by another
radiologist, working at a different workstation
A useful refinement - is to have an intermediate status assigned to
examinations if they have been reported by a junior radiologist and require
checking at a later time

 Computer network is a communication system for a collection
  of interconnected computer devices.
      exchange of information
      multiple access of centralized information
      resource sharing
Medium for transmission

 Medium                    Distance   Cost

 Copper    Twisted pair    100 mtr    Low
           Coaxial thick
           Coaxial thin
 Optical                   150 km     High
Network Topologies

Used   in Ethernet

Difficult   to trace problems when a channel fails

      A                 C                E

                B              D               F

   Simple
   In a single ring, the network fails if the channel
    between two nodes fails.

        A               C                 E

               B                D                F
Star (Hub)

 High   speed Ethernet switch, ATM switch
 simple   to isolate a fault
 single   point failure at switch

               C                       E

         B                      D            F



                   D   F
LAN – local area network for a lab, floor or
MAN – metropolitan area network for a building,
    campus or a city
WAN- wide area network for city, province or
    country – interconnects LAN and MAN
LAN Types

 Ethernet           10 Mbps

 Fast Ethernet      100 Mbps

 Token ring

 Asynchronous tranfer mode – different transmission
 media can be used together
 Hubs – signal amplification for onward transmission
 Switches – additional capabilities of switching the
       connectivity to between two nodes
 Routers – increases efficiency by limiting traffic between
      network segments
 Modern hospitals have a switched network - allows the whole
  bandwidth (e.g. 100 Mbps ethernet) available to each switch
  in the network
 Hub network - the entire hub accommodates the total
  bandwidth (e.g. the 100 Mbps) - all the attached items have
  to share a portion

   The maximum rate at which data can pass between two points in the network.
   Bandwidth depends -
   the transmission medium (copper wires, fiberoptics, wireless)
   the number of computers sharing the same infrastructure
   The time required for an image to be sent from a PACS server to a workstation
    depends –
   the bandwidth of the intervening network
   the number of simultaneous requests from users.
   PACS should be granted dedicated bandwidth used only by PACS workstations
    and servers.
   Prevents nonessential data transmissions from interfering with departmental
 Image   compression is a means of decreasing the bandwidth
 needed to transmit images rapidly

 LOSSLESS   - compression scheme - very detail of the original
 image can be faithfully restored


   Store information identifying patients and cataloguing their

   Images are stored separately in components specially
    designed to provide rapid access

   Use single relational database like Sybase, Oracle or
    Microsoft access

   Should provide rapid responses to queries of the user

Examination   retrievable in 2 s or less

Fault-tolerantRAID devices (containing magnetic disks)-
expensive, very high performance

   Examination retrievable in 2 min or less

   Compact disks (CD-ROMs)- 650 MB

   Magneto-optical disks (MODs)- 6 GB

   Digital versatile disks (DVD)- 16 GB, secure medium

   Fluorescent multilayer disk (FMD)- 50 GB

   The standard computer hard drive or magnetic disk, also known as a direct-access
    storage device, is the fastest medium from which to retrieve data. Presently
    available devices have a capacity of 10–200 Gbytes and a rapidly decreasing cost.

 Ultra   long term back up

 Stored    on- or off-site

 Medium      should be cheap, need not be rapidly accessible

 Digital   linear tape (DLT)- 35Gb

 Tapeas secondary level storage- to reduce cost- DLT, AIT
 (advanced intelligent tape, Sony)
 Online versus off line

   Some of the data on a PACS are immediately available whenever a
    radiologist requests them.
   usually includes the most recent images and their relevant comparison
   refers to less accessible archive images and need to be restored to online
    status before they can be viewed.
   In a single-tier storage system, all the data are online all the time and
    are stored on a single medium (usually spinning disks).
   In a multitier storage system,some of the data are online (usually on
    spinning disks), while other data are off line (usually on optical media
    or tape).
 Amount of storage

   Determining storage requirements is one of the most difficult aspects of
    planning a PACS.
   The proper ratio of online to off-line storage, as well as the proper
    storage media
   There are two important principles in determining storage requirements:
         (a) Storage is easy to underestimate—the PACS will probably need more storage than
             planners suspect
         (b) the system must easily accommodate additional storage at a reasonable cost in the
Storage        Requirements per Modality
        Image Size
        Average # of Images/Exam                                   Storage
        Average # of Exams/Year

 Medical imaging data are of critical importance - unacceptable to
  permit one computer error to destroy all copies of the data
 REDUNDANCY    refers to storage of multiple copies of imaging data.
 Also used when several computers or network components perform
  the same job—if one element fails, the redundant elements keep the
  system functioning until the failed component can be replaced.
A   redundant array of inexpensive disks (RAID) is the most
  frequently used redundancy system
 In a RAID, the data are spread over several hard drives, such that if
  any one drive fails, the data can be reconstructed from the surviving
 PACSwith a single-tier architecture must have another backup
 system for archiving in case the main storage fails. (This
 backup system usually takes use of inexpensive storage
A   third form of redundancy is related to disaster recovery.
 Additional  copies of data are stored at a geographically
 distant site as an extreme emergency backup.

DICOM (Digital image communication in medicine)
 Itis a "co-operative standard" that allows compatibility between
  imaging systems
 An international standard for interchange of biomedical images and
  image-related information
 Each image is associated with a header information about the
  patient, the date, the series, parameters of acquisition etc. Hence can
  not be lost or misplaced
 Theformat is independent of different machines         and
  communication protocols
History and evolution of DICOM standard

   In early eighties, the American College of Radiologists (ACR) and
    National Electrical Manufacturers Association (NEMA) acknowledged
    need for a standard - facilitate connectivity of imaging and associated
    medical equipments of different vendors

   The first and earliest official Standards Publication titled ACR/NEMA No.
    300-1985, referred to as version 1.0 was released in 1985, with an aim
    to "promote communication of digital image information, regardless of
    device manufacturer, facilitate development and expansion of picture
    archiving and communication systems (PACS)―.
    Need for DICOM standard

It offers a range of beneficial features :
   It facilitates multi-vendor connectivity.
   It obtains the images of patient and all epidemiological information
    associated with it, in an identical format.
   It obtains non-image data like waveforms, reports, ECG (12-lead,
    continuous, Holter), hemodynamic (pressure), voice, audio etc. by creation
    of explicit "information objects―.
   It allows interconnection and interaction ("interoperability") of
    equipments and transfer of data.
   It enables integration of scanners, servers, workstations, printers, and
    network hardware from multiple vendors into a PACS.
   It therefore promotes the development of PACS and image networking in
    LAN and WAN.
DICOM conformance statement

   This is essentially a vendor's claim of compliance to the DICOM
    standard, for a specific type of equipment.
   A conformance statement allows "a user to determine which optional
    components of the DICOM Standard are supported by a particular
    implementation, and what additional extensions or specializations an
    implementation adds".
   All that conformance statements offer is a simple and basic overview of
    their DICOM capabilities for easy comparison.
   It will not guarantee whether equipments will work together or not.

    Currently used version is ACR/ NEMA 3 (1993)
    Popularly known as DICOM 3.0
    The format is independent of different machines and communication protocols
    It can be adapted to different medical specialities like radiology, cardiology,
pathology, gastroenterology etc
    DICOM compatibility of imaging modalities
         CT, MRI, DSA
         New generation Ultrasound
         CR, DR or x ray film digitizer
         Frame grabber for older USG, Fluoroscopy monitor
DICOM Viewers

    There are several DICOM Viewers available both free and
     Some of the DICOM Viewers include:
   DICOM Works, Osirix, SureVistaVision , UniPACS, Syngo Imaging,
  VRRender, ImageJ and MicroDicom.
   Various viewers can connect directly to a PACS server or retrieve
  images from local storage.
HL7 - health level 7

   Refers to a worldwide standard for data information systems such as
    HIS and RIS. It is a less rigorous standard than DICOM.
   The term Health Level Seven has its origins based on a seven-layer
    International Organization of Standards (ISO)Communication Model.
   Each layer has a role wherein layers one to four deal with
    communication; comprising Physical, Data Link, Network and Transport
    communication layers.
   Layers five to seven deal with functions like Session,Presentation and
   The highest level or seventh level is regarded as the application level,
    which deals with the definition of data to be exchanged.
IHE - integrating the health care enterprise

   The core strategy of Integrating the Healthcare Enterprise(IHE) is
    integrating radiology workflow within a healthcare setup using
    existing standards like DICOM and HL7.

   IHE accomplishes this by a four stage process:

   a) interoperability problem identification; b) integration profile
    specification; c) implementation and testing at connectathon and
    d) integration profile conformance statements
HIS and RIS Connection

   There are at least three and up to five information systems
    in a radiology department that are required to handle the
    data associated with an examination

   These systems include the hospital information system
    (HIS), the RIS, the PACS, the voice recognition system, and
    an electronic teaching file system

   Integration with other information systems and the ability
    to display relevant data on the desktop are critical for the
    success of PACS.

       demographic data of all the patients e.g. patient
 Stores
 name, identification number, date of birth

 Also records admission and discharge dates, outpatient
 appointments, clinicians responsible for patient care and so

 Other    modules of HIS document laboratory data

   Can be a stand-alone computer platform, or may be a
    module of the HIS

   Stores information specific to the radiology department
    including radiological reports

   Modern RIS will incorporate some DICOM features such as
    modality worklist, modality performed procedure step,
    interpretation worklist, and structured reporting

Preferably bidirectional- 3 main reasons

 Input   of demographic data only once , minimizing human
 Anyupdate to a patients demographic data on HIS, RIS, or
 PACS is propagated to all systems automatically
 Any scheduling or status data is distributed to all systems
 automatically, providing advanced notice of events and
 allowing them to prepare.               HIS

                              RIS                  PACS
 Twotypes of RIS-HIS integrations are now offered, one type via a
 broker and another without a broker .
 The brokerless technology is preferred, as there is less opportunity
 for data inconsistencies.

   Patient demographics entered only once
   Patient identifier issued and tracked systematically
   Orders entered only once
   Performed procedure steps coded – billing automated
   Image and other exam data stamped with patient and order meta-
   Images and other exam data available for viewing anywhere,
   Persistence of acquired image and exam data
   Data migration to other vendors
patient registers one time
Doctor places an order; everyone who needs it
gets it
Data backups
Proprietary data backups are distributed & complicated
           Scheduled Workflow Profile
  Registration                                                Report
        patient                                                               Diagnostic         Film
     information                                                              Workstation      Lightbox
                                                                   PACS              retrieved

     Orders Placed
                                               scheduled                                        Film
                                                                               Image Manager
                                           Prefetch any relevant                               Folder
examination orders                                                               & Archive
                                           prior studies
                                      modality                        images
                                      worklist                         stored
       RIS         Orders Filled
                                   acquisition                                                   Film
                                    completed                                 images
Benefits of this approach

   A more cohesive workflow process for transfer of
    information from HIS to RIS to PACS
   Smooth, reliable transfer of information between
    computer systems from different companies
   Patient journey can be more efficiently and
    accurately planned
   Mistakes can be more easily corrected

 weakest    aspects of hospital infrastructures
   is important for radiologists (and all physicians) - aware of the
 It
  most frequent security errors that can lead to compromise of
  patient data.
 Personalcomputers within the hospital network are particularly
  vulnerable because of their varied uses
 User   specific log in and password
 Monitor   screen savers
 Workstation   time outs
 Firewalls

   No image can be lost or misfiled
   Easy comparison
   Simultaneous multilocation viewing
   Faster image retrieval
   Computerized data allowing automatic chronological
    ordering, rapid database search, easy duplication and back
   Improved work flow

   Improved throughput and productivity
   Rapid, remote, and simultaneous access to image data
 Image   postprocessing
 Cost   effectiveness
 Time   saving for non-radiological clinicians
 Reduced    film storage space
 Introduction   of teleradiology over a wide area network

   Expensive, technologically complex

   Absolute dependency of hospital

   Hospital is no longer equipped to run a film based service

   Requires dedicated maintenance programme and a carefully devised plan
    to provide essential clinical services in case of PACS failure

   Trained hospital staff

   Vendor provided maintenance service
Film System vs. PACS
Film System               PACS
                           Multiple softcopies
Single   hardcopy         Digital (image database)
Analog                    Automatic & electronic
                           No film loss
Manual                    Simultaneous & immediate
Film   loss                viewing

Film   storage problem    Initial purchasing cost of
                            PACS equipment
                           Maintenance benefits
                            (visible & invisible benefits)

        Expensive                  Cost-effective
PACS- Issues and Developments

Reporting/dictation      Macros

Structured   reporting

Speech   recognition programme

XML-   extensible markup language

   most important advance- integration of speech-recognition systems
    into PACS.

    If speech recognition and PACS act as a single software system,
    radiologists can maximize their efficiency

   the term macro refers to predefined text that may be used instead of or in
    addition to free-form dictation .

   Macros improve the efficiency of some speech-recognition systems,
    particularly when the accuracy of the speech-recognition engine is poor

   The term voice recognition is frequently used as a synonym for speech
Multimedia Reporting
Telemedicine “beyond space & time”

 Teleradiology        Medical consultation
 Telepathology        Fetal monitoring
 Teledermatology      Telepresence surgery
 Telecardiology       Quality assurance
 Telepsychiatry       Continuing medical
 Teleophthalmology     education
Inevitable Forces to Drive Telemedicine

 Desire for quality medicine
 Increasing comfort with technology
 Globalization of medicine
 Continued competition
    Cost-effectiveness
    Cost-advantage
    Resouce utilization
 Focus on marketing orientation
    Patient satisfaction
    Outcomes
Benefits of Telemedicine
Improve   patient care
     Affordable access to experts beyond space and time
     Expedites decision making

Provide economic benefits

     Save travel time and costs (doctors and patients)
     Reduce re-examination cost

     Expedites utilization of human resources and equipment

Provide strategic advantage

       Interchange of physicians’ knowledge and experiences
       Improve hospital administration
       Improve quality control and education programs
      Telemedicine Healthcare Network

                         Rural hospitals

       Imaging centers                            Clinics

      International      Medical Center
                                                  Doctors home
      health center      Complex

          center                                Patient’s home
                         Geriatric facilities

Telemedicine - Challenges

   Creation and adption of standards
      Technical
    Clinical protocols
    Information exchange (data formats,
     communication protocols, compression)
 Establish cost-effective in order to secure
  reimbursement for services
   Regulatory and medico-legal issues (FDA,
    patient confidentiality, licensure, etc)

      CT , MRI        Image

                                     512K, 256K


                                       T1, E1


                     PACS              Internet

                                                            Film Printer
                               Wide Area Network (> 2 km)

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