The SCAR TRIPTM Initiative

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The SCAR TRIPTM Initiative DICOM

• Katherine P. Andriole
• Society for Computer Applications in Radiology
• PACS Clinical Coordinator
• University of California at San Francisco
• Department of Radiology
• Laboratory for Radiological Informatics
• and
• Department of Bioengineering
• University of California at Berkeley

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OUTLINE

• The Problem
• The SCAR TRIPTM Initiative
• Historical Review
• Imaging in Other Fields vs Medicine
• Entertainment Industry, DoD NASA

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OUTLINE

• Concepts Involved
• Human Perception, Image Processing,
  Visualization, Navigation, Usability, Standards,
  Databases, Integration, Evaluation, Validation

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OUTLINE

• Affected Processes
• Interpretation, Communication, Workflow
  Efficiency, Diagnostic Accuracy, Quality of
  Care
• Role of / Impact on DICOM
• Incorporated but not widely used concepts
• Necessary new features functionality

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The Problem

• Information Image Data Overload
• Requires medical image interpretation paradigm
  shift to evaluate, manage exploit the massive
  amounts of data acquired for improved
• Efficiency
• Accuracy
• Survival

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The SCAR TRIPTM Initiative

• Transforming the Radiological Interpretation
  Process
• to spearhead research, education, discovery of
  innovative solutions to address the problem of
  information image data overload.

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SCAR TRIPTM Initiative

• Radiology must shift its image interpretation
  management processes to deal with the burgeoning
  medical image data sets acquired by digital
  imaging devices.

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SCAR TRIPTM Initiative

• Will foster interdisciplinary research on
  technological, environmental human factors to
  better manage exploit the massive amount of
  data.

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SCAR TRIPTM Initiative

• Will focus on
• Improving efficiency of interpretation
• Improving timeliness effectiveness
• Decreasing medical errors
• Goal is to improve the quality safety of
  patient care.

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Historical Review Why Is Medicine So Far
Behind?(DoD, NASA, Hollywood)

• Special Challenging Environment
• Urgency of Results
• Safety Limitations Restrictions
• Cost of Error
• Tremendous Variability of Human Data within
  between Individuals.

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Why Is Medicine So Far Behind?

• Special Challenging Environment
• Difficult to Validate Performance
• Poor Understanding of Human Perception its
  Relationship to the Art of Medicine.

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Why Is Medicine So Far Behind?

• Slower Adoption of Technology in General
• Cultural Practicality Barriers
• More Difficult to See Clinical Impact Initially
• Interdisciplinary Nature of the Solution

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Often there is a disconnect between
Scientist-Researchers End-Users in the
Clinical Arena
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Enabling Technologies(creating urgency for
TRIPTM)

• Computing Networking Capabilities
• Real-Time Processing
• Increased Bandwidth Ubiquitous Access
• Visualization Technologies
• 3-D Rendering, Color, Motion

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Enabling Technologies

• Digital Imaging Modalities
• True 3-D Data Acquisition Isotropic Voxels
• More Intuitive Graphical User Interfaces
• Although much more needs to be done

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Concepts Involved

• Human Perception
• Image Processing CAD
• Visualization
• Navigation Usability
• Standards, Databases Integration
• Evaluation Validation

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Human Perception

• Develop a Standard for Image Quality
• Develop Objective Methodologies Criteria
• From which to determine optimal presentation
  parameters
• Based on Diagnostic Performance
• Develop Display Standards

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Psychophysical Models for Detection of
Abnormalities

• Define Develop Optimal Presentation Parameters
  by understanding
• What is desired by the observer
• What properties of radiological images are most
  useful in their interpretation
• How can these properties be enhanced to improve
  accuracy of interpretation.

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DICOM Role

• WG 11 Display Function Standard
• Gray Scale Std Display Function GSDF
• Presentation-LUT
• IHE Consistent presentation of images
• AAPM TF18 Image Quality, QA
• Still must address Clinical Correspondence

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Image Processing CAD

• Man-Machine Systems for Image-Based Diagnosis
  which take advantage of both human machine
  capabilities.
• Relinquish more routine chores to the computer.
• Have human concentrate on judgment
  comprehension tasks.

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Image Processing CAD

• Develop Computer Aids for Feature Perception
• Cuing, Overlay Annotation
• Develop Radiology Workstation of the Future
• Implement computer aids into a broadly supportive
  workstation.
• Decision Support, Data Mining Reference
  Libraries

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Image Processing CAD

• Design a workstation that can grow to accommodate
  future computer tools advances.
• Support clinical, research teaching needs.

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DICOM Role

• Image processing capabilities at the PACS display
  are currently very minimal.
• Processing typically done at the modality and/or
  required specialty workstations.
• How can DICOM pass image processing parameters
  without disclosing proprietary information?
• Structured Reporting CAD (WG8 15)

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Visualization

• Static Film
• Dynamic Soft Copy Image Manipulation
• Tile Mode
• Stack or Cine Mode
• Linked Stack Mode for 3-D Correspondence
• Multimodality Image Fusion

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Combining Functional Anatomical Information
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3D Spectra Anatomy Overlay
Courtesy Cynthia Chin, M.D., UCSF
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Visualization

• Maximum Intensity Projection
• Multi-Planar Reconstruction
• 3-D Surface/Volume Rendering
• Virtual Reality Representations
• ???

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CT Cholangiogram - Axial
Courtesy Richard S.Breiman, M.D., UCSF
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Sliding MIP
Bile Duct Anomalies missed by MRCP in potential
partial liver donors.
Courtesy Richard S.Breiman, M.D., UCSF
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3-D Surface/Volume Rendering
Courtesy Gary R. Caputo, M.D., UCSF
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Courtesy Cynthia Chin, M.D., UCSF
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DICOM Role

• Currently most 3-D representations must be
• processed on specialty workstations
• some must be saved as screen-capture
• manually push to PACS workstations
  Enterprise-wide Web (if capable of displaying)
• Raw data often not stored.

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DICOM Role

• How can DICOM pass 3D Model without disclosing
  proprietary information?
• How simplify interoperability?
• Unify Architecture

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DICOM Role

• DICOM conceived as a strategy for moving
  storing collections of single images.
• Network utilization is suboptimal
• PACS must accommodate multiple images which can
  be treated as a single unit
• Series-Awareness, 3D, 4D, Functional Sets,
  Cross-Referencing of Objects Fusion
• Unified presentation of Color WG11 others.

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DICOM Role

• WG16, Supplement 49 defines multiframe (MR)
  images model for CT WG17, 20, 21.
• enhanced image storage SOP class
• allows multiple images to be combined into one
  instance
• Raw Data
• Dimensionality
• Context Info

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Navigation Usability

• 3-D Motion
• Virtual Reality Fly-Throughs
• Hand-Eye Cues
• Hand-Helds for Point-of-Care Delivery
• Context Matching
• Voice Activation
• ???

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3-D Surface RenderingCABG
Courtesy Gary R. Caputo, M.D., UCSF
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Virtual Reality Fly-Through of Coronary Arteries
Courtesy Gary R. Caputo, M.D., UCSF
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Sliding VR
Courtesy Richard S.Breiman, M.D., UCSF
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Michael Teistler, Technical Institute of
Braunschweig
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Hand-Helds for Point-of Care Delivery
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DICOM Role

• Navigation by radiologist/clinician at the PACS
  display (or enterprise-wide web) in real-time
• Raw Data Processing Model
• Color Encoding
• Overlays
• Waveforms
• Audio or Other Sense?

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Standards, Databases Integration

• Open Standards
• Real-Time Processing at PACS Display
• 3-D Integrated into PACS Display Web
• Other Relevant Data Integrated
  HIS-RIS-PACS-Speech IHE (maintaining user
  patient focus)

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Evaluation Validation

• Objective Methodologies
• Standard Datasets for Performance Testing
• Collaborative Comparison Research

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Affected Processes

• Interpretation
• Communication
• Workflow Efficiency
• Diagnostic Accuracy
• Reduction of Medical Errors
• Quality of Care

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We Have Come a Long Way, But
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What SCAR Hopes To Do

• Bring Forward the Problem
• Facilitate Exchange of Ideas
• Between Researchers, End-Users, Industry, Other
  Fields
• Via Workshops Forums
• By Lobbing NIH Other Agencies
• Sponsor Research
• Communicate Issues Results

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DICOM Role(especially)

• WG4 Compression WG8 Structured Reporting
• WG10 Strategic WG11 Display Function
  Std
• WG16 Magnetic Resonance, Sup49 WG17 3D
• WG20 Imaging Information Systems Integration
• WG21 Computed Tomography

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DICOM Role

• Join in the TRIP!