Medicexchange Portal Provides Online Shopping for Radiologists
Teaching File System Offers IHE-Compliant Control
Explore the Underlying Software of Creating CDs
Siemens Medical Creates New Image and Knowledge Management Division

Medicexchange Portal Provides Online Shopping for Radiologists

David Sumner

A new commercial Web site specializing in visualization software made its debut at the 2006 Annual Meeting of the Radiological Society of North America (RSNA), Oak Brook, Ill., a division of Medicsight Inc, London, is being marketed as an “ for medical-imaging software,” a portal for imaging professionals featuring coverage of the latest clinical research combined with pay-per-use versions of software from multiple vendors. Axis Imaging News spoke with Medicexchange Asia CEO David Sumner about what the site has to offer.

IE: What inspired this system?

Sumner: The real catalyst behind the development of Medicexchange was when we realized that a pay-per-use CAD would be a very favorable way to enter the market. So, we needed to work out a suitable distribution mechanism for that. As we were thinking that through, we decided that maybe it’s a good idea to use a medical-imaging portal to distribute not just Medicsight CAD online, but also other medical-imaging software products. One thing led to another, and then the idea grew bigger.

IE: How will it work for a US radiologist?

Sumner: We realized that medical-imaging software on its own might not be enough of a reason for somebody to keep coming back to a Web site. So, the idea is that radiologists would visit the site, almost on a daily basis, and collect all of their clinical news as they would do with other resources available today. And once there, they would have the option to view and demo medical-imaging software.

IE: They do not actually have access to the software?

Sumner: No—they demo it, and then they can download it. First, they’ll go there for the clinical news and information. Then, they’ll also have the opportunity to review the various different software products. The idea is that they’ll then try it for a 30-day period; assuming it works for them, either they download it, or, if it’s a shippable product, they can order it online.

IE: Are these products from third-party vendors?

Sumner: Some of the products will be from Medicsight. Others will be third-party products, absolutely.

IE: Is it geared to the worldwide market?

Sumner: We’re going to have core sites. One will be the United States, one will be Europe, one is Japan, and one is China.

IE: Did that present any challenges when you were setting up the portal?

Sumner: More than you can ever believe. It was a big idea, and we knew it was going to be difficult. The biggest problem was cultural differences: language, billing, and regulatory issues.

IE: Do different countries have different privacy requirements regarding electronic communication?

Sumner: Yes, but they’re pretty much all the same. Some are more relaxed than others, but we’ve taken the stance that we will treat all as the United States.

IE: What are the rates? Or does it depend on what area of the site you are accessing?

Sumner: It changes according to the software you’re accessing. For example, if you assume all software on the site is pay-per-click, the radiologist would go in and pay $5 to $30 per click, depending on the type of software.

IE: What is the financial benefit to radiologists?

Sumner: One of the reasons we developed the business is because when someone buys a large piece of hardware, say a CT or an MRI, the software usually is bundled in. It can be quite restrictive for the users, because if they’ve already spent the money on the hardware, they don’t want to go out and look for the different bits of software. Our market research showed that 95% of radiologists felt restricted in terms of their ability to choose different medical-imaging software. With Medicexchange, they get a choice.

IE: Do you have affiliates?

Sumner: Yes. We’ve launched in China, and we’ve been very lucky to work with the Chinese Chairman of Radiology. Another affiliate is And as we build, we’ll sign up more affiliates.

IE: It seems like a customized home page for radiologists.

Sumner: Exactly. The best analogy I can use is to call it the of medical-imaging software.

IE: Have you negotiated special prices with vendors so that there is a benefit to buying software through your site as opposed to independently?

Sumner: Absolutely, and they are favorable terms for both sides. We all make money at the end of the day, but the radiologist isn’t penalized because the distribution costs go out the window when utilizing a portal like this.

Cat Vasko is associate editor of  Axis Imaging News. For more information, contact .

Teaching File System Offers IHE-Compliant Control

The caseVue system from peerVue allows users to create records of their own teaching files.

A new digital teaching file solution from peerVue LLC, Burlington, Vt, facilitates diagnostic collaboration and medical education, all within an IHE-compliant framework. The caseVue system runs on a high-speed relational database, and is managed through a thin client model for increased flexibility. The newest customer to install the system is Montefiore Medical Center, New York City, which chose caseVue for its compliance with two rarely supported IHE profiles.

Nogah Haramati, MD, chief of radiology at Montefiore, explains his department’s selection process. “We needed a product that would be fully compliant with IHE, especially the MIRC and teaching profiles,” he says. “We needed it to be able to export images directly into PowerPoint or be made suitable for PowerPoint. We needed to be able to easily anonymize images and examinations. We needed individual users to create records of their own teaching files or cases they were following—for either academic purposes, research purposes, or educational purposes—to be able to share them or keep them separate. And it needed to be a product that was easy to use, could have a central server, and could be remotely accessible.”

Integration with his department’s PACS and RIS has been a slow process, Haramati notes, but is coming along according to IHE standards. “We have GE Healthcare’s PACS and RIS, and we also have Dynamic Imaging’s PACS on the premises,” he says. “The integration is in process. Right now, we have them all functioning in our IHE integration environment, and the method of sending examinations back and forth is using IHE protocols.”

That factor is crucial to Haramati, in terms of both meeting federal regulations and creating an environment that will be adaptable as electronic medical records become increasingly prevalent. “We’re working on connecting to other medical centers, sharing information in a protected HIPAA-compliant manner, which is complying with the national initiatives toward electronic medical records,” he says. “That’s a very important area to us.”

The caseVue system is used by transferring digital images from PACS to the caseVue teaching file; then, users are free to manipulate images as they will. “They’re no longer making any changes to the clinical production system for PACS or the PACS archives,” Haramati explains. “They’re making changes only in the teaching file environment, and there’s a full audit trail of everything they do.”

Now, the radiology department at Montefiore has full control over its teaching files. “We need to know anybody who’s touched a case,” Haramati says. “We need to know what they’ve done and what they’ve extracted. We require the users to sign confidentiality and privacy agreements before we give them access to our information systems, and we need a way to know who’s looked at what case.”

—C. Vasko

Explore the Underlying Software of Creating CDs

In a high-volume radiology center, implementing an efficient process for the production of DICOM and patient CDs is essential to maintain workflow efficiency. This means more than purchasing an automated, robotic DICOM CD/DVD recording system and adding it to a network of digital modalities or a PACS. Understanding the capabilities of the software that operates the system and knowing how it can be optimized are of critical importance. The latest version of software recently added to our already high-performance system has the potential to increase our CD production burning capability by 75%.

The PACS Support Center at Ohio State University Medical Center (OSUMC), Columbus, receives between 2,000 and 2,500 requests for individual examinations to be copied to CD per month. In 2005, DICOM CDs were produced for more than 25,000 examinations.

OSUMC is a large, complex health care institution. It consists of five hospitals and 30 community-based treatment centers in Columbus and environs. It is the fourth-largest medical teaching institution in the United States and operates several nationally renowned research institutes. In 2005, more than 1 million patient visits were logged, and more than 400,000 diagnostic imaging procedures were performed.

Our department burns CDs upon request. The constituency requesting patient images on CDs includes referring physicians, patients, researchers, and attorneys. Residents request CDs for individual study, credentialing purposes, and research projects. Clinical and support staff participating in national research projects need to send anonymized CDs to other research institutes and centralized data collection locations.

Diagnostic imaging is a huge operation at OSUMC, which implemented a full-fledged PACS in March 2001. In February 2005, 1.1 million images were stored in the PACS, and by February 2006, this number had increased to 2.2 million. This 100% rise is attributed to the increased use of multidetector CT, PET/CT, and sophisticated MRI procedures. Our PACS archive contains more than 21 terabytes (TB) of mirrored storage.

But portable media are needed even in this digital age. Requests for CDs are made by phone, fax, e-mail, and letter. Our PACS/IT staff members currently are developing a HIPAA-secure electronic form whereby requests can be made through the intranet. When a request is received in whatever format, a standard paper form is created. Loathe as our department is to use paper, the process works better with it, as it standardizes the inquiries. This uniformity increases the efficiency of our system analysts. It also makes it easier for us to prioritize urgent requests or bump a request to the top of the queue for processing.

A request is filled by finding the patient file on the Impax PACS from Agfa HealthCare, Greenville, SC, using the query software provided with the CD/DVD recording system from Sorna Corp, Eagan, Minn. Then, the patient’s electronic folder is opened. DICOM disc-burning software should have the ability to transfer relevant patient demographics automatically, saving time and eliminating keyboard entry errors, and ours does.

Keyboard entry is not completely eliminated, as it might be necessary to modify fields in the display for CDs that require anonymization. Our numerous research projects might request that patients be identified by their initials and a number. A research study ID number also might need to be added. But the process should be automated as much as possible, and client customization to meet these requirements should be one of the capabilities of the software.

Until the advent of highly automated systems, it was necessary for the person filling a request to:

  1. log on to the system and open the patient database;
  2. select an examination, or open the exams that need a subset of images, series, or studies to be recorded and select them;
  3. query the archive or online storage system to retrieve each exam;
  4. select a subset of images (if this option in Step 2 cannot be performed until an exam is retrieved);
  5. verify that the exam successfully transferred to the server of the CD recording system;
  6. repeat the process for each additional exam or report;
  7. compile the contents of the disc in the requisite order;
  8. burn the CD; and
  9. burn a label and affix it to the CD if it does not do this automatically.

For us, this process averaged 15 to 25 minutes, assuming that images requested were retrieved immediately without a network hang-up slowing their delivery. If a label is not automatically affixed to the CD by the system, a minimum of 2 to 3 minutes can be added to the process.

The software innovation of being able to request the information that needed to be put on the CD and having the system do the rest was a remarkable time-saver. Depending on their complexity, an average request takes 3 to 5 minutes. When the cost of staff time is factored in, the return on investment of what might seem to be an expensive high-performance system becomes extremely realistic (Tables 1 and 2 below).

Table 1.
Table 2.

With automated retrieval, compilation, and burning capability, the productivity of an individual spending 1 hour of time efficiently filling CD requests jumps from a maximum of four CDs per hour to a realistic 12 to 16 CDs per hour, or a 300% to 400% increase without pushing the limits of the equipment.

High-performance systems still have inefficiencies when performing automatic query and retrieval (or “DICOM send” to the CD burner). It is necessary to set a time for the CD burner to remain inactive while waiting for all the images to be retrieved and assembled in the server. A 4-minute default is safe and conservative—but it means that there is a 4-minute delay for all DICOM send requests, which effects the productivity of the system. As a rule, the burners are not utilized until the software has received all the images. Once all of the images have arrived on the server, or the time-out expires, the entire folder is compiled by the software and then is sent to the robot for production.

At the conclusion of the time-out, the CD is burned. But it is possible that if there has been a network hang-up, an examination—or, in the case of a large-volume exam, all of the images in that exam—might not have arrived. Without actually performing a quality assurance check of the CD contents, there is no way of knowing that the CD is incomplete. That is, until a physician calls to say that the CD he or she received is incomplete.

For a department utilizing one or more DICOM recording systems at maximum capacity, even if all examinations arrive in the idle time window allocated and all the CDs produced incorporated everything they needed, a 3-minute otherwise unnecessary idle time equates to a productivity decrease of 75% of what the machine is capable of producing. Once all of the images have arrived in the server, it takes a high-performance system 60 seconds or less to burn a CD, print a label, affix the two together, and deliver the completed product. (If the printer is integrated with the burner, it prints the label on the CD itself, and the step to affix label and CD together is eliminated.)

When the CD is burned, it is matched to the paper requisition form. This includes the method by which the CD will reach the requestor, and proper action is taken. CDs are picked up at our office, sent by mail to their destination, or shipped using a commercial courier that picks up at the office. For on-site pick-up, the form is held with the CD so that it can be signed, along with any additional release forms that may be required. All forms ultimately end up in a basket, where they are scanned daily into our department record-keeping system. Then, they are shredded.

We track all CD requests in our RIS in the same manner that one would track film-based releases of patient records. We record which examinations and reports are being burned, keeping track of the status of when they were burned and when they left our offices. This provides redundancy to our scanned sign-out files, keeping us comfortably in HIPAA conformance.

Clearly, if software can make a CD-burning system work at 100% capacity instead of 25% capacity, future purchases of CD-burning equipment can be postponed or eliminated. It may be easier for outlying facilities to justify the purchase of additional automated equipment to improve patient convenience and customer service. The return on investment of such a system is impressive.

It is important for administrators in any sized department or imaging center to realize that inefficient CD production can directly impact the bottom line. When selecting or upgrading a DICOM CD/DVD system, it is important to look beyond the hardware.

Hospitals and imaging centers purchasing PACS evaluate the features and performance of diagnostic workstations and the PACS themselves. Months are spent selecting the most appropriate system for both radiologists’ and health care institutions’ requirements. Similar attention to detail should be paid in evaluating the software capabilities of a CD-burning system. Not only is efficiency an issue with respect to cost savings and better utilization of staff resources, but it also impacts the quality of patient care.

The majority of image requests presume timely receipt and review by a medical professional who needs them. No matter what a facility’s CD production volume is, this should never be underestimated. The performance capabilities of a DICOM CD burner as they meet (or exceed) the needs of an imaging department are as important a consideration in the process of digital conversion as the rest of the PACS.

Philip E. Larkin, RT(R), is the PACS operations manager/imaging records custodian at Ohio State University Medical Center, Columbus, where he manages the process and supervises the three PACS analysts who fill CD requests. For more information, contact .

Siemens Medical Creates New Image and Knowledge Management Division

By Cat Vasko

Ajit Singh, PhD

Siemens Medical Solutions, Malvern, Pa, recently announced the creation of a new Image and Knowledge Management Division. Combining three Siemens Medical businesses—the syngo multimodality imaging software platform, RIS/PACS, and CAD—the new segment will focus on knowledge-based clinical decision support. Axis Imaging News spoke with Ajit Singh, PhD, leader of the division, about the impetus behind its inception and where Siemens Medical will go from here.

IE: What was the inspiration for creating this new division?

Singh: If I was to put it in one sentence, the requirement is imaging workflow solutions that have the following three characteristics: They are role-based, which means that each stakeholder has a front end that is suitable for that person or that role; they are context-sensitive, which means only the information or data that is relevant to your context is brought to you, so you’re not inundated with information; and they are knowledge-based. They should bring the relevant empirical and actionable knowledge at the point of decision-making. Because the market has moved to that realm, we need to integrate the three underlying components so that we can deliver that knowledge. That’s the guiding motivation. Of course, we’re acting a few years before this would truly become a trend. We see just the emergence of the trend and believe that we have to prepare ourselves for the point when this becomes mainstream.

IE: What are some changes that you will implement as the leader of the new division?

Singh: Changes come at multiple levels. Let’s work backward. I believe that since this is an emerging field, customers don’t always know what they want. The sense is, “I’ll know it when I see it, but if you ask me to put my finger on something, I can’t.” Which means that the customer would have to be extensively involved in the early-stage conception process. In our philosophy of product development, the customer is always involved, but I think we’ll have to take it to an entirely new realm. That’ll be one broad sweeping change.

Second, the product itself must have those three characteristics that I mentioned earlier, and that requires a much higher degree of integration than has been the norm in the industry. The industry has generally kept itself satisfied with what I would call an interfacing-based approach as opposed to an integration-based approach. Interfacing is good; integration is better.

The third thing is the implementation itself. This is not a product business; this is a project business, which means that the “professional services” that come into play once a customer has signed up must involve a much more extensive job of understanding the current workflow, what the workflow needs to be, and how the technology needs to be interspersed so that the workflow of the future is accomplished and is flexible and changeable over time.

Those are the top three changes. The fourth is that this is a global business, and I believe there’s a lot to be harnessed in terms of product development synergies by looking at the market at a much more global level. We will be incorporating that element into our product development and whole business philosophy.

IE: What does this mean for Siemens Medical? Does this alter the structure of the different divisions?

Singh: It doesn’t change the structure of anything outside what we’ve talked about. What it does do, however, is implement much faster development cycles. Software development cycles ought to be at the rate that you see at the likes of Google. That may be extreme, because in a regulated industry, it’s not possible to make that kind of leap. But in principle, the development cycles will be much faster, which means that the modalities will be able to benefit from these faster development cycles of the workflow paradigm. Stated differently, if the key differentiators in the modality business going forward are workflow, then workflow advantages ought to be made available to the modalities on a much more frequent basis—hence, the need for fast development cycles.

IE: What is on the Image and Knowledge Management Division agenda?

Singh: If I go back to the very first statement I made, I said we are in the business of imaging workflow solutions that are role-based, context-centered, and knowledge-driven. Now, put the word “trendsetting” in front of it. When I say trendsetting, it means that somebody must follow. To be more specific, I believe that in the knowledge segment of the business, which has acted very independently—not only at Siemens, but at our competitors as well as third-party companies—if you look at small original equipment manufacturers who are doing CAD-like products, knowledge products have always been stand-alone. They have not been an integral part of the workflow paradigm. I think that’s the most pressing and most visible change you will see on the horizon.

IE: Would you like to add anything?

Singh: I think the only one point I can add is that health care in general, and imaging in health care in particular, has really been enjoined from the benefits of workflow solutions. I think one of the problems has been that people have looked at radiology, cardiology, and oncology—all those imaging-heavy or imaging-intensive applications—as very fragmented. I believe that our three elements naturally lend themselves to creating a unified solution that cuts across radiology, cardiology, oncology, etc. I think there’s a tremendous amount of efficiency to be had when we do that.

Cat Vasko is associate editor of  Axis Imaging News. For more information, contact .