Digital Imaging and Informatics Requirements

The importance of privacy and security of information is an area that needs extra attention in the people and process components of any installation. Depending on the local legal environment, image data encryption should be considered if images and data are sent outside the LAN. User account management is needed to address: security issues; practical implementation — timely access to accounts; user name and password regimens; user authentication and external access issues. Technical capabilities Medical imaging requires the combination of an adequate infrastructure that includes well-maintained equipment, suitably trained personnel and a quality assurance programme which ensures that diagnostically and clinically valuable information about the patient under examination is obtained using the minimal amount of radiation.

  The provision of a sustainable, high quality, safe and effective medical imaging service requires that all these factors be in place. The purchase and installation of the appropriate imaging equipments is a necessary pre-condition, but this alone is insufficient to ensure that such a service can be provided or sustained.

More the number of patients visiting/taking services at our center; more economically viable we can be. Financial sustainability of such services can be achieved faster if the workload / turnover is larger

Digital Imaging and Informatics Requirements

Equipment Selection

Due to the need of establishing a well equipped image center with new technology equipment xxxxx ngo has set a serious note on selection of equipment. Traditionally, most purchasers of equipment will utilize past relationships with vendors and not understand the details of all the customer expectations.

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Purchasers also may not comprehend all of the available options that are available by modality. The equipment criteria selection process for this project will utilized a team approach of including radiology technologists, managers, directors, administrators, and consultant expertise. The process that will follow a high level procedures, first equipment vendor presentation meetings will be scheduled and site visits will be planned based on initial presentations. For the site visits, the team will create the criteria in a scoring grid for what made the most sense to satisfy partnership, technology, service, and cost.

The equipment selection criteria tool will be utilized by the team on the site visits and summarized for the Partners/Granter, NGO and GHIC of which all together will form a committee in the project implementation, that will have final decision making authority about initial implementation of project. The equipment selection tool will based on a tool called Quality Functional Deployment (QFD). The QFD is a matrix based decision tool that utilizes the voice of the customer from a cross functional team. It uses a structured approach to defining customer needs or requirements and translates them into different levels of importance ratings. “Voice of the customer” is the term used to describe customer needs or requirements.

Reliable Power Supply

Film based and digital imaging equipment, and particularly computers and network equipment, require a reliable and stable supply of power. Provision of uninterruptable power supplies (UPS) should be considered a necessary part of this installation. These systems are particularly useful for computers and are relatively inexpensive. Backup power sources such as generators may be critical for consistent use of the imaging systems.

Climate Control

Extreme temperatures and very high humidity levels can permanently damage electrical and electronic equipment. Most computer and imaging equipment requires certain temperature and humidity ranges for safe and reliable operation. This may require specific building requirements to provide for air cooling/heating and humidity control, with appropriate housing and maintenance. Weatherproof and climate controlled housing of imaging equipment is thus not a luxury, but should be considered essential for safe and reliable operation of such equipment over any significant length of time.

 Storage Media

Optical media, as almost all current imaging systems capture and store their image data in digital format, at least locally, distribution through CD or DVD media has become commonplace. Such media are widely available, cheap and relatively reliable. In a digital imaging environment, they are readily used for storage and transport. Typically, equipment vendors will ensure that patient data are packaged Paper can be used as a viewing medium, and has been used extensively in ultrasound. However, its use is limited and it has poor archival qualities. For best results, special papers are necessary, and printing supplies may become a problem. Compared to film, laser printing on paper is vastly inferior, inkjet printing is impermanent, and dye sublimation printing requires special paper and printing inks that are very expensive. Wax printers are a special case, as the quality of output is largely independent of the type of paper, but replacement costs are high and limited to very few suppliers.

Computer Systems

In the past, the demands of digital image acquisition, storage, networking and processing required highly customized and expensive computer hardware. A powerful dedicated computer (often called a graphics workstation) was usually the only available solution and thus the norm. Rapid advances in hardware development combined with falling costs of memory and storage mean that standard off the shelf computers are often adequate for all but the most demanding of digital medical imaging tasks. A good quality PC with adequate memory (typically >10 GB RAM), good graphics performance, display and hard drive space can be purchased for a very competitive price and can function as an effective image review station. However, it is important when purchasing such computers to specify minimum specifications. Not only will older machines or very low end machines not have the performance which is required for an efficient review of medical images, but the likelihood of the need to upgrade soon after purchase is also maximized

Staff

The staff of a radiology facility is part of a multidisciplinary team that typically includes radiological medical practitioners (referred to as radiologists in this text), radiographers, technical assistants, sonographers, nurses, medical physicists, service engineers, IT specialists and administrative staff. The staffing levels of the organization and the professional competence of the staff will be sufficient to provide safe imaging examinations of good quality, and to meet the specified objectives of the institution for radiological services. Facilities will implement processes to ensure that staff work in a collaborative relationship as part of a team. It will be mandatory as the minimum qualifications and continuing education of all staff involved in delivery, supervision, support and management of diagnostic imaging services are consistent with clinical requirements, and meet appropriate national and local regulatory requirements. Resources for training and education are often difficult to access and this may be an area where distance education (tele-expertise) may be the first option for isolated professionals.

Radiologists

Every imaging installation will have clinical imaging specialists, usually radiologists, available to: Provide medical oversight and leadership in imaging; Give advice regarding selection of imaging examinations; interpret imaging findings; Develop protocols (including referral criteria) for imaging examinations; Ensure appropriate safety protocols are in place for radiation exposure and contrast injections; Consult with other clinicians. For the provision of an optimal service, there will be radiologists available on-site. However, when this is not feasible, off-site teleradiology presence can be considered a real alternative in many cases. Such a service can also support services delivered by on-site radiologists. In such teleradiology applications, there will be appropriate involvement of the off-site radiologists with the local department regarding operational matters, imaging protocols and consultations in addition to the reporting of studies.

Radiographers and Imaging Technological

Medical radiographers will be appropriately qualified, according to the requirements of Tanzania standard. Relevant focused imaging training will also be provided especially when position is multifunctional, i.e. covers more than one imaging modality. Within the context of digital radiology, radiographers can take on the role of PACS administrators and as such would require additional training to allow them to appropriately manage those aspects of the radiology service.

Medical Physicists

Large facilities will have full time medical physicists available. All practices should have access to a medical physicist; the level and extent of involvement of the physicist should be dependent on the complexity and number of the procedures undertaken. A medical physicist with competence in diagnostic radiology will have primary responsibility for assuring the quality and consistency of most of the technical aspects of radiology, including equipment acquisition, quality assurance, dosimetry and calibration. This includes supervision of quality assurance programs, whether provided by the center as part of a service contract. Because of their technical backgrounds, medical physicists are often good resources to use in the conversion to digital imaging and implementation of PACS. Furthermore, the medical physicist would also act as a radiation protection officer, providing specialist expertise with respect to radiation protection of the patients and staff. Alternatively, the facility may have procured the services of a separate radiation protection officer.

IT Staff

IT is a key element of any digital radiology facility that intends to store, review and distribute images electronically. Even in facilities with digital acquisition systems that choose to store and distribute using hard copy, IT is still very important. Although much IT hardware is now commercialized, and imaging vendors provide specialised software and even some imaging system connectivity, any other electronic connectivity and networking requires some IT expertise for planning, deployment, testing and maintenance. Such support can range from solving simple printer problems to the design of complex networks and backup strategies. The complexity of the installation may determine the extent of IT expertise needed on-site. In general, large complex facilities usually require resident IT staff to ensure consistent and reliable operation of all facets of the imaging facility’s computing technologies. Smaller facilities usually need IT personnel to help plan and implement the technical aspects of the initial installation, undertake modality connections and assist in troubleshooting DICOM association setups, and assist where necessary with DICOM device mappings and configurations. IT expertise can also be accessed through off-site and remote support technologies for many tasks that do not involve hardware repairs. Such IT support should be seen separately from the management support of the digital radiology system, which really requires a different skill set.

PACS Management

Digital imaging facilities usually have a database to manage images, requests and reports. This is usually in the form of a PACS, often combined with a RIS, which can be used in a localized fashion within radiology, or be scaled to distribute images within the facility to clinical areas outside the radiology department, or off-site, for remote interpretation and consultation. These systems, despite best attempts and technologies, will accumulate problems requiring local administration to correct errors in data entry, incomplete studies and so on. The management of these problems is the role of the PACS administrator. This is an individual who has a detailed understanding of the PACS and any RIS, understands the radiology workflow and understands the clinical processes.

The PACS administrator often relies on super users to carry out his or her duties. These are trained people (often radiographers) who have some administrative privileges needed to ensure that the data integrity of the system is maintained regularly and frequently. PACS managers and super users may be radiographers, imaging technologists or administrative officers who have been trained and who regularly perform these tasks. External IT personnel as discussed above are still needed for overall technical system maintenance.

Non-Imaging Clinical Experts

Imaging does not operate in a vacuum; all referrals come from a clinician, and all results go back to a clinician. Appropriate selection of imaging tests requires clinical judgments and understanding of the limitations and strengths of the available imaging tests. The relationship between the imaging service and the clinical staff of the health centre is important to ensure appropriate consultation, collaboration and cooperation in obtaining satisfactory imaging outcomes for referred patients. Any digital system should facilitate these processes.

 Local Area Network

In the simplest set-up, the minimum requirement for digital imaging is a machine specific local area network (LAN), for example, from a CT scanner to an imaging workstation. The extent of the network will be dependent on the number of imaging machines served (including imaging modalities, control workstations, image reporting stations, PACS and RIS servers, image review stations and other network devices, such as storage drive arrays). The level of complexity in a facility has a direct impact on the technical IT support needed at all stages of development, implementation and maintenance.

 Internet and External Connectivity

One of the major advantages of digital imaging is electronic image distribution. Within a facility, this is achieved through the local networking infrastructure. Outside a facility, a connection of some type is needed to ensure images and text can be transmitted for off-site storage, reading, consultation and review, as well as for Internet based medical resources such as standards and teaching web sites, and medical journals that can be used to support local image interpretation. Dedicated data networking (e.g. ISDN (integrated services digital network) cable, satellite) is often preferable as performance is usually fast and more consistent than public Internet access. However, such approaches are expensive and may not necessarily permit Internet access. On the other hand, public Internet performance is usually more variable and also asymmetrical (faster for download than upload). It is often less reliable. Usually, ISDN and satellite links are also up-links to public networks. However, satellite connections have extremely high latency times related to the great distances at which geostationary satellites are situated. There are several options for external connectivity:

Public Internet connections:

• Landline copper or fibre optic cable using a cable modem;
• Distributed subscriber line (DSL) through a wired telephone network;
• Wireless telecommunications network (3G/4G, WiMAX, Wi-Fi (IEEE802.11a–n, etc.)); — Dedicated connections:
• ISDN through dedicated cables;
• Microwave transmission (requires dedicated hardware and a line of sight relay, and performance may be influenced by weather conditions);
• Satellite connection (requires dedicated hardware; can be used anywhere).

Each of these technologies has advantages and disadvantages, For instance, satellite connectivity (geostationary satellite) has significant, intrinsic latency, and is thus less efficient on highly conversational protocols (which include DICOM). Selection of the most appropriate networking technology will depend on the rationale for image transmission (e.g. urgent immediate review versus delayed batch reading or backup), location of the imaging centre, the relationship of the imaging facility to other health care facilities, and health care organization in the Member State. Furthermore, many of these technologies continue to improve in performance and fall in cost over time, so the choice of networking technology for any centre should be reviewed periodically.

Reporting

In principle, the written opinion of a radiologist has a greater medico-legal status than the images that are reported upon. The provision of a formal expert opinion in the form of a radiological report is therefore a crucial component of the delivery of any imaging service, digital or otherwise. Digital imaging infrastructures where PACS and RIS are involved make the provision and accessibility of the report easier and more reliable, and ensure that the images are always accompanied by any associated reports. Reporting can occur remotely once images are transferred for reporting at another site. In addition, reports can be amended and added to by one or more radiologists to provide a more complete or accurate report if additional opinions are sought, or new clinical information comes to light. Reporting is a specialized skill that requires formal training and experience to produce a clear, coherent and consistent report that provides useful information for clinical decision making.

However, the traditional free text report is highly variable in length, structure and quality, and varies considerably from radiologist to radiologist. To improve this situation, the center will use structured templates, it will develop a set of its own templates to facilitate and speed up their reporting tasks. In many instances, templates are not necessary, but the center will do offer a method of improving not only the consistency of report writing, but also help to reduce clinical confusion over the meaning of a report. This is particularly true of examinations that are repeated in the same patient over time for the purposes of disease or treatment monitoring. Examples of such applications are serial monitoring of oncology patients, or orthopaedic measurements of chronic disorders such as scoliosis.