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Medical Image Management: DICOM Images Sharing Process

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5 minutes, 29 seconds read

For modern healthcare organizations, extending better patient care across the service continuum involves new challenges that surround sharing information over a distributed network. Effectively sharing patient information remains a challenge. However, the inability to access these records in a time-sensitive manner results in re-imaging and re-testing the patients. It affects both — ‘time-to-treatment’ and the bottom line. Effective medical image management thus becomes crucial for every digital healthcare enterprise. 

The release process for medical images is altogether complicated — brimming with security related-risks. Images (such as X-Ray Scans, MRI scans, PET scans, etc.) are created and released across several departments and systems while being purposefully kept ‘out-of-reach’ from a host of unauthorized users.

Training & controls on release policies and procedures require ‘health information management’ expertise. It’s because image Handling (electronically) can become susceptible to data corruption, complex accessibility/sharing issues and high-security risks. All of these raise potential red flags for health information management (HIM) professionals.

So how does Medical Image sharing work in this environment? What, if any — are the safeguards surrounding the ‘release’ process?

Medical Image Management: Sharing DICOM Images across healthcare enterprises

Before we go further, let’s delve into the term ‘Medical Imaging’. According to the WHO, the technique embodies different imaging modalities and processes to image the human body (creating visual representations) for diagnostic and treatment purposes. — making it crucial for improving public health initiatives across all population groups.

First, the image is captured using a medical imaging device (routine imaging techniques like ultrasound, MRI, etc.). Then it is necessary to archive and store the images for future use and further processing. Unlike regular images (.png, .jpeg), medical images use DICOM format for storage. DICOM is Digital Imaging and Communication in Medicine standard. The medical practitioner responsible for acquiring and interpreting such medical images is a ‘Radiologist’. And the system they rely on for storing electronic image data is ‘PACS’ (Picture Archiving and Communication System).

If a healthcare organization or an outside consultant (physician, clinician) needs access to an individual patient’s medical images, then the access and retrieval will have to go through PACS. Typically, a Radiologist has authority to control and operate PACS.

Here is a simple process diagram of a medical imaging system —

medical imaging system process diagram

A Typical HIPAA-compliant Medical Imaging Management System places a request (for a specific file) to ‘PACS’ via an intermediary system known as ‘Edge Server’. The sole purpose of the Edge Server is to function as a request-node so that other hospitals or physicians can contact the particular radiologist (who possesses the images stored in PACS) and place a request to access a copy of the file in question.

[Related: Modern Medical Enterprises Absolutely Need Test Automation. Here’s Why.]

Medical image sharing use cases

Critical use cases arise for medical image sharing involving support for:

  • Remote image viewing (out of network)
  • Specialist consults
  • Telehealth (examples such as teleburn, telestroke)
  • Trauma transfers
  • Ambulatory image review

Typically, PACS store digital medical images locally for retrieval. A PACS consists of four major components: 

  1. The imaging modalities such as X-ray plain film (PF), CT and MRI 
  2. a secure network for the transmission of patient information
  3. workstations for interpreting and reviewing images
  4. archives for the storage and retrieval of images and reports. 

To communicate with the PACS server we use DICOM messages that are similar to DICOM image ‘headers”, but with different attributes. The Edge Server manages several functions that allow users to sort through hundreds of thousands of large-volume data and retrieve a specific file from a database either stored in ‘PACS’ or on the ‘MIMS’.

Each of the three highlighted sections (see diagram) can perform various functions, while communication is defined through specific rules and standards that are legally enforced and universally followed.

DICOM medical image sharing via PACS and MIMS

Through the ‘Edge Server’, we can access images stored in PACS. The ‘Management Services’ operation is the first and foremost feature. It means that a user can control & maintain the complete functionality of the server through this. Using ‘Remote Authentication’, users can obtain centralized authorization and authentication to request files from PACS. Please note, Remote Authentication is a networking protocol operating by way of specific ports.

To verify basic DICOM connectivity to the server — i.e, to check if the server is live or not, a C-Echo message is sent to ping the server, after which it will wait for its response. Once identifying the server as live, a user can perform querying and retrieval-based operations. Next, the user can begin the process of requesting DICOM images from the Medical Image Management System — known as ‘Ingestion’. DICOM Ingestion involves pre-assigned IP and port addresses (default ports are 2104-2111).

Basic DICOM Operations

Client: First, it’s important to check the location of the specific image(s) on a particular server. For this, a query-based C-FIND operation sends a request to the server. The user establishes a network connection to the PACS server and prepares a C-FIND request message (which is a list of DICOM attributes). The user then fills in the C-FIND request message with ‘keys’ that match. (E.g. to query for a patient ID, the user fills the patient ID attribute with the patient’s ID.) Then, the C-FIND request message is sent to the server.

Server: The server reverts a list of C-FIND response messages. Each of these messages contain a list of DICOM attributes with values for each match. It then initiates C-MOVE request using the DICOM network protocol to retrieve images from the PACS server. 

One can retrieve images at the Study, Series or Image (instance) level. The C-MOVE request specifies where the retrieved instances should be sent (using separate C-STORE messages). The C-STORE operation, also known as DICOM Push simply pushes (sends) the images to the PACS server (or P2P — Push to PACS). 

C-STORE message implements the DICOM storage service. The SCU sends a C-STORE-RQ (request) message to the server, which includes the actual dataset to transfer. The server answers by returning a C-STORE-RSP (response) message to the user, communicating success or failure of the storage request.

DICOM Images Benefits

Using DICOM images, health management professionals, physicians, and radiologists can utilize secure protocols in handling confidential medical image data. It extends the ability to view such images discreetly and instantly; avoiding duplication costs; and reducing unnecessary radiation exposure to patients.

Medical Image Sharing furthers the “Health 2.0” initiative by being able to instantly and electronically exchange medical information between physicians, as well as with patients — improving communication within the industry.

[Related: How AI is innovating healthcare sector?]

About the author: Rijin Raj is a Senior Software Engineer-QA at Mantra Labs, Bangalore. He is a seasoned tester and backbone of the organization with non-compromising attention to details.

Related:

DICOM FAQs

What is the DICOM Image format?

DICOM stands for — Digital Imaging and Communication. It is a medical standard for sharing a patient’s MRI, X-ray, and other image files over the internet.

How are DICOM Images stored?

Unlike regular images (png, jpg, etc.) DICOM is a secure format for storing confidential medical images. Usually, PACS (Picture Archiving and Communication System) and MIMS (Medical Image Management System) are used to store DICOM Images.

What is DICOM used for?

DICOM is used for securely storing and retrieving confidential images in distributed networks (internet).

Why is DICOM important?

Using DICOM images, health management professionals, physicians, and radiologists can securely handle confidential medical image data.

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Virtual health: Delivering care through technology

8 minutes, 52 seconds read

Virtual Care, Telehealth, Telemedicine, etc. are terms used very synonymously. Indeed they are interrelated, however, Virtual Care is a broader term in which healthcare providers use digital tools to communicate and deliver care to their patients. Telehealth and Telemedicine are a part of Virtual Care where doctors deliver care to their patients, remotely via phone, video, or instant messaging. Virtual health includes care delivery beyond video consultation where hospitals provide services using technology such as wearables for remote monitoring, instruments for post-op care and second opinions, e-pharma services, and medical information, etc. 

The outbreak of the COVID-19 pandemic gave an impetus to Virtual Care, but even in the Pre-COVID time, the Healthcare sector was slowly gearing up for this next wave in care delivery. What COVID-19 did was, help patients get acclimatized to the digital health tools and services. 

What does Virtual Health help with?

The pandemic has brought the burning issues of the healthcare sector to center stage. Patient experience and access to healthcare services are key differentiators for people while choosing a healthcare provider. Let’s take a look at some of these issues addressed by technology in the healthcare sector-

The increasing number of patients

Apart from the pandemic, there’s already been a rise in the number of patients due to drastic changes in lifestyle and food habits, an increase in pollution levels, increase in new types of viruses, etc. This has caused undue stress on healthcare institutions and workers and has led to the deterioration of the quality of patient care. Virtual Health technology such as mHealth apps, EHR (Electronic Health Record), video conferencing, etc. has helped reduce the pressure on hospitals.

Difficulty in traveling for old patients

The pace of life is increasing at a rapid rate. It is getting insanely difficult for the elder population to navigate through the traffic and commute long distances for a check-up. Many times, they have to depend on their family members to take them to hospitals. Moreover, they are at risk of exposure to viruses in hospitals and clinics. Now that they have had the experience of virtual consultations, they prefer care delivery at home rather than going to hospitals.

Chronic Diseases treatment

The number of people above the age of 45 face health issues. Some patients are suffering from chronic diseases regardless of age. Regular monitoring of their vitals is very important. Moreover people now prefer Virtual healthcare services which are easily accessible and save a lot of time, effort, and money. Now that people have found these services effective, they will opt for online consults rather than frequent in-person visits. 

Post-op Care

The duration of post-operative care is quite long and tedious. If given a choice, people will lean towards wearables which will help keep doctors posted on the status of the treatment. Many times, the cost of post-op care is more than the actual treatment and sometimes is not covered under insurance. Virtual care-delivery services will help reduce the financial burden of people going through these treatments.

Follow-ups/Second opinion  

Some health conditions need multiple follow-ups and second opinions to figure out the right approach to treat the issue. It is much easier for patients to do follow-up consults virtually rather than going through the tedious process of appointment booking, commuting, and waiting for their turn. It helps reduce the queue outside the doctor’s office as well. Some health issues need a second opinion, sometimes both by patients and doctors. Virtual Healthcare technologies make it possible for them to take second opinions from doctors all over the world. With electronic records and image sharing, doctors can diagnose the problem better.

What does Virtual Health include?

Virtual Health can be broadly divided into below applications-

mHealth Applications

mHealth applications have widespread use. From symptom checkers to appointment booking, from fitness trackers to uploading medical records, from video conferencing features to chatbot integrations, mHealth apps are on a rise mainly because of easy accessibility for the tech-savvy customers. According to a study by NCBI, among the 22 selected mHealth apps operating in India, Practo, mfine, DocsApp, 1mg, Netmeds, Lybrate, MediBuddy, and Medlife were found to be the eight most popular ones with over a million downloads and on average four-plus user rating out of five. All the above apps are mainly being used for online consults. This just goes about showing that people prefer having homecare services instead of stepping out. 

E-Triage Tools

The rising number of patients with different stages of COVID symptoms was a task to deal with. E-triage software here enables hospitals to triage patients into different sections when there’s an overload of patients at a particular time. Now, in the case of home care, e-triage tools help patients to access the gravity of their health condition and notify the healthcare provider accordingly. Such tools help reduce A&E waiting time and improve NHS performance. Many companies are building healthcare software integrating the E-triage module within EHR, telemedicine, clinical decision making, billing, etc. In India, Persistent Systems’ cutting edge platform has a Nurse Triage system that enables nurses to see the queue of patients and triage via phone calls. Once the calls are done, a triage report is generated and sent to care providers. Many leading doctors feel that AI in image triage will see a boost in near future.

Remote Patient Monitoring 

There are multiple benefits such as reduced post-op expenditure, time wastage, less exposure to other diseases, etc. The global remote patient monitoring devices market is expected to expand at a CAGR of 7.1% during the forecast period (2019–2027) according to Coherent Market Insights. Some of the top players in this space are Biotronik, Boston Scientific Corporation, CAS Medical Systems, CONTEC MEDICAL, Dragerwerk, GE Healthcare, Guangdong Biolight Meditech, Medtronic, Mindray Medical, Nihon Kohden, Philips Healthcare, Spacelabs Healthcare, Abbott. Companies such as GE Healthcare and Philips Healthcare have done a great job with building remote patient monitoring systems within the hospital premises as well as homecare for COVID patients. The main goal was to reduce the exposure of healthcare workers to at-risk patients. 

Synchronous and Asynchronous Telehealth

Synchronous telehealth, in other words, Telemedicine is where there is a live conversation between the patient and the doctor. Asynchronous telehealth involves the exchange of recorded data e.g. images, video, medical reports, pathology reports between patients and doctors, at times between doctors as well. Similar to mHealth space, companies like Practo, 1mg, Lybrate, Medlife, and Portea Medical in India are some of the top players in telehealth and telemedicine. Lybrate’s USP lies in CMS (Clinical Management System) which helps doctors with tedious tasks of managing patients and providing better care. Meanwhile, Portea Medical’s home consults and pharma delivery have more relevance with the audience as it combines technology with a touch of personalization. 

Digital Therapeutics

Digital Therapeutics delivers evidence-based therapies with the help of software which can be used both as a preventive measure as well as treatment application. The effectiveness of the medication and lifestyle changes on patients are monitored by leveraging technology. In India, major non-communicable diseases that account for 62% of the total mortality rate are CVD, diabetes, respiratory conditions, and cancer. Prominent global players in this space include Noom (US), Livongo Health (US), Omada Health (US), WellDoc (US), Pear Therapeutics (US), Proteus Digital Health (US), Propeller Health (US), Akili Interactive Labs (US), Better Therapeutics (US), etc. Omada Health is the pioneer in the DTx (Digital Therapeutics) that focused primarily on diabetes and pre-diabetes but now is branching out in the mental health space as well. In India, Altran (a part of Capgemini) is into building personalized DTx applications for clients. Whereas a start-up called Wellthy Therapeutics has ready solutions catering to multiple diseases.

Future of Virtual Health

Undoubtedly, there has been a massive increase in the adoption of Virtual Health technologies as people have gotten accustomed to the ease of certain services at home. In the coming future, mHealth apps, remote patient monitoring, and Digital therapeutics see a surge in demand from the customers. According to a study by Markets and Markets, “The global digital therapeutics market is projected to reach USD 6.9 billion by 2025 from USD 2.1 billion in 2020, at a CAGR of 26.7% during the forecast period (2020–2025).” A study by Fortune Business Insights, “The global mHealth market size is projected to reach USD 293.29 billion by 2026, exhibiting a CAGR of 29.1% during the forecast period.” A Research and Markets report says, “The remote patient monitoring market is expected to reach US$31.326 billion by the end of 2023.” Apart from the above, development in digital infrastructure such as virtual health stations where doctors can provide consultations globally, mobile ICUs, MRIs, X-rays, ultrasound equipment, the establishment of rural virtual care units reaching the remote areas of the country are some of the trends which will gain momentum. The focus would always lie upon the personalization of the virtual care experience for patients driven by data exchange and interoperability. 

Indeed, there are certain challenges to the implementation of these technologies, lack of infrastructure, and digital literacy amongst elders and lower strata of society. Many healthcare institutions still have inhibitions while investing in digital technologies fearing rejection from the customers. It will be crucial for care providers to choose the right partner for implementing these technologies and create awareness amongst people to adopt them.  

In a Nutshell

The success of virtual care relies on how well the digital experience is designed for the patient. “By 2025, as many as 95 percent of all customer interactions will be through channels supported by artificial intelligence (AI) technology” – Microsoft. The use of algorithms and AI for personalizing these experiences will be the key. 

Find out more about unchartered territories in ‘Blue Ocean’ of Digital Health. Join our webinar hosted by Parag Sharma (CEO, Mantra Labs) as he shares his insights on untapped opportunities using digital self-care tools within behavioral healthcare & emotional wellness.

Save your spot! 

Further Readings:

  1. Reimagining Medical Diagnosis with Chatbots
  2. HealthTech 101: How are Healthcare Technologies Reinventing Patient Care
  3. What will be the state of the healthcare industry post pandemic?
  4. Healthcare Chatbots: Innovative, Efficient, and Low-cost Care
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