U-Healthcare

5. PACS

2011. 4. 13(biahn99@gmail.com)Mcomputing.tistory.com@LBSAHNU-HealthCare SystemMedical Imaging Tech & PACSCTMRIPET/CTPACSDICOM

U-HealthCare SystemWhy use different methods of imaging ?Cost Effectiveness A good guiding principle in many walks of life is

Always pick the simplest solution for your problem.In many cases the cheapest solution is the best.You do not need to give every pregnant mother in the country an MRI scan.The capital cost of installation varies widely:UltrasoundX-ray CTMRIPET20k - 100k500k - 1M2M - 4M>5MU-HealthCare SystemWhat is the CT?Mathematical transform to the measured data.Reconstruct n dimension function (image)=> projection data of n 1 dimension Radon Transform (1917)Two dimension and three dimension object can be reconstructed from the infinite set of projection data.The First CT: 1973 in the U.S.4 minutes scan, thickness of 10mmU-HealthCare SystemConcept of CTGetting the shape by back projection of the projection data.For example, outward view is the quadrangle => it is the cylinder

CTAlgorithm

U-HealthCare SystemCT

(From Picker)

(From Siemens)U-HealthCare SystemXBasic principle of CT-Reconstruction of 2 dimensional image-Simple BackprojectionProjection DataBlurxyxycurvilinear integral of absorption coefficient regarding YobjectX-raytubeX-ray detector arrayData Acquisition fieldReconstruction fieldXXYU-HealthCare SystemBasic principle of CT -Reconstruction of 2 dimensional image-Filtered BackprojectionProjection DataxyxMultidirectional BackprojectionReconstruction FilterorxFiltered Projection dataxXU-HealthCare SystemReconstruction process

U-HealthCare SystemReconstruction process

Data acquisition at angle : 0 180 degreeObtain F(u,v) and then 2D IFFT -> reconstructionRadon Transform is equivalent to Filtered backprojection !U-HealthCare SystemExample of SimulationModel ImageSimpleBackprojectionFiltered Backprojection

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Magnetic Resonance Imaging

U-HealthCare SystemMagnetic ResonanceUses equipment producing magnetic fields from 0.5 Tesla to 3 TeslaEarths magnetic field is 50 microteslaCost of equipment is approx 700k per Tesla

U-HealthCare SystemObtaining the DataAll atoms have a magnetic field or orientationWhen placed in a strong magnetic field the atomic nuclei align with that fieldPulses of Radio Frequency aimed at area of interest in the body Imparts high energy state to the nuclei of those areasRelaxation of that state produces resonance which can be detectedLocation and intensity will translate into pixel location and intensity

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U-HealthCare SystemSlices

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U-HealthCare SystemImage Processing

U-HealthCare SystemImage Manipulation and EnhancementTwo time frames T1 and T2 relate to percentages of nuclei which have resumed normal stateT1 improves resolutionT2 improves sensitivityContrast media can be introducedfMR can monitor specific physiologyU-HealthCare SystemAnatomy or Physiology?

U-HealthCare SystemUsing Data Manipulation

U-HealthCare SystemImage Manipulation

U-HealthCare SystemWhen Do We Use MRI?Excellent for soft tissue imagingResolution is goodDoes NOT use ionising radiation but does have some safety issues

U-HealthCare SystemMR Versus CTMRDigital manipulationNon-ionisingNon-invasiveGood for soft tissueCan image physiologyTechnique can be altered to account for data requiredExpensiveCTDigital manipulationIonising XraysNon-invasiveGood for range of tissue types, soft tissue to a lesser extentCan only image physiology when used with other modalitiesVariation in technique possibleRelatively CheapU-HealthCare System25PET / CT System

U-HealthCare SystemPET / CT ?PET / CT (Positron Emission Tomography) (Computed Tomography) . PET / CT CT, . .U-HealthCare SystemPET / CT ??PET , , , , , .PET/CT PET CT .PET .U-HealthCare System

U-HealthCare System28PET / CT PET/CT . (+) (-) 511 KeV . PET/CT .

U-HealthCare SystemPET / CT CT . . . , . 40% . .U-HealthCare SystemPET / CT . , , , . 3~4 mm .

U-HealthCare SystemPET / CT PET/CT . PET/CT , , , , , , . , PET/CT . U-HealthCare SystemPET / CT PET / CT PET / CT PET / CTU-HealthCare System PET / CT 40 CT , PET ., , , , , , , , , , , , , .U-HealthCare System

, PET/CT .PET/CT , , U-HealthCare System PET / CT , , () . , . . . MRI .U-HealthCare System

U-HealthCare System PET / CT . .U-HealthCare SystemWhat is PACS ?P: Picture, Images & ReportsA: Archive, Online, Near line, OfflineC: Communication, Networking, Transfer ProtocolsS: System, Components & Architecture

PACS: for storage and distribution of images and information when necessaryU-HealthCare SystemPACS: Small or Large

Web Server DistributionU-HealthCare SystemScale of PACS No. of Beds in Hospital/ Exams per yearNo. of ModalitiesNo. of Switches

Considerations:System connectivity, expandability, reliability and cost-effectiveness

U-HealthCare System41Connection among various hospital information system, open architecture,Data migration is painful enough if you have moneyTypes of images1D, 2D, 3D, 4DDifferent DICOM Modality type: Cardiac / PET / 4D U/S..Image size: Resolution and bit depthImage quality: Bit Depth and resolutionColor / MonochromaticExam. Size: image size x no. of imagesStructured ReportsNew DICOM IOD:Endoscopic & Microscopic images / ECGs / Security Profiles..

U-HealthCare System42IOD=information object definition; Mammo CAD use SR output; DICOM waveform IOD; DICOM visible light IOD; Digital Envelop over Digital Signature1D, 2D, 3D, 4D, fusion

U-HealthCare System1D, 2D, 3D, 4D, fusion

U-HealthCare SystemImage Resolution/ Bit depth

U/S DF CR CR Mammogram 256 x 256 8 bit65 KBytes1k x 1k10 bit1.25 MByte2k x 2.5k12 bit7.5 MByte

4k x 5k12 bit30 MByteU-HealthCare System

Properties of imageBit depthGrayscale or colorResolution in pixel

Example image size of mammogram = 4k x 5k x 12 bit = 30 MBU-HealthCare System46Microcalcification need 130 m resolutionPACS ArchitectureU-HealthCare System Data Base ServerCR/ DR QAWorkstation ComputedRadiographyor DRGateway orFrame GrabberFilmDigitizerNon-DICOMModalityArchiveDICOMModalityWeb Server RISDiagnosticWorkstations (DICOM)Image Server(RAID) Clinical Workstations (DICOM)PACS Central ArchitectureDiagnosticWorkstation

U-HealthCare System48Central ArchitectureImage Server and Database Manager is the HEARTAny image, any where, any timeUnique central copyEasy update of dataRequires high performance serversPotential single point of failure at serverBandwidth demanding

U-HealthCare System Data Base ServerCR QAWorkstation ComputedRadiographyGateway orFrame GrabberFilmDigitizerNon-DICOMModalityArchiveDICOMModalityWeb ServerDiagnosticWorkstation

RISDiagnosticWorkstations(DICOM) Clinical Workstations(DICOM)PACS Distributed ArchitectureU-HealthCare System50Distributed ArchitectureExams are routed from modality to selected workstations Complex routing algorithms based on department / user preferenceDifficult to support concurrent review of imagesLess destructive for failure at database serverU-HealthCare SystemComponents of PACSHIS/ RISBrokerePR gatewayDatabase ServerImage Server (RAID)Long Term/ Near line ArchiveNetworksDigitizer

U-HealthCare System52Components of PACSAcquisition GatewaysNon-DICOM modality gatewayDICOM Print ServerMedia ServerReporting ServerMonitor QC ServerWeb ServerWorkstations

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PACS layout 1U-HealthCare SystemPACS layout 2

U-HealthCare System55All in blue must mentionPACS layout 3

U-HealthCare System Data Base Server CR/ DR QAWorkstation ComputedRadiographyor DRGateway orFrame GrabberFilmDigitizerNon-DICOMModalityLTS ArchiveSAN/NASDICOMModalityWeb Server Broker for RIS/HISDiagnosticWorkstations (DICOM)Image Server(RAID) Clinical Workstations (DICOM)PACS ComponentsDiagnosticWorkstation

Media ServerePR gatewayW/S QA ServerEnterprise ArchiveThrough Acq. gatewayU-HealthCare System57CRUSXRAY RISPCsW/SFilm DigitizerCR QAFrame GrabberHIS/RISInterface(Broker)CTR&FMRNMDGAcquisition (DICOM) GatewayU-HealthCare System58Role of Acquisition gatewayCompression/ decompression and securityCheck the images for integrityConvert to PACS format (header, byte-order, matrix size)Queue for images (priority) to database server (background)Share the workload and no point of failure for multiple Acquisition gatewayU-HealthCare SystemCRUSXRAY RISPCsW/SFilm DigitizerCR QAFrame GrabberHIS/RISInterface(Broker)CTR&FMRNMDGDatabase Server and Image ServerDatabaseServerRAIDU-HealthCare System60Database Server (PACS controller)The Heart of the systemIntegration cross point between HIS/RIS and PACS (status update)Create and manages patient foldersManage reading worklists and user profilesManage data transfer within the systemSupport data mining and teaching folders

U-HealthCare SystemImage Server (RAID)Online (rapid access) exam storage and distribution deviceSupport simultaneous exam input and output transfer operationsUp to Three months of storage capacityScalable capacityU-HealthCare SystemRedundant Array of Independent DisksBandwidth equal to sum of disk transfer rates Highest speed disk storage availableImageDisk Array2 MB/s1234567816 MB/sHot SwapParityWhat is RAIDU-HealthCare System63RAID 5 configurationIf disk fails, disk can be rebuilt- fault tolerantHigh data transfer rate for read, write slowerMin. 3 disks to startArray capacity is N-1

U-HealthCare SystemBandwidth is a measure of the information (data) carrying capacity of a network10/100/1000 MB/sec Information FlowData Pipe (Network)BandwidthU-HealthCare System65Network BottleneckThe bandwidth of an information delivery system is limited to the bandwidth of the slowest component in the systemNetwork BottleneckU-HealthCare System66Data compression reduces the information rate a network must supportUncompressed DataCompressed DataData CompressionU-HealthCare System67Decompressed image is identical to original imageJPEG lossless compressionAverage compression of 2:1 for x-ray images

ICDI - D = 0

Lossless Image CompressionU-HealthCare System68JPEG 2000 CompressionSelected parts of the image can be defined as Regions of Interest, they can then be delivered before other parts of the image, or losslessly, whilst other parts of the imagethat are less critical use normal lossy compression JPEG 2000 codestream can be ordered to deliver images of lower resolution before the full image can be transmitted Motion JPEG 2000 does not have any form of extrapolation (and hence potential distortion) in the time domain. Each frame is a separate JPEG 2000 coded imageU-HealthCare SystemJPEG 2000 images

U-HealthCare SystemCRUSXRAY RISPCsW/SFilm DigitizerCR QAFrame GrabberHIS/RISInterface(Broker)CTR&FMRNMDGStorage Device (Long Term)DatabaseServerRAIDMODDLTU-HealthCare System71Types of storage mediaMediaDVDMODWORMDLT9840AIT2GB3.85.2352050CostLess Expen.Expen.Expen.CheapMost Expen.Load + AssessVery fastVery fast113 sec15 sec45 secMax. T rate MB/s55.15106U-HealthCare SystemLong Term ArchiveUsed to store digital data for longer periods of timeStorage ranges from 100 MB to 10 TBOptical disk most common media- 5 1/4 MOD- 2.6 GB and 5.2 GB CapacityDLT used for longer term storage and redundancyISP module

U-HealthCare SystemCRUSXRAY RISPCsW/SFilm DigitizerCR QAFrame GrabberHIS/RISInterface(Broker)CTR&FMRNMDGStorage Device (Near line)DatabaseServerRAIDMODDLT

SAN/NASU-HealthCare System74Storage Area NetworkSAN is a high-speed sub-network of shared storage devicesContains storage device (disk) for storing dataSAN's architecture works in a way that makes all storage devices available to all serversUse of Fiber ChannelHigh scalability for additional storage and redundant networks

PCsStorage devicesU-HealthCare SystemNetwork Area StorageNAS is a class of dedicated hard disk-based storage devices which provide LAN users with additional disk storage through a standard network connectionIn most cases, a NAS device (or NAS server) receives an IP address, connects to the LAN through an Ethernet cable, and resides on the LAN as an independent network deviceUsers are not demanding the server's processing time for mundane storage tasks -- often improving the performance of local application serversNAS systems also include some onboard memory (RAM) to cache network data to or from the disks U-HealthCare SystemSAN Vs NASDifference between NAS and SAN is subtleNAS devices are big, single purpose storage appliances that you plug into networkNAS sits between your application server and your file systemAs perform only 1 task, can serve files very fastNAS is network-centricSAN is a defined architecture that sits between your file system and your underlying physical storageSAN is data-centricU-HealthCare SystemCRUSXRAY RISPCsW/SFilm DigitizerCR QAFrame GrabberHIS/RISInterface(Broker)CTR&FMRNMDGDisplayDatabaseServerRAIDMODDLT

SAN/NASDiagnostic W/SDedicate W/SU-HealthCare System78WorkstationsFour Primary Categories- Advanced Analysis: Used by specialists for advanced diagnosis - 3D, volume renderingDiagnostic: For primary diagnosis; located in reading rooms; high-end 2K monitorsClinical: Used by clinicians and staff to consult; ICU / ER applications; less costly than diagnostic; 1K monitorsAt Home Review: low-end; PC based; cost-effective; review application; lossy compressed for faster transmit

U-HealthCare SystemStandalone Vs direct PACS w/sStandalone WorkstationDirect PACS Client WorkstationHard Disk Storage Yes, variesMinimalQuery PACS numberAll PACS system (CT, ACC, Angio.)Single PACS system (ACC PACS)Retrieval mechanismDICOM Q/R and association made with different vendorsDirect attached, same vendorRetrieval timeSlowerFasterDiagnostic valueDepends on Monitor Grade and Modules like MPR, 3D etcDepends on Monitor Grade and Modules like MPR, 3D etcSuggested usagefor meeting/museum purposefor single modality image reviewing and reporting like Radworks in U/S RmDirect PACS workstation for reportingU-HealthCare SystemWeb distributionHigh availability, low costReports / select images to referring physician desktopPoint of integration with electronic patient recordLossy compression for performancePotential for TeleRadiologySecurity issues to be resolved

U-HealthCare SystemRIS, HIS, ePR and PACS integrationU-HealthCare SystemCRUSXRAY RISPCsW/SFilm DigitizerCR QAFrame GrabberHIS/RISInterface(Broker)CTR&FMRNMDGBroker HIS/RIS and PACS interfaceU-HealthCare System83Hospital Information SystemSupport clinical and medical patient care activities in the hospitalAdminister the hospitals daily business transactions like finance, payroll etcEvaluate hospital performances and costs and make long-term forecast U-HealthCare SystemClinical System in HA, HKPatient AdministrationIn-Patient and Out-Patient Administration SystemAccident & Emergency Information SystemMedical Record Abstract SystemMedical Record Tracking SystemClinical SupportLaboratory Information SystemRadiology Information SystemPharmacy Management SystemDietetics Catering Management SystemClinical ManagementClinical Management System (In-Patient) Discharge SummaryClinical Management System (Out-Patient)Electronic Patient RecordsClinical Data Analysis and Reporting SystemU-HealthCare SystemNon-Clinical System in HAHuman Resources and Payroll SystemsHospital Based Financial SystemMaterials Management SystemPatient Billing and Revenue Collection SystemExecutive Information System

Code 9 and view codesU-HealthCare SystemRadiology Information SystemsSimilar to HIS but of smaller scaleInterfaces to PACS based on HL7Department administrative management- Scheduling and Film tracking- Resource management and reporting- Monitor patient statusLink to Hospital Information System (HIS)- Billing and Master RecordLink to Clinical Management System (CMS)- Prefetch for Clinical visit- ePR integration

U-HealthCare SystemExamOrderExamScheduledRISPatient ExamIs PerformedModality WorklistDemographicsDownloadedDatabase server/ArchiveOrder EventPrefetch ExamsFrom StorageImagestransferred in STSPACS WorklistUpdatedImages /Prior ReportsImage migration STS to LTAExamTranscribedReportVerifiedFinal reportavailableExamReadDictatedstatusPreliminary statusImagescopied onweb-serverWebdistributionto referringphysiciansRIS workflowU-HealthCare System88Broker serviceHAHISHARISHA CMSClinical visitADTMitraPACSBroker interfaceAppt., X-ray requestDRCRUSDFModalities: Get WORKLISTGet REPORT, Get INFODatabase serverU-HealthCare SystemBroker serviceA restricted access account will be created at Sybase that gives limited authority for the DICOM Broker solely for the purpose of the interfaces In general, for data flow from RIS to the Broker, the RIS write the supported events to the table, and the Broker polls against the events table and calls the associated stored procedures for the conversion to DICOM messages U-HealthCare SystemBroker serviceBroker main function:- Worklist generation- Reports storageRegistration + Post exam data capture (RIS)Acc # generation + call broker for updateBroker poll RIS event table and convert to DICOM infoModalities query Broker for worklist updateNeed SOME time!!U-HealthCare SystemePR Architecture Selected images from individual hospitals PACS are sent make use of the ePR record indexing and browsing capabilities to read the radiology images through CMS workstations

U-HealthCare SystemData Flow DiagramRISePRRIS operational dataRIS statistical dataePRData warehouseAppointment AttendanceExam recordsReports (15mins)Attendance Exam & workload units (daily)HA systemCMSNon clinical systemWeb ServerPACSU-HealthCare SystemCharacteristics of ePRNear instant image reviewWeb distribution can be within hospital, to other hospitals or even private clinicsTeleRadiography possibleUpdate of patient informationLossy Vs losslessBroken pathway15 minutes time lagU-HealthCare SystemGuidelines for HIS, RIS, PACS interfaceEach system remain unchanged in its configuration and function, only data are sharedIdentify the subset data to be shared and set up access rights/ authorizationConvert the subset data to HL7 standard Define transfer protocol (TCP/IP or DICOM)U-HealthCare SystemTypical patient and data flowAdmission: Patient registration, notify HIS (HL7)Order entry/Arrival: Schedule exam and notify RISBroker notified and PACS database server updated (prefetch)DICOM worklist to modalityExam completed: data to DICOM gateway (MPPS)Information/images to database/image server through gateway (DICOM store)Images stored in PACS archiveImages to workstations from PACS archiveDictation, transcription etc: workstation to RIS/PACS RIS reporting and PACS updated for reportsTransfer: HIS/RIS to PACS, images to other PACSDischarge: HIS/RIS to PACS, images rub out

U-HealthCare SystemMobile PACS

U-HealthCare SystemWhat is DICOM? The standard for Digital Imaging and Communications in Medicine. Developed by the National Electrical Manufacturers Association (NEMA) in conjunction with the American College of Radiology (ACR). Covers most image formats for all of medicine. Specification for messaging and communication between imaging machines.U-HealthCare SystemA little historyThe first version was ACR-NEMA, released in 1985.Its goal in developing a standard wasTo enable users to retrieve images and associated information from digital imaging equipment in a standard format using point-to-point connection.To hide differences same across multiple image equipment manufacturers.To handle developing network and image standarts, a new standard, DICOM, was proposed in 1981.U-HealthCare SystemDICOM Application Domain

MAGNETOM

Information Management SystemStorage, Query/Retrieve, Study ComponentQuery/RetrieveResults ManagementPrint ManagementMedia ExchangeLiteBoxU-HealthCare SystemSummary of DICOM FeaturesNETWORK PROTOCOLDICOM incorporates negotiation to permit peers to agree on the functions to be performedMESSAGE ENCODINGDICOM defines 24 data types (V2.0 had 4)DICOM message encoding includes JPEG compression (17 varients)DICOM supports multiple character repertoiresU-HealthCare SystemSummary of DICOM FeaturesOBJECT DATA MODELDICOM is based on a completely specified data model DICOM includes a robust UID mechanismDATA DICTIONARYDICOM includes a large number of new data elementsSERVICE CLASSESDICOM defines classes of service for specific applications (e.g. image management, printing) and conformance levelsU-HealthCare SystemDICOM ObjectsThings such as images, reports, and patients are all objects and are called information objects.Two kinds of objects in DICOM:Composite objects (Old objects inherited from NEMA).Normalized objects (New objects defined in DICOM).All objects and their format constitutes Data Dictionary.DICOM uses UIDs to identify information objects, such as the images, reports, or transfer syntaxes.The form of the UID conforms to an international standard.1.2.840.10008 is the root and the same for every DICOM UID.Example: UID for the DICOM explicit VR little endian transfer syntax is 1.2.840.10008.1.2.1U-HealthCare SystemDICOM Service ClassesCompositeVerificationStorageQuery/RetrieveStudy Content NotificationNormalizedPatient ManagementStudy ManagementResults ManagementBasic Print ManagementU-HealthCare SystemImage Reading:Hardcopy ReadingHardcopy DICOM Print as Seen at ModalityReporting:RIS-Based Transcription / Validation of Narrative ReportRIS-Based Report Storage and ManagementSend ReportsQuery Prior Reports

Hardcopy Image Reading +Dictation/Transcription (Use Case 1)U-HealthCare SystemHardcopy Image Reading +Dictation/Transcription (Use Case 1)Hardcopy Interpretation& DictationTranscription& CorrectionprintReportRepositoryRISValidationsendmanualnetworkDICOMHL7/otheroptionalNarrativeInfo OnlyElectronic ReportElectronic ReportFilm ArchivequeryPaper print/Mail/Fax/E-mailAcquisitionReport Storage / Mgmt.FilmingU-HealthCare SystemImage Reading:Hardcopy ReadingHardcopy DICOM Print as Seen at ModalitySoftcopy ReadingHardcopy DICOM Print as Seen During Softcopy ReadingReporting:RIS-Based Transcription / Validation of Narrative ReportRIS-Based Report Storage and ManagementSend ReportsQuery Prior ReportsHardcopy and Softcopy Image Reading +Dictation/Transcription (Use Case 2)U-HealthCare SystemHardcopy and Softcopy Image Reading +Dictation/Transcription (Use Case 2)Hardcopy Interpretation& DictationprintReportRepositoryRISValidationsendmanualnetworkDICOMHL7/otheroptionalNarrativeInfo OnlyElectronic ReportElectronic ReportFilm ArchivequeryPaper print/Mail/Fax/E-mailAcquisitionSoftcopyInterpretation& DictationstoreReport Storage / Mgmt.Transcription& CorrectionSelectedImagesFilmingU-HealthCare SystemImage Acquisition:RIS-based Acquisition Workflow Support (Modality Worklist)Image Reading:Hardcopy ReadingHardcopy DICOM Print as Seen at ModalitySoftcopy ReadingHardcopy DICOM Print as Seen During Softcopy ReadingDICOM Store Images -> Burn CD/DVDReporting:RIS-Based Transcription / Validation of Narrative ReportRIS-Based Report Storage and ManagementSend ReportsQuery Prior ReportsOptional DICOM Store Reports -> Burn CD/DVD

Acquisition Workflow Support +Burn CD/DVD (Use Case 3)U-HealthCare SystemHardcopy and Softcopy Image Reading +Dictation/Transcription (Use Case 3)Hardcopy Interpretation& DictationprintReportRepositoryRISValidationsendmanualnetworkDICOMHL7/otheroptionalNarrativeInfo OnlyElectronic ReportElectronic ReportFilm ArchivequeryPaper print/Mail/Fax/E-mailAcquisitionSoftcopyInterpretation& DictationReport Storage / Mgmt.Transcription& CorrectionModality WorklistBurn CD/DVDOff-Line ArchivestoreSelectedImagesstoreFilmingU-HealthCare SystemImage Acquisition:RIS-based Acquisition Workflow Support (Modality Worklist)Image Reading:Hardcopy ReadingHardcopy DICOM Print as Seen at ModalitySoftcopy ReadingHardcopy DICOM Print as Seen During Softcopy ReadingDICOM Store Images for Burning CD/DVDPACS-based Storage and Management of DICOM Persistent ObjectsArchive Imaging StudiesQuery Prior Imaging StudiesReporting:RIS-Based Transcription / Validation of Narrative ReportRIS-Based Report Storage and ManagementSend ReportsQuery Prior ReportsOptional DICOM Store Reports for Burning CD/DVD

PACS for Management of DICOM Persistent Objects (Use Case 4)U-HealthCare SystemImageRepositoryPACSPACS for Management of DICOM Persistent Objects (Use Case 4)Hardcopy Interpretation& DictationprintReportRepositoryRISValidationsendmanualnetworkDICOMHL7/otheroptionalNarrativeInfo OnlyElectronicReportElectronic ReportFilm ArchivequeryPaper print/Mail/Fax/E-mailAcquisitionSoftcopyInterpretation& DictationObject Storage / Mgmt.Transcription& CorrectionModality WorklistBurn CD/DVDOff-Line ArchivestoreSelectedImagesstoreFilmingstoreq/rstoreU-HealthCare System