PRACTICAL IMAGING INFORMATICS foundations and applications for.

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Introduction The Evolution of the Imaging Informatics Professional Who Should Read This Book The Organization of This Book Contents Contributors Part I: Medical Imaging Chapter 1: Introduction to Medical Images 1.1 Healthcare and Medical Imaging 1.2 Why Medical Images Are Helpful in Healthcare 1.2.1 Establishing a Diagnosis and Misdiagnosis 1.2.2 Screening and Delayed Diagnosis 1.3 The Chain of Events for Medical Imaging 1.4 Urgency in Radiology (Why Physicians Need the Results Now!) 1.5 Additional Healthcare Data Needed for Medical Imaging 1.5.1 Relevant Clinical Information 1.5.2 Results Reporting References Chapter 2: Medical Terminology 2.1 Introduction 2.2 Subspecialty Sections in the Radiology Department 2.3 Positions, Planes, and Projections 2.3.1 Directional Terms 2.3.2 Imaging Planes 2.3.3 Body Positions 2.3.4 Imaging Projections 2.4 Anatomical Terms in a DICOM Header 2.4.1 Image Laterality (0020,0062) 2.4.2 Patient Orientation (0020,0020) 2.4.3 Body Part Examined (0018,0015) 2.4.4 Study Description (0008,1030) 2.4.5 Patient Position (0018,5100) Chapter 3: Medical Imaging Modalities and Digital Images 3.1 Introduction 3.1.1 Special Aspects of Medical Images 3.1.2 Medical Imaging Terminology 3.2 Diagnostic Imaging Modalities 3.2.1 Projection Radiography 3.2.2 Mammography and Tomosynthesis 3.2.3 Fluorography 3.2.4 Computed Tomography (CT) 3.2.5 Magnetic Resonance Imaging (MRI) [1] 3.2.6 Nuclear Medicine and Positron Emission Tomography (PET) 3.2.7 Ultrasound 3.2.8 Visible Light 3.3 Digital Images 3.3.1 Definition 3.3.2 Digital Image Formation 3.3.3 Image Quality Factors Reference Suggested Reading Chapter 4: Image Post-Processing 4.1 Introduction 4.2 Image Filtering 4.2.1 Histogram Manipulation 4.2.2 Enhancement 4.2.3 Frequency Filtering 4.2.4 Noise Reduction 4.2.5 Practical Considerations 4.3 Segmentation 4.3.1 Basics 4.3.2 Morphological Operators 4.3.3 Classification 4.4 Registration 4.4.1 Transforms 4.4.2 Similarity Metrics 4.4.3 Optimization 4.5 3D Visualization 4.5.1 Volume Data and Its Grid Structure 4.5.2 Projection Rendering 4.5.3 Surface Rendering 4.5.4 Direct Volume Rendering 4.5.5 Cinematic Rendering 4.6 Post-processing and Billing Suggested Readings Chapter 5: Incorporating Nonimage Data 5.1 Introduction 5.2 Sources of Non-Image Objects 5.2.1 Scanned Documents 5.2.2 External Sources 5.2.3 Modalities 5.3 Data and Workflow Considerations 5.3.1 Paper Scanned Documents 5.3.2 DICOM SR 5.3.3 AI applications 5.3.4 Shared Considerations Part II: Information Technology Chapter 6: Computers and Networking 6.1 Introduction 6.2 Computers 101: Hardware 6.2.1 Hardware Elements of Computers 6.2.2 GPUs/TPUs 6.2.3 Memory Types 6.2.4 Storage 6.2.5 Input/Output 6.2.6 Data Bus 6.2.7 BIOS 6.2.8 Virtual Machine 6.3 Computers 101: Software 6.3.1 Computer Operating System 6.3.2 Application Software 6.3.3 Software Containers 6.3.4 Programming Languages 6.3.4.1 Low-Level Programming Language 6.3.4.2 High-Level Programming Language 6.3.4.3 Integrated Development Environment 6.4 Computer Networking 6.4.1 Physical (Hardware) Networking Components 6.4.2 Network Switches, Hubs, Bridges, and Routers 6.4.3 Network Processes and Protocols 6.4.4 Data Packets 6.4.5 Bandwidth and Latency 6.5 Client-Server Architecture 6.5.1 Cloud Computing 6.5.1.1 SaaS, PaaS, and IaaS 6.5.2 Web Services 6.5.3 Protocols 6.6 Database Applications Chapter 7: Data Storage 7.1 Philosophy of Storing Electronic Protected Health Information (ePHI) 7.1.1 Enterprise Storage Versus Departmental Silos of Storage 7.1.2 Storage Management Responsibilities 7.1.3 Economics of Storage Management 7.2 Datacenters 7.2.1 Tier Rating of Datacenters 7.3 Types of Medical Data 7.3.1 Variable Content Files (VCF) 7.3.2 Fixed Content Files (FCF) 7.4 Storage Requirements for ePHI 7.4.1 Health Information Portability and Accountability Act (HIPAA) 7.4.2 Storage Requirements for Clinical Studies 7.5 Retention and Destruction Requirements for ePHI 7.5.1 Retention Requirements for ePHI 7.5.2 Film Screen and Digital Mammograms 7.5.3 Destruction Requirements for ePHI 7.6 Storage Technology 7.6.1 Types of Storage Media 7.6.2 Storage Management Infrastructure and Hardware 7.6.3 Storage Management Software 7.6.4 Cloud Storage 7.6.5 Vendor Neutral Archive (VNA) 7.7 Compression of Medical Images 7.7.1 Basic Concepts 7.7.2 Lossless Compression 7.7.3 Lossy Compression Chapter 8: Data Security and Patient Privacy 8.1 Background 8.1.1 Definitions 8.1.1.1 Patient Privacy 8.1.1.2 Data Security 8.1.2 History 8.1.3 Regulations 8.1.4 Targets and Adversaries 8.2 Attacks on Patient Health 8.3 Network Attacks 8.4 Social Engineering 8.4.1 Phishing 8.4.2 Protection Systems 8.5 Future Threats Chapter 9: PACS and Other Image Management Systems 9.1 Introduction: What Is PACS? 9.2 History of PACS 9.3 Core Components of Traditional PACS Architecture 9.3.1 Acquisition Devices 9.3.2 Network 9.3.3 Archive 9.3.4 Database 9.3.5 Image Viewers 9.3.6 Radiology Information System (RIS) 9.3.7 Interface Engine/PACS Broker 9.4 Other Image Management Systems 9.5 Imaging Workflow Elements of PACS and Other Image Management Systems 9.6 Valuable Imaging Workflow Advances Made Possible by PACS and Other Image Management Systems Chapter 10: Ancillary Software 10.1 Introduction 10.2 Build Versus Buy 10.3 Results Management 10.3.1 Critical Results 10.3.2 Noncritical Actionable Findings 10.4 Radiation Exposure Management 10.5 Decision Support 10.5.1 Clinical Decision Support 10.5.2 Radiologist Decision Support 10.6 Education 10.6.1 Teaching Files 10.6.2 Discrepancy Tracking 10.7 Quality Improvement 10.7.1 Adverse Event Reporting 10.7.2 Opportunities for Improvement 10.8 Consultation Tools References Part III: Imaging Informatics Chapter 11: Databases and Data Retrieval 11.1 Introduction 11.2 Developing a Database for Imaging Research 11.2.1 Planning What Data Need to Be Collected for an Imaging Research Protocol 11.2.2 Types of Image Databases 11.2.3 Information Governance: Approval and Anonymization 11.2.4 Transfer of Data from PACS and EHR: Quality Assurance 11.2.5 Data Processing 11.2.6 Software for Image Databases 11.2.7 Security and Safety of the Database 11.3 Using the Database 11.3.1 Information Governance: Data Sharing and Access 11.3.2 Planning Data Usage in the Context of a Study 11.3.3 Database Merging and Sustainability References Chapter 12: Standards and Interoperability 12.1 Introduction 12.2 The Problem: A Dynamic Multivendor Ecosystem 12.2.1 Systems to Integrate 12.2.2 Workflows to Integrate 12.2.3 The Cost of Proprietary Integration 12.2.4 Final Word 12.3 HL7, the Health Data Standard 12.3.1 Overview 12.3.2 HL7 v2 12.3.3 FHIR 12.4 DICOM, the Imaging Standard 12.4.1 Overview 12.4.2 DICOM Structure 12.4.3 DICOM Information Object Definitions 12.4.4 DICOM Workflow and Transport 12.4.5 DICOMweb 12.5 Coding Systems 12.5.1 SNOMED-CT 12.5.2 LOINC 12.5.3 ICD 12.6 Integrating the Healthcare Enterprise (IHE) 12.6.1 Introduction 12.6.2 Key IHE Profiles for Radiology 12.6.3 Key IHE Profiles for IT Infrastructure 12.7 Bringing It All Together 12.7.1 Building an Integration 12.7.2 Identity 12.7.3 Security References Chapter 13: Billing and Coding 13.1 Introduction 13.2 Revenue Cycle 13.3 Terminology and Standards 13.4 Required Practices 13.4.1 CPT Codes 13.4.2 ICD-10 Codes 13.5 Information Transfer References Chapter 14: Artificial Intelligence and Machine Learning 14.1 Introduction 14.2 Machine Learning and Deep Learning 14.2.1 “Traditional” Machine Learning 14.2.2 Deep Learning and Neural Networks 14.2.3 Supervised vs. Unsupervised Tasks 14.2.4 Datasets 14.2.5 Validation Metrics 14.3 Applications 14.3.1 Detecting, Classifying, Localizing, and Segmenting 14.3.2 Enhancing Image Quality 14.3.3 Improving the Workflow 14.3.4 Guiding Interventional Radiology 14.3.5 Extracting More Information with Radiomics 14.4 Limitations and Challenges 14.4.1 Data 14.4.2 Generalizability 14.4.3 Explainability or Interpretability 14.4.4 Detection of Errors 14.4.5 Automation Bias Further Reading Part IV: Image Interpretation and Support Chapter 15: Roles and Relationships in Healthcare 15.1 Introduction 15.2 Imaging – Widening the Aperture 15.2.1 Embracing the Enterprise 15.2.2 The Illusion of Communication 15.2.3 Aligning with the Care Team 15.2.4 Understanding the Imaging Value Chain 15.3 Internal Relationships 15.3.1 The Radiologist-Clinician Relationship 15.3.2 Information Technology 15.3.3 Alignment Models and the C-suite 15.4 Decision-Making 15.4.1 Organizing for Success 15.4.2 A Seat at the Table 15.5 External Relationships 15.5.1 Vendor Partners 15.5.2 External Organizations 15.6 Conclusion References Chapter 16: Workflow Steps in Radiology 16.1 Introduction 16.2 Understanding Basic Concepts 16.3 Documentation and Process Flow 16.4 Key Steps of Workflow 16.5 IHE Workflow Steps 16.6 Structured Content 16.7 Web Services 16.8 IHE Workflow Models 16.9 Goals 16.10 Summary Chapter 17: Viewing Images 17.1 Introduction 17.2 Basics of Human Perception 17.3 Display Hardware Basics 17.4 Display Software Considerations 17.5 Human-Computer Interface 17.6 Fatigue in the Reading Room 17.7 Special Considerations for Mammography, Tomosynthesis, and Breast Imaging References Chapter 18: Reporting and Dictation 18.1 Introduction 18.2 Structured Reporting 18.2.1 Advantages of Structured Reporting 18.2.2 Disadvantages of Structured Reporting 18.2.3 Recommendations 18.2.4 Implementation Strategies 18.3 Lexicons, Coding Systems, and Ontologies 18.3.1 ACR Reporting and Data Systems 18.3.2 RadLex [21] 18.3.3 LOINC/RSNA Radiology Playbook 18.3.4 RadElement Common Data Elements 18.4 Communications 18.4.1 Radiology Reports and Patients 18.4.2 Critical Results and Actionable Findings 18.5 Speech Recognition 18.5.1 How Does Speech Recognition Work? 18.5.2 Advantages of Speech Recognition 18.5.3 Disadvantages of Speech Recognition 18.5.4 Speech Recognition Errors and Possible Remedies 18.5.5 Implementation 18.6 Interfaces and Integration 18.7 The Radiology Report of the Future References Chapter 19: User Governance 19.1 Introduction 19.2 Roles of Governance, Mission, and Principles 19.2.1 Mission Statement 19.2.2 Roles of Governance 19.3 Necessary Components of Imaging Informatics Governance 19.3.1 Clinical Governance 19.3.2 Data, Information, and Knowledge Governance 19.3.3 Technology Governance 19.3.4 Financial Governance 19.3.5 Program Governance 19.4 Imaging Governance Operations 19.4.1 Imaging Governance Composition 19.4.2 Top-Down Approach 19.4.3 Bottom-Up Approach 19.4.4 Systems for Prioritizing 19.5 When You Present to Imaging Governance References Chapter 20: External Data 20.1 Introduction 20.2 Image Transfer 20.2.1 Image Transfer Protocols 20.2.2 Inbound and Outbound Image Transfer 20.2.3 Outside Image Consultation and Interpretation 20.3 Imaging Repositories and Research 20.3.1 Multi-institutional Image Sharing 20.3.2 Health Information Exchanges (HIEs) 20.3.3 Research Repositories References Part V: Work Environment and User Training Chapter 21: Reading Room Design 21.1 Introduction 21.2 History and Evolving Impact of Reading Room Design 21.2.1 The Impact of Reading Room Design 21.2.2 Reading Room Locations 21.3 Challenges of Reading Room Design 21.3.1 Educating the Design Team 21.3.2 Optimal Reading Space 21.4 Room Configuration 21.4.1 Subdivision of Moderately Sized Spaces 21.4.2 Conference Space 21.5 Reading Room Environment and Design Optimization 21.5.1 Lighting 21.5.2 Acoustics 21.5.3 Thermal Comfort 21.6 Ergonomics 21.7 Connectivity 21.8 Fatigue 21.9 Airflow in the Pandemic and Post-Pandemic Era 21.9.1 Airflow Design 21.9.2 Air Recycling Chapter 22: Enterprise Distribution 22.1 Introduction 22.2 The Evolution of Enterprise Image Distribution 22.3 Image Availability Notifications 22.4 EMR Integration 22.4.1 Orders-Based Distribution 22.4.2 Encounters-Based Distribution 22.5 Infrastructure Considerations 22.5.1 Storage 22.5.2 Viewer Accessibility 22.5.3 Logins and Permissions 22.5.4 Encryption 22.5.5 Auto-Routing and Prefetching 22.6 Enterprise Viewers 22.7 Image Sharing and Exchange Chapter 23: Customer Relations 23.1 Introduction 23.2 Customer Groups and Their Concerns 23.2.1 Radiologists and Other Imaging Physicians 23.2.2 Clinicians 23.2.3 Technologists 23.2.4 Hospital IT 23.2.5 Hospital Personnel 23.2.6 Vendors 23.2.7 Patients 23.3 Tools of the Trade 23.3.1 Documentation and Education 23.3.2 Ticket and Issue Tracking 23.3.3 Proactive System Monitoring 23.4 Final Thoughts Chapter 24: User Training 24.1 Introduction 24.2 Assessing the Need 24.2.1 Training Purpose 24.2.2 Typical Training Methods 24.3 Design and Development 24.3.1 Training Adult Learners 24.3.2 Learning Objectives 24.3.3 Select a Delivery Method 24.3.4 Creating Materials and Documentation 24.4 Implementation 24.4.1 Schedule 24.4.2 Preparation 24.5 Evaluation 24.5.1 Learning Cycle 24.5.2 Financial Assessment 24.5.3 Creating Assessment Materials 24.6 Follow-Up References Chapter 25: Quality Improvement and Workflow Engineering 25.1 Introduction 25.2 Establish an Organizational Foundation 25.2.1 Leadership 25.2.2 Key Staff Roles 25.3 Project-Based Improvement 25.3.1 When to Initiate a QI Project 25.3.2 Identify the Problem 25.3.3 Form a Team 25.3.4 Identify Methodology 25.3.5 Observe Current Performance 25.3.6 Measure Performance 25.3.7 Identify Problems and Causes 25.3.8 Develop and Implement Solutions 25.3.9 Sustain Improvement 25.4 Workflow Engineering 25.4.1 Workflow Enhancements 25.4.2 Workflow Bottlenecks Chapter 26: Change Management and Acceptance Testing 26.1 Introduction 26.2 Change Management 26.2.1 Initiating Change 26.2.2 Managing Expectations 26.2.3 Accepting Change 26.2.4 Change Control Process 26.3 Acceptance Testing 26.3.1 System Integration and Interfaces 26.3.2 Modality Integration 26.3.3 PACS Components 26.3.4 Workstation Functionality 26.3.5 PACS Monitor Testing 26.4 Conclusion Part VI: Operations Chapter 27: Imaging Quality Assurance 27.1 Introduction 27.2 QA of Digital Imaging 27.2.1 Errors in a Digital Imaging System 27.2.2 False Sense of Security 27.2.3 Errors Inside and Outside the Digital World 27.2.4 Consequences of Well-Known Errors 27.3 Processes and Products in the Imaging Department 27.3.1 Report Is the Product; Images Are Auxiliary 27.3.2 Process Mapping 27.4 Measurable Indicators of Quality of Imaging Services 27.4.1 Availability and Quality of Images and Reports 27.4.2 Physical Aspects of Image Quality 27.4.3 Ionizing Radiation Dose 27.4.4 Electronic Display Quality 27.4.5 Repeated Images 27.4.6 Discrepancies in Demographic and Exam Information 27.4.7 Misidentification 27.5 Mechanisms for Improving Performance in the Digital Department 27.5.1 Selection of Indicators and Action Limits 27.5.2 Timeline Analysis 27.5.3 Radiation Dose Index Monitoring 27.5.4 Reject Analysis 27.5.5 Reliability Analysis 27.5.6 Radiologist Image Critique 27.5.7 Training and Orientation 27.5.8 Service Support 27.6 Roles and Responsibilities for QA 27.6.1 Radiologic Technologist 27.6.2 Imaging Informatics Professional 27.6.3 Qualified Medical Physicist (QMP) 27.6.4 Radiologist 27.6.5 Radiology Administrator 27.6.6 QA Committee Further Reading Chapter 28: Disaster Recovery 28.1 Introduction 28.2 Disaster Recovery 28.2.1 General 28.2.2 Planning 28.2.2.1 Critical Infrastructure 28.2.2.2 Identify DR Scenario(s) 28.2.3 Resources 28.2.4 Budget 28.3 Execution of Disaster Recovery 28.3.1 Testing Scenarios 28.3.2 In Practice 28.4 Protection 28.4.1 Standards of Practice 28.4.2 Cyber Monitoring of Threats 28.4.3 Protecting Critical Data on DR Systems 28.5 Validation 28.5.1 Testing Scripts 28.6 Documentation 28.6.1 Enterprise Level 28.6.2 Department Level 28.7 The Future of Disaster Recovery 28.7.1 Filling the Disaster Recovery Skills Gap 28.7.2 The Disaster Recovery Return on Investment 28.7.3 Shift from “Recovery” to “Continuity” 28.7.4 Real-Time Adaptation to Threats Chapter 29: Downtime Procedures 29.1 Introduction 29.2 Downtime Considerations and Scenarios 29.2.1 Scheduled Downtimes 29.2.2 Unscheduled Downtimes 29.3 Planning for Downtimes 29.4 Business Continuance 29.4.1 Fault Tolerance 29.4.2 High Availability 29.4.3 Disaster Recovery 29.5 Policies and Procedures 29.6 Conclusion Further Reading Chapter 30: Policy Management and Regulatory Compliance 30.1 Introduction 30.2 The Health Information Privacy and Accountability Act (HIPAA) 30.2.1 Overview 30.2.2 Title II: Administrative Simplification 30.2.3 The Privacy Rule 30.2.4 The Security Rule 30.2.5 The Enforcement Rule 30.2.6 The HITECH Act 30.2.7 The Final Omnibus Rule 30.2.8 State, Local, and Organizational Regulations 30.3 Interoperability 30.3.1 ONC 10-Year Interoperability Roadmap 30.3.2 CMS and ONC Interoperability Legislation 30.4 FDA Medical Device Regulation 30.5 Mammography Quality Standards Act 30.5.1 Accreditation, Certification, and Inspection 30.5.2 Requirements 30.5.3 Mammography Quality Control (QC) 30.5.4 Patient Results 30.5.5 Full-Field Digital Mammography 30.5.6 Digital Breast Tomosynthesis 30.5.7 Breast Density Reporting 30.5.8 Proposed MQSA Update 2019 30.6 Imaging Informatics Professional Certification (CIIP) 30.6.1 Overview 30.6.2 Certification Exam Requirements 30.6.3 Certification Exam Preparation 30.6.4 Continuing Education 30.6.5 Ten-Year CIIP Recertification Further Readings Chapter 31: Availability and Notification 31.1 Introduction 31.2 Measuring Availability for Service Level Agreements 31.2.1 Key Services in Medical Imaging 31.2.2 System Availability 31.2.3 Defining Appropriate Service Level Agreements 31.2.4 Identifying Service Level Agreement Breaches 31.3 Identifying Service Interruptions 31.3.1 Proactive Identification 31.3.2 Reactive Identification 31.4 Service Interruption Management 31.4.1 Incidents 31.4.2 Problem Management 31.4.3 Managing Alerts 31.5 Service Interruption Communication 31.5.1 Policies and Procedures 31.5.2 Notification Practices References Part VII: Project Management Chapter 32: PACS Readiness and PACS Migration 32.1 Introduction 32.2 Choosing to Change PACS 32.3 Assessment 32.3.1 Assessing Workload 32.3.2 Workflow 32.3.3 Personnel 32.3.4 Interfaces 32.3.5 What Kind of PACS? 32.4 Change Management 32.4.1 Training Issues 32.4.2 IT Historians and Their Roles and Importance 32.4.3 Getting Help 32.5 Data Migration 32.5.1 Migration Methods 32.5.2 What to Migrate 32.5.3 Data Enhancement in Migration 32.5.4 Data Cleansing and Reconciliation 32.5.5 Do-It-Yourself Migration 32.5.6 Commercial Migration 32.5.7 Specifying a Migration Project References Chapter 33: Procurement 33.1 Introduction 33.2 Standard Practices for Acquisition of Technology 33.2.1 Developing an Appropriate Business Plan 33.2.2 Request for Information 33.2.3 Request for Proposal 33.2.4 Technology Acquisition Components 33.3 Requirements 33.3.1 Vendor Management Strategies 33.3.2 Technical and Hardware Requirements 33.3.3 Additional RFP Information 33.3.4 Defining Expected Performance and Product Stability 33.4 RFP Review 33.4.1 Review Responses to RFP 33.4.2 Site Visits 33.4.3 Proof of Concept (POC) 33.4.4 Deconstructed PACS 33.5 Contracts 33.5.1 Business Terms 33.5.2 Technical Terms 33.5.3 Legal Terms 33.5.4 Negotiating the Contract 33.5.5 Payment Terms and Budgeting Chapter 34: Imaging Program Management 34.1 Introduction 34.2 Imaging Program Oversight 34.2.1 Imaging Program Committee Membership 34.2.2 Strategy and Tactics 34.2.3 Imaging Operations Workgroup 34.3 Identify Goal, Scope, and Risks 34.3.1 Imaging Project Goals 34.3.2 Imaging Project Scope 34.3.3 Project Milestones 34.3.4 Project Team Membership 34.3.5 Common Risks for Imaging Informatics Projects 34.3.6 Risk Mitigation Strategies 34.4 Evaluation of Project Feasibility 34.4.1 Local Environment Assessment 34.4.2 Physical Plant Assessment 34.4.3 Financial Feasibility 34.4.4 Project Prioritization 34.4.5 Project Management Methodology 34.5 Common Project Management Tools 34.5.1 Project Development Stages 34.5.2 Project Management Methodologies 34.5.3 Project Management Forms and Tools 34.5.4 The Role of the Imaging Informatics Professional Further Reading Answer Key Glossary Index