DIGITAl RADIOGRAPHY

AND PACS
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DIGITAl RADIOGRAPHY
AND PACS

Christi E. Carter, MSRS, RT(R)

Professor and Director
Radiologic Sciences
Program Brookhaven
College Farmers
Branch, Texas

Beth [Link]é, [Link]., RT(R)(QM)

Associate Professor of Radiologic Sciences
Midwestern State University
Wichita Falls, Texas
11830 Westline Industrial
Drive St. Louis, Missouri 63146

DIGITAL RADIOGRAPHY AND PACS ISBN: 978–0–323–07221–2

Copyright © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means,
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Notice

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge,
changes in practice, treatment and drug therapy may become necessary or appropriate. Readers are advised to check the
most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of the practitioner, relying on their own experience and knowledge of the
patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all
appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the Editors/Authors assume
any liability for any injury and/or damage to persons or property arising out of or related to any use of the material
contained in this book.
The Publisher

Library of Congress Cataloging-in-Publication Data

Carter, Christi E.
Digital radiography and PACS / Christi E. Carter, Beth L. Vealé. -- 1st ed., rev.
p. ; cm.
Includes index.
ISBN 978-0-323-07221-2 (pbk. : alk. paper) 1. Radiography, Medical--Digital techniques. 2. Picture
archiving and communication systems in medicine. I. Vealé, Beth L. II. Title.
[DNLM: 1. Image Processing, Computer-Assisted--methods. 2. Radiographic Image Interpretation,
Computer-Assisted--instrumentation. 3. Radiographic Image Interpretation, Computer-Assisted--methods.
WN 26.5 C323d 2010]
RC78.7.D35C37 2010
616.07'572–dc22 2009019833

Publisher: Jeanne Olson

Senior Developmental Editor: Linda Woodard
Editorial Assistant: Luke Held
Publishing Services Manager: Pat Joiner-Myers
Senior Project Manager: David Stein
Design Direction: Kim Denando

Printed in Canada

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Reviewers
Alberto Bello, Jr., [Link]., RT(R) Barbara J. Smith, MS, RT(R)(QM),
(CV) Radiologic Technology Program FASRT
Director Danville Area Community Instructor, Radiologic Technology
College Danville, Illinois Portland Community College
Portland, Oregon
Terri L. Fauber, Ed.D., RT(R)
(M) Associate Professor and Patti Ward, [Link]., RT(R)
Program Director—Radiography Associate Professor/Clinical
Virginia Commonwealth University Coordinator Mesa State College
Richmond, Virginia Grand Junction, Colorado
Richard Joseph Fucillo, RT(R), Christine Wiley, [Link]., ARRT,
FASRT (R)(M) Professor/Program
Lead CT Technologist Director—Radiologic Technology
Samaritan Albany General Hospital Education
Albany, Oregon North Shore Community
College Danvers,
Massachusetts
v
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 To
Our families
and
Colleagues too numerous to name
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Preface
Digital imaging is not new; in fact, it has been in
hardware, monitors, operating systems, and computer
constant development since the 1960’s. Despite that, its
uses in radiology.
arrival on the diagnostic imaging scene was a bit of a
Chapter 3 introduces the reader to computer net-
surprise to most imaging technologists. Computed
working. This chapter covers network classifications,
tomography, magnetic resonance imaging, and
hardware components, and networking topologies. The
ultrasound have utilized digital imaging techniques for
chapter also introduces the reader to DICOM (digital
quite some time, but its use in diagnostic radiography is
imaging communication in medicine) and HL-7 (health
relatively new. Digital imaging has expanded so rapidly
level 7) to provide a better understanding of digital
in the last few years that it has changed forever the way
communication within the radiology department.
radiographic examinations are viewed.
Chapter 4 investigates cassette-based digital imaging,
Although Digital Radiography and PACS is intended
with particular attention to how the image is captured,
for entry-level radiography students, we have discovered
converted, and viewed. Also known as computed radiogra-
that few technologists have nearly enough information
phy (CR), this chapter looks into imaging techniques
to allow them to do the best job they can. This book will
and equipment necessary to produce CR images.
benefit anyone with the desire to understand why
Chapter 5 looks more deeply into how the cassette-
digital imaging works and how they can provide the
based system functions. Proper selection of imaging fac-
best imaging techniques possible for better patient
tors such as exam menu choices, technical factors, imaging
care.
plate size, grids, and markers is discussed as are
As of this writing, we could find no text that pulled
vendor- driven exposure indicators.
together digital imaging and PACs as comprehensively
Chapter 6 discusses cassetteless digital imaging and
as we have tried to do in this book. All imaging science
highlights its similarities and differences to cassette-based
pro- fessionals can benefit not only from reading this
digital imaging. Both direct and indirect capture methods
book, but also by suggesting updates and
are discussed, with attention to digital conversion with
improvements. If the information is as forthcoming as
anamorphous silicon detectors, CCDs, and CSI detec-
we would like, then perhaps among all of us we can get
tors. We have provided a comparison between detector
what we need.
DQE and that of cassette-based systems, as well as a dis-
cussion of the impact of detector size, orientation, and
FEATURES
factors that affect spatial resolution.
This book was written with the reader in mind; hence,
Chapter 7 takes both cassette-based and
we have attempted to present the information as clearly
cassetteless digital imaging from acquisition to
and simply as possible. We have supplemented textual
processing, focusing on image histogram formation and
explanations with as many illustrations, photographs,
automatic rescaling functions. A comparison is made
and charts as would help illuminate ideas without dis-
between image latitude in digital imaging and that of
tracting from concepts. Each chapter includes Objectives
conventional film/screen imaging. Contrast
and Key Terms lists to help students focus on what
enhancement is discussed as are image conversion
they need to learn and finishes with a Summary
factors such as the Nyquist theorem, algo- rithm
section and Chapter Review Questions to reinforce
application, and MTF. Image manipulation factors and
the readings. To ensure a common language, we have
image management are also discussed.
included a Glossary and an Abbreviation Table to
Chapter 8 begins the study of Picture Archival and
completely define key concepts.
Communication Systems (PACS) with an overview of
how a PACS functions and the basic categories of
ORGANIZATION
workstations. This chapter covers a simple PACS
Chapter 1 starts with a basic overview of the concepts workflow, showing how the images are moved
central to the focus of this book, including latent image throughout the department. Also dis- cussed are PACS
formation for both conventional and digital image architectures, common workstation functionality, and
processing, with an introduction to PACs and how digital several specialty workstation functions.
image processing integrates with digital storage systems.
Chapter 9 introduces the PACS archive. Short-term
Chapter 2 provides a basic overview of the computer,
and long-term archival components are discussed along
assuming the reader has no prior knowledge or
with their practical uses. Application service providers
understanding. The chapter introduces basic computer
and disaster recovery are also discussed.
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ix
x Preface

Preface
Chapter 10 provides an overview of the following
PACS peripherals: film digitizers, film imagers (printers),
EVOLVE
Evolve is an interactive learning environment designed
and CD/DVD burners. Each section provides a basic
to work in coordination with Digital Radiography and
explanation of operation and their common uses.
PACS. Instructors may use Evolve to provide an Inter-
Chapter 11 discusses the process of ensuring
net-based course component that reinforces and
quality in a PACS. The chapter begins with a basic
expands on the concepts delivered in class. Evolve may
overview of quality terms and theories. This chapter is
be used to publish the class syllabus, outlines, and
dedicated to ensuring display quality, whether it be on
lecture notes; set up “virtual office hours” and email
monitor or film. Other quality factors are discussed,
communication; share important dates and information
such as speed, data integrity, and training.
through the online class Calendar; and encourage
Chapter 12 provides a discussion of total quality
student participation through Chat Rooms and
the- ory and includes timelines and schedules for daily,
Discussion Boards. Evolve allows instruc- tors to post
weekly, and monthly quality control activities for the
exams and manage their grade books online. For more
technolo- gist, service personnel, and radiation
information, visit [Link]
physicist for cas- setteless and cassette-based digital
Carter/digital/ or contact an Elsevier sales representative.
radiography. Repeat analysis, problem reporting, and
We encourage any correspondence regarding the
personal responsibility for proper image marking,
information contained in this textbook. We will strive to
repeats, and prevention of artifacts are also discussed.
provide the most up-to-date information at the time of
publication and we hope that you find this information
TEACHING AIDS FOR THE
useful in your classroom and throughout your studies.
INSTRUCTOR
Please feel free to drop either of us an email with your
Instructor manuals accompany the text. This
questions, comments, and suggestions.
resource consists of:
■ Instructor’s Manual, which includes laboratory activi-
Christi E.
ties and experiments. Answers to the review
Carter
questions are included in the text.
Brookhaven
■ PowerPoint slides to assist in classroom lecture
College 3939
prepa- ration.
Valley View Lane
■ Test Bank, which includes over 350 questions in
Farmers Branch,TX
Examview format.
75244
■ Electronic Image Collection, which includes all the
ccarter@[Link]
images from the text in PowerPoint and jpeg format.
Evolve also includes a Course Management System u
for instructors and a list of relevant Websites for
students. Beth [Link]é
Midwestern State University
3410 Taft
Blvd Bridwell Hall
Room 212 Wichita
Falls,TX 76308
[Link]@mwsu.e
du
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We would like to thank Elsevier for giving us this won-

supportive and patient. She would especially like to
derful opportunity, no matter how painful the process.
thank the following really special folks: Glenn Hallauer,
Christi would also like to thank her family and friends
Eastman Kodak Company; Ralph Schaetzing, Ph.D.,
for putting up with her long hours and always lugging
Fuji Healthcare (you rock!); John Lampignano and Rees
around books, papers, and the laptop no matter where
Stuteville who said “Go for it!”; Haley and Corey Small-
she went; her friends and colleagues at Brookhaven
wood; Kell West Imaging Center; and Excel Imaging.
College (espe- cially Valerie and Stephanie) for their
This book is for her students and colleagues who make
patience in deal- ing with her on a day-to-day basis
her want to be a better teacher. Both of us would like
during this process; the Children’s Medical Center,
to thank Jeanne Wilke, Linda Woodard, Luke Held, and
Medical Center of Plano, and Trinity Medical Center for
David Stein at Elsevier for their support,
allowing her to photo- graph their departments for this
encouragement, and guidance.
text; and her students for inspiring her to finish this
task, knowing that it was really all for them. Beth would
Christi E. Carter, MSRS,
like to thank her two rea- sons for being: Paul and Erin,
RT(R) Beth L. Vealé, [Link].,
and her good friends at MSU (Bob, Lynette, Jeff, James,
RT(R)(QM)
and Gary) for being so
Acknowledgments
xi
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Contents
Part I: Introduction Part IV: PACS
1 Introduction to Digital Radiography 8 PACS Fundamentals, 132
and PACS, 2 9 PACS Archiving, 166
10 Digitizing, Printing, and Burning, 184
Part II: Basic Principles
2 Basic Computer Principles, 18 Part V: Quality Control and
3 Networking and Communication Quality Management
Basics, 40 11 Ensuring Quality in PACS, 196
12 Total Quality Management of CR
Part III: Digital Radiographic and DR Systems, 214
Image Acquisition and Processing
4 Cassette-Based Equipment: The Glossary, 227
Computed Radiography Cassette,
Imaging Plate, and Reader, 62 Abbreviation Table, 233
5 Cassette-Based Image Acquisition, 78
6 Cassetteless Equipment and
Image Acquisition, 100
7 Digital Radiographic Image Processing
and Manipulation, 110

xiii
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 PART 1

Introductio
n
 CHAPTER 1

Introduction to
Digital Radiography
and PACS

Conventional Radiography

Digital Imaging

Historical Development of Digital

Imaging

Digital Radiography

Computed Radiography
Digital Radiography
Comparison of CR and DR with
Conventional Radiography

Picture Archival and

Communication Systems

PACS Uses
2
 OBJECTIVES

1. Define the term digital imaging 4. Compare and contrast the latent image
2. Explain latent image formation for forma- tion process for indirect capture
conventional radiography digital radiog- raphy and direct capture
3. Describe the latent image formation digital radiography
process for computed radiography 5. Explain what a picture archival and
communica- tion system (PACS) is and
how it is used
6. Define digital imaging and
communications in medicine

K E Y T E R M S

Computed radiography (CR) Indirect capture digital radiography

DICOM Picture archival and communication
Digital imaging system (PACS)
Digital radiography (DR) Teleradiology
Direct capture digital
radiography
3
4 CHAPTER 1 Introduction to Digital Radiography
and PACS

This chapter is intended to present a brief overview of digital radiography (DR)

(cas- sette-based and cassette-less systems) and picture archival and communication
system (PACS); both topics will be covered in depth in the chapters that follow. The
chapter also presents several basic definitions, compares and contrasts digital and
analog imag- ing, and presents the historic development of both DR and PACS. It is
important to grasp the basic definitions and concepts before moving to the more
involved topics because this information will be useful throughout the textbook.

CONVENTIONAL RADIOGRAPHY

Before defining and discussing digital imaging, a basic understanding of

conventional film/screen imaging must be established. Conventional radiography
uses film and intensifying screens in its image formation process. Film is placed on
one or between two intensifying screens that emit light when struck by x-rays. The
light exposes the film in proportion to the amount and energy of the x-rays incident
on the screen. The film is then processed with chemicals, and the manifest image
appears on the sheet of film. The film is taken to a radiologist and placed on a
lightbox for interpretation. For further review of how conventional radiographic
images are created, please consult your radiographic imaging textbook for a more
in-depth explanation of this process.

DIGITAL IMAGING

Digital imaging is a very broad term. Digital imaging is what allows text, photos,
drawings, animations, and video to appear on the World Wide Web. In medicine,
digital imaging was first used with the introduction of the computed tomography
(CT) scanner by Godfrey Hounsfield in the 1970s. In the decades since then, other
imaging modalities have become digital.
The basic definition of digital imaging is any imaging acquisition process that
produces an electronic image that can be viewed and manipulated on a computer.
Most modern medical imaging modalities produce digital images that can be sent
through a computer network to a host of locations.

Hi storical Development of Digital Imaging

Second only to the discovery of the x-ray as a major milestone in medical imaging is
the invention of the CT. CT brought about the coupling of the computer and imaging
devices. The earliest CT unit built by Hounsfield took several hours to acquire a
single slice of information. The machine then took a few days to reconstruct the raw
data into a recognizable image. The first commercial CT scanners built were made to
image the head only. Figure 1-1 shows one of the early CT scanners built for imaging
the head.
Magnetic resonance imaging (MRI) was introduced commercially for health care
use in the early 1980s. Several companies began pioneering efforts in the mid to late
 Digital v
Radiography

Figure 1-1 First-generation EMI CT unit: dedicated head scanner.

(Photograph taken at Roentgen Museum, Lennep, Germany.)

1970s after the publication of an article by Paul Lauterbur in 1973. Many scientists
and researchers were involved in the development of the MRI as we know it today.
Fluoroscopy saw many advances during the 1970s as well thanks to the
advances in computer technology. Analog-to-digital converters made it possible to
see the dynamic (real-time) image on a television monitor in higher resolution and
to store the frames digitally on a computer. Ultrasound and nuclear medicine were
easy con- verts to the digital world early on because the images created in these
modalities were simply frame-grabbed (the current image on the screen is captured
and sent as an image file) and converted to a digital image. Improved image quality
in computed radiography (CR) and digital radiography opened the way for
mammography to con- vert to a digital format.

DIGITAL RADIOGRAPHY

The concept of moving images digitally was by Albert Jutras in Canada during his
experimentation with teleradiology (moving images via telephone lines to and
from remote locations) in the 1950s. Early PACSs were developed by the U.S.
military in an effort to move images among Veterans Administration (VA) hospitals
and battlefield images to established hospitals. These strides were taking place in
the early to mid 1980s, and without the government’s participation, this technology
would not be where it is today. To provide the PACS a digital image, early analog
radiographs were scanned into a computer (digitized) so that the images could be
sent from computer to
6 CHAPTER 1 Introduction to Digital Radiography
and PACS

computer. The inherently digital modalities were sent via a PACS first, and then as
CR and DR technologies advanced, they joined the digital ranks.

Computed Radiography
Computed radiography, or cassette-based DR, is the digital acquisition modality that
uses storage phosphor plates to produce projection images. CR can be used in stan-
dard radiographic rooms just like film/screen. The use of CR requires the CR
cassettes and phosphor plates, the CR readers (Figure 1-2) and technologist quality
control workstation, and a means to view the images, either a printer or a viewing
station.
The storage phosphor plates are very similar to our current intensifying
screens. The biggest difference is that the storage phosphors can store a portion of
the incident x-ray energy in traps within the material for later readout. More will be
presented on this topic in Chapter 4.
CR was first introduced commercially in the United States in 1983 by Fuji
Medical Systems of Japan (Figure 1-3). The first system consisted of a phosphor
storage plate, a reader, and a laser printer to print the image onto film. CR did not
take off very quickly

Figure 1-2 Fuji CR reader, cassette and storage-phosphor screen.

 Digital 7
Radiography

Figure 1-3 Examples of two CR readers. A, A high volume reader capable of processing between
110 and 140 imaging plates per hour. B, A much smaller system designed for medical offices, surgery,
or inten- sive care units, capable of processing 50 to 60 imaging plates per hour.
(A, from Ballinger: Merrill’s atlas, ed 10, St. Louis, 2003, Mosby; B, courtesy FujiFilm Medical Systems, USA.)

because many radiologists were reluctant to embrace the new technology. In the early
1990s, CR began to be installed at a much greater rate because of the technological
improvements that had occurred in the decade since its introduction. Several major
vendors have CR systems installed in hospitals throughout the United States.

Di gital Radiography
Most digital radiography (cassette-less) systems use an x-ray absorber material cou-
pled to a flat panel detector or a charged coupled device (CCD) to form the image.
Therefore an existing x-ray room needs to be retrofitted with these devices if a new
DR room is not installed (Figure 1-4).
DR can be divided into two categories: indirect capture and direct capture.
Indirect capture digital radiography devices absorb x-rays and convert them into
light. The light is then detected by an area-CCD or thin-film transistor (TFT) array
and then converted into an electrical signal that is sent to the computer for
processing
8 CHAPTER 1 Introduction to Digital Radiography
and PACS

Figure 1-4 Axiom Aristos MX DR unit.

(Courtesy Siemens.)

and viewing (Figure 1-5). Direct capture devices convert the incident x-ray energy
directly into an electrical signal, typically using a photoconductor as the x-ray
absorber, and send the electrical signal to the computer for processing and viewing
(Figure 1-6). In the early 1970s, several early digital pioneers developed the first
clinical appli- cation for digital images, digital subtraction angiography (DSA) at the
University of Arizona in Tucson. Drs. M. Paul Capp and Sol Nudelman with Hans
Roehrig, Dan Fisher, and Meryll Frost developed the precursor to the current full-
field DR units. As the technology progressed, several companies began developing
large field detec- tors, first using the CCD technology developed by the military and
shortly thereafter using TFT arrays. CCD and TFT technology developed and
continues to develop in
parallel. Neither technology has proven to be better than the other.

Com parison of CR and DR with

Conventional Radiography
When comparing film/screen imaging with CR and DR, several factors should be
considered (Table 1-1). For conventional x-ray and CR, a traditional x-ray room with
a table and wall Bucky is required. For DR, a detector replaces the Bucky apparatus
in both the table and wall stand. Because both conventional radiography and CR
use
 Digital 9
Radiography
X-ray energy

Scintillator
screen

Focusin
g lenses

Mirro
r
CCD cameras
CCD Detector with Scintillator Screen

Figure 1-5 The image acquisition process of an indirect capture DR system using CCD tech-
nology.

X-ray energy
Field electrode

Dielectric layer

Semi-
conductor
(a-
Selenium)

Electrode
collection array
with a-Silicon
Thin-Film Transistor
(TFT) matrix and storage
capacitor

Amorphous Selenium DirectRay Dectector

Figure 1-6 The image acquisition process of a direct capture DR system.

cassettes, technologists often rate them the same in terms of ease and efficiency, but
DR has an advantage because the processing is done right at the room’s console. The
image will appear in 3 to 5 seconds, and the technologist knows right away if the
image needs to be repeated.
Latent image formation is different with conventional radiography (Figure 1-7),
CR, and DR. In conventional radiographic imaging, a film is placed inside a cassette
that contains an intensifying screen. When the x-rays strike the intensifying screen,
light is produced. The light photons and x-ray photons interact with the silver halide
grains in the film emulsion, and an electron is ejected from the halide. The ejected
electron is attracted to the sensitivity speck. The speck now has a negative charge,
1 CHAPTER 1 Introduction to Digital Radiography
0 and PACS
and silver ions are attracted to equal out the charge. This process happens many
times
 Digital I
Radiography I

TABLE 1 - 1COMPARISON OF CONVENTIONAL,

COMPUTED, AND DIGITAL
RADIOGRAPHY
Factors
Consider Conventional
ed Radiography Computed Radiography Digital Radiography

Imaging
Traditional x-ray Traditional x-ray room Retrofit traditional x-ray room or
room
room install detectors in new room
Ease of Use cassette and Use cassette with No cassette; process at console
use for film; process with phosphor plate; process
technologist chemicals in CR reader
Latent image X-rays strike X-rays strike phosphor X-rays strike detector. Indirect:
formation intensifying screen; plate. X-ray energy phosphor emits light;
light is emitted, and deposited in the photodetector (silicon and TFT)
film exposed to light phosphor; energy is detects light and converts to
released from phosphor electrical pulse. Direct: X-rays
when stimulated by light detected by photoconductor and
in reader converted to electrical signals
Processing Image processed by Image processed by light; Image detected; image processing
chemicals; image image processing takes takes place at the acquisition
appearance based place in a quality console based on preset image
on technical factors control station based on algorithms
and film/screen preset image algorithms
combination
Exposure Nonlinear; narrow Linear; wide Linear; wide exposure latitude
response exposure latitude exposure latitude
Image kVp and film kVp and LUTs kVp and LUTs
contrast response curve
Density mAs Image processing LUTs Image processing LUTs
Scatter Important for patient Important for patient Important for patient dose
radiation dose reduction dose reduction and reduction and image processing;
image processing; the the detector can be more
phosphor can be more sensitive to low energy photons
sensitive to low
energy photons
Noise Seen with low Seen with Seen with inadequate mAs
mAs and fast inadequate mAs
screens

within the emulsion to form the latent image. After chemical processing, the
sensitivity specks will be processed into black metallic silver, and the manifest
image is formed.
In CR, a photostimulable phosphor plate is placed inside the CR cassette. Most
I CHAPTER 1 Introduction to Digital Radiography
0 and PACS
storage phosphor plates today are made of a barium fluorohalide (where the halide
is bromine and/or iodine) with europium as an activator. When x-rays strike the
photo- stimulable phosphor, some light is given off, as in a conventional intensifying
screen,
 Digital I
Radiography I
X-ray energy

Scintillator
screen
Film

Scintillator
screen

Screen-Film System

Figure 1-7 Conventional radiography latent image formation.

X-ray energy

Photo
stimulatable
storage
phosphor
imaging plate

Imaging plate
moved to
reader

Storage
phosphor
imaging plate

Laser

Computed Radiography

Figure 1-8 CR latent image formation.

but some of the photon energy is deposited within the phosphor particles to create
the latent image (Figure 1-8). The phosphor plate is then fed through the CR reader.
To release the latent image, focused laser light (from one or more lasers) is scanned
over the plate, causing the electrons to return to their original state and emitting
light in the process. This light is picked up by a photomultiplier tube and converted
into an electrical signal. The electrical signal is then sent through an analog-to-
digital con- verter to produce a digital image that can be sent to the technologist
review station.
I CHAPTER 1 Introduction to Digital Radiography
0 and PACS
In DR there are no cassettes. The image acquisition device is either built into the
table and/or wall stand or enclosed in a portable device. There are two distinct
image
I CHAPTER 1 Introduction to Digital Radiography
2 and PACS

acquisition methods: indirect capture and direct capture. Indirect capture is very
simi- lar to CR in that the x-ray energy stimulates a scintillator, which gives off light
that is detected and turned into an electrical signal. With direct capture, the x-ray
energy is detected by a photoconductor that converts it directly to a digital electrical
signal. This process will be described more in depth in later chapters.
Image processing in conventional radiography is done with chemicals and the
shape of the film’s response curve. With CR and DR, image processing takes place in
a computer. For CR the computer is located near the readers, whether there are
several readers distributed throughout the department or there is one centrally
located reader. For DR the computer is either located next to the x-ray console or is
integrated within the console, and the image is processed before moving on to the
next exposure.
The exposure latitude or dynamic range used in conventional radiography is
based on the characteristic response of the film, which is nonlinear. Acquiring
images with CR or DR, on the other hand, involves using a detector that can respond
in a linear manner. The exposure latitude is very wide because a single detector can
be sensitive to a wide range of exposures. In conventional radiography, radiographic
contrast is primarily controlled by kilovoltage peak (kVp). With CR and DR, kVp still
influ- ences subject contrast, but radiographic contrast is primarily controlled by an
image processing look-up table. (A look-up table [LUT] is a table that maps the
image gray- scale values into some visible output intensity on a monitor or printed
film.) With conventional radiography, optical density on film is primarily controlled
by milliam- perage seconds (mAs). For CR and DR, mAs has more influence on image
noise, whereas density is controlled by image processing algorithms (with LUTs). It is
impor- tant to minimize scattered radiation with all three acquisition systems, but
CR and DR can be more sensitive to scatter than screen/film. The materials used in
the many CR and DR image acquisition devices are more sensitive to low energy
photons. For example, the barium fluorohalide phosphor screens have a k-edge at
37 keV, which produces increased absorption in this energy range, a range that
frequently contains x-ray scatter.

PICTURE ARCHIVAL AND

COMMUNICATION SYSTEMS

A picture archival and communication system is a networked group of

computers, servers, and archives that can be used to manage digital images (Figure 1-
9). A PACS can accept any image that is in digital imaging and communications in
medicine (DICOM) format, for which it is set up to receive, whether it is from
cardiology, radiology, or pathology. A PACS serves as the fileroom, reading room,
duplicator, and courier. It can provide image access to multiple users at the same
time, on-demand images, electronic annotation of images, and specialty image
processing.
A PACS is often custom designed for a facility. The software is generally the
same, but the components are arranged differently. Specific factors are involved in
designing a PACS for an institution, such as the volume of patients, the number of
areas where
 Picture Archival and Communication I
Systems 3

Acquisition Printe
devices r RIS

RIS-PACS
Broker
Modalities/
Network
Gateways
Networ
k Database/
Image
Network server
switches

Web server

Network
switches
Tele-PACS (e.g.
Satellite connection to
remote facility) Networ
k Short- Archiv Long-
term e term
archive serve archive
r

Web-based
clinical
review
ICUs
Teleradiology Secondary displays Primary displays
Operating
Rooms
Conference
Rooms
Outpatient
clinics

Figure 1-9 PACS

network.

images are interpreted, the locations where images are viewed by physicians other
than radiologists, and the money available for purchase.
In the mid to early 1980s, different versions of PACS were being developed, pri-
marily by research and academic institutions. They were homegrown and usually
involved one or possibly two modalities. These early systems were hard to put
together because there was little standardization in image formats. Each vendor had
its own proprietary way of archiving images, and there was little need or desire to share
archiving methods. Once DICOM (standards that allow imaging modalities and PACS
I CHAPTER 1 Introduction to Digital Radiography
4 and PACS
to com- municate in the same “language”) was established, more vendors began
using it to communicate between modalities and PACS. Full-scale acceptance of
DICOM was pushed by the consumer to make it possible for equipment from different
manufactur- ers to talk to each other. The first full-scale PACS in the United States
was installed at
 Picture Archival and Communication I
Systems 3

the VA Medical Center in Baltimore in 1993. Their PACS covered all modalities
except mammography. Soon after installing their PACS, the Baltimore Medical
Center asked the vendor to interface to their radiology information system (RIS),
hospital information system (HIS), and electronic medical record (EMR).

PACS Uses
A PACS is made up of many different parts, such as the reading stations, physician
review stations, web-access, technologist quality control stations, administrative
stations, archive systems, and many interfaces to various hospital and radiology sys-
tems. Early PACSs were mainly seen in radiology and sometimes in cardiology
departments. Now a PACS can receive images from any department in the hospital
that sends in a DICOM format for which the PACS has been set up to receive. Archive
space (and expense) can now be shared among different hospital departments.
Many PACS reading stations also have image processing capabilities.
Radiologists can remain at their workstation and do three-dimensional (3D)
reconstructions of a CT (Figure 1-10) or stitch a complete spine together to perform
specialized mea- surement functions for scoliosis. Some PACSs also offer orthopedic
workstations for orthopedic surgeons to plan joint replacement surgery before
beginning the operation. Specialized software allows the surgeon to load a plain x-ray
of the joint and a template for the replacement joint and to match the best
replacement to the patient. This software saves a great deal of time in the operating
room.

Figure 1-10 Three-dimensional reconstruction of an aneurysm.

(Courtesy Siemens.)
I CHAPTER 1 Introduction to Digital Radiography
6 and PACS

SUMMARY

All of the topics covered in this chapter will be covered in depth more throughout the
book. In summary:

■ Digital imaging is any imaging acquisition process that produces an electronic

image that can be viewed and manipulated on a computer.
■ CR is the digital acquisition modality that uses photostimulable phosphor plates
to produce digital projection images.
■ DR is divided into two categories: indirect capture and direct capture.
■ Indirect capture uses a detector that produces light when struck by x-rays, and
then the light is captured and converted to an electrical signal.
■ Direct capture uses a detector that captures the x-ray energy and converts it
directly to an electrical signal.
■ A PACS is a networked group of computers, servers, and archives that can be
used to manage digital images.
■ DICOM is a standard that allows imaging modalities and PACSs to communicate
in the same “language.”
■ PACSs are made up of many different parts, such as the reading stations,
physician review stations, web-access, technologist quality control stations,
administrative stations, archive systems, and many interfaces to various
hospital and radiology systems.

CHAPTER REVIEW QUESTIONS

1. Define digital imaging.

4. How is the latent image formed when using
cassette-less digital radiography?
2. What is the latent image formation for conven-
tional imaging?
5. What does the acronym PACS stand for, and
what are its uses?
3. Compare the latent image formation for con-
ventional imaging with cassette-based digital
6. What does the acronym DICOM stand for, and
radiography.
how is it used?
This page intentionally left blank Chapter Review I
Questions v
 PART II

Basic
Principles
 CHAPTER 2

Basic Computer
Principles
How Does the Computer Work?

Hardware Components

“The Box”
The Motherboard
Sound Card
Network Card
Hard Drive
CD/DVD Drive
Peripherals

Monitors

CRT
LCD
Plasma Displays
Monitor Advantages and Disadvantages

Operating Systems

Computers in the Radiology

Department

18
 OBJECTIVES

1. Describe the major components of a 5. Explain the measurements used to classify

computer mon- itors
2. Define binary code, bit, and byte, and 6. Compare and contrast an operating
discuss how they relate to one system and application software
another 7. Discuss the uses of computers in a
3. List and define the hardware components radiology department
dis- cussed in this chapter
4. List the three most common types of
monitors

K E Y T E R M S

Aspect Hard drive

ratio Matrix
Binary Memory
code Motherboar
Basic input/output system d
(BIOS) Bit Operating system
Bus (OS) Pixel
Byte Port
Central processing unit (CPU) Power
Complementary metal oxide supply
semiconductor (CMOS) Refresh
Computer rate
Dot pitch Resolution
Viewable
area
19
20 CHAPTER 2 Basic Computer
Principles

A computer is a programmable electronic device that can store, retrieve, and pro-
cess data. This chapter will provide an overview of how a computer works, the basic
hardware components of a computer system, the differences between each type of
system, and the different types of monitors. These topics will be explored to pro-
vide a basic overview of computers so that picture archival and communication
(PAC) and digital radiographic systems can be better understood in the following
chapters.

HOW DOES THE COMPUTER WORK?

In its basic form, a computer consists of input, output, and processing devices
(Figure 2-1). Input devices are keyboards, mice, microphones, barcode readers,
touch screens, and image scanners, and any of these can be found in any modern
radiology department. Common output devices are monitors, printers, and
speakers. The computer also has various communication devices that it uses to
share information. The processing of information is done in the central processing
unit (CPU), which will be detailed later in the chapter.
The computer takes data from the user and processes it using a machine
language of 1s and 0s, known as binary code. The computer processing is performed
by a series of transistors, which are switches that are either on or off (Figure 2-2). If
the transistor circuit is closed and current passes through, it is assigned a value of 1.
If no current passes because of the circuit being open, it is assigned a value of 0. A
computer’s tran- sistors can be switched on and off millions of times in a second.
Each 1 and 0 repre- sents a bit. A bit is a single unit of data. A byte is made up of
eight bits and is the amount of memory needed to store one alphanumeric character
(Figure 2-3). Because one character takes up a byte of memory, memory is generally
talked about in kilobytes, megabytes, gigabytes, and even terabytes.

Figure 2-1 A basic personal computer

consisting of a CPU, keyboard, mouse, and LCD
monitor.
 Hardware 21
Components

Figure 2-2 Binary code consists of 1s and 0s.

HARDWARE COMPONENTS

“The Box”
The computer encasement is made from a heavy metal and has two major functions:

1. To hold all of the components in a relatively cool, clean, and safe environment
2. To shield the outside environment from the radio frequencies being emitted
by the electronic components of the computer

The box comes in two major configurations: the desktop model and the tower
(Figure 2-4). The desktop model is generally positioned in a horizontal box, whereas
a tower model is in a vertical box. As the name implies, most desktop models are
placed on the desk underneath the monitor. The tower model is generally placed
underneath the desk within arm’s reach of the operator. The biggest disadvantage of
the desktop model is the space it takes up on the desk; the smaller the box, the less
room for expansion and upgrades. The tower model consistently provides adequate
room for expansion of components, and it is easily placed out of the way and off the
work surface.

The Motherboard
The motherboard (Figure 2-5) is the largest circuitry board inside the computer,
and it contains many important small components to make the computer function
prop- erly. This chapter will only cover a few of these components in detail: the CPU,
basic input/output system (BIOS), memory, bus, ports, and complementary metal
oxide semiconductor (CMOS).
22 CHAPTER 2 Basic Computer
Principles

Letter Binary code Letter Binary code

A 01000001 a 01100001

B 01000010 b 01100010

C 01000011 c 01100011

D 01000100 d 01100100

E 01000101 e 01100101

F 01000110 f 01100110

G 01000111 g 01100111

H 01001000 h 01101000

I 01001001 i 01101001

J 01001010 j 01101010

K 01001011 k 01101011

L 01001100 l 01101100

M 01001101 m 01101101

N 01001110 n 01101110

O 01001111 o 01101111

P 01010000 p 01110000

Q 01010001 q 01110001

R 01010010 r 01110010

S 01010011 s 01110011

T 01010100 t 01110100

U 01010101 u 01110101

V 01010110 v 01110110

W 01010111 w 01110111

X 01011000 x 01111000

Y 01011001 y 01111001

Z 01011010 z 01111010

Figure 2-3 Binary representation of the alphabet.

 Hardware 23
Components

Figure 2-4 The desktop model is pictured on the left, and the tower is pictured on the right.

Figure 2-5 Motherboard.

24 CHAPTER 2 Basic Computer
Principles

The CPU
Many people refer to the personal computer’s (PC) box as the CPU. This is incorrect.
The central processing unit (CPU), or microprocessor, is a small chip found on the
motherboard (Figure 2-6). The microprocessor is the brain of the computer. It con-
sists of a series of transistors (discussed earlier) that are arranged to manipulate
data received from the software.
Microprocessors come in many different sizes and speeds and are manufactured
by two major companies, Intel (Figure 2-7) and Advanced Micro Devices (AMD). The
CPU’s basic tasks are to read data from storage, manipulate the data, and then move
the data back to storage or send it to external devices, such as monitors or printers.
The microprocessor is named after its manufacturer and the speed at which it
manipulates data. The first microprocessor to be placed in a computer was made in
1979 by Intel and was called the 8088.
It had a clock speed of a mere 4.77 MHz. The more modern Pentium 4 micropro-
cessor has speeds upward of 3.2 to 3.8 GHz. To put these speeds in perspective, the
8088 needed about 12 cycles to complete one basic instruction, and the modern
Pen- tium processor can complete one instruction per cycle.

Figure 2-6 Central processing unit.

 Hardware 25
Components

Figure 2-7 An Intel Pentium processor.

The BIOS
The basic input/output system (BIOS) contains a simple set of instructions for the
computer. The microprocessor uses the BIOS during the boot-up process of the com-
puter to help bring the computer to life. The BIOS also runs the start-up diagnostics
on the system to make sure all of the peripherals are functioning properly. After the
computer has booted up, the BIOS oversees the basic functions of receiving and
inter- preting signals from the keyboard and interchanging information with various
ports. The BIOS is the intermediary between the operating system (OS) and the
hardware.

The Bus
The bus is a series of connections, controllers, and chips that creates the
information highway of the computer. There are several buses throughout the
computer that con- nect the microprocessor, the system memory, and various
peripherals. Most modern PCs have what is called a peripheral component
interconnect (PCI) bus on the moth- erboard to serve as the connection of
information to the various adapters. Other buses found within the computer are for
the small computer system interface (SCSI) con- nections, the accelerated graphics
port (AGP) for video adapters, and the universal serial bus (USB) for a variety of
devices. Simply put, the bus provides the connections for the information to flow
within the computer.
26 CHAPTER 2 Basic Computer
Principles

Memory
The memory in the computer is used to store information currently being pro-
cessed within the CPU (Figure 2-8). This memory is also known as random access
memory (RAM). The RAM is short-term storage for open programs. The micropro-
cessor has a small amount of memory within itself but not enough to tackle the large
amounts of data being generated by high-level programs. The RAM will take the
data from the CPU so that the CPU can handle the processing needs of the pro-
grams that are running. The RAM is only temporary; once the computer has
been turned off, the RAM is wiped clean. With today’s high level programs and
graphics, computers require more memory to function at an acceptable level. There
are many different types of RAM available: DRAM, EDO RAM, VRAM, SRAM,
SDRAM, SIMM, DIMM, and ECO. Most modern PCs have an SDRAM-DDR,
but some may have RDRAM for high graphics programs. Memory is measured in
bytes and can be found in configurations such as 128 MB, 512 MB, and 1 GB. In
some of the first PCs, memory came in 16-kilobyte blocks and sold for
approximately 100 dol- lars, which equates to approximately 4000 dollars per
megabyte. With more modern pricing, one can purchase 256 MB of SDRAM for
approximately 30 dollars, which equates to 12 cents per megabyte. These figures
are given for perspective purposes and become quickly outdated, so please research
current memory capacities and prices for up-to-date information.

Figure 2-8 Memory chip.

(Courtesy Sun Corporation.)
 Hardware 27
Components

Ports
The computer’s ports are a collection of connectors sticking out of the back of the
PC that link adapter cards, drives, printers, scanners, keyboards, mice, and other
peripher- als that may be used. There are many different types of ports, such as
parallel, serial, USB, integrated drive electronics (IDE), and SCSI. We will take a look
at each of these types and how they may be used within a system.
A parallel port is a 25-pin connector found on the back of most modern PCs
(Figure 2-9). The parallel port is synonymous with a printer port because it is most
often used for this purpose. A parallel port can send 8 bits of data through the
connec- tion, whereas a serial port can only send 1 bit of data down a single wire. A
serial port can be universally used for many of the components plugged into the
computer, such as a mouse, which does not require the speed of a parallel port. Most
serial ports are of the 9-pin variety, but some can have up to 25-pin connectors.
USBs are a common interface connection used between most devices commonly
used today (Figure 2-10). The advantage of a USB port is that multiple devices may
be

Figure 2-9 Parallel port.

Figure 2-10 USB port.

(Courtesy Sun Corporation.)
28 CHAPTER 2 Basic Computer
Principles

connected into one port. In older computers there were only ports for the keyboard and
the mouse, one parallel port for a printer, and one serial port for a modem. By using
USB ports the user can connect up to 127 devices to one single USB port. Most com-
puters have more than one USB port available, so the possible connections are
many.
IDE ports can be found on the motherboard and connect the hard drive, floppy
drive, and CD-ROM drive to the board. A series of ribbon cable runs throughout the
computer to connect the IDE devices to the IDE port on the motherboard. The fifth
type of port is the SCSI port. It is the fastest and most versatile way for a PC to com-
municate with its peripherals. A single SCSI controller can manage up to seven
devices through a daisy chain connection. The most common SCSI devices are hard
drives, CD-ROM drives, scanners, and printers.

CMOS
The complementary metal oxide semiconductor (CMOS) is a special type of
mem- ory chip that uses a small rechargeable or lithium battery to retain
information about the PC’s hardware while the computer is turned off. The CMOS is
also the location of the system clock that keeps track of the date and time. The system
clock uses a vibrating quartz crystal to set the speed for the CPU. A single tick of the
clock represents the time it takes to turn a transistor on and off. Because modern
CPUs are measured in gigahertz, a PC with a 3.0-GHz CPU would have a system clock
that would tick 3 bil- lion times per second. Any changes in the system after the last
basic system configura- tion will be detected, and the system will be prompted to
install the new hardware.

So und Card
The sound card contains all of the circuitry for recording and reproducing sound on
the PC. It may be in the form of an expansion card, or it may be built into several
chips found on the motherboard. Ports are located externally to connect amplified
speakers, headphones, microphone, and a compact disk (CD) player input into the
computer. The sound card interprets many different file types such as waveform
audio (WAV) files, moving picture experts group audio layer 3 (MP3) files, and
musical instrument digital interface (MIDI) files.

Net work Card

The network interface card (NIC) can come either as an expansion card (Figure 2-
11) plugged into a slot or as part of the PC motherboard circuitry. The network card
will have an RJ-45 adapter jack (Figure 2-12) at the rear of the PC for the acceptance
of a twisted-pair wire with RJ-45 connector (Figure 2-13). This network card will
enable this PC to connect to other PCs that are on the same network. Detailed
information about networks will be discussed in the next chapter.

Power Supply
The power supply (Figure 2-14) delivers all electricity to the PC and contains a fan
to help keep the inside of the computer cool. It contains a transformer that converts
 Hardware 29
Components

Figure 2-11 Network interface card (NIC).

Figure 2-12 RJ-45 jack.

Figure 2-13 RJ-45 connector.

30 CHAPTER 2 Basic Computer
Principles

Figure 2-14 Power supply.

the wall outlet alternating current (AC) to direct current (DC) in the voltages appro-
priate for each powered device. All components, from the motherboard to the hard
drive, get their power directly from the main supply through different colored wires
that end in plastic shielded connectors. The power supplies deliver +/– 12 V, +/– 5
V, and in some machines +3.3 V. Power supplies are rated in watts. Most power
supplies deliver between 150 to 300 W, but some computers require a 400-W
power supply. The power supply is designed to take the brunt of the force if the
computer ever receives a power surge. In such a case, the power supply is easily
replaced.

Hard Drive
The hard drive is the main repository for programs and documents on a PC. The
hard drive is made up of many hard, thin magnetic platters that are stacked one on
top of the other with only enough space for a read-write head to glide over the
surface of the disks (Figure 2-15). The disks are spun at a fast speed by a small
motor, and the read/write head glides to the area that houses the particular
information needed and reads or writes as asked.
The early disks had a storage capacity of 10 MB and could be accessed in
approxi- mately 80 ms. The more modern disks can hold upward of 100 GB with an
access speed of 8.7 ms. As storage capacity has skyrocketed, the price per megabyte
of storage
 Hardware 31
Components

Figure 2-15 Looking inside the hard drive.

has drastically decreased. The drives may be faster than ever, but they are still the
slowest part of the PC because they are both mechanical and electrical. These
figures were given for perspective purposes and become quickly outdated, so please
research current hard drive capacities and prices.

CD/DVD Drive
A CD is a thin injection-molded polycarbonate plastic disk (Figure 2-16). The disk is
impressed from a mold to form microscopic bumps that indicate either a 1 or 0 to
the computer. Over the bumps is a reflective layer of aluminum, and over that is a
clear protective coat of acrylic. A CD can hold up to 74 minutes of music or
approximately 780 MB of data.
A digital versatile disk (DVD) holds up to seven times more than the CD,
which equates to about 9.4 (single-sided) to 17 GB (double-sided) of data. A DVD
has mul- tiple layers of polycarbonate plastic. Aluminum is used behind the inner
layers, and gold is used behind the outer layers. The gold is semireflective so that
it allows the laser to penetrate through to the inner layers of plastic.
There are three main types of CD/DVD drives available in today’s market: the
ROM (read-only memory), the R (write once–read many), and the RW (read and
write

Figure 2-16 Compact disks.

32 CHAPTER 2 Basic Computer
Principles

many times). CD-ROM drives were placed into early computers. Few computers
today can be bought with a simple ROM drive installed. Most modern computers
have either a CD-RW or a CD/DVD-RW. With an R or RW drive, information that
needs to be saved, transported, or archived can be “burned” (information written on
a disk). The information is burned onto the disk, starting in the center and spiraling
out to the edge of the disk. The laser burns a tiny depression (pit) into the disk to
represent the data being saved. A burned disk will be a series of pits and lands, or
areas that were not burned by the laser. Two-sided DVDs can be burned on both
sides to double the capacity of the disk.

How CD/DVD Drives Work

A CD/DVD drive is found on the front of the encasement of a computer. The drive
consists of a disk tray, a motor, a read head, and possibly a write head. The drive has
a small door that opens horizontally, and a tray appears for the disk to be placed.
After the door closes, a motor constantly varies the speed of the disk so that the
portion above the read head spins at a constant speed no matter its location over
the disk. The laser beam of the read head penetrates the disk and strikes the
reflective layer. If the laser strikes a land area, the light reflects back; if the laser
strikes a pit, the light is scat- tered. The light reflected back is read by a light-sensing
diode that translates the impulses into 1s and 0s for the computer to generate into
recognizable data.

Periph erals
Keyboard
There are two basic types of keyboards: soft and click. If there is an audible sound
when the keys are depressed, it is a click keyboard. The first keyboards made by
IBM were click keyboards. Most modern keyboards connect using an IBM
programming system 2 (PS/2) connection and connect into the back of the box. Some
keyboards use the USB connection because of its versatility and ease of use. With the
advent of wireless con- nections, keyboard makers use either infrared or radio
frequency (RF) signals.
When the keys are depressed on the keyboard, a signal is sent through the
switch to the motherboard, where it is interpreted in the keyboard microprocessor.
Because of all the switches underneath the keys, keyboards should be kept clean,
and food and drink should never be consumed near the keyboard.

Mouse
A mouse is a device with two or sometimes three buttons that allow the user to move
the computer’s cursor to activate and perform functions within the computer’s
software.
There are five types of mouse connections (all are serial-type connections):

■ Serial mouse: uses a standard serial connection

■ Bus mouse: uses a dedicated controller card that is connected to the motherboard
■ PS/2 mouse: a special connection for mice that does not use the standard serial port
■ USB mouse: attaches to a USB port
 Hardware 33
Components
■ Infrared mouse: uses the computer’s infrared port (wireless)
 Monitor 33
s

There are three types of mice commonly used:

■ Mechanical: This mouse uses a hard rubber ball inside an opening on the
bottom that is surrounded by sensing devices. The ball moves around based on
the move- ment of the user’s hand over the mouse and triggers the sensors
within the mouse to move the cursor on the screen.
■ Optical: This mouse has a high-intensity diode that bounces light off surfaces
and back to a receiver inside the mouse. As with the mechanical mouse, the
cursor is made to move by the movements of the mouse over a hard surface and
by the light that is reflected back to the sensors within the mouse.
■ Optomechanical: This mouse is a hybrid of mechanical and optical mouse. It uses
a rubber ball that interacts with rollers that trigger the optical sensors within
the mouse. Light is reflected back to the sensors based on the movement of the
rollers.

Scanners
Scanners are devices that capture drawings or written paper documents and convert
them into a digital image or document that can be edited. Special image scanners in
radiology departments are used to convert an analog (film) image into a digital
image. The purpose is to provide a way to compare a hardcopy image with a digital
image on a PAC system (PACS). More information will be given on this topic in
Chapter 10.

Speakers
Speakers receive sound data from a sound card that is either built into the mother-
board or is an expansion card. The sound data are converted from an electrical
signal to a series of vibrations in the speaker to create sound. Speakers have become
an inte- gral part of the modern PC because they give audible signals from the
software to alert us to various tasks.

Microphones
Microphones are used to record voice or to use voice dictation software. Voice dicta-
tion software is becoming more common in radiology departments. The technology
has progressed to a point that most people’s voices can be recognized by the
system’s software.

MONITORS

There are two major types of monitors: the cathode ray tube (CRT) and the liquid crystal
display (LCD); a third type, the plasma screen, is quickly gaining acceptance. To
understand how these monitors work, we must first look at several basic terms and
measurements related to onscreen viewing.
A basic picture element on a display is known as a pixel. A pixel is an individual
controllable set of dot triads. A dot triad is a grouping of one red dot, one green dot,
34 CHAPTER 2 Basic Computer
Principles

and one blue dot. The number of pixels on a display is known as its resolution. The
more pixels in an image, the higher the resolution of the image and the more
informa- tion that can be displayed. Resolution can also be defined as the process or
capability of distinguishing between individual parts of an image that are adjacent.
Pixels are arranged in a matrix, a rectangular or square table of numbers that
represents the pixel intensity to be displayed on the monitor. Common screen
resolutions are 1024 × 768, 1280 × 1024, 2048 × 1536, and 2048 × 2560. The last
two matrices are common in image viewing applications.
A third measurement is dot pitch. Dot pitch is the measurement of how close
the dots are located to one another within a pixel; the smaller the dot pitch of a
display, the finer the resolution. Dot pitch may be expressed as aperture grille pitch
or slot pitch, depending on the monitor maker.
One of the most important measurements of a monitor is its refresh rate or
verti- cal scanning rate. The refresh rate is the measure of how fast the monitor
rewrites the screen or the number of times that the image is redrawn on the display
each second. The refresh rate helps to control the flicker seen by the user; the higher
the refresh rate, the less flicker. Most refresh rates on today’s computers are set
between 60 and 75 Hz; the image is redrawn 60 to 75 times per second. Another set
of display terms is aspect ratio and viewable area. The aspect ratio is the ratio of
the width of the moni- tor to the height of the monitor. Most CRT monitors have an
aspect ratio of 4:3; LCD monitors have a ratio of 16:9. The viewable area is
measured diagonally from one corner of the display to the opposite corner.

CRT
The CRT monitors are the most popular monitors on the market (Figure 2-17). The
CRT consists of a cathode and anode within a vacuum tube. The CRT works much
like an x-ray tube, in that the cathode boils off a cloud of electrons and then a
potential difference is placed on the tube. A stream of electrons is sent across to the
monitor’s anode, which is a sheet of glass coated with a phosphor layer. The
electrons strike the phosphor on the glass, causing the glass to emit a color, which is
determined by the intensity of the interaction and area with which the electrons
interacted.
The electrons interact with either a red, green, or blue dot to form the color and
image that is being sent from the video card signal. The electron beam starts in the
upper left corner and scans across the glass from side to side and top to bottom, and
once it reaches the bottom, it starts back over at the top left. On average, most moni-
tors have 350 lines to be scanned. Earlier we discussed the refresh rate being 60 to
75 Hz. This equates to 350 lines being scanned 60 to 75 times per second.

LCD
An LCD monitor produces images by shining or reflecting light through a layer
of liquid crystal and a series of color filters (Figure 2-18). An LCD has two pieces
of polarized glass with a liquid crystal material between the two. Light is allowed
through the first layer of glass, and when a current is applied to the liquid crystal, it
aligns and allows light in varying intensities through to the next layer of glass
through color filters to form the colors and images seen on the display.
 Monitor 35
s

Figure 2-17 Cathode ray tube (CRT) monitor.

Figure 2-18 Liquid crystal display (LCD).

36 CHAPTER 2 Basic Computer
Principles

Figure 2-19 Plasma display.

(Courtesy Pioneer Inc.)

Plasma Displays
Plasma displays are still new to the consumer market (Figure 2-19). They have been
heavily used in government and military applications since the late 1960s. The
plasma displays are made up of many small fluorescent lights that are illuminated to
form the color of the image. The plasma display varies the intensities of the various
light com- binations to produce a full range of color.

Monitor Advantages and Disadvantages

Most consumers want a monitor that can provide the highest resolution for the best
price. Table 2-1 outlines the advantages and disadvantages of the three major types
of monitors. Most radiology departments have traditionally used the CRT because of
its superior resolution, but LCDs are increasingly gaining popularity because they
are slimmer and lighter.

OPERATING SYSTEMS

An operating system (OS) is the software that controls the computer hardware and
acts as a bridge between applications and the hardware. There are three major OSs
in use today: Windows by Microsoft, the Macintosh OS, and UNIX/Linux. PCs
generally run a Windows version of an OS, such as Windows 95, 98, 2000, ME,
XP, or NT.
There are four types of OSs:

■ Real-time OS: used to control specific machinery, scientific instruments, and

industrial systems, such as digital x-ray consoles found on modern x-ray
equipment.
■ Single-user, single-task: designed so that a computer can effectively do one task
for one person at a time, such as a Palm OS for the hand-held personal
organizer.
 Operating 37
Systems

TABLE 2 - 1 ADVANTAGES AND DISADVANTAGES OF CRT, LCD,

AND PLASMA MONITORS
Monitor Advantages Disadvantages
Type
CRT Less expensive Bulky
Better color representation The
and largerthe
heavier theunit
viewing area, the deeper
More responsive than LCD Not easily adjusted for viewing
at different heights and
angles
Can provide multiple resolutions More
rugged and can sustain rough
handling
LCD Takes up less space than a CRT Costs more than CRT
Consumes less power than CRT Less of a viewing angle
Produces less heat than CRT Not as bright as CRT
Surface produces little or no glare Each display is only capable of working
with one physical resolution
Requires a smaller frame around display
Plasma Wide screen with a thin depth High cost
Brighter than LCD Low availability
Can be viewed at varying angles
Light weight

■ Single-user, multitask: designed for one user to perform multiple functions at

the same time, such as the OS on a PC.
■ Multiuser: designed to handle multiple users and multiple tasks at the same
time, such as UNIX running on a large server or as a mainframe computer
supporting an entire company.

The computer must have an OS for it to be able to fully come up and function as it
was intended. The OS takes over just after the computer wakes up and allows the com-
puter to begin doing tasks. All other software run using the OS. The various
programs that are used on the computer are specifically designed to run on the OS
that is loaded on the computer. Early OSs, such as Microsoft–Disk Operating System
(MS-DOS), were command based and very difficult to use. The user needed to know
word com- mands to type in to get the computer to do simple tasks, such as saving a
file. Today most computers use what is called graphical user interface (GUI) to perform
various computer functions. A GUI (goo-ee) is a picture (icon)-based program, where
the mouse is used to point and click on the function that needs to be performed. The
GUI also has easy to use drop-down word menus that can be selected to perform
various functions.
38 CHAPTER 2 Basic Computer
Principles

As mentioned earlier, IBM-type PCs have traditionally used a Windows-

based OS. Large workstations that are used to complete multiple tasks may use
Windows NT, or they may opt to use UNIX or Linux for the OS. UNIX is a very
robust OS. It was first developed by Bell Laboratories and was given out free to
universities. It is primarily used by industry for larger server applications. Some
PACS vendors began their software on UNIX-based systems but have since migrated
to the Windows plat- form because of cost, ease of use, and customer demand.
Linux was derived from UNIX by a Finnish computer science student and is widely
used by computer aficio- nados. Linux is what is known as open-source software;
programmers can make changes in the code as long as the changes are shared with
others.
All digital medical imaging devices have some sort of OS running behind the
user interface. Depending on the vendor, it may be one of the three discussed here or
it may be a proprietary (written and known only by the vendor) system developed
specifically for a particular device. PACS is no exception. Most modern PACSs use
a Windows- based platform, but some may still use UNIX on their large servers
because of its exceptional multitasking capabilities.

COMPUTERS IN THE RADIOLOGY

DEPARTMENT

Computers are used throughout radiology departments, from the front desk to the
file room and from the technologist’s work area to the radiologist’s reading room.
Many computer applications are used throughout the day by the various staff within
the department to improve the care that is given to the patient. In most areas, a
simple computer can do the job, but in some more robust applications, a specialty
workstation is needed to handle the complicated tasks. Most radiology imaging
equipment manu- factured today has a computer built into the machine itself, or it
has a separate com- puter that is attached for various applications.
Computer hardware and software are chosen to match the applications used by the
staff. Comfort, cost, quality, and purpose are just four areas that are addressed when
choosing the appropriate equipment and accessories. For example, a radiologist
would require a monitor with high brightness, high resolution, and a large screen to
view digi- tal images for diagnosis, whereas a file room clerk would only need a
basic monitor.

SUMMARY

■ A computer is a programmable electronic device that can store, retrieve, and

process data.
■ A bit is a single unit of data. There are 8 bits in a byte.
■ A computer consists of input, output, and processing devices.
■ Input = keyboard, mouse, scanner, barcode reader, and microphone
■ Output = monitor, printer, and speakers
 Operating 39
Systems
■ Processing = motherboard, microprocessor, BIOS, bus, memory, ports, and
CMOS
 Chapter Review 39
Questions

■ Modern computers contain many types of drives: hard drives, CD-ROM, CD-
R, CD-RW, DVD-R, DVD-RW, and floppy. These drives perform specific tasks
and functions for the computer.
■ Various expansion cards are used within modern PCs: sound cards, network
cards, and other peripheral cards.
■ Keyboards and mice are the most common input devices. There are various
types of each.
■ Monitors are measured by several factors: resolution, dot pitch, refresh rate, aspect
ratio, and viewable area.
■ There are three types of monitors: CRT, LCD, and plasma.
■ An OS is the software that controls the computer hardware and acts as a bridge
between applications and hardware.
■ Computers are found throughout the radiology department, and each has been
chosen to fulfill a specific purpose.

CHAPTER REVIEW QUESTIONS

1. What is a computer?
5. What are the measurements used to classify
monitor quality?
2. Define binary code, bit, and byte.
6. Name and define the different types of OSs.
3. Name several computer hardware components,
and list their uses.
7. How are computers utilized in the radiology
department?
4. What are the three major types of monitors,
and what are their advantages and
disadvantages?
 CHAPTER 3

Networking and
Communication Basics

Network Classifications

Geographic Classifications
Component Role Classification

Typical Components of a Network

Computers
Network Connectivity
Network Communication

Network Topology

Bus
Ring
Star
Mesh

Application Interfacing

DICOM
HL-7

40
 OBJECTIVES

1. Distinguish between different types of 5. Differentiate between the common

networks (geographic and component network topologies
roles) 6. Discuss the use of DICOM in medical
2. Identify common network hardware imaging
components 7. Define HL-7, and describe its use in
3. Describe different types of network health care information systems
cabling and their uses
4. Define network communication protocol

K E Y T E R M S

Bus topology Network

Client-based network router
Coaxial cable Network
Digital imaging and switch
communications in medicine Peer-to-peer network
(DICOM) Radiology information
Fiberoptic system Ring topology
cable HL-7 Server
Hospital information Server-based
system Local area network Star
network (LAN) Mesh topology
topology Thick-
Network client
Network Thin-
bridge client
Network Topology
hub Twisted-pair wire
Network interface card (NIC) Wide area network
Network protocol (WAN) Wireless
Wireless access point
41
42 CHAPTER 3 Networking and Communication
Basics

People use all types of networks every day to do things like check the status of a
pack- age being shipped or register for a class at school. Many daily tasks involve
transferring information, either from person to person (Figure 3-1) or from
computer to computer (Figure 3-2).
A computer network is defined as (1) two or more objects sharing resources
and information, or (2) computers, terminals, and servers that are interconnected by
com- munication channels sharing data and program resources. Devices other than
comput- ers can also be found on a network, such as printers, scanners, and
barcode readers.

Figure 3-1 Person-to-person communication chain.

Figure 3-2 Five computers connected via a network to share

resources.
 Network 43
Classifications

These devices can be shared among a group of computers to save money and space
for the users.
This chapter explores network classifications, whether they are based on geo-
graphic boundaries or the various roles that the hardware components play. An
over- view of the basic hardware components that make up a computer network and
how the networks are physically constructed is also included. This chapter also
provides a brief introduction to how medical devices, such as computed tomography
(CT) scanners and computed radiography (CR) readers, fit within a network and how
they communicate.

NETWORK CLASSIFICATIONS

Geographic Classifications
A network can be classified into two major geographic categories: local area
network (LAN) and wide area network (WAN). (Other geographic classifications
exist but are of little consequence to radiology.) These two terms are fairly self-
explanatory: a LAN is close by, whereas a WAN expands over a distance.

LAN
A local area network (LAN) (Figure 3-3) is a small area networked with a series of
cables or wireless access points that allow computers to share information and
devices on the same network. These are the least expensive to install, and they are
much faster than a WAN because of their smaller size. A LAN has the fastest
communication tech- nology because less equipment and fewer resources are
needed to complete the net- work. Generally the larger networks are composed of
several LANs interconnected to create the WANs. The picture archival and
communication system (PACS) worksta- tions in a radiology reading room would be
considered a LAN. The computers are interconnected and communicate by sharing
images and reports.

WAN
A wide area network (WAN) (Figure 3-4) is a network that spans a large area: city,
state, nation, continent, or the world. It is used to connect computers that are not
physically attached through conventional network cables but are rather connected
through other means, such as telephone lines, satellite links, or other types of com-
munication cable. The use of these long distance communication links drives up the
operating costs of this type of network because most often these communication
links are owned by a separate company, and because of the distance covered, the cost
of hav- ing the highest speed equipment is expensive.

Component Role Classification

Networks are typically classified as either peer-to-peer or server/client-based, depend-
ing on what role their various components play. The network is classified according to
44 CHAPTER 3 Networking and Communication
Basics

The Alcatel 100

Internet ADSL
Converter

Gatewa
y

Firewal Firewall
Web
l
server
Ethernet Ethernet
1 2

Color
inkjet
printer

Laser BubbleJe
The print Mini-tower t
tower er 1 Mini-tower 2 printer

Scanner
Figure 3-3 Typical office local area network.

what role the computers play in the network’s operation and which computer
controls the network operation.

Peer-to-Peer Network
In a peer-to-peer network (Figure 3-5), each computer on the network is
considered equal; no computer has ultimate control over another. Each computer
controls its own information and operation and can function either as a client or as a
server depending on the needs of the other computers on the network. The peer-to-
peer network is the most popular small office or home network configuration
because it is the least expen- sive and most simple to set up. But a peer-to-peer
network has a limited scope because the maximum number of peers that should be
connected is 10. More than 10 causes
 Network 45
Classifications

LAN

WAN

LAN LAN

Figure 3-4 Wide area network (WAN) connecting several local area networks (LANs).

Resources are shared

among equals in a peer-to-
peer network.

Figure 3-5 Peer-to-peer network.

46 CHAPTER 3 Networking and Communication
Basics

bottlenecks and collisions on the network. An example of a peer-to-peer network is

a small medical office with several computers connected to check in patients, verify
insurance, produce bills for the service, and document patient history. A printer is
shared among the group of computers.

Server-Based Network
In a server-based network (Figure 3-6), there is a centralized computer (the
server) that controls the operations, files, and sometimes the programs of the
computers (the clients) attached to the network. The server provides a location for
centralized storage and retrieval on the network. This allows the users to move from
computer to com- puter and access their files from a central location. When a client
requests a file, the server sends the entire file to the client for processing. Once the
processing is com- pleted, the client sends the entire changed file back to the server
for storage. This type of network requires that the server be of high quality and high
capacity, although the client computers can be less expensive.
There can be multiple servers on this type of network, but there must be one
dedicated server that controls the network. An example of this type of network is a
radiology department using a PACS to read and distribute images throughout the
hos- pital. Computers throughout the hospital are connected to the centralized
server that contains all of the images, and the images are sent out to the computers
as requested.
A client-based network is similar to a server-based network in that there is a
centralized computer that controls the operations of the network; however, rather

Server sharing its OS

Programs run at
and applications with
clients locally and
clients
independently

Fit
Client
(diskless
LAN
)
connectio
n

Linux server with

ShaoLin Aptus
installed

Figure 3-6
Server/client-based
Clients store network.
data to
server
 Network 47
Fit Client (diskless) Classifications
 Typical Components of a 47
Network

than sending the entire original resource to the client for processing, the server pro-
cesses the resource as requested by the client and returns only the results back to
the client. This smaller exchange of information cuts down the load on the network
and allows more room for other requests.

TYPICAL COMPONENTS OF A NETWORK

Computers
Typically there are three types of computers found on a network: servers, thin-
client, and thick-client (Figure 3-7). Each of the three has a specific purpose on the
network. A server is a computer that manages resources for other computers,
servers, and networked devices. It may also house applications, provide storage for
files, or manage various other networked tasks. A server is most often dedicated to
one task for the network and is usually the most robust computer on the network.
There may be one server that provides storage for files, one that manages the print
functions, and another
that provides Internet access for the network.
A thin-client is a device that is found on a network that requests services and
resources from a server. The thin-client may be another computer, a printer, or any
other networkable device that needs a server to complete its tasks. Almost any personal
computer (PC) can be a client, as long as it can be attached to the network.
A thick-client is a computer that can work independently of the network and
process and manage its own files. The thick-client is networked so that it can share
resources such as printing and take advantage of the additional security available on
networks through dedicated servers. A thick-client is generally a high-end computer
that does high-level processing for specific purposes. In health care, specialty
applica- tion workstations (thick-client) are most often found in cross-sectional
imaging modalities for which three-dimensional imaging is used to aid diagnosis.
The cross- sectional images are fed into the workstation’s application, and the
application trans- forms the slices into a 3D image that can be evaluated.

Client
s

Serve Workstatio
r n
Figure 3-7 A server, workstation, and client on a network.
48 CHAPTER 3 Networking and Communication
Basics

Network Connectivity
Communication Medium
Once it has been determined what files and resources are to be shared and the
pieces of equipment are in place, they are connected via some sort of communication
medium. The physical connection between the devices is one of four types: coaxial
cable, twisted-pair wire, fiberoptic cable, or electromagnetic waves. Several factors
deter- mine which type of communication medium is most appropriate.
Coaxial cable (Figure 3-8) is similar to the wiring used for the cable television
that is run into a house. This type of cable consists of a center conducting wire sur-
rounded by insulation and then a grounded shield of braided wire. The shield mini-
mizes electrical and radio frequency interference. Coaxial cable is the sturdiest wire
used and is often found in the network infrastructure throughout a building. It is
often connected to another type of communication medium before it meets the
device interface.
Twisted-pair wire (Figure 3-9) is similar to telephone wire, but whereas tele-
phone wire has only four wires, twisted-pair wire usually consists of four twisted
pairs of copper wire that are insulated and bundled together with an RJ-45
termination. Twisted-pair wire comes in various levels of quality and capacity. The
minimum recommended standard is Cat 5 (category 5) cable. It is the most
commonly used connection medium in LANs.
Fiberoptic cable (Figure 3-10) uses glass threads to transmit data on the
network. It consists of a fiberoptic core that is surrounded by a plastic protective
covering. It is

Figure 3-8 Coaxial cable network connection.

 Typical Components of a 49
Network

Figure 3-9 RJ-45 jack connected with twisted-

pair Ethernet wire.

Figure 3-10 The glow from glass fibers in a

fiberoptic cable.

much faster than its metal counterparts, but it is more expensive and much more
frag- ile. Fiberoptic cabling can easily be damaged by kinking and twisting the cable.
It is most often used in the infrastructure of the network, in network closets, and in
large archive/computer rooms.
Wireless connections (Figure 3-11) are becoming more commonplace as
technol- ogy continues to improve. The connection is made by using either infrared
or radio frequencies as its means of communication. There is no physical cabling
needed, but each device must contain the appropriate wireless
transmitter/receiver. The biggest advantage of wireless connections is mobility and
convenience, but it has a limited range. When using wireless access points as the
means of connection, the thickness and composition of the wall and the distance
from the source must be taken into account.
50 CHAPTER 3 Networking and Communication
Basics

Figure 3-11 Wireless routers.

Network Interface Card

The network interface card (NIC) (Figure 3-12) provides the interface between
the computer and the network medium; it provides the physical connection
between the network and computer. NIC works with networking software to
establish and man- age the data, to chop up the data into packets, and to handle
addressing issues. Most NICs plug directly into the motherboard as an expansion
card, but they can also come as small adapter cards that insert into a slot on the side
of the portable computer (Figure 3-13).

Network Hub
A network hub is the simplest device that can be used to connect several pieces of
equipment together for network communication purposes. It has several wiring
ports available on it to receive and transmit data to the various connected pieces of
equipment.

Figure 3-12 Network interface card (NIC).

 Typical Components of a 51
Network

Figure 3-13 External NIC for a laptop computer.

When the hub receives data from a device, it generally sends those data to all
devices connected to it. The hub does not know what the data are, nor to which
device they should go, so it simply forwards the bits. Hubs are commonly used in
small office and home applications.

Network Switch
A network switch is similar to a hub, but it sends data only to those devices to
which the data are directed. It will read the destination address from the data and
select a direct path to the intended target. This reduces the network traffic, speeds
up the overall network connection, and makes the network more efficient. In general,
switches are not commonly used in small office or home applications because there
is not enough traffic to warrant the equipment.

Network Bridge
A network bridge is sometimes created so that larger networks can be segmented
or broken up into smaller networks to reduce traffic within that network. These
segments can then be connected with a bridge. The bridge is a physical (wired)
connection from one network segment to another. It can recognize in which
segment a particular desti- nation address resides and send data to it. The bridge
can also bring two or more net- works together that speak the same language (i.e.,
use the same protocol).

Network Router
A network router is a more sophisticated device. It can read portions of messages
and direct them to their intended target, even if the device is on a separate network
and uses a different network protocol. It also helps with segmenting the network to
allow access only for approved devices within that segment. In large networks there
will be multiple routers, switches, and hubs that work in concert to perform the
necessary tasks that enable the network to perform up to its potential.
52 CHAPTER 3 Networking and Communication
Basics

Ne twork Communication
We have learned that devices communicate via a NIC through some sort of commu-
nication medium. We know that the data are sent through some sort of box and that
the box reads the destination address in the data to send them to the appropriate
tar- get. So where does the address come from?
Each computer on the network is assigned a unique address. The address is
a combination of a physical address from the computer’s hardware and a node
address given by the network. One type of addressing is Internet protocol (IP)
addressing, which is made up of four octets (groups of 8 bits) of numbers. The
numbers range from 0 to 255 (e.g., [Link]). The first set of numbers
indicates the network class, and the rest of the numbers tell other devices its exact
location. When a message is sent, the computer’s NIC will read the destination
address and check to see whether it matches the computer’s network address. If it
matches, it will receive the message. If it does not match, it just ignores the message.
The data travel along the network using an agreed-on set of rules known as a
net- work protocol. Most network protocols send data in packets from one device
to another. A packet is a piece of the data with added information, such as the
destination address, the source address, the sequence of the packets (e.g., 2 of 12),
and whether there were any errors in transmission. The protocol is delivered in
layers of commu- nication known as protocol stacks. Each layer of the
communication represents a par- ticular aspect of network functionality.
Typically a network communication model is explained using seven layers (OSI
Model). We need to understand only the basic principles of network communication,
so we will simplify the model and concentrate on the bottom four layers.

■ Layer 4: The transport layer makes sure data packets are sequenced correctly
and that they do not contain errors. For example, the most common transport-
layer protocol, the transmission control protocol (TCP), resides in layer 4
and manages the connection for the purpose of controlling the flow of the data
packets.
■ Layer 3: The network layer breaks up the data into frames and decides which
network path the frame will take to its destination. For example, the IP
mentioned above is concerned with sending the message to the correct address.
■ Layer 2: The data link layer packages the data so that they can be transmitted
over the physical layer. Ethernet is an example protocol that performs at layer 2
and layer 1 levels.
■ Layer 1: The physical layer consists of the networking media and the
components required to pass on a signal from one end of the network to the
other. This is the layer that moves bits from one place to another.

The most important thing to understand is that because of this standardized

model, different types of networkable machines can be connected to transmit
data to each other. As long as the machines share the same low-level protocols
or know how to convert from one into another, the packets can be received and
reconstructed.
 Network 53
Topology

NETWORK TOPOLOGY

Topology is the physical (geometric) layout of the connected devices on a network.

There are four common topology configurations: bus, ring, star, and mesh. Many
things should be considered when deciding what type of topology should be used,
such as the type of communication media, the network speed, the connecting
equipment design, and the number of devices to be connected. Each of these four
will be dis- cussed in the following section.

Bus
A bus (Figure 3-14) is a network in which all devices are physically attached to and
listen for communication on a single wire. In a true bus network there is a single
point of failure, the wire. If at some point on the wire there is a break, the entire
network is down. (In some circumstances communication can take place between
the computers on either side of the break.) This type of topology does not need any
switches or hubs because the computers simply broadcast all the information down
the single wire, and all computers connected to that single wire receive the
information.

Ri ng
A ring (Figure 3-15) is a network in which the devices are connected in a circle.
Each device passes its received messages to the next node on the ring (always in the
same direc- tion), and the data transmissions move around the circle until they reach
the correct receiver. If there is a break at some point in the ring, the entire network
comes to a halt. One type of ring topology is called a token ring. The computers are
connected in a circle, and a token is transmitted around the ring. When a computer
is ready to send a transmission to another computer, it picks up the empty token as it
passes by and fills it with the message. As the token passes the other computers, the
destination address is read by each passing computer and is ignored if the address
does not belong to that computer. When the addressed computer is found, the data
are deposited, and the token is now free again. If another computer wishes to send out
information but the token is
occupied, it must wait until the token becomes free again before it can transmit.

Figure 3-14 Bus network topology.

54 CHAPTER 3 Networking and Communication
Basics

Figure 3-15 Ring network topology.

Sta r
A star (Figure 3-16) is a network that has the devices connected to a central hub or
switch. A star topology can be thought of as a bus topology with the bus collapsed
into a central box: the hub or switch. The data are sent through the hub out to the
destina- tion device. This transmission of data may be through another hub or
switch to an adjacent network or directly to the device. This is the most commonly
used network topology.

Mesh
A mesh (Figure 3-17) is a network that has multiple pathways interconnecting
devices and networks. This type of network has redundancy built in with the
multiple connec- tions. The Internet is based on this topology, and it is used most
often to connect networks to other networks.

APPLICATION INTERFACING

DICOM
DICOM stands for digital imaging and communications in medicine. DICOM has
become an almost universally accepted standard for exchanging medical images among
networked medical devices. DICOM is layered on top of TCP/IP, the most common
network communication standard used, and it has multiple layers like TCP/IP.
 Application 55
Interfacing

Figure 3-16 Star network topology.

DICOM was developed by the American College of Radiology (ACR) and the
National Electrical Manufacturers Association (NEMA). The first version was com-
pleted in 1985, addressing only point-to-point connections between devices. At
publication of this book, the current version is 3.1. (There are revisions and
additions in progress.) Up-to-date information can be found on NEMA’s web site at
http:// [Link].
DICOM (3.0) was better than its predecessors for several reasons:

■ It required a communications protocol that runs on top of TCP/IP (or other

stan- dardized protocol stack), permitting the devices to make use of
commercial hard- ware and software.
■ It required strict contents of the image “header” and the structure of the pixel
data itself for each type of modality, therefore improving interoperability.
■ It required a conformance system, so that a user could determine from the ven-
dor’s documentation whether the devices would operate together.
■ It embraced an open standard of development between the vendors and users
to come to consensus on the direction of the standards.

The DICOM standard is made up of 16 different parts ranging from image dis-
play to media storage. Not every device conforms to every part of the DICOM,
but rather a device will conform to the parts that are necessary to perform the tasks
it is assigned according to what is desired by the user. The standard is maintained
on a
56 CHAPTER 3 Networking and Communication
Basics

Figure 3-17 Mesh network topology.

continuous basis and is published periodically. Supplements are published with new
updates and error corrections, and new parts are being investigated as new
functions are developed. Table 3-1 shows the 16 parts and their corresponding
titles.
The DICOM standard defines so-called service classes or functions that a device
can perform on a defined information object (like a CT image). The allowed service/
object pairs (SOPs) for a device are spelled out explicitly in the device’s DICOM con-
formance statement. A device performs either as a service class user (SCU) for a
given service and object or as a service class provider (SCP) or as both. The SCU
and SCP are commonly referred to as roles. Network communications (i.e.,
transactions) in DICOM are always between an SCP and an SCU. The most
common service classes seen in modalities and PACS are:

■ Image storage
■ Query/retrieval
■ Print
■ Modality worklist
■ Modality performed procedure
■ Storage commitment
■ Interchange media storage
 Application 57
Interfacing

TABLE 3 - 1 THE 16 PARTS OF THE DICOM STANDARD 3.1 (2004)

Part 1 Introduction and

overview Part 2 Conformance
Part 3 Information object
definitions Part 4 Service class
specifications Part 5 Data structures
and encoding Part 6 Data dictionary
Part 7 Message exchange
Part 8 Network communication support for message exchange
Part 9 Media storage and file format for media interchange
Part 10 Media storage application profiles
Part 11 Media formats and physical media for media
interchange Part 12 Grayscale standard display function
Part 13 Security and system management
profiles Part 14 Content mapping resource
Part 15 Explanatory information
Part 16 Web access to DICOM-persistent objects (WADO)

Each of these services defines a specific transaction for the modality and PACS,
and because of the standardization provided by DICOM, device interoperability is
possible (or at least more likely). The DICOM conformance statement of a device
details the various SOPs and possible roles that the modality or workstation can
fulfill with those SOPs. For example, if a magnetic resonance imaging (MRI) scanner
con- formance statement lists the MRI storage SOP class in the SCU role, and the
receiv- ing PACS archive lists MRI storage SOP class in the SCP role, the MRI scanner
would be able to send images to the archive based on those statements. If either
statement does not support the proper SOP class and role, the transfer is not
possible. Most modalities manufactured today are DICOM conformant. The vendors
will provide conformance statements, and the buyer must closely inspect these
statements to ensure that the modalities can communicate with existing image
viewing devices.
DICOM also has specifications for uniquely identifying each study, series, and
image (instance). DICOM uses unique identifiers (UIDs) to globally identify each
image set, so that if the images are sent to multiple systems, the identifying number
will remain unique and not get confused with those images on other systems. Each
study is identified by a study instance UID, which breaks down into series instance
UIDs, and further into instance UIDs. The numbers are created based on a vendor
number, serial number of the equipment, date, time, patient or processing number,
and then the study, series, or image number. A typical study instance UID may look
like this: 1.2.840.8573.4567.1.20051011764589.8765.1.
58 CHAPTER 3 Networking and Communication
Basics

DICOM also provides a framework for the use of compression technologies on

image data. For example, DICOM accommodates joint photographic experts group
(JPEG) lossless compression of 2 to 1. This is the most common compression tech-
nique used within hospitals because there is no image degradation on viewing after
decompression. But when moving images outside of the hospital, it may be
necessary to use lossy compression to shrink the file size to suit external networks.
Some loss of image detail can occur when higher compression values are used.
When a patient arrives for a procedure, the technologist either has to manually
type in the patient’s demographics, risking error, or alternatively pull the
information directly from the radiology information system (RIS). A modality can
pull this infor- mation when it supports the service class of modality worklist
management, and the RIS can either interface via DICOM or through a gateway that
creates an interface with the health level 7 (HL-7) device and the DICOM device.

HL-7
HL-7 is an American National Standards Institute (ANSI)–accredited Standards
Developing Organization (SDO).
It is used in most health care applications such as medical devices, imaging,
insur- ance, and pharmacy. The HL-7 standard oversees most clinical and
administrative data such as demographics, reports, claims, and orders. As with
DICOM, HL-7 is composed of many parts and is used at many levels within various
hospital systems. It is the standard generally used in communication between the
hospital information system (HIS) and the radiology information system (RIS).
The HIS holds the patient’s full medical information, from hospital billing to the
inpatient ordering sys- tem. The RIS holds all radiology-specific patient data, from
the patient scheduling information to the radiologist’s dictated and transcribed
report. The electronic medi- cal record (EMR) has recently come to the forefront of
information technology. The EMR is either a part of the HIS or runs along with it and
contains all of the patient’s record, including lab results, radiology reports, pathology
results, and nurses’ and doc- tors’ notes. The EMR interfaces with most of the
ancillary service systems to retrieve reports so that they can be viewed in this one
common format. PACS have also begun interfacing with EMRs to present images to
referring physicians through the same common system.

SUMMARY

■ A network is defined as two or more objects sharing resources and information.

■ A network can be classified into two major geographic categories: LAN and
WAN. There are two typical classifications of networks based on the roles that
various components play: peer-to-peer and server/client-based.
■ A server is a computer that manages resources for other computers, servers,
and networked devices. A client is a device that is found on a network that
requests services and resources from a server. A thick-client is a computer that
can work independently of the network and can process and manage its own
files.
 Chapter Review 59
Questions

■ The physical connection among the devices is one of the following three types:
coaxial cable, twisted-pair wire, or fiberoptic cable.
■ Information is transmitted via a NIC through a communication medium onto the
network and possibly through a hub, switch, bridge, or router.
■ The data travel along the network using an agreed-on set of rules known as a
protocol.
■ Topology is the physical layout of the connected devices on a network. There
are four common topologic configurations: bus, ring, star, and mesh.
■ DICOM stands for digital imaging and communications in medicine. It is a uni-
versally accepted standard for exchanging medical images among networked
med- ical devices.
■ DICOM defines specific information objects and the functions (service classes)
that can be performed on them.
■ The HL-7 standard oversees most clinical and administrative data such as
demo- graphics, reports, claims, and orders.
■ The HIS holds the patient’s full medical information, from hospital billing to the
inpatient ordering system. The RIS holds all radiology-specific patient data,
from the patient scheduling information to the radiologist’s dictated and
transcribed report.

CHAPTER REVIEW QUESTIONS

1. How are networks classified?

6. What is the difference between a network hub,
switch, bridge, and router?
2. Define the various network classifications.
7. Define network topology, and name the four
3. What are the common network hardware com- physical topologies and their characteristics.
ponents, and how are they used?
8. What is DICOM, and how is it used?
4. What are the different types of network
cabling, and what are their advantages and
9. What is HL-7, and how is it used?
disadvan- tages?

5. What is the difference between a thin-client

and a thick-client?
This page intentionally left blank
 PART
III

Digital
Radiographic
Image
Acquisition
and
Processing
 CHAPTER 4

Cassette-Based
Equipment
The Computed Radiography
Cassette, Imaging Plate,
and Reader

Computed Radiography Equipment

Cassette
Imaging Plate
The Reader

62
 OBJECTIVES

1. Describe the basic construction of a 6. Describe the process of laser beam

computed radiography cassette. formation.
2. Describe the construction of a computed 7. Explain the process of reading the
radi- ography imaging plate. imaging plate.
3. Identify the various layers of the imaging 8. Compare conventional radiographic
plate. screen and film speed to computed
4. Describe the purpose of each layer of the radiography systems.
imag- ing plate.
9. Discuss how an image is erased from the
5. Explain the process of photostimulation in imag- ing plate.
the imaging plate.

K E Y T E R M S

Backing layer Phosphor layer

Barcode label Photomultiplier
Barium Photostimulable
fluorohalide phosphor
Cassette
Photostimulable luminescence (PSL)
Color layer Protective layer
Conductive Raster
layer Imaging Reflective
plate Laser layer Speed
Phosphor center Support layer
63
64 CHAPTER 4 Cassette-Based
Equipment

The phrase digital radiographic image acquisition and processing is being used in
this book to categorize the different ways of acquiring and processing digital
radiographic images. One way to do this is through a cassette-based system
commonly known as computed radiography (CR). Another way is through an image
detector system that is cassette-less and hard-wired to a computer network and is
commonly known as digital radiography (direct or indirect capture; DR). Both
systems use computers to analyze and manipulate the image.
The term radiographic refers to general x-ray procedures as distinct from other
digital modalities such as computed tomography (CT), magnetic resonance imaging
(MRI), and ultrasound (US).
This chapter introduces the basic principles of CR and discusses how CR equip-
ment works. Some similarities between CR and conventional radiography are dis-
cussed. A basic understanding of how CR works prepares you to make sound ethical
decisions when performing radiographic examinations.
Cassette-based or CR systems differ from conventional radiography in that the
cassette is simply a light-proof container that protects an imaging plate from light
and handling. The imaging plate takes the place of radiographic film and is capable
of storing an image formed by incident x-ray photon excitation of phosphors. The
reader releases the stored light and converts it into an electrical signal, which is
then digitized.

COMP UTED RADIOGRAPHY EQUIPMENT

Cassette
The CR cassette looks like the conventional radiography cassette. It consists of a
durable, lightweight plastic material (Figure 4-1). The cassette is backed by a thin
sheet of aluminum that absorbs x-rays (Figure 4-2). Instead of intensifying screens
inside, there is antistatic material (usually felt) that protects against static electricity
buildup, dust collection, and mechanical damage to the plate (Figure 4-3).

Imaging Plate
Construction
In CR, the radiographic image is recorded on a thin sheet of plastic known as the
imaging plate. The imaging plate consists of several layers (Figure 4-4):

■ A protective layer. This is a very thin, tough, clear plastic that protects
the phosphor layer.
■ A phosphor or active layer. This is a layer of photostimulable phosphor that
“traps” electrons during exposure. It is usually made of phosphors from the bar-
ium fluorohalide family (e.g., barium fluorohalide, chlorohalide, or
bromohalide crystals). This layer may also contain a dye that differentially
absorbs the stimulat- ing light to prevent as much spread as possible and functions
much the same as dye added to conventional radiographic screens.
 Computed Radiography 65
Equipment

Figure 4-1 CR cassette.

■ A reflective layer. This is a layer that sends light in a forward direction when
released in the cassette reader. This layer may be black to reduce the spread of
stimulating light and the escape of emitted light. Some detail is lost in this
process.
■ A conductive layer. This is a layer of material that absorbs and reduces static
electricity.
66 CHAPTER 4 Cassette-Based
Equipment

Figure 4-2 Aluminum absorber in cassette.

Figure 4-3 Antistatic felt in cassette.

■ A color layer. Newer plates may contain a color layer, located between the
active layer and the support, that absorbs the stimulating light but reflects
emitted light.
■ A support layer. This is a semirigid material that gives the imaging sheet some
strength.
■ A backing layer. This is a soft polymer that protects the back of the cassette.
 Computed Radiography 67
Equipment

Protective

Phosphor
layer Light
layer
reflective layer
Conductive

Support
layer
Bar code
layer label
Backing Light shielding layer

layer

B
Figure 4-4 A, Imaging plate. B, Construction.

The cassette also contains a window with a barcode label or barcode sticker on
the cassette that allows the technologist to match the image information with the
patient-identifying barcode on the examination request (Figure 4-5). For each new
examination, the patient-identifying barcode and the barcode label on the cassette
must be scanned and connected to the patient position or examination menu. The
cas- sette will also be labeled with green or blue stickers indicating the top and left
side of the cassette or with a label on the back of the cassette indicating the top and
right sides of the patient (Figure 4-6). These stickers serve to orient the cassette to
the top of the patient and the patient’s right side so that the image orientation is in
line with the computer algorithm. This is discussed more in depth in Chapter 7.

Acquiring and Forming the Image

The patient is x-rayed exactly the same way as in conventional radiography. The patient
is positioned using appropriate positioning techniques, and the cassette is placed either
on the tabletop or within the table Bucky. The patient is then exposed using the
proper combination of kilovoltage peak (kVp), milliamperage seconds (mAs), and
68 CHAPTER 4 Cassette-Based
Equipment
distance. The difference lies in how the exposure is recorded. In CR, the remnant
beam interacts with electrons in the barium fluorohalide crystals contained within
the imaging plate. This interaction stimulates, or gives energy to, electrons in the
crystals, allowing them
 Computed Radiography 69
Equipment

Figure 4-5 Barcode identification labels.

to enter the conductive layer, where they are trapped in an area of the crystal known
as the color or phosphor center. This trapped signal will remain for hours, even
days, although deterioration begins almost immediately. In fact, the trapped signal is
never completely lost. That is, a certain amount of an exposure remains trapped so
that the imaging plate can never be completely erased. However, the residual trapped
electrons are so few in number that they do not interfere with subsequent
exposures.

Th e Reader
With CR systems, no chemical processor or darkroom is necessary. Instead,
following exposure, the cassette is fed into a reader (Figure 4-7) that removes the
imaging plate and scans it with a laser to release the stored electrons.

The Laser
A laser, or light amplification of stimulated emission of radiation, is a device that
cre- ates and amplifies a narrow, intense beam of coherent light (Figure 4-8). The
atoms or molecules of a crystal such as ruby or garnet or of a gas, liquid, or other
substance are excited so that more of them are at high energy levels rather than low
energy levels. Surfaces at both ends of the laser container reflect energy back and
forth as atoms bombard each other, stimulating the lower energy atoms to emit
secondary photons in
70 CHAPTER 4 Cassette-Based
Equipment

Figure 4-6 A, Fuji cassette orientation stickers. B, Kodak orientation label.

the same frequency as the bombarding atoms. When the energy builds sufficiently,
the atoms discharge simultaneously as a burst of coherent light; it is coherent
because all of the photons are traveling in the same direction at the same frequency.
The laser requires a constant power source to prevent output fluctuations. The laser
beam passes through beam-shaping optics to an optical mirror that directs the laser
beam to the surface of the imaging plate (Figure 4-9).

Using the Laser to Read the Imaging Plate

When the cassette is put into the reader, the imaging plate is extracted and scanned
with a helium laser beam or, in more recent systems, solid-state laser diodes. This
beam, about 100 μm wide with a wavelength of 633 nm (or 670 to 690 nm for solid
state), scans the plate with red light in a raster pattern and gives energy to the
trapped electrons. The red laser light is emitted at approximately 2 eV, which is
necessary to energize the trapped electrons. This extra energy allows the trapped
7 CHAPTER 4 Cassette-Based
0 Equipment

Figure 4-7 Fuji SmartCR CR reader.

Cathod Anode
Lase
r e Helium-neon gas
outp reservoir
ut

Laser bore tube

Outpu
t Glass envelope High
couple reflect
r or

Figure 4-8 Laser

construction.

electrons (Figure 4-10) to escape the active layer where they emit visible blue light at an
energy of 3eV as they relax into lower energy levels. As the imaging plate moves
through the reader, the laser scans across the imaging plate multiple times. The plate
movement through the scanner is known as translation because it moves in a parallel
manner at a certain rate through the reader. This scan process produces lines of light
intensity infor- mation that are detected by a photomultiplier that amplifies the light
and sends it to a digitizer. The translation speed of the plate must be coordinated with
the scan direction of the laser, or the spacing of the scan lines will be affected. The action
 Computed Radiography 71
Equipment
of moving the laser beam across the imaging plate is much like holding a flashlight at
the same height and moving it back and forth across a wall. The more angled the
beam is, the more elliptical the shape of the beam. The same thing happens with the
reader laser beam as it scans.
7 CHAPTER 4 Cassette-Based
0 Equipment

Lase
r
Beam
deflecto

Beam shaping
optics

Scan
direction

Cassette
direction

Figure 4-9 CR reader laser optics.

Scanning
laser (Arrows represent emitted blue
light)

Imaging plate direction of travel (translation)

Figure 4-10 The laser scans the imaging plate, releasing stored energy
as blue light (arrows).
72 CHAPTER 4 Cassette-Based
Equipment

This means that if this change in the beam shape were ignored, the output of the
screen would differ from the middle to the edges, resulting in differing spatial
resolu- tion and inconsistent output signals, depending on the position and angle of
the laser beam. To correct this, the beam is “shaped” by special optics that keep the
beam size, shape, and speed largely independent of the beam position. A beam
deflector moves the laser beam rapidly back and forth across the imaging plate to
stimulate the phos- phors. Mirrors are used to ensure that the beam is positioned
consistently. Because the type of phosphor material in the imaging plate has an effect
on the amount of energy required, the laser and the imaging plate should be
designed to work together. The light collection optics direct the released phosphor
energy to an optical filter and then to the photodetector (Figure 4-11).
Although there will be variances among manufacturers, the typical throughput
is 50 cassettes/hr. Some manufacturers claim up to 150 cassettes/hr, but based on
average hospital department workflow, 50/hr is much more realistic.

Digitizing the Signal

When we talk about digitizing a signal, such as the light signal from the photomulti-
plier, we are talking about assigning a numerical value to each light photon. As
humans, we experience the world analogically. We see the world as infinitely
smooth gradients of shape and colors. Analog refers to a device or system that
represents changing values as continuously variable physical quantities. A typical
analog device is a watch: the hands move continuously around the face and are
capable of indicating every possible time of day. In contrast, a digital clock is capable
of representing only a finite number of times (e.g., every tenth of a second). In the
process of digitizing the light signal, each phos- phor storage center is scanned, and
the released electrons enter a digitizer that divides the analog image into squares
(matrix) and assigns each square in the matrix a number based on the brightness of
the square. Each square is called a pixel or picture element. The typical number of
pixels in a matrix ranges from about 512 × 512 to 1024 × 1024 for CT but can be as
large as 2500 × 2500 for radiography. The more pixels there

Lase Beam
r deflecto

Beam shaping
optics

Light
collection
Scan
optics direction

Cassette
direction

Figure 4-11 Laser optics.

 Computed Radiography 73
Equipment

are, the greater the image resolution. The image is digitized both by position (spatial
location) and by intensity (gray level). Each pixel contains bits of information, and
the number of bits per pixel that define the shade of each pixel is known as bit depth. If a
pixel has a bit depth of 8, then the number of gray tones that pixel can produce is 2
to the power of the bit depth, or 28, or 256 shades of gray. Therefore how many
photons are detected will determine where it will be located in the matrix in
conjunction with the amount of gray level or bit depth (Figure 4-12). Some CR
systems have bit depths of 10 or 12, resulting in more shades of gray. Each pixel can
have a gray level between 0 (20) and 4096 (212). The gray level will be a factor in
determining the quality of the image.

Spatial Resolution
The amount of detail present in any image is known as its spatial resolution. Just as
the crystal size and thickness of the phosphor layer determine resolution in
film/screen radiography, phosphor layer thickness and pixel size determine
resolution in CR. The thinner the phosphor layer, the higher the resolution. In
film/screen radiography, resolution at its best is limited to approximately 10 line
pairs (lp)/mm. In CR, resolu- tion is approximately 2.55 to 5 lp/mm, resulting in less
detail. However, because the dynamic range, or the number of recorded densities, is
much higher, the difference in resolution is more difficult to discern. More tissue
densities on the digital radiograph are seen, giving the appearance of more detail.
For example, an anteroposterior (AP) knee radiograph typically does not show soft
tissue structures on the lateral aspects of the distal femur or proximal tibia or fibula.
An AP knee digital image shows not only the soft tissue but also the edge of the skin
(Figure 4-13). This is because of the wider dynamic recording range and does not
mean there is additional detail. Spatial resolu- tion is discussed in more detail in
Chapter 7.

5 0 0 5

2 6 3 3

8 3 5 0

7 0 0 5

A B
Figure 4-12 Pixel location by intensity (A) and its corresponding bit depth
(B). The numbers correspond to the shade of gray, determined by raising 2 to that
power.
74 CHAPTER 4 Cassette-Based
Equipment

Figure 4-13 A, Film/screen AP knee radiograph. B, CR AP knee image. Note

the differences in the amount of soft tissue shown in detail.

Speed
In conventional radiography, speed is determined by the size and layers of crystals
in the film and screen. In CR, speed is not exactly the same because there is no
intensify- ing screen or film. The phosphors emit light according to the width and
intensity of the laser beam as it scans the plate, resulting in a relative “speed” that is
roughly equivalent to a 200 speed film/screen system. CR system “speeds” are a
reflection of the amount of photostimulable luminescence (PSL) given off by the
imaging plate while being scanned by the laser. For example, Fuji Medical Systems
(Tokyo, Japan) reports that a 1-mR exposure at 80 kVp and a source-to-image
distance of 72 inches will result in a luminescence value of 200, hence the “speed”
number. In CR, most cassettes have the same “speed”; however, there are special
extremity or chest cassettes that produce greater resolution. These are typically 100
relative “speed.” Great care must be taken when converting to a CR system from a
film/screen system to adjust technical factors to reflect the new “speed.” For
example, if the technique for a knee
 Computed Radiography 75
Equipment

was 20 mAs at 70 kVp in the Bucky with a 400 screen speed system, then the new
CR technique would be 40 mAs at 70 kVp, if the grid ratios are equal. If they are not
equal, then a grid conversion factor is used. More detail about exposure settings for
CR systems is discussed in Chapter 5.

Erasing the Image

The process of reading the image returns most but not all of the electrons to a lower
energy state, effectively removing the image from the plate. However, imaging
plates are extremely sensitive to scatter radiation and should be erased to prevent a
buildup of background signal. The plates should be run at least once a week under
an erase cycle to remove background radiation and scatter. CR readers have an
erasure mode that allows the surface of the imaging plate to be scanned without
recoding the gener- ated signal. Systems automatically erase the plate by flooding it
with light to remove any electrons still trapped after the initial plate reading (Figure
4-14). Cassettes should be erased before using if the last time of erasure is unknown.

Preprocessing, Processing, and Forwarding the Image

Once the imaging plate has been read, the signal is sent to the computer where it is
preprocessed. The data then go to a monitor where the technologist can review the

Strong light
source

Imaging plate

Figure 4-14 Fluorescent floodlight is used to remove any remaining trapped energy.
76 CHAPTER 4 Cassette-Based
Equipment

image, manipulate it if necessary (postprocessing), and send it to the quality control

(QC) station and ultimately to the picture archiving and communications system
(PACS). This process is explored in more detail in Chapter 8.

SUMMARY

■ The cassette-based imaging system has a specially designed cassette made of

dura- ble, lightweight plastic.
■ The imaging plate is multilayered with protective, phosphor, reflective, conduc-
tive, color, support, and backing layers.
■ Barcodes are used to identify the cassette or imaging plate and examination
request to link the imaging plate with the patient examination.
■ Barium fluorohalide crystals in the imaging plate release light energy, which is
then stored in the conductive layer.
■ The imaging plate reader uses a laser to scan the imaging plate, releasing the
energy stored in the conductive layer as blue light.
■ A photomultiplier amplifies the light and sends it to a signal digitizer.
■ The digitizer assigns a numerical value to each pixel in a matrix according to the
brightness of the light and its position.
■ Spatial resolution of the digital image is determined by the thickness of the
phos- phor layer and the number of pixels, which also affects resolution of the
pixels. Cassette-based spatial resolution is approximately 2.55 to 5 lp/mm
(lower than conventional radiography’s 10 lp/mm).
■ Because so many more densities are recorded in CR (wide dynamic range),
images appear, but are not, more detailed.
■ Because energy stored in the imaging plate dissipates over time, imaging plates
should be read as quickly as possible to avoid losing image information.
■ Images are sent to the QC station where they are analyzed and sent to PACS for
long-term storage.
■ Imaging plates are erased by exposing them to bright light such as fluorescent light.
 Chapter Review 77
Questions

CHAPTER REVIEW QUESTIONS

1. What are the parts of the digital imaging cas-

5. How is the imaging plate read?
sette, and what purpose do they serve?
6. How does “speed” of a CR system relate to con-
2. How is the imaging plate constructed?
ventional film/screen radiography?
3. What are the different layers in the imaging
7. How is the imaging plate erased?
plate, and what does each of the layers do?

4. What is photostimulation, and what is its pur-

pose in the imaging plate?
 CHAPTER 5

Cassette-Based Image
Acquisition

Computed Radiography
Image Acquisition

Exposure

Part Selection
Technical Factors
Equipment Selection
Collimation
Side/Position Markers
Exposure Indicators
Image Data Recognition and
Preprocessing

Artifacts

Imaging Plate Artifacts

Plate Reader Artifacts

Printer Artifacts
Operator Errors

78
 OBJECTIVES

1. Discuss the importance of matching 4. Describe the grid selection process.

the body part being examined to the 5. Discuss the importance of
examination menu. preprocessing colli- mation.
2. Discuss the selection of technical 6. Discuss the importance of patient side
factors for density, contrast, and markers.
penetration. 7. Compare exposure indicators for the major
3. Relate imaging plate size selection to com- puted radiography manufacturers
radio- graphic examinations. and vendors.

K E Y T E R M S

Artifacts Kilovoltage peak (kVp)

Automatic data Logarithm of the median exposure (lgM)
recognition Milliamperage seconds (mAs)
Collimation Moiré
Exposure index (EI) Multiple manual selection mode
Exposure indicator Quantum mottle
number Fixed mode
Quantum noise
Focused grid
S, sensitivity number
Grid
Semiautomatic mode
frequency
Shuttering
Grid ratio
Histogram
79
80 CHAPTER 5 Cassette-Based Image
Acquisition

COMPUTED RADIOGRAPHY IMAGE

ACQUISITION

This chapter introduces you to the process of acquiring an image using computed
radiography (CR). Key topics include selection of appropriate technical factors and
equipment selection, exposure indicators, image data recognition, and artifacts.

E XPOSURE

Part Selection
Once the patient has been positioned and the plate has been exposed, you must
select the examination or body part from the menu choices on your workstation. For
exam- ple, if you are performing a skull examination, select “skull” from the
workstation menu (Figure 5-1). Selecting the proper body part and position is
important for the proper conversion to take place. Image recognition is
accomplished through complex mathematical computer algorithms, and if the
improper part and/or position is selected, the computer will misinterpret the image.
For example, if a knee examination is to be performed and the examination selected is
for skull, the computer will interpret the exposure for the skull, resulting in improper
density and contrast and inconsistent
 Exposur 81
e
Figure 5-1 Workstation menu skull selection.
82 CHAPTER 5 Cassette-Based Image
Acquisition

image graininess (Figure 5-2). It is not acceptable to select a body part or position
dif- ferent from that being performed simply because it looks better. If the proper
exami- nation/part selection results in a suboptimal image, then service personnel
should be notified of the problem to correct it as soon as possible. Improper menu
selections may lead to overexposure of the patient and/or repeats.

Technical Factors
Kilovoltage Peak Selection
Kilovoltage peak (kVp), milliamperage seconds (mAs), and distance are chosen
in exactly the same manner as for conventional film/screen radiography. kVp must
be chosen for penetration and the type and amount of contrast desired. In the early
days of CR, kVp minimum values were set at about 70 kVp. This is no longer
necessary. kVp values now range from around 45 to 120. It is not recommended that
kVp values less than 45 or greater than 120 be used because those values may be
inconsistent and

Figure 5-2 A, Anteroposterior (AP) knee with proper menu selection. B, AP knee
with AP skull selected.
 Exposur 83
e

produce too little or too much excitation of the phosphors. The k-edge of phosphor
imaging plates ranges from 30 to 50 keV so that exposure ranges of 60 to 110 kVp
are optimum. However, exposures outside that range are widely used and will
depend on the quality desired. Remember, the process of attenuation of the x-ray
beam is exactly the same as in conventional film/screen radiography. It takes the
same kVp to pene- trate the abdomen with CR systems as it did with a film/screen
system. It is vital that the proper balance between patient dose and image contrast
be achieved.

Milliamperage Seconds Selection

The mAs is selected according to the number of photons needed for a particular
part. If there are too few photons, no matter what level of kVp is chosen, the result
will be a lack of sufficient phosphor stimulation. When insufficient light is produced,
the image is grainy, a condition known as quantum mottle or quantum noise
(Figure 5-3). CR systems typically utilize automatic exposure controls (AECs), just as
many film/screen systems do. Backscatter from the cassette/detector will influence
the amount of mAs necessary to create the image. When converting from
film/screen systems to a CR system, it is critical that the AEC be recalibrated.

Eq uipment Selection
Imaging Plate Selection
Two important factors should be considered when selecting the CR imaging
cassette: type and size. Most manufacturers produce two types of imaging plates:
standard and

Figure 5-3 Grainy appearance because of insufficient light

produced in imaging plate.
84 CHAPTER 5 Cassette-Based Image
Acquisition

high resolution. Cassettes should be marked on the outside to indicate high

resolution imaging plates. Typically, high resolution imaging plates are limited to
size range and are most often used for extremities, mammography, and other
examinations requiring increased detail.
In conventional film/screen radiography, we are taught to select a cassette
appro- priate to the size of the body part being imaged. CR cassette selection is the
same but even more critical. CR digital images are displayed in a matrix of pixels
(Figure 5-4), and the pixel size is an important factor in determining the resolution
of the displayed image. The CR reader scans the imaging plate at a relatively
constant frequency, about 2000 × 2000 pixels. Using the smallest imaging plate
possible for each examination results in the highest sampling rate. When the
smallest possible imaging plate is selected, a corresponding matrix is used by the
computer algorithm to process the image. A 2000 × 2000 matrix on an 8 × 10
cassette results in much smaller pixel size, thereby increasing resolution. If, for
example, a hand was imaged on a 14 × 17 cas- sette (Figure 5-5), the entire
cassette is read according to a 14 × 17 matrix size with much larger pixels so that
the resultant image is very large. Postexposure manipulation of the image to a smaller
size reduces the resolution. Appropriate image plate selection for the examination
also eliminates scatter outside the initial collimation and increases image resolution.
In addition, the image size on hardcopy and softcopy is affected by cassette
selection.
There are units that use newer CR imaging plate technology but are cassette-
less. These units are typically used for chest imaging. The imaging plate is enclosed
within the unit. The storage phosphors have a needle-like structure that allows light
to be guided with little light spread. Combined with line-scan readouts and charge-
coupled device (CCD) detectors, these units have a complex reader within the fixed
system. This technology is very similar to the digital radiography (DR) systems that
will be discussed more fully in Chapter 6.

Figure 5-4 Pixel matrix.

 Exposur 85
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Figure 5-5 Posteroanterior hand on 14 × 17 cassette.

Grid Selection
Digital images are displayed in tiny rows of picture elements or pixels. Grid lines
that are projected onto the imaging plate when using a stationary grid can interfere
with the image. This results in a wavy artifact known as a moiré pattern that occurs
because the grid lines and the scanning laser are parallel (Figure 5-6). The
oscillating motion of a moving grid, or Bucky, blurs the grid lines and eliminates the
interference. Because of the ability of CR imaging plates to record a very high
number of x-ray photons, the use of a grid is much more critical than in film/screen
radiography. Appropriate selec- tion of stationary grids reduces this interference as
well. Grid selection factors are frequency, ratio, focus, and size.

Frequency
Grid frequency refers to the number of grid lines per centimeter or lines per inch.
The higher the frequency or the more lines per inch, the finer the grid lines in the
image and the less they interfere with the image. Typical grid frequency is between
80 and 152 lines/in. Some manufacturers recommend no fewer than 103 lines/in
and strongly suggest grid frequencies greater than 150. The higher the frequency,
the less
86 CHAPTER 5 Cassette-Based Image
Acquisition

Figure 5-6 Moiré pattern artifact caused by incorrect grid alignment with laser scan direction.
(From Cesar LJ, Schueler BA, Zink FE, et al: Artefacts found in computed radiography, Br J Radiol 74:195–202, 2001.)

positioning latitude is available, increasing the risk for grid cutoff errors, especially
in mobile radiography. In addition, the closer the grid frequency is to the laser
scanning frequency, the greater likelihood of frequency harmonics or matching and
the more likely the risk of moiré effects.

Ratio
The relationship between the height of the lead strips and the space between the
lead strips is known as grid ratio. The higher the ratio, the more scatter radiation is
absorbed. However, the higher the ratio, the more critical the positioning is, so high
grid ratio is not a good choice for mobile radiography. A grid ratio of 6:1 would be
proper for mobile radiography, whereas a 12:1 grid ratio would be appropriate for
departmental grids that are more stable and less likely to be mispositioned, causing
grid cutoff errors.
8 CHAPTER 5 Cassette-Based Image
6 Acquisition
Focus
Most grids chosen by radiography departments are parallel and focused. Parallel
grids are less critical to beam centering but should not be used at distances less than
48 inches. Focused grids consist of lead strips angled to coincide with the diversion
of the x-ray beam and must be used within specific distances using a precisely
centered beam.

Size
The physical size of the grid matters in CR examinations. The smaller the cassette
being used, the higher the sampling rate. When using cassettes that are 10 × 12
or smaller, it is important to select a high frequency grid to eliminate scatter that
will interfere with quality image interpretation by the computer algorithm.
Remember that the CR imaging plate is able to record a wider range of exposure,
including scatter.

Col limation
When exposing a patient, the larger the volume of tissue being irradiated and the
greater the kVp used, the more likely it is that Compton interactions, or scatter, will
be produced. Whereas the use of a grid absorbs the scatter that exits the patient and
affects latent image formation, properly used collimation reduces the area of
irradia- tion and the volume of tissue in which scatter can be created. Collimation is
the reduction of the area of beam that reaches the patient through the use of two
pairs of lead shutters encased in a housing attached to the x-ray tube. Collimation
results in increased contrast as a result of the reduction of scatter as fog and reduces
the amount of grid cleanup necessary for increased resolution. Through
postexposure image manipulation known as shuttering, a black background can be
added around the original collimation edges, virtually eliminating the distracting
white or clear areas (Figure 5-7). However, this technique is not a replacement for
proper preexposure collimation. It is an image aesthetic only and does not change
the amount or angles of scatter. There is no substitute for appropriate collimation
because collimation reduces patient dose.

Side /Position Markers

If you have used CR image processing equipment, you already know that it is very
easy to mark images with left and right side markers or other position or text
markers after the exposure has been made. However, we strongly advise that
conventional lead markers be used the same way they are used in film/screen
systems. Marking the patient examination at the time of exposure not only identifies
the patient’s side but also identifies the technologist performing the examination.
This is also an issue of legality. If the examination is used in a court case, the images
that include the technol- ogist’s markers allow the possibility of technologist
testimony and lend credibility to his or her expertise.
When all of the appropriate technical factors and equipment have been selected,
the cassette can be exposed and inserted into the reader. The image will then be dis-
played. The radiographer must now consider a number of factors: image exposure
indicators, image processing modes, and image processing parameters.
 Exposur 87
e

Figure 5-7 A, Lateral ankle without shuttering. B, Lateral ankle with shuttering.
(Images courtesy Haley Smallwood.)

Expos ure Indicators

The amount of light given off by the imaging plate is a result of the radiation
exposure the plate has received. The light is converted into a signal that is used to
calculate the exposure indicator number. This number varies from one vendor to
another (Table 5-1). (The total signal is not a measure of the dose to the patient but
indicates how much radiation was absorbed by the plate, which gives only an idea of
what the patient received.) The base exposure indicator number for all systems
designates the middle of the detector operating range. For the Fuji (Tokyo, Japan),
Philips (Eindhoven, The Netherlands), and Konica Minolta (Tokyo, Japan) systems,
the exposure indicator is known as the S or sensitivity number. It is the amount of
luminescence emitted at 1 mR at 80 kVp and has a value of 200. The higher the S
number with these systems, the lower the exposure. For example, an S number of
400 is half the exposure of an S number of 200, and an S number of 100 is twice the
exposure of an S number of 200. The numbers have an inverse relationship to the
amount of exposure so that each change of 200 results in a change in exposure by a
factor of 2.
Kodak (Rochester, NY) uses exposure index (EI) as the exposure indicator.
A 1-mR exposure at 80 kVp combined with aluminum/copper filtration yields an EI
88 CHAPTER 5 Cassette-Based Image
Acquisition

TABLE 5 - 1 RECOMMENDED EXPOSURE INDICES

Adult: Distal
Overexposure Underexposure Nongrid Extremities
and Grid Nongrid
Kodak >2500 <1600 tabletop; 1800–2100 2200–2400
<1800 Bucky
Agfa >2.9 <2.1 2.1–2.3 2.4–2.6
Fuji/Philips/Konica <100 >250 tabletop; 200–300 75–125
Minolta >400 Bucky

number of 2000. An EI number plus 300 (EI + 300) is equal to a doubling of

exposure, and an EI number of –300 is equal to halving the exposure. The numbers
for the Kodak system have a direct relationship to the amount of exposure, so that
each change of 300 results in change in exposure by a factor of 2. This is based on
logarithms, but instead of using 0.3 (as is used in conventional radiographic
characteristic curves) as a change by a factor of 2, the larger number 300 is used.
This is also a direct relation- ship: the higher the exposure index, the higher the
exposure.
The term for exposure indicator in an Agfa (Mortsel, Belgium) system is the log-
arithm of the median exposure (lgM). An exposure of 20 μGy at 75 kVp with
copper filtration yields a lgM number of 2.6. Each step of 0.3 above or below 2.6
equals an exposure factor of 2. A lgM of 2.9 equals twice the exposure of 2.6 lgM,
and a lgM of
2.3 equals an exposure half that of 2.6. The relationship between exposure and lgM
is direct.
A table of recommended exposures to determine the imaging plate sensitivity
(“speed”) can be seen in Table 5-2. These ranges depend on proper calibration of

TABLE 5 - 2 RECEPTOR EXPOSURES FOR DETERMINING

IMAGING PLATE SENSITIVITY
Kodak Agfa Fuji/Philips/Konica Minolta

Symbol EI lgM S
Exposure factors 1 mR at 80 kVp 20 μGy at 75 kVp 1 mR at 80
kVp Filtration Al/Cu Cu Al
Sensitivity value 2000 2.6 200
Relative sensitivity +300 = 2x +0.3 = 2x ½ S = 2x
x = exposure –300 = ½ –0.3 = ½ 2x S = ½
x x x
Exposur 89
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90 CHAPTER 5 Cassette-Based Image
Acquisition

equipment and represent the minimum and maximum exposure numbers that
correspond with radiation exposure within the diagnostic range. Exposure numbers
outside the range indicate overexposure and underexposure. Pediatric examination
ranges will vary, as will specific body part indices.

Image Data Recognition and Preprocessing

The image recognition phase is extremely important in establishing the parameters
that determine collimation borders and edges, and histogram formation. A histogram
is a graphic representation of the numerical tone values of an x-ray exposure. All CR
systems have this phase, and each has a specific name for this process. Agfa uses the
term “collimation”; Kodak uses the terms “segmentation”; and Fuji uses the phrase
“exposure data recognition.” All systems use a region of interest to define the area
where the part to be examined is recognized, and the exposure outside the region of
interest is subtracted. Each vendor has a specific tool for different situations such as
neck, breasts, pediatrics, and hips in which the anatomy requires some special
recogni- tion. The science behind each of these is beyond the scope of this textbook.
However, a brief description of the function of four common data recognition modes
for Fuji imaging systems will be discussed.

Automatic Data Recognition

With automatic data recognition, the image recording range is automatically
deter- mined. When the automatic mode is selected, the radiographer must also
select whether the field is divided for multiple exposures and in what pattern the
exposure will be made. This mode automatically adjusts reading latitude (L) and
sensitivity (S). Collimation is automatically recognized, and a complete histogram
analysis occurs. It is critical that good collimation practices are used because
overcollimation and under- collimation lead to data recognition errors that affect the
histogram. Lead markers must be in the exposure area. Avoid overlapping
exposures because overlaps will be interpreted as areas of increased exposure and
will negatively affect the histogram. Each of the exposure regions is processed to
identify the shape of the field and the approximate center. Data recognition then
occurs diagonally from the center out. When the value of the pixels exceeds a preset
threshold, those points are interpreted as collimation. Exposure data outside the
collimation points are subtracted in the his- togram analysis.

Semiautomatic Mode
In the semiautomatic mode, the latitude value of the histogram is fixed, and only a
small reading area is used. There is no collimation detection. The proper kilovolt
must be used to maintain subject contrast because the latitude value does not
change. This mode is especially useful for examinations of the odontoid, L5/S1 spot
film, sinuses, and any other tightly collimated examinations. When using this mode,
pre- cautions must be taken to carefully center the part to be examined. This mode
is not recommended for high absorption objects such as prostheses. Selection of
several dif- ferent semiautomatic modes may be available where the size of the
region of interest
 Exposur 91
e

is different (5 × 5 cm, 7 × 7 cm, 10 × 10 cm) or with multiple areas of interest where

the values of the areas are determined and the resultant maximum value is used
such as a PA chest examination.

Multiple Manual Selection Mode

In multiple manual mode, the area of interest is selected by the technologist, and
the image is derived from the selected areas imaged in semiautomatic mode. Fuji calls
this the Semi-X mode, and their user selects from nine different areas on the imaging
plate. The same precautions for semiautomatic mode apply to multiple manual
mode. The cassette orientation label must be noted with relation to the area of
interest. This mode is helpful in cross-table examinations for which the body part
may not align with automatically selected imaging plate regions.

Fixed Mode
In fixed mode, the user selects the exposure index, or sensitivity number, and the
value of the latitude from a menu. There is no histogram analysis and no recognition
of imaging plate division. Using fixed mode is like using film/screen: the density of
the image directly reflects the technique that is used. This mode is useful when
imaging cross-table hips, C7-T1 lateral view of the cervical spine, any body part with
a lot of metal, and parts that cannot be centered.

ARTIFACTS

As with film/screen, artifacts can degrade images. Artifacts are any undesirable
densi- ties on the processed image other than those caused by scatter radiation or
fog. There are four common types of artifacts (in addition to operator errors that
may cause arti- facts): imaging plate artifacts, plate reader artifacts, image
processing artifacts, and printer artifacts.

IMAGING PLATE ARTIFACTS

As the imaging plate ages, it becomes prone to cracks from the action of removing
and replacing the imaging plate within the reader. Cracks in the imaging plate
appear as areas of lucency on the image (Figure 5-8). The imaging plate must be
replaced when cracks occur in clinically useful areas. Adhesive tape used to secure
lead markers to the cassette can leave residue on the imaging plate (Figure 5-9). If
static exists because of low humidity, hair can cling to the imaging plate, creating
another type of image plate artifact (Figure 5-10).
Backscatter created by x-ray photons transmitted through the back of the
cassette can cause dark line artifacts (Figure 5-11). Areas of the lead coating on the
cassette that
92 CHAPTER 5 Cassette-Based Image
Acquisition

Figure 5-8 A, Cracks in the imaging plate which produce areas of radiolucency. B, Imaging plate (IP) artifact. (1)
Thumb radiograph showing cracks (white arrow) that usually first become visible on the IP edges. As deterioration
progresses, cracks appear closer to the clinically used areas of the IP (black arrow). (2) In some instances, early cracking
along the edge of the IP does not occur. This crack appears as a lucency near the radius, which could be confused with
a foreign body. (A, Image courtesy Eastman Kodak Company. B, From Cesar LJ, Schueler BA, Zink FE, et al: Artefacts found in computed
radiography, Br J Radiol 74:195–202, 2001.)
92 CHAPTER 5 Cassette-Based Image
Acquisition

Figure 5-9 Residue from adhesive tape used to attach lead markers to the outside of the
cassette has caused artifacts (arrow) when the tape came in contact with the imaging plate.
(From Cesar LJ, Schueler BA, Zink FE, et al: Artefacts found in computed radiography, Br J Radiol 74:195–202, 2001.)

Figure 5-10 Static caused a hair to cling to the IP on this skull image.
(From Cesar LJ, Schueler BA, Zink FE, et al: Artefacts found in computed radiography, Br J Radiol 74:195-202, 2001.)

are worn or cracked allow scatter to image these weak areas. Proper collimation
and regular cassette inspection help to eliminate this problem.

Pl ate Reader Artifacts

The intermittent appearance of extraneous line patterns can be caused by problems
in the plate reader’s electronics (Figure 5-12). Reader electronics may have to be
replaced to remedy this problem.
Horizontal white lines may be caused by dirt on the light guide in the plate reader.
Service personnel will need to clean the light guide.
If the plate reader loads multiple imaging plates in a single cassette, only one of
the plates will usually be extracted, leaving the other to be exposed multiple times.
 Imaging Plate 93
Artifacts

Figure 5-11 Backscatter causing dark line artifacts on AP ankle (A) and imaging plate artifact (B). The dark line
along the lateral portion of this upper abdomen is caused by backscatter transmitted through the back of the cassette.
The line corresponds to the cassette hinge where the lead coating was weakened or cracked. Artifact remedy: to
reduce backscat- ter, the radiographer should collimate when possible. Since backscatter cannot be eliminated in
every case, knowledge of the radiographic appearance of cassette backs is useful.
(From Cesar LJ, Schueler BA, Zink FE, et al: Artefacts found in computed radiography, Br J Radiol 74:195–202, 2001.)

Figure 5-12 Extraneous line patterns caused by noise in the plate reader electronics.
(Image courtesy Eastman Kodak Company.)
94 CHAPTER 5 Cassette-Based Image
Acquisition

The result is similar to a conventional film/screen double-exposed cassette (Figure

5-13).
Incorrect erasure settings result in a residual image left in the imaging plate
before the next exposure. The results will vary depending on how much residual
image is left and where it is located.
Orientation of a grid so that the grid lines are parallel to the plate reader’s
laser scan lines results in the moiré pattern error. Grids should be high frequency,
and the grid lines should run perpendicular to the plate reader’s laser scan lines
(Figure 5-14).

Figure 5-13 This artifact occurred because the plate reader loaded two imaging plates (IPs)
in a single cassette. After an exposure, the bottom IP was extracted, read, and replaced as
usual, leaving the top IP to be exposed numerous times. Artifact remedy: double-loaded
cassettes will be discovered during routine IP cleaning. If a cassette containing two IPs is
discovered, the IPs should be erased before being put back into use.
(From Cesar LJ, Schueler BA, Zink FE, et al: Artefacts found in computed radiography, Br J Radiol 74:195–202, 2001.)
 Imaging Plate 95
Artifacts

Figure 5-14 A, An exposure of a correctly oriented grid with the grid lines perpendicular
to the plate reader’s scan lines. B, A moiré pattern caused by an incorrectly oriented grid, with
the grid lines parallel to the plate reader’s scan lines.
(Images courtesy Eastman Kodak Company.)
96 CHAPTER 5 Cassette-Based Image
Acquisition

Pri nter Artifacts

Fine white lines may appear on the image because of debris on the mirror in the
laser printer. Service personnel will need to clean the printer.

Oper ator Errors

Insufficient collimation results in unattenuated radiation striking the imaging plate
(Figure 5-15). The resulting histogram will be changed so that it is outside the
normal exposure indicator range for the body part selected. Using the smallest
imaging plate possible and proper collimation, especially on small or thin patients,
will eliminate this error.
If the cassette is exposed with the back of a cassette toward the source, the
result will be an image with a white grid-type pattern and white areas that corre-
spond to the hinges. Care should be taken to expose only the tube side of the
cassette (Figure 5-16).
Underexposure produces quantum mottle, and overexposure affects contrast.
The proper selection of technical factors is critical for both patient dose, image
quality, and to ensure the appropriate production of light from the imaging plate
(Figure 5-17).

Figure 5-15 Insufficient collimation error. A, Properly collimated lateral ankle. B, Improper collimation
resulting in poor histogram analysis.
 Imaging Plate 97
Artifacts

Figure 5-16 This axillary shoulder was exposed through the back of a cassette. Artifact
remedy: be sure radiographers are well educated about how to use the entire computed
radiography system.
(From Cesar LJ, Schueler BA, Zink FE, et al: Artefacts found in computed radiography, Br J Radiol 74:195–202, 2001.)

Figure 5-17 A, Underexposed image caused by insufficient mAs, resulting in quantum

mottle. B, Overexposed image caused by insufficient kVp, resulting in decreased contrast.
98 CHAPTER 5 Cassette-Based Image
Acquisition

SUMMARY

■ Menu choices are critical to proper image acquisition. The menu choice must
match the part being examined.
■ kVp should be selected for the type and amount of contrast desired. Beam
attenu- ation is the same in DR as it is in film/screen radiography.
■ Sufficient photons are necessary to form any x-ray image. Insufficient photons
result in quantum noise or mottle. Care must be taken not to overuse mAs to
avoid quantum mottle.
■ Imaging plate selection is very important to ensure the proper matrix and
resolution.
■ Because of the wide range of densities produced, the use of a grid is key. Specific
guidelines should be followed as to the frequency, ratio, focus, and size. Care
should be taken to avoid the moiré grid error.
■ Collimation not only reduces the area irradiated, thereby reducing scatter
produc- tion, but also reduces the amount of grid cleanup.
■ A black background can be added postexposure, eliminating distractive light-
transmitting borders.
■ Side or position markers should always be used, regardless of the opportunity
to add them postexposure.
■ S, EI, and lgM are terms used by manufacturers to indicate the amount of expo-
sure. The exposure range numbers represent the maximum to minimum diagnostic
exposures. The middle value in that range represents the S, EI, or lgM number.
■ Image recognition takes place through computer algorithms that determine col-
limation borders and edges and histogram formation. Typical recognition pro-
grams are, as in Fuji systems: automatic, semiautomatic, multiple manual selection,
and fixed modes.
■ Four common types of artifacts are plate artifacts, plate reader artifacts, image
processing artifacts, and printer artifacts. Operator errors can also create
artifacts.
 Chapter Review 99
Questions

CHAPTER REVIEW QUESTIONS

1. What is meant by matching the body part to be

5. Why is preprocessing collimation important?
imaged with the examination menu selection?
How could a lack of collimation affect the
image and the examination?
2. How are technical factors chosen for each
exam- ination?
6. Why is it important to properly mark the
patient’s right or left side with radiographic
3. Why is the size of the imaging plate important?
markers?
What determines the choice of imaging plate
size?
7. How do the major equipment manufacturers
determine exposure indicators? What are
4. How is the grid selected for an examination?
some potential problems of working with
more than one system?
 CHAPTER 6

Cassetteless
Equipment and
Image Acquisition

Flat-Panel Detectors

Direct Conversion
Indirect Conversion

Complementary Metal Oxide

Silicon Detective Quantum

Efficiency Detector Size

Spatial Resolution

Pixel Size and Matrix Size

Technical Factor and

Equipment Selection

Potential Cassetteless Image

Acquisition Errors
 Chapter Review 10
100 Questions 1
 OBJECTIVES

1. Describe the construction of direct and 5. Compare detector detective quantum

indirect cassetteless systems. efficiency to cassette-based systems.
2. Differentiate between direct and indirect 6. Explain the importance of detector size
image capture. and ori- entation.
3. List the steps for x-ray to digital 7. Discuss factors that affect spatial
conversion with amorphous silicon resolution in cassetteless systems.
detectors.
4. Discuss the function of a charge-coupled
device.

K E Y T E R M S

Cesium iodide (CsI) Electronic memory

scintillator Charge- artifact Field effect
coupled devices (CCDs) transistor (FET) Flat-
Complementary metal oxide silicon panel detector
(CMOS) Detective quantum Indirect
efficiency (DQE) Detector size conversion Rare-
Direct conversion earth scintillator
Thin-film transistor (TFT)
101
10 CHAPTER 6 Cassetteless Equipment and Image
2 Acquisition
Digital radiography (DR) imaging is another way to record x-ray exposure after it
has passed through the patient. Whereas digital radiography includes both
computed radiography (CR) and direct or indirect methods of digital image capture,
the term DR is used to describe images recorded on an electronically readable
device. Unlike CR, DR is hard-wired to the image processing system and is
cassetteless. In DR detec- tors, the materials used for detecting the x-ray signal and
the sensors are permanently enclosed inside a rigid protective housing. Thin-film
transistor (TFT) detector arrays may be used in both direct- and indirect-conversion
detectors.

F LAT-PANEL DETECTORS

Flat-panel detectors consist of a photoconductor, amorphous selenium (a-Se), which

holds a charge on its surface that can then be read out by a TFT. This category
also includes silicon and CCD detectors.

Direct Conversion
In direct conversion, x-ray photons are absorbed by the coating material and
immedi- ately converted into an electrical signal. The DR plate has a radiation-
conversion material or photoconductor, typically made of a-Se. This material
absorbs x-rays and converts them to electrons, which are stored in the TFT
detectors (Figure 6-1). The thin-film transistor (TFT) is a photosensitive array
made up of small (about 100 to 200 μm) pixels. Each pixel contains a photodiode
that absorbs the electrons and generates electrical charges. A field-effect
transistor (FET) or silicon TFT isolates each pixel element and reacts like a switch
to send the electrical charges to the image processor (Figure 6-2). More than 1
million pixels can be read and converted to a composite digital image in less than 1
second. A line of TFT switches, each associated

X-Rays

Absorbe
r

Detector

Line driving
ICs &

Figure 6-1 Flat-panel detector showing the recording process.

 Flat-Panel 103
Detectors

Charge-
collector

TFT switch

Figure 6-2 Anatomy of an indirect flat-panel detector.

with a storage capacitor, allows the electric charge information to discharge when
the switches are closed. The information is discharged onto the data columns and
read out with dedicated electronics. Specialized silicon integrated circuits are
connected along the edges of the detector matrix. On one side, integrated circuits
control the line scan- ning sequence, and on the other side, low-noise, high-
sensitivity amplifiers perform the readout, amplification, and analog-to-digital
conversion. High-speed digital electronics are then used to achieve fast image
acquisition and processing.

Indirect Conversion
Indirect-conversion detectors are similar to direct detectors in that they use TFT
technology. Unlike direct conversion, indirect conversion is a two-step process:
x-ray photons are converted to light, and then the light photons are converted to an
electrical signal. A scintillator converts x-rays into visible light. That light is then
converted into an electric charge by photodetectors such as amorphous silicon pho-
todiode arrays or charge-coupled devices (CCDs). X-ray photons striking the dielec-
tric receptor are absorbed by a scintillation layer in the imaging plate that converts
the incident x-ray photon energy to light. A photosensitive array, made up of small
(about 100 to 200 μm) pixels, converts the light into electrical charges. Each pixel
contains a photodiode that absorbs the light from the scintillator and generates elec-
trical charges. A FET or silicon TFT isolates each pixel element and reacts like a
switch to send the electrical charges to the image processor. As with direct conver-
sion, more than 1 million pixels can be read and converted to a composite digital
image in less than 1 second (Figure 6-3).
104 CHAPTER 6 Cassetteless Equipment and Image
Acquisition

Incident x-ray photons

Cesium iodide scintillator Scintillator absorbs x-rays
Ligh and converts them to light
t FET/TFT photodiode/transistor FET/TFT array absorbs light
array and converts it to electronic
containing charges
electrons
Readout Each pixel is read digitally
electronics Digital by low noise electronics and
information sent to the image processor

Figure 6-3 Thin-film

transistor.

Amorphous Silicon Detector

This type of flat-panel sensor uses thin films of silicon integrated with arrays of pho-
todiodes. These photodiodes are coated with a crystalline cesium iodide (CsI)
scintilla- tor or a rare-earth scintillator (terbium-doped gadolinium dioxide sulfide).
When these scintillators are struck by x-rays, visible light is emitted proportionate to
the incident x-ray energy. The light photons are then converted into an electric
charge by the photo- diode arrays. Unlike the selenium-based system used for direct
conversion, this type of indirect-conversion detector technology requires a two-step
process for x-ray detection. The scintillator converts the x-ray beams into visible
light, and light is then converted into an electric charge by photodetectors, such as
amorphous silicon photodiodes.

CsI Detectors
A newer type of amorphous silicon detector uses a CsI scintillator. The scintillator is
made by growing very thin crystalline needles (5μm wide) that work as light-
directing tubes, much like fiberoptics (Figure 6-4). This allows greater detection of
x-rays, and because there is almost no light spread, there is much greater resolution.
These nee- dles absorb the x-ray photons and convert their energy into light,
channeling it to the amorphous silicon photodiode array. As the light hits the array,
the charge on each of the photodiodes decreases in proportion to the light received.
Each photodiode repre- sents a pixel, and the amount of charge required to recharge
each photodiode is read electronically and converted to digital data. This process is
very low-noise and very fast (approximately 30 million pixels/sec).

Charge-Coupled Devices
The oldest indirect-conversion DR system is based on charge-coupled devices (CCDs).
X-ray photons interact with a scintillation material, such as photostimulable phosphors,
and this signal is coupled, or linked, by lenses or fiberoptics that act like cameras.
These cameras reduce the size of the projected visible light image and transfer the
image to one or more small (2 to 4cm2) CCDs that convert the light into an electrical
charge. This charge is stored in a sequential pattern and released line by line and
sent to an analog- digital converter. Even though CCD-based detectors require optical
coupling and image size reduction, they are both widely available and relatively low
 Flat-Panel 105
Detectors
cost (Figure 6-5).
106 CHAPTER 6 Cassetteless Equipment and Image
Acquisition

Figure 6-4 Cesium iodide crystal structure used in CsI detectors.

(Photo courtesy Dr. Reiner F. Schulz, SIEMENS Medical Solutions, Vacuum Technology Division.)

Figure 6-5 Charge-coupled device.

 Flat-Panel 107
Detectors

COMPLEMENTARY METAL OXIDE SILICON

Developed by NASA, complementary metal oxide silicon (CMOS) systems use

specialized pixel sensors that, when struck with x-ray photons, convert the x-rays
into light photons and store them in capacitors. Each pixel has its own amplifier,
which is switched on and off by circuitry within the pixel, converting the light
photons into electrical charges. Voltage from the amplifier is converted by an
analog-to-digital converter also located within the pixel. This system is highly
efficient and takes up less fill space than CCDs.

DETE CTIVE QUANTUM EFFICIENCY

How efficiently a system converts the x-ray input signal into a useful output image is
known as detective quantity efficiency (DQE). DQE is a measurement of the per-
centage of x-rays that is absorbed when they hit the detector. The linear, wide-
latitude input/output characteristic of CR systems relative to screen/film systems
leads to a wider DQE latitude for CR, which implies that CR has the ability to convert
incoming x-rays into “useful” output over a much wider range of exposure than can
be accom- modated with screen/film systems. In other words, CR records all of the
phosphor output. Systems with higher quantum efficiency can produce higher
quality images at lower dose.
Both indirect and direct DR capture technology has increased DQE over CR.
However, DR direct capture technology, because it does not have the light conver-
sion step and consequently no light spread, increases DQE the most. There is no
light to blur the recorded signal output; less dose is required than for CR; and higher
quality images are produced. Newer CMOS indirect DR capture systems may be
equal to direct image acquisition because of the crystal light tubes, which also
prevent light spread.
The DQE of detectors changes with kilovoltage peak (kVp), but generally the
DQE of selenium- and phosphor-based systems is higher than for CR, CCD, and
CMOS systems. CCD in particular has problems with low light capture.
The area of a TFT array is limited because of the structure of the matrix. This
also affects the size and number of pixels available. Known as the fill factor, the
larger the area of the TFT photodiodes, the more radiation can be detected and the
greater amount of signal generated. Consequently, the greater the area of the TFT
array, the higher the DQE.

DETECTOR SIZE

Detector size is critical. Detectors must be large enough to cover the entire area to
be imaged and small enough to be practical. For chest x-rays, the detector needs to
 Technical Factor and Equipment 107
Selection

be at least 17 × 17 inches so that both lengthwise and crosswise examinations are

possible. Special examinations such as leg length and scoliosis series may require
dedicated detectors.

SPATIAL RESOLUTION

Depending on the detector’s physical characteristics, spatial resolution can vary a

great deal. Spatial resolution of a-Se for direct detectors and CsI for indirect detec-
tors is higher than CR detectors but lower than film/screen radiography. Excessive
image processing, in an effort to alter image sharpness, can lead to excessive noise.
Digital images can be processed to alter apparent image sharpness; however, exces-
sive processing can lead to an increase in perceived noise. The best resolution will
be achieved by using the appropriate technical factors and materials.

PIXEL SIZE AND MATRIX SIZE

The amount of resolution in an image is determined by the size of the pixels and the
spacing between them, or pixel pitch. More pixels do not always mean better reso-
lution because of the amount of x-ray scatter, light scatter, or both within the recep-
tor. Larger matrices combined with small pixel size will increase resolution, but it
may not be practical to use large matrices. The larger the matrix, the larger the size
of the image, and the greater the space needed for network transmission and picture
archival and communication system (PACS) storage. Typically, 2000 pixels/row are
adequate for most diagnostic examinations. Smaller pixel sizes may be necessary for
mammographic examinations. Pixel size in TFT displays is related to the design of
the capacitance elements and also to the fill factor of these devices.

TECHNICAL FACTOR AND

EQUIPMENT SELECTION

Selection of kVp, milliamperage seconds (mAs), distance, collimation, and anatomic

markers is the same for cassetteless systems as it is for cassette-based systems.
Typically only one exposure is made at a time on the image receptor, but that does
not mean that collimation is unnecessary. In fact, collimation may be more critical
because the cas- setteless systems are more sensitive to scatter radiation. When
grids are used in any digital imaging system, there is always the possibility that the
grid lines will interfere with the pixel rows, resulting in the moiré pattern error.
Grid interaction artifacts are not always easy to identify and can decrease image
quality, so caution and proper selection of the grid are advised.
108 CHAPTER 6 Cassetteless Equipment and Image
Acquisition

POTENTIAL CASSETTELESS IMAGE

ACQUISITION ERRORS

Although the conversion of x-rays to a digital signal occurs very quickly, each step of
the conversion has the potential of signal loss. The major cause of noise in this
system is electronic noise, and this is the main factor limiting quality. The more time
allowed for signal conversion, the more precise the pixel values. Incomplete charge
transfer will cause inaccuracies in pixel values in subsequent exposures, reducing image
quality. Additionally, if exposures are taken in too rapid sequences, there may not be
enough time for each previous exposure to transfer the entire signal, resulting in what is
known as electronic memory artifact. The detector readout may have built-in
safeguards against this, but it would be wise to know whether these protective
measures are in place. Not all cassetteless systems are appropriate for high speed,
rapid succession imaging such as fluoroscopy.

SUMMARY

■ There are two types of cassetteless digital imaging systems: direct and indirect.
■ Direct sensors are TFT arrays of amorphous silicon coated with a-Se.
■ Direct sensors absorb x-ray photons and immediately convert them to an
electri- cal signal.
■ Indirect conversion detectors use a scintillator that converts x-rays into visible
light, which is then converted into an electric charge.
■ CCDs act as miniature cameras that convert light produced by x-ray interaction
with photostimulable phosphors into an electrical charge.
■ Pixel and matrix size are important both in determining the amount of
resolution and the size of the image to be stored in the PACS system. In TFT
technology, both pixel and matrix size are determined by the amount of area
available to “fill” with photons.
■ Technical and equipment factors in cassetteless systems are equivalent to cassette-
based systems but may be more critical in terms of grid use and collimation.
■ Incomplete transfer of the signal generated in the cassetteless receptor or the
amount of signal retained by the receptor can cause artifacts, especially with
short acquisition or rapid succession acquisitions.
 Chapter Review 109
Questions

CHAPTER REVIEW QUESTIONS

1. How are indirect cassetteless imaging systems

5. What is detector quantum efficiency? How
constructed?
does the DQE of cassette-based systems
compare with detector-based systems?
2. What are the differences between indirect and
direct imaging systems?
6. How does the size and orientation of the detec-
tor impact digital imaging?
3. What are the x-ray to digital conversion steps
with amorphous silicon detectors?
7. What factors affect spatial resolution in cas-
setteless systems?
4. How does a CCD work?
 CHAPTER 7

Digital Radiographic
Image Processing
and Manipulation

Digital Radiographic Image Quality Control Workstation

Processing and Manipulation Functions
Computed Radiography Reader
Functions Image Processing Parameters
Contrast Manipulation
CR Image Sampling Spatial Frequency Resolution
Spatial Frequency Filtering
The Nyquist Theorem
Basic Functions of the
Processing System
Digital Radiography Image
Sampling
Image Manipulation
Aliasing
Image Management
Automatic Rescaling
Look-Up Table
Latitude Patient Demographic Input
Manual Send
Modulation Transfer Function Archive Query

110
 OBJECTIVES

1. Describe the formation of an image 6. Describe the effects of improper

histogram. algorithm application.
2. Discuss automatic rescaling. 7. Explain modulation transfer function.
3. Compare image latitude in digital imaging 8. Discuss the purpose and function of
with film/screen radiography. image manipulation factors.
4. List the functions of contrast 9. Describe the major factors in image
enhancement parameters. management.
5. State the Nyquist theorem.

K E Y T E R M S

Archive query Patient

Automatic demographics
rescaling Contrast Shuttering
manipulation Edge Smoothing
enhancement
Spatial frequency resolution
High-pass filtering
Window
Histogram
Image
Image orientation
annotation Image sampling
Low-pass Image stitching
filtering Latitude
Magnification
Level
Manual send
Look-up table (LUT)
Modulation transfer
function Nyquist
theorem
111
112 CHAPTER 7 Digital Radiographic Image Processing and
Manipulation

DIGITAL RADIOGRAPHIC IMAGE

PROCESSING AND MANIPULATION

Once x-ray photons have been converted into electrical signals, these signals are
avail- able for processing and manipulation. This is true for both cassette-based and
cassette- less systems, although a reader is used only for cassette-based systems.
Processing parameters and image manipulation controls are also similar for both
systems.
Preprocessing takes place in the computer where the algorithms determine the
image histogram. Postprocessing is done by the technologist through various user
functions. Digital preprocessing methods are vendor-specific, so only general infor-
mation on this topic can be covered here.

COMPUTED RADIOGRAPHY READER

FUNCTIONS

The computed radiography (CR) imaging plate records a wide range of x-ray expo-
sures. If the entire range of exposure were digitized, values at the extremely high
and low ends of the exposure range would also be digitized, resulting in low-density
reso- lution. To avoid this, exposure data recognition processes only the optimal
density exposure range. The data recognition program searches for anatomy
recorded on the imaging plate by finding the collimation edges and then eliminates
scatter outside the collimation. Failure of the system to find the collimation edges
can result in incorrect data collection, and images may be too bright or dark. The
data within the collimated area produce a graphic representation of the optimal
densities called a histogram. Because the information within the collimated area is
the signal that will be used for image data, this information is the source of the
vendor-specific exposure data indicator.

CR IMAGE SAMPLING

With image sampling, the plate is scanned, and the image’s location and its orienta-
tion are determined. The size of the signal is then determined, and a value is placed
on each pixel. A histogram is generated from the image data, which allows the
system to find the useful signal by locating the minimum (S1) and maximum (S2)
signal within the anatomical regions of interest on the image. The histogram
identifies all densities on the imaging plate in the form of a graph on which the x-
axis is the amount of expo- sure read, and the y-axis is the number of pixels for each
exposure. This graphic rep- resentation appears as a pattern of peaks and valleys
that varies for each body part. Low energy (kilovoltage peak [kVp]) gives a wider
histogram; high energy (kVp) gives a narrower histogram. The histogram shows the
distribution of pixel values for any given exposure. For example, if pixels have a
 Digital Radiography Image 113
Sampling
value of 1, 2, 3, and 4 for a specific expo- sure, then the histogram shows the
frequency (how often they occurred) of each of
114 CHAPTER 7 Digital Radiographic Image Processing and
Manipulation

those values, as well as the actual number of values (how many were recorded). The
histogram sets the minimum (S1) and maximum (S2) “useful” pixel values.
Analysis of the histogram is very complex. However, it is important to know that
the shape of the histogram is anatomy specific, which is to say that it stays fairly
con- stant for each part exposed. For example, the shape of histogram generated
from a chest x-ray on an adult patient will look very different from a knee histogram
gener- ated from a pediatric knee examination. This is why it is so important to
choose the correct anatomic region on the menu before exposing the patient. The
raw data used to form the histogram are compared with a “normal” histogram of the
same body part by the computer (Figure 7-1).

Th e Nyquist Theorem
The Nyquist theorem states that when sampling a signal (such as the conversion from
an analog to a digital image), the sampling frequency must be greater than twice the
band- width of the input signal so that the reconstruction of the original image will
be nearly perfect. In digital imaging, at least twice the number of pixels needed to
form the image must be sampled. If too few pixels are sampled, the result will be a
lack of resolution.
The number of conversions that occur in CR—electron to light, light to digital
information, digital to analog signal—results in loss of detail. Light photons do not
travel in one direction, so some light will be lost during the light-to-digital
conversion because light photons spread out. Because there is a small distance
between the phos- phor plate surface and the photosensitive diode of the
photomultiplier, some light will spread out there as well, resulting in loss of
information. In addition, even though the imaging plate is able to store electrons for
an extended period of time, the longer the electrons are stored, the more energy
they lose. When the laser stimulates these elec- trons, some of the lower energy
electrons will escape the active layer, but if enough energy was lost, some lower
energy electrons will not be stimulated enough to escape, and information will be
lost. All manufacturers suggest that imaging plates be read as soon as possible to
avoid this loss.

DIGITAL RADIOGRAPHY IMAGE

SAMPLING

Although both indirect and direct radiography lose less signal to light spread, the
Nyquist theorem is still applied to ensure that sufficient signal is sampled. Because the
sample is preprocessed by the computer immediately, signal loss is minimized but
still occurs.

Aliasing
When the spatial frequency is greater than the Nyquist frequency and the sampling
occurs less than twice per cycle, information is lost and a fluctuating signal is pro-
duced. A wraparound image is produced, which appears as two superimposed
images that are slightly out of alignment, resulting in a moiré effect. This can be
 Digital Radiography Image 115
Sampling
problematic because the same effect can occur with grid errors. It is important for
technologists to look at both (Figure 7-2).
116 CHAPTER 7 Digital Radiographic Image Processing and
Manipulation

Figure 7-1 Workstation screen showing the histogram for a PA upright chest with
acceptable contrast (A) and a histogram for the same PA upright chest manipulated to have
much lower contrast (B). Note that the shapes of the histograms are the same, but the
intensity peaks vary slightly. Note the line depicting the “characteristic” curve of the image
intensities, which is more vertical in (A) and much flatter in (B).
 Digital Radiography Image 117
Sampling

Figure 7-2 Aliasing artifact caused by grid aliasing, also known as the moiré effect.
(From Cesar LJ, Schueler BA, Zink FE, et al.: Artefacts found in computed radiography, Br J Radiol 74:195–202, 2001.)

Au tomatic Rescaling
When exposure is greater or less than what is needed to produce an image,
automatic rescaling occurs in an effort to display the pixels for the area of interest.
Automatic rescaling means that images are produced with uniform density and
contrast, regard- less of the amount of exposure. Problems occur with rescaling when
too little exposure is used, resulting in quantum mottle, or when too much exposure
is used, resulting in loss of contrast and loss of distinct edges because of increased
scatter production. Rescaling is no substitute for appropriate technical factors.
There is a real danger in relying on the system to “fix” an image through rescaling
and so using higher milliamperage seconds (mAs) values than necessary to avoid
quantum mottle.

Loo k-Up Table

A look-up table (LUT) is a histogram of the luminance values derived during image
acquisition. The LUT is used as a reference to evaluate the raw information and
118 CHAPTER 7 Digital Radiographic Image Processing and
Manipulation

correct the luminance values. This is a mapping function in which all pixels (each
with its own specific gray value) are changed to a new gray value. The resultant
image will have the appropriate appearance in brightness (density) and contrast.
There is a LUT for every anatomic part. The LUT can be graphed by plotting the
original values ranging from 0 to 255 on the horizontal axis and the new values (also
ranging from 0 to 255) on the vertical axis. Contrast can be increased or decreased
by changing the slope of this graph. The brightness (density) can be increased or
decreased by moving the line up or down the y-axis (Figure 7-3).

Lati tude
Latitude refers to the amount of error that can be made and still result in the capture
of a quality image. DR histograms show a very wide range of exposure because of
automatic rescaling of the pixels. The exposure latitude is slightly greater than that of
screen/film exposures. In CR if the exposure is more than 50% below the ideal
exposure, quantum mottle results. If the exposure is more than 200% above the ideal
exposure, contrast loss results. The biggest difference between digital and film/screen
radiography lies in the ability to manipulate the digitized pixel values, which leads to
what seems like greater exposure latitude. Proper kilovolt and mAs values prevent
both mottle and contrast loss. Kodak (Rochester, NY) has added a feature to its
CR systems called enhanced visualization image processing (EVP). EVP takes
image diagnostic quality to a new level by increasing latitude while still preserving
the contrast of image detail. Kodak’s EVP process decreases windowing and leveling
on workstations and virtually eliminates
detail loss in dense tissues (Figure 7-4).

White
250
Contrast
enhance
200 d image
data
L
Displayed E 150
pixel V
value E
L 100 Non-
enhanced
unprocessed
50

Black 0
5
0 100 200 250

150

Window Actual
value of
pixel

Figure 7-3 Look-up table. Gray-level transformation required for contrast enhancement of
images with 256 shades of gray for an 8-bit matrix. The nonenhanced image data are trans-
formed so that data with pixel values less than 50 are displayed as black, and all data with
 Digital Radiography Image 119
Sampling
pixel values greater than 150 are displayed as white. All data with pixel values between 50 and
150 are displayed using an intermediate shade of gray.
120 CHAPTER 7 Digital Radiographic Image Processing and
Manipulation

Figure 7-4 A, Raw data chest image. B, Chest image with some image processing known as
“perceptual tone scale image processing” (ptone). C, Final enhanced image using enhanced
visualization image processing (EVP).
(Images courtesy Eastman Kodak Company.)
 Digital Radiography Image 121
Sampling

MODULATION TRANSFER FUNCTION

The ability of a system to record available spatial frequencies is known as

modulation transfer function (MTF). The sum of the components in a recording
system cannot be greater than the system as a whole. What this means is that when
any component’s function is compromised because of some type of interference, the
overall quality of the system is affected. MTF is a way to quantify the contribution of
each system component to the efficiency of the entire system. MTF is a ratio of the
image to the object, so that a perfect system would have an MTF of 1% or 100%. In
digital detectors where x-ray photon energy excites a phosphor so that it produces
light, there will always be a spread- ing out of the light that reduces system efficiency.
Therefore the more light spread, the less the image looks like the object and the
lower the MTF (Figure 7-5).

QUALITY CONTROL WORKSTATION

FUNCTIONS

Image Processing Parameters

As previously discussed, digital systems have a greater dynamic range than
film/screen imaging. The initial digital image appears linear when graphed because
all shades of gray are visible, giving the image a very wide latitude. If all of the
shades were left in the image, the contrast would be so low as to make adjacent
densities difficult to dif-

100%

MTF 50%

0%
Spatial frequency amplitude
122 CHAPTER 7 Digital Radiographic Image Processing and
Manipulation
Figure 7-5 MTF comparison. The blue line shows high spatial frequency, which results in an MTF of 100%. The
maroon line shows a substantially lower spatial frequency, indicating system inefficiency. The closer the amplitude of
the spatial frequency is to becoming a flat line, the lower the MTF.
 Quality Control Workstation 119
Functions

ferentiate. To avoid this, digital systems use various contrast enhancement

parameters. Although the parameter names differ by vendor (Agfa [Mortsel,
Belgium] uses MUSICA; Fuji [Tokyo, Japan] uses Gradation; and Kodak uses
Tonescaling), the purpose and effects are basically the same.

Contrast Manipulation
Contrast manipulation involves converting the digital input data to an image with
appropriate density and contrast using contrast enhancement parameters. Image
contrast is controlled by using a parameter that changes the steepness of the
exposure gradient. By using a different parameter, density can be varied at the toe
and shoulder of the curve to remove the extremely low- and extremely high-density
values. Another parameter allows density to remain unchanged, whereas contrast is
varied. These parameters should be used only to enhance the image. No amount of
adjustment can take the place of proper technical factor selection (Figure 7-6).

Figure 7-6 Workstation screen showing contrast manipulation choices.

120 CHAPTER 7 Digital Radiographic Image Processing and
Manipulation

Sp atial Frequency Resolution

Detail or sharpness is referred to as spatial frequency resolution. In film/screen
radi- ography, sharpness is controlled by various factors such as focal spot size,
screen and/ or film speed, and object-image distance (OID). Focal spot and the OID
affect image sharpness in both film/screen and DR. The digitized image, however,
can be further controlled for sharpness by adjusting processing parameters. You can
choose the structure to be enhanced, control the degree of enhancement for each
density to reduce image graininess, and adjust how much edge enhancement is
applied. Great care must be taken when making adjustments to processing
parameters because if the improper algorithms are applied, image formation can be
degraded.
Many health care facilities do not want the technologist to manipulate the image
much before it goes to the picture archival and communication system (PACS)
because their changes reduce the amount of manipulation that the radiologist can
do. Once the image is stored in the PACS, all postprocessing results in a loss of
information from the original image.

Spa tial Frequency Filtering

Edge Enhancement
After the signal is obtained for each pixel, the signals are averaged to shorten processing
time and storage. The more pixels involved in the averaging, the smoother the image
appears. The signal strength of one pixel is averaged with the strength of adjacent
pixels, or neighborhood pixels. Edge enhancement occurs when fewer pixels in the
neighbor- hood are included in the signal average. The smaller the neighborhood, the
greater the enhancement. When the frequencies of areas of interest are known,
those frequencies can be amplified and other frequencies suppressed. This is also
known as high-pass filtering and increases contrast and edge enhancement.
Suppressing frequencies, also known as masking, can result in the loss of small
details. High-pass filtering is useful for enhancing large structures like organs and soft
tissues, but it can be noisy (Figure 7-7).

Smoothing
Another type of spatial frequency filtering is smoothing. Also known as low-pass
filtering, smoothing occurs by averaging each pixel’s frequency with surrounding
pixel values to remove high-frequency noise. The result is a reduction of noise and
contrast. Low-pass filtering is useful for viewing small structures such as fine bone
tissues.

BASIC FUNCTIONS OF THE PROCESSING

SYSTEM

Image Manipulation
Window and Level
 Quality Control Workstation 121
Functions

The most common image processing parameters are those for brightness and contrast.
Window level controls how light or dark the image is, and Window width controls the ratio of
 Basic Functions of the Processing 121
System

Figure 7-7 Edge enhancement. A, AP hip without edge enhancement. B, The same AP hip image
with edge enhancement.
122 CHAPTER 7 Digital Radiographic Image Processing and
Manipulation
black and white, or contrast. The user can quickly manipulate both by using the mouse.
One direction (vertical or horizontal) controls brightness, and the other direction
controls con- trast. To further control density and contrast, contrast enhancement
parameters are used.

Background Removal or Shuttering

Anytime a radiographic image is viewed, whether it is film/screen or digital, unex-
posed borders around the collimation edges allow excess light to enter the eye.
Known as veil glare, this excess light causes oversensitization of a chemical within
the eye called rhodopsin that results in temporary white light blindness. Although
the eye recovers quickly enough so that the viewer recognizes only that the light is
very bright, it is a great distraction that interferes with image reception by the eye.
In film/screen radiography, black cardboard glare masks or special automatic
collimation view boxes were sometimes used to lessen the effects of veil glare, but
no technique has ever been entirely successful or convenient. In CR, automatic
shuttering is used to blacken out the white collimation borders, effectively
eliminating veil glare. Shuttering is a view- ing technique only and should never be
used to mask poor collimation practices.
Background removal is also beneficial. Removing the white unexposed borders
results in an overall smaller number of pixels and reduces the amount of
information to be stored (Figure 7-8).

Figure 7-8 Shuttering. A, AP foot with collimation. B, AP foot with collimation and black surround or shuttering.
(Images courtesy Eastman Kodak Company.)
 Basic Functions of the Processing 123
System

Image Orientation
Image orientation refers to the way anatomy is oriented on the imaging plate. The
image reader has to be informed of the location of the patient’s head versus feet and
right side versus left side. The image reader scans and reads the image from the
lead- ing edge of the imaging plate to the opposite end. The image is displayed
exactly as it was read unless the reader is informed differently. Vendors mark the
cassettes in differ- ent ways to help technologists orient the cassette in such a way
that the image will be processed to display as expected. Fuji uses a tape-type
orientation marker on the top and right side of the cassette. Kodak uses a sticker
reminiscent of the film/screen cas- sette identification blocker. Some examinations,
however, require unusual orientation of the cassette. In these cases, the reader must
be informed of the orientation of the anatomy with respect to the reader. In DR, for
which no cassette is used, the position of the part should correspond with the
marked top and sides of the imaging plate.

Image Stitching
When anatomy or area of interest is too large to fit on one cassette, multiple images
can be “stitched” together using specialized software programs. This process is
called image stitching. In some cases special cassette holders are used and
positioned verti- cally, corresponding to foot-to-hip or entire spine studies. Images
are processed in computer programs that nearly seamlessly join the anatomy for
display as one single image. This technique eliminates the need for large (36-inch)
cassettes previously used in film/screen radiography (Figure 7-9).

Image Annotation
Many times, information other than standard identification must be added to the image.
In screen/film radiography, time and date stickers, grease pencils, or permanent
markers were used to indicate technical factors, time sequences, technologist
identification, or position. The image annotation function allows selection of preset
terms and/or manual text input and can be particularly useful when such additional
information is necessary. (Function availability depends on the manufacturer.) The
annotations overlay the image as bitmap images. Depending on how each system is set
up, annotations may not transfer to PACS. Again, input of annotation for identification
of the patient’s left or right side should never be used as a substitute for
technologist’s anatomy markers (Figure 7-10).

Magnification
Two basic types of magnification techniques come standard with digital systems.
One technique functions as a magnifying glass in the sense that a box placed over a
small seg- ment of anatomy on the main image shows a magnified version of the
underlying anatomy. Both the size of the magnified area and the amount of magnification
can be made larger or smaller. The other technique is a “zoom” technique that allows
magnification of the entire image. The image can be enlarged enough so that only parts
of it are visible on the screen, but the parts not visible can be reached through mouse
navigation (Figure 7-11).
Figure 7-9 Image stitching. A, AP projection of upper thoracic spine. B, AP projection of lower thoracic and
upper lumbar spine. C, AP projection of lower lumbar spine. D, All three images joined by digital stitching, resulting
in AP projection of entire spine for scoliosis.
(Images courtesy Eastman Kodak Company.)
 Image 125
Management

Figure 7-10 CR workstation screen for image annotation. Note that even though both PA
and AP choices are checked, only the first (PA) shows on the screen.

IMAGE MANAGEMENT

Patient Demographic Input

Proper identification of the patient is even more critical with digital images than
with conventional hard copy film/screen images. Retrieval of digital images can be
nearly impossible if not properly and accurately identified. Patient demographics
include things like patient name, health care facility, patient identification number,
date of birth, and examination date. This information should be input or linked via
barcode label scans before the start of the examination and before the processing
phase. Occa- sionally errors are made, and demographic information must be
altered. If the tech- nologist performing the examination is absolutely positive that
the image is of the correct patient, then demographic information can be altered at
the processing stage. This function should be tracked and changes linked to the
technologist altering the information to ensure accuracy and accountability.
Problems arise if the patient name is entered differently from visit to visit or
examination to examination. For example, if the patient’s name is Jane A. Doe and is
entered that way, that name must be entered that way for every other examination.
If entered as Jane Doe, the system will save it as a different patient. Merging these
files can be difficult, especially if there are several versions of the name. If a patient
gives
126 CHAPTER 7 Digital Radiographic Image Processing and
Manipulation

Figure 7-11 Image magnification. A, Digital image of various everyday objects. B,

Magnified view of a cell phone.
 Summar 127
y

a middle name on one visit but has had multiple examinations under his or her first
name, retrieval of previous files will be very difficult and in some cases impossible.
The right images must be placed in the correct data files just as hard copy films had
to be placed in the correct patient folder.

Manual Send
Because the quality control (QC) workstation is networked to the PACS, it also has
the capability to send images to local network workstations. The manual send
function allows the QC technologist to select one or more local computers to receive
images.

Ar chive Query
In the event that the technologist wishes to see historical images, the PACS archive
can be queried. Archive query is a function that allows retrieval of images from the
PACS based on date of examination, patient name or number, examination number,
pathologic condition, or anatomic area. For example, the technologist could query or
ask the PACS to retrieve all chest x-rays for a particular date or range of dates, or
query retrieval of all of a certain patient’s images. There are multiple combinations
of query fields that can generate reports that include many categories of
information or a few very specific categories to be retrieved from storage.

SUMMARY

■ Recognition of exposure data involves processing only the optimal density

expo- sure range and generates a graphic representation or histogram of the
optimal densities.
■ After the plate is scanned and the image location and orientation are
determined, a value is placed on each pixel, and the histogram is generated
displaying the minimum and maximum diagnostic signal.
■ Histograms are different for specific anatomic regions and remain fairly
constant from patient to patient.
■ Automatic rescaling allows pixel display for the area of interest, regardless of
the amount of exposure, unless the exposure is too low or too high. In those
cases, quantum mottle or contrast loss occurs.
■ There is no substitute for proper kVp and mAs. Insufficient photons, insufficient
penetration, or overpenetration results in a loss of diagnostic information that
cannot be manufactured by manipulating the image parameters.
■ Exposure latitude is slightly greater with digital imaging than with film/screen
imaging because of the wider range of exposures recorded with digital systems.
■ Contrast enhancement parameters allow enhancement of the image by
controlling the steepness of the exposure gradient, density variance, and
contrast amount.
■ Spatial frequency resolution is controlled by focal spot, OID, and computer
algorithms.
128 CHAPTER 7 Digital Radiographic Image Processing and
Manipulation

■ The Nyquist theorem is applied to digital images to ensure sufficient signal sam-
pling for maximum resolution.
■ MTF refers to the contribution of all system components to total resolution. The
closer the MTF value is to 1, the better the resolution.
■ Edge enhancement is accomplished by limiting the number of pixels in a neigh-
borhood of the matrix. Known area-of-interest frequencies can be amplified or
high-pass filtered to increase contrast and edge enhancement.
■ Suppressing frequencies of lesser importance, known as masking, can cause
small detail loss.
■ Low-pass filtering or smoothing is the result of pixel averaging to remove high
frequency noise. Contrast and noise are decreased, allowing small structures to
be seen.
■ Window and level parameters control pixel brightness and contrast.
■ Shuttering is a process that removes or replaces the background to block
distract- ing light surrounding a digital image. This does not take the place of
proper col- limation and can be removed to show proper collimation.
■ Digital imaging cassettes are marked for orientation to the top and right sides.
This ensures that images will be displayed correctly.
■ Image stitching is a computer program process that allows multiple images to
be joined when the anatomy is too large for one exposure. The result is a nearly
seamless single image.
■ On digital systems, magnification techniques are available that allow small area
enlargement or whole image enlargement.
■ Proper patient demographic input is the responsibility of the technologist per-
forming the examination. Any alteration of patient demographics should be
avoided unless absolute identification is possible.
■ The manual send function allows images to be sent to one or more networked
computers.
■ Historical study of patient examinations can be accomplished through the archive
query function. Querying for retrieval of radiographic studies can be specific to
a patient, examination date, or examination type or include a broader search for
date ranges, combinations of anatomic areas, and so on.
 Chapter Review 129
Questions

CHAPTER REVIEW QUESTIONS

1. What is an image histogram?

6. What is the Nyquist theorem? How does it
affect digital image processing?
2. How is the image histogram formed?
7. What happens if the incorrect algorithm is
3. What is the purpose of automatic rescaling? applied to an examination?
4. How does image latitude in digital imaging 8. What does image manipulation mean? What
compare with film/screen radiography? are the different types of manipulation choices,
and what are their functions?
5. What are the different contrast enhancement
parameters? What are the advantages and 9. What are the major factors in image manage-
dan- gers of their use? ment?
This page intentionally left blank
PART
IV

PACS
 CHAPTER 8

PACS Fundamentals

Fundamentals

Image Acquisition
Display Workstations
Archive Servers
Workflow

System Architecture

Client/Server-Based Systems
Distributed Systems
Web-Based Systems

Display Workstations

Radiologist Reading Stations

Physician Review Stations
Technologist QC Stations
File Room/Image Management
Stations
Common Functions
Advanced Workstation
Functions

132
 OBJECTIVES

1. Define picture archiving and 4. Define system architecture, and

communication system (PACS). recognize the three major models.
2. Compare and contrast the various 5. Summarize the common functions
types of PACS display workstations. found on a PACS workstation.
3. Differentiate among the different types of 6. Describe the situations and users that
digital imaging workflow. may require advanced PACS workstation
functions.

K E Y T E R M S

Archive Quality control (QC)

Client/server-based system station Reading station
Digital imaging and communications Review workstation
in medicine (DICOM) Softcopy
Display workstation System architecture
Distributed or stand alone Teleradiology
system File room workstation Web-based
Hanging protocol system
Navigation functions Workflow
Picture archiving and
communication system (PACS)
133
134 CHAPTER 8 PACS
Fundamentals

The picture archiving and communication system (PACS) is becoming more

com- monplace in today’s hospitals because hospital administrators have come to
see the necessity of having such a system to serve physicians and patients even
though the cost is great. The initial capital cost is great, but the benefit of having the
system far out- weighs the cost. This chapter outlines the basic concept of a PACS
and its compo- nents, common PACS architecture, and typical PACS workflows that
may be seen in a hospital.

F UNDAMENTALS

As discussed in Chapter 1, a PACS consists of digital acquisition, display

workstations, and storage devices interconnected through an intricate network
(Figure 8-1). The PACS is an electronic version of the radiologist reading room and
the file room. The first PACSs were used in the early 1980s and generally served one
single modality. Large research institutions housed early systems because most were
developed by the scientists who worked at those institutions. As vendors became
more involved, they developed proprietary systems that were very specific to their
modalities. Finally, as physicians and hospitals became interested, it was determined
that there must be stan- dardization.
Digital imaging and communications in medicine (DICOM) is a universally
accepted standard for exchanging medical images among the modality, viewing
stations,

Radiology
informati
on
Archiv
e

Web
Web clients
server

Radiology Archive
workstatio server

Input modalities
Figure 8-1 A typical PACS design.
 Fundamental 135
s

and the archive. First completed in 1985, this standard laid the groundwork for the
future development of integrated PACSs. Now each modality and PACS
communi- cates via DICOM, and it continues to be refined every year. Every vendor
and modal- ity boasts DICOM compatibility (Figure 8-2), but each DICOM
statement must be read carefully to determine the extent of the compatibility.
DICOM compatibility issues are outside of the scope of this textbook.
To understand what a PACS is and how it is used, the following sections break
down a PACS into its three fundamental parts (Figure 8-3): image acquisition,
display workstations, and archive servers. Each of these topics is covered in depth in
other chapters of the book.

Ima ge Acquisition
In modern radiology departments, most images are acquired in a digital format,
mean- ing that the images are inherently digital and can be transferred via a
computer net- work. Ultrasound, computed tomography (CT), magnetic resonance
imaging (MRI), and nuclear medicine have been digital for many years and have been
taking advantage of PACS far longer than general radiography has. As stated earlier,
the first PACS served a single modality, namely, ultrasound. Ultrasound mini-PACS
networks were the norm in many hospitals. Radiologists routinely made diagnoses
by looking at images on the modality’s computer screen. It was a natural step from
there to convert ultrasound to softcopy reporting, i.e., reading images on the
computer without hardcopy films.
As the CT and MRI image sets became larger because of the increased number
of cross-sectional images per patient, radiologists routinely went to the modality to
view the images. This slowed down the scanning process for the technologists, and
vendors began getting requests for extra console stations for radiologist viewing.
These workstations were directly connected to the modalities. Radiologists could
view the large stacks of images and perform simple image manipulation. These
workstations morphed into mini-PACS and eventually into full-blown systems for
CT and MRI. As discussed in Chapters 4 through 7, general radiography has taken
the digital leap with computed radiography (CR) and direct and indirect capture
digital radiography (DR). Now the conversion to a completely digital radiology
department is a reality.

Disp lay Workstations

A display workstation is any computer that a health care worker uses to view a
digital image (Figure 8-4). It is the most interactive part of a PACS, and these work-
stations are used inside and outside of radiology. The display station receives
images from the archive or from the various radiology modalities and presents them
for viewing. The display workstation has PACS application software that allows the
user to perform minor image-manipulation techniques to optimize the image being
viewed. Some display stations have advanced software to perform more complex
image-manipulation techniques. More details about display workstations will be
given later in the chapter.
136 CHAPTER 8 PACS
Fundamentals

DICOM Conformance

Statement CR

Console
(Standard)

April,
2004 5th
Edition

Copyright Fuji Photo Film Co., Ltd., Japan

 Fundamental 137
s
Figure 8-2 A DICOM conformance statement for a CT scanner.
(Courtesy Fuji Photo Film Co., Ltd., Tokyo, Japan.)
138 CHAPTER 8 PACS
Fundamentals
Image
acquisition Archive server

Display
workstations

Figure 8-3 A collage of PACS components: image acquisition, display workstation, and
archive server.

Figure 8-4 A display workstation for image review.

Archi ve Servers
An archive server is the file room of the PACS. It is composed of a database server or
image manager, short-term and long-term storage, and a computer that controls the
PACS workflow, known as a workflow manager (Figure 8-5). The archive is the cen-
tral part of the PACS and houses all of the historic data along with the current data
being generated. In many institutions the archive serves as the central hub that receives
all images before being released to the radiologists for interpretation. The archive and
all of its components will be studied in depth in Chapter 9.
 Fundamental 139
s

Long-
term

Archiv
e

Workflo Short-
w term

Databas
e server
Figure 8-5 The common components of an archive.

Workfl ow
Wvorkf l ow is a term that can be used in any industry or in any organization. It
simply means how a process is done, step by step. In radiology, we have always used
the term workflow to describe how we complete an examination from order entry to
transcribed report. This section describes a generic film-based workflow and then
compares it with a generic PACS workflow. The workflow in each radiology
department is different because there are many variables.

Film-Based Workflow
Most departments were designed years ago for film and chemical processing. Pass
boxes were built into walls that fed into darkrooms and into large open reading
rooms that had gigantic multiviewer lightboxes lining the walls (see Figure 8-11).
Eventually chemical processing time decreased from a few minutes to less than 60
seconds in some cases. As film and processing technology advanced, workflow
became more effi- cient, despite having to still hand deliver film to radiologists and to
make the occasional copy for a referring physician.
The following list outlines a typical workflow in a radiology department, from
entering the order to transcribing the report (Figure 8-6).

■ The first step in any radiology department workflow is the entry of the order.
The order may be a paper prescription from the ordering doctor, or the order
may have been placed in the computer system by the emergency room (ER) or
intensive care unit (ICU) staff. Either way, an order is placed in the radiology
information
140 CHAPTER 8 PACS
Fundamentals

Exam performed
Order-
entry
Film processed
Film-based
workflow

Transcribed
report Film interpreted

Figure 8-6 A typical film-based workflow from order entry to transcribed report.

system (RIS), and a requisition is generated. A requisition generally contains the

following information:
● Patient’s name
● Patient’s hospital identification (ID) number
● Date of birth
● Ordering physician’s name
● Examination ordered
● Reason for examination
● Chief complaint
■ The paper requisition is then passed on to the technologist who will be
perform- ing the examination.
■ The technologist prepares the room for the patient and brings the patient back
to the room.
■ The technologist verifies all of the patient’s information and completes a patient
history. The technologist also inquires whether the patient needs a complete set
of copies to take to the next doctor’s appointment.
■ The technologist performs the examination and processes all of the film after
the complete examination is done.
■ The technologist critiques each film and repeats exposures as necessary.
■ The technologist makes copies if necessary and releases the patient with the films.
■ The technologist goes to the file room to find the film jacket with all of the
patient’s historic images, if applicable. The film jacket may not be located on site
and may be kept at an off-site storage location. The film jacket is ordered to be
picked up by the film courier.
■ The film jacket arrives a couple of hours or even days later, and the current
films are hung on a multiviewer lightbox to be read by a radiologist. The file
room clerk may hang a set of historic images from the film jacket for
comparison.
■ The radiologist reads the films and dictates a report into the dictation system.
 Fundamental 141
s

■ The multiviewer lightbox is cleared of read films by the file room clerk, and the
films are placed back into the film jacket. The film jacket is filed in the file room.
■ A transcriptionist retrieves the recorded dictation and transcribes a report into
the RIS. This may occur later that same day or the next day.
■ The radiologist reviews the report, makes corrections, and signs the report as
final. The final report is printed and placed in the patient’s film jacket along with
any previous reports. A final report is also sent to the ordering physician for review.
This final report may come several days after the examination was completed.

Generic PACS Workflow

The PACS workflow is in many ways different from the film-based workflow (Figure 8-
7). The technologist may get the order via an electronic worklist or a paper
requisition, but after that, things begin to change.

■ Changes in the order entry are on the horizon, but for now, the order-entry pro-
cess is the same as in film-based departments. The technologist needs a
requisition to verify the patient ID and to take a patient history.
■ The order is input into the RIS, and the RIS sends a message to the PACS to find
all historic images and put them on the short-term archive. This eliminates
wait- ing for the file room to retrieve a film jacket from the off-site storage
location.
■ The technologist prepares the room, retrieves the patient, and performs the
patient history. The history is recorded on the paper requisition or input
electronically into the patient’s computerized medical record.
■ The technologist performs the examination, and depending on the type of image
acquisition device, the images are processed and repeated as necessary and sent
to the appropriate PACS device. The patient images have been tagged with
informa-

Exam Image processed

Order-entry performed

PACS-based workflow

Image interpreted
Transcribed report
142 CHAPTER 8 PACS
Fundamentals
Figure 8-7 This diagram represents a typical PACS-based workflow from order entry to
transcribed report.
 System 141
Architecture

tion from the RIS so that historic image reports are available at the PACS when
the new images are sent.
■ The requisition is either taken to the radiologist, or the radiologist may pull the
images from an electronic worklist. The radiologist also pulls up historic images
and reports and compares the previous images with the current images.
■ The radiologist dictates a report and has it transcribed, or voice recognition
software may be used. If the radiologist uses voice recognition software, he or she
can review the report right after dictation, make corrections, and sign the report,
making it final.

With PACS it is possible that the time it takes from performing the examination
to completing the final radiologist’s report is only a couple hours, compared with a
couple days for the film-based workflow.

SYSTEM ARCHITECTURE

System architecture can be defined as the hardware and software infrastructure of a

computer system. In a PACS, the system architecture normally consists of
acquisition devices, storage, display workstations, and an image management system.
The following discussion outlines three common PACS architectures and takes a look
at the flow of images after acquisition.

Client/Server-Based Systems
In a client/server-based system, images are sent directly to the archive server
after acquisition and are centrally located (Figure 8-8). The display workstation
functions as a client of the archive server and accesses images based on a centralized
worklist that is generated at the archive server. The health care worker at the
display workstation chooses a name from the central list, and the archive server
sends the image data to display station. After the “client” is finished, the image data
are flushed from its mem- ory. Most systems allow basic image manipulation at the
display workstation or “client,” and the changes are saved on the archive server.

Advantages
■ Any examination sent to the PACS is available anywhere without other interventions.
■ Only one person can open the study with the intent to read it. Others that open
the study will receive a message that the study is open and being read.
■ There is no need to pull or send historic images to a particular workstation because
the old studies are available with the new on the archive.

Disadvantages
■ The archive server is seen as a single point of failure. If the archive goes down,
the entire system is down, and no image movement can take place. All newly
acquired images must remain at the modality until the archive is up and can
again receive the images.
142 CHAPTER 8 PACS
Fundamentals

image
ima
As grecs
h serve
iv e
imr ag es

Reading room 1 Reading room ER Reading room

2

image
ima
As grecs
h serve
iv e
imr ag es

Reading room
ICU
Figure 8-8 A client/server-based system architecture.

■ The system is very network dependent. The images are flying back and forth
between the archive and the workstations, and the network can become bogged
down because of the large volume of data being moved.
■ The archive server is handling many requests at once and can become bottle-
necked because of the high volume of requests.

Di stributed Systems
In a distributed or stand-alone system, the acquisition modalities send the images to a
designated reading station and possibly to review stations, depending on where the
order originated (i.e., ICU or ER) (Figure 8-9). In some systems, the images are sent
from the modality to the archive server, and the archive server distributes the
images to the designated workstation. The reading station designations may be
designed based on radiologist reading preferences. For example, MRI may be sent to
one station and CT to another, or all cross-sectional neurological images may be
sent to one station but all body imaging are sent to another. The designation is
decided after extensive workflow observation. Moreover, in a distributed model, the
worksta- tions can query and retrieve images from the archive. All images are then
stored locally and then are sent to the archive server after they have been read. These
images remain on the local hard drive of the workstation until they are deleted
either by a user or by system rules.
 System 143
Architecture

CT CT MRI MRI

images
images
Archive
images C-
PET/Spec images
images Arm
images

US Fluor
o

US CR/DR CR/DR

Figure 8-9 A distributed system architecture model.

Advantages
■ If the archive server goes down, local reading at the workstations is not inter-
rupted, other than not being able to get historic images. After the archive comes
back up, the images that have been changed and signed off by the radiologist
will be forwarded automatically to the archive to be saved.
■ Because the images can be distributed to many locations at once, copies of an
examina- tion exist at various locations. Therefore it is less likely that PACS data
will be lost.
■ The system is less dependent on the network for its speed. The user can be
work- ing on one examination while the workstation is pulling and getting the
next examination ready to be read. The workstation can fetch historic images
according to rules the user sets up.

Disadvantages
■ There is heavy reliance on the assumption that the distribution of images is
being done correctly. If the distribution is wrong, the prefetching of historic
examinations will not be correct either.
■ Each workstation has a different worklist, and therefore only one person can be
working on that list at a time.
■ It can be inconvenient to read additional studies; the radiologist would have to
move to another workstation to read the images designated for that
workstation.
■ The users must depend on the query-and-retrieve function when nonscheduled
examinations arrive at the workstation to be read.
144 CHAPTER 8 PACS
Fundamentals

■ It is also possible for two radiologists to be reading the same examination and
not know that the other has it until they try to start dictation. The paper
requisition is very important with this type of PACS.

Web -Based Systems

A web-based system is very similar to a client/server system in how data flow. The sig-
nificant difference is that both the images and the application software for the client
display are held centrally (Figure 8-10). In a client/server system, the client still has
appli- cation software locally loaded to the client, and only the images are held at the
archive.

Advantages
■ The hardware at the client can be anything that will support an appropriate web
browser. This allows for greater flexibility with hardware but can also be a
disadvan- tage because image displays (monitors) may not be able to support
diagnostic quality.
■ The same application can be used on site and at home in teleradiology
situations. Teleradiology is a term used to describe the reading of images from
outside of the hospitals walls. It can be down the road at the radiologist’s home
or on the other side of the world during nighttime hours.

Disadvantages
■ The system’s functionality may be limited because the software is not installed
locally. The bandwidth of the network connection limits the amount of data that
can be transmitted for download, and some programs are too large to be
transmitted over the network that is installed.
■ As with client/server systems, the network is the biggest obstacle to performance.

images
images
image image
s
Web
image
image
s s
images s
Archive Server
images

images images

images images
images

Figure 8-10 A web-based system architecture.

 Display 145
Workstations

DISPLAY WORKSTATIONS

The display workstation is the most interactive part of a PACS, consisting of a

monitor and a computer with a mouse and keyboard. In addition, each system has
hardware that fits the users’ requirements.
As you know, conventional film/screen radiography uses large multiviewer
light- boxes to display the images (Figure 8-11). Early in the history of PACS,
radiologists believed that they needed four to six monitors to match the viewing
capability they had with the lightboxes. As the radiologists have become more
comfortable viewing images on monitors, the number of monitors required by the
radiologists has decreased to an average of two (Figure 8-12). This decrease can
also be attributed in part to the continued development of viewing software and
better hardware, namely, mice.
The monitor is one of the most important elements of a PACS display
station. The cathode ray tube (CRT) (Figure 8-13) and the liquid crystal display
(LCD) (Figure 8-14) are the most popular types of monitors in a radiology
department. The LCD has decreased in price and increased in quality during the past
few years and will soon take over the entire PACS display market because of its
size, resolution, and lack of heat production. The LCD also requires less
maintenance, gives out more light, and can be used in areas with a high amount
of ambient light. In early PACS reading rooms, supplemental air conditioning had
to be installed to offset the heat put out by multiple CRTs. Along with the
number of monitors used, the

Figure 8-11 Multiviewer lightbox that was commonly seen in radiology departments for
146 CHAPTER 8 PACS
Fundamentals
film viewing.
 Display 147
Workstations

Figure 8-12 A four-bank monitor workstation and a two-bank monitor workstation.

resolution and orientation of the monitor are also factors in determining which type
of monitor to buy for each workstation. Most cross-sectional imaging is read on a 1K
square monitor (Figure 8-15), and most CR and DR are read on at least a 2K portrait
monitor (Figure 8-16).
Remember from Chapter 2 that a basic picture element on a display is known as
a pixel. The number of pixels contained on a display is known as its resolution. The
relationship between pixels and resolution can be stated as follows: the more pixels
in an image, the higher the resolution of the image, and the more information that
can be displayed. Resolution can also be defined as the process or capability of
distin- guishing between individual parts of an image that are adjacent. Pixels are
arranged in a matrix. A matrix is a rectangular or square table of numbers that
represents the pixel intensity to be displayed on the monitor. Common screen
resolutions that are found on today’s monitors are 1280 × 1024 (1K), 1600 × 1200
(2K), 2048 × 1536 (3K),
and 2048 × 2560 (5K).
148 CHAPTER 8 PACS
Fundamentals

Figure 8-13 A cathode ray tube (CRT) monitor.

(Courtesy Agfa, Mortsel, Belgium.)

Figure 8-14 A liquid crystal display (LCD) monitor.

(Courtesy Barco, Kortrijk, Belgium.)

Medical displays are generally of a higher quality than displays used for other
applications. Radiologists often use the highest resolution monitors available for the
modality that is being read. For example, mammography requires a 5K or 5-
megapixel resolution to provide the viewing capacity needed, but a cross-sectional
image requires only a 1K monitor to view the necessary information. Because a
referring physician is not the primary doctor reading the examinations, a 1K
monitor would be sufficient for his or her viewing needs.
 Display 149
Workstations

Figure 8-15 A 1K monitor.

(Courtesy Barco.)

Figure 8-16 A 2K monitor.

(Courtesy Barco.)
 Display 149
Workstations

Display stations can be categorized by their primary use: primary reading

stations for radiologists, review stations for referring physicians, technologist
quality control (QC) stations where technologists review images, and image
management stations for the file room personnel. Each of these workstations has one
specific main purpose and is strategically located near the end-user of its designated
purpose.

Radiol ogist Reading Stations

The radiologist reading station (Figure 8-17) is used by a radiologist when making
a primary diagnosis. The reading station has the highest quality hardware, including
the best monitor. The computer hardware meets the needs of the PACS vendor, but
it will usually be very robust, requiring little downtime. The keyboard and mouse
can be customized. There are many different styles of mice available that can
increase the efficiency of the software being used (Figure 8-18).
There is generally access to a nearby RIS, with a dictation system near or even
connected to the PACS station. Many PACSs have software that integrates the RIS
and dictation system.

Physici an Review Stations

The physician review workstation (Figure 8-19) is a step-down model of the
radiolo- gist reading station. Many vendors use the same level of software but may
eliminate some of the more advanced functions. One of the most important features
on a physician review station is the ability to view current and previous reports along
with

Figure 8-17 A radiologist reading station.

150 CHAPTER 8 PACS
Fundamentals

Figure 8-18 A wheel mouse, trackball mouse, and an ergonomic mouse.

(Courtesy Logitech, Fremont, CA.)

Figure 8-19 A physician review station.

the images. This can be accomplished with the integration of RIS functions with the
PACS software mentioned above. Most referring physicians want to read the radiologist’s
report along with seeing the patient’s images, and often the report is more important
to them than the images.
The software may either be loaded on a stand-alone station that is dedicated to
viewing images, or it may be delivered over a web browser on any personal
computer (PC) within an office or on a floor. In high-volume areas such as the
ER and ICU
 Display 151
Workstations

(Figure 8-20), there are dedicated PACS workstations for image viewing. These
dedi- cated stations may have the higher-end monitors like the radiologist reading
stations, but many may have lower-end monitors because of cost constraints.
One of the greatest advantages of a PACS is the ability to view the same set of
images in multiple locations at one time. In the film/screen era, referring physicians
would make the trek to the radiology department to consult with a radiologist about
a patient’s image, hoping that the films would be found in the file room and that the
radiologist was available to consult. Now with PACS, the referring physician can pull
up the patient’s images in his or her office and read the radiologist’s report. The
refer- ring physician and the radiologist can consult on the telephone while looking
at the images simultaneously. This is one way that PACSs have improved continuity
and speed of patient care.

Technolo gist QC Stations

The technologist QC station (Figure 8-21) is used to review images after acquisition
but before sending them to the radiologist. The QC station may be used to improve
or adjust image quality characteristics, or it may be used to verify patient
demographic

Figure 8-20 A physician review workstation.

152 CHAPTER 8 PACS
Fundamentals

Figure 8-21 A technologist QC workstation.

information. Many QC stations are placed between the CR and DR acquisition

modalities as a pass-through to ensure that the images have met the departmental
quality standard. The technologist QC station generally has a 1K monitor. When
manipulating images, the technologist must be careful not to change the appearance
too much from the original acquired image. The technologist should consult fre-
quently with the radiologist to ensure that the images being sent are of the required
quality.
The QC workstation can also be used to query and retrieve historic images
before beginning an examination so that the technologist can check previous
pathology or
 Display 153
Workstations

body characteristics. This can help with the selection of technical factors or
procedural protocol. It is common protocol in a film-based department to pull film
jackets on patients before performing an examination. The QC station affords the
same benefit as pulling the film jacket.

File Room /Image Management Stations

The file room in a PACS environment has seen many changes in the past few years.
Before PACS, the file room was a large open room with endless rows of shelves full
of film jackets. Today a file room in a PACS environment may be as simple as a
couple of computers and a dry laser to make copies for outside needs.
The file room workstation (Figure 8-22) may be used to look up examinations
for a physician or to print copies of images for the patient to take to an outside
physician. Many hospitals are moving away from printing films to save the cost of
the film and are instead moving toward burning compact disks (CDs) with the
patient’s images because they are less expensive. The CD of images can be viewed
on any PC and generally comes with easy-to-use software burned onto it with the
images.
The file room may also be responsible for correcting patient demographics. If
images with incorrect demographics are sent to the archive, then it is difficult to pull
those images the next time the patient comes in for an examination. The archive is a
database and is only as good as the information that is put into it.

Figure 8-22 A file room workstation used for image management purposes.
154 CHAPTER 8 PACS
Fundamentals

Common Fun ctions

This section provides an overview of common functions found on a PACS worksta-
tion. All of the functions should be available on any level of the workstation except
for the advanced functions, which are specific to different types of workstations. The
functions can be broken down into four categories: navigation functions, image
manipulation and enhancement functions, image management functions, and advanced
workstation functions.

Navigation Functions
Navigation functions (Figure 8-23) are used to move through images, series, stud-
ies, and patients. The worklist is used to navigate through patients. Most worklists
are customizable for the user. One doctor may want to see only unread CT studies,
and another may want to see all neurologic studies done that day regardless of the
modality. Most modern PACS software conforms to the Windows (Microsoft, Red-
mond, WA) look and feel. The use of grab bars on the right side of Windows to scroll
through a list and the activation of the scroll wheel on the mouse to scroll through
the list are common features. The mouse is also a very useful navigation tool. The
right mouse offers many short-cut features in a menu of frequently used tasks and
applications.

Hanging Protocols
Once a patient has been selected from the worklist, the images load into the display
software. In most PACSs, each user has the ability to set up custom hanging proto-
cols. A hanging protocol (Figure 8-24) is how a set of images will be displayed on

Figure 8-23 A screen shot of PACS worklist.

 Display 155
Workstations

Previous study

Current study

Previous study

Figure 8-24 Typical hanging protocols seen on a PACS workstation.

the monitor. For example, when I select a CT examination, I want to view four
images on each monitor, but when I view a CR image, I want to view one image
on each monitor.
Users can choose the hanging protocols they prefer for each modality. The
hanging protocols can also be required to show the previous examination on one
monitor and the current examination on the other. Once the hanging protocols have
been set, the most efficient study navigation is determined.

Study Navigation
A study in PACS is the current or previous examination being viewed. A study may
comprise two or three single images such as the case with CR and DR, or it may con-
tain several series of images such as the case with MRI. The images can be paged
through either with the scroll wheel or with arrows on the keyboard, or they can be
run through in stacks. Many vendors call the stack mode of scrolling through images
cine. This term comes from the word cinematic, and it means to move through frame
by frame of the series of images. The images can be quickly moved through manually
using the mouse, but most vendors have an automatic setting that runs through the
images at a preset pace. The cine function is used most often in cross-sectional
imaging.
Many vendors provide icons (pictures within the software that activate
software functions) that allow the user to move among a patient’s various studies or
open the next unread patient in the worklist after having read the current study.
Another navi- gation tool that is commonly found is a close patient or close study
icon. This icon
156 CHAPTER 8 PACS
Fundamentals

closes the active patient or study and either pulls up the worklist or moves to the
next unread patient in the worklist. Users can set up these tools according to their
prefer- ences.

Image Manipulation and Enhancement Functions

Once the images have been opened on the display, there are many tools that can be
used to change the appearance of the image. Here is a bulleted list of some of the
most commonly used functions:

■ Window/level (Figure 8-25): This is usually a default function of the left mouse
button when an image is actively displayed in the software. By depressing and
holding down the mouse button and moving the mouse up and down and left
and right, the window and level can be adjusted. The window represents the
range of gray values that are being viewed, and the level represents the center
value of the range. Changing the window and level changes the brightness and
contrast of the image on screen.
■ Annotations (Figure 8-26): Most PACSs can annotate text or graphics onto the
image. This function should NOT be used to label left or right to indicate the
patient’s side because digital R and L will not hold up in court because of the
abil- ity to mark anywhere on the image and flip and rotate the image into any
layout on the screen. Annotations can indicate prone or supine, 30 minutes,
upright or flat, or any other image information the department deems
appropriate. Radiolo- gists frequently place arrows or circles around pathology
or questionable areas so that the referring physician can pinpoint what is in
question.
■ Flip and rotate (Figure 8-27): These functions are used to orient the image in
the anatomical hanging position desired by the department. There are usually
left-to-

Figure 8-25 The same image, but each has a different window/level setting.
 Display 157
Workstations

Figure 8-26 Text annotations can be placed directly on the image.

Figure 8-27 This image has been flipped left to right.

right flip and 90-degree clockwise and counterclockwise icons. This function
makes it very important that lead markers are used to ensure that the
radiologist reads the correct side.
■ Pan, zoom, and magnify (Figure 8-28): These functions are used primarily by
the radiologist to increase the size of an area on the image. The magnify
function will usually enlarge a square area of the image, and the square can be
moved around the image to quickly see various areas enlarged. The pan and
zoom functions are
158 CHAPTER 8 PACS
Fundamentals

Figure 8-28 This section of the image has been magnified to show closer detail of the bone.

usually used together. The image is first zoomed up to the desired magnified level,
and then the pan icon is activated so that the zoomed image can be moved
around, allowing the user to view the different areas of the image.
■ Measurements (Figure 8-29): There are various measurement functions found on
a PACS station. The most common is the distance measurement. The size of a
pixel is a known measurement, so the software can measure structures on the
image based on this known measurement. Another common measurement is
the angle measurement, which measures the angle between two structures. It is
com- monly used when reading spine studies. Another common measurement a
radi- ologist may use is a region of interest (ROI). It will determine the pixel
intensity of a certain area. Because each type of tissue or fluid has a little bit
different inten- sity reading, the radiologist can make a determination whether
something is solid or fluid.

Image Management Functions

Most PACSs allow the user to modify patient demographics (Figure 8-30) at the
tech- nologist QC station, the reading station, and the file room station. It is
imperative that the patient demographics are correct. If wrong information is
archived, images will not come up when correct information is entered when trying
to retrieve them. Only make changes when the information is absolutely known to
be wrong. To mini- mize errors, many hospitals only allow certain people the access
to change demo- graphics.
Another image management function is the query/retrieve function used to
retrieve studies from the archive (Figure 8-31). The query function allows the user
to
 Display 159
Workstations

Figure 8-29 The distance measurement tool can be used to measure structures on the image.

Figure 8-30 Patient demographics can be changed after image acquisition on

some PACS workstations.
(Courtesy Fuji.)
160 CHAPTER 8 PACS
Fundamentals

Figure 8-31 The user can query images from the archive using various search parameters.

query a study on multiple fields such as the patient’s name or ID, date of service, or
modality. Some systems also allow a query based on a diagnosis code or comment
field.
Many vendors have provided a CD-burning option that allows users to save
studies to a CD for outside use. The feature may only be available in the file
room to control the CDs that are sent out. Health Insurance Portability and
Account- ability Act (HIPAA) compliance must also be maintained. Another
common fea- ture is the ability to copy and paste images into a document. This is
frequently used with the web-based systems when creating presentations for
conferences. The patient information must be removed from the image before it is
placed into a presentation.
Some hospitals have retained the ability to print films for outside use. This is
also usually done only in the file room so that control can be maintained over the
printed films for HIPAA purposes and cost reasons. Some hospitals have also
connected workstations to paper printers for quick consults and medical records.

Advanced Wo rkstation Functions

Advanced functions are usually placed on specialty workstations for the radiologist,
but some are found on the technologist QC station to further enhance the images.
Here is a bulleted list of some of the most common advanced functions.
 Display 161
Workstations

Reading Station Advanced Functions

■ Multiplanar reconstruction (MPR) (Figure 8-32): One of the most commonly
used three-dimensional (3D) rendering techniques. When doing a CT scan of a
patient, thin axial slices can be acquired of a volume of tissue. The slices can
then be loaded into the MPR software, and a reconstruction in another plane
can be produced. The most common application is producing coronal images
from the axial set to reduce radiation to the patient and scan time at the
modality.
■ Maximum intensity projection and minimum intensity projection (MIP and
MinIp) (Figure 8-33): Used to visualize vessels (MIP) and air-filled structures
(MinIp). Commonly performed after the injection of contrast on CT and MRI
studies, the contrast will show areas of strictures and blockages within the
vessels.
■ Volume rendering technique (VRT) (Figure 8-34): Similar to MIP but allows the
user to assign colors based on the intensity of the tissue so that bone, contrast
agent, and organs can be seen in different colors. The technique uses a
histogram-type graph to differentiate the various structures.
■ Shaded surface display (SSD) (Figure 8-35): Using a threshold of pixel intensity
values, everything below the threshold will be removed, and everything above
will be assigned a color and shown as a 3D object.

Figure 8-32 An MPR image.

(Courtesy Siemens, Berlin and Munich, Germany.)
Figure 8-33 An MIP image.
(Courtesy Siemens.)

Figure 8-34 A VRT image.

(Courtesy Siemens.)
 Display 163
Workstations

Figure 8-35 A 3D shaded surface image.

(Courtesy Siemens.)

Technologist QC Station Advanced Functions

■ Stitching (Figure 8-36): Used when multiple images need to be put together into
one image. The most common application is for full-spine x-rays or a scoliosis
series. The examination was traditionally performed on a 3-foot film and pro-
cessed; CR manufacturers have developed a 3-foot CR cassette that contains
mul- tiple imaging plates (IPs). Each of the IPs is scanned through the reader,
and the individual images are sent to the QC workstation. The software then
interpolates the images and connects them using known markers from the IPs.
The technolo- gist can adjust how the images are connected. Another
application of stitching is producing long leg images for leg length discrepancy
studies. The images are acquired in a fashion similar to the one described above
and stitched together. If the special 3-foot cassettes are not available, a
radiopaque ruler must be used to ensure that the images are stitched at the
right area.
■ Image postprocessing: Is regarded as an advanced function of the workstation.

There are many other advanced workstation functions available to be added to the
PACS workstation. This is a growing field with advancements coming each year. Spe-
cific information about how to perform these procedures can be found in the
vendor’s user manual.
164 CHAPTER 8 PACS Fundamentals

Figure 8-36 This image was stitched together from two separate images.
(Courtesy Siemens.)

SUMMARY

■ A PACS consists of digital acquisition, display workstations, and storage devices

interconnected through an intricate network.
■ DICOM is a universally accepted standard for exchanging medical images
between the modality, viewing stations, and the archive.
■ A display workstation is any computer that a health care worker uses to view a
digital image, and it is the most interactive part of a PACS.
■ The archive is the central part of the PACS and houses all of the historic data
along with the current data being generated.
 Chapter Review Questions 165

■ Workflow is how a process is done step by step or how a task is completed.

■ System architecture can be defined as the hardware and software infrastructure
of a computerized system.
■ Common system architectures found with a PACS are client/server-based sys-
tems, distributed or stand-alone systems, and web-based systems.
■ Display stations can be categorized by their primary use, such as reading
stations for radiologists, review stations for referring physicians, technologist
QC station for technologist review of images, and image management station for
the file room personnel.
■ There are many functions available on a PACS workstation, and each set of func-
tions can be broken down into four categories: navigation functions, image
manip- ulation and enhancement functions, image management functions, and
advanced workstation functions.

CHAPTER REVIEW QUESTIONS

1. What does the acronym PACS stand for, and

5. What are the advantages and disadvantages of
what is its definition?
the three system architecture models?
2. What are the different types of PACS worksta-
6. What are the most common functions found on
tions, and how are they used?
a PACS workstation?
3. Define workflow, and give an example of a
7. What specialized PACS workstations may be
generic PACS workflow from scheduled proce-
found in a hospital, and how are they used?
dure to finalized report.

4. What is the definition of system architecture,

and what are the three major models?
 CHAPTER 9

PACS Archiving

Archiving Components

Image Manager
Image Storage

Archive Considerations

166
 OBJECTIVES

1. Describe the use of an image archive. 5. Compare and contrast the various
2. Explain the function of the image manager. long-term archive technologies used in
3. Discuss the uses of short-term archive current picture archival and
storage. communication systems.
4. Describe the levels 0, 1, 3, and 5 of 6. Define the concept of an application
redundant array of independent disks.
service provider.

K E Y T E R M S

Application service provider Magnetic disk storage

(ASP) Archive Magneto-optical disk
Archive server (MOD)
Digital versatile disk (DVD) Redundant array of independent
Disaster recovery (inexpensive) disks (RAID)
Image Tap
manager e
Image Tier
storage Ultra density optical (UDO) disk
167
168 CHAPTER 9 PACS
Archiving

ARCHIVING COMPONENTS

The term archive can be defined as a place where records or documents are
preserved (Figure 9-1). In a picture archival and communication system (PACS), the
electronic archive serves as the new file room and warehouse for all digital imaging
and commu- nications in medicine (DICOM) imaging modalities (Figure 9-2). It
stores all patient and image data, often on magnetic tape or optical disk. The PACS
archive controls the receipt, storage, and distribution of new and historic images.
With the explosion of digital imaging in radiology, the archive is one of the fastest
growing components in the PACS. Archive technology continues to make drastic
improvements each year; the storage capacity is said to double every 18 to 24
months, and the price per gigabyte also continues to decrease.
The archive is a complex arrangement of computers and storage space. As a
whole, it consists of several components, both hardware and software. These can be
divided into two major categories: image manager/controller and image
storage/server or

Figure 9-1 The archives at the National Archives in Washington, DC.

 Archiving 169
Components

Figure 9-2 MOD and jukebox.

(Courtesy Sun Microsystems.)

archive server. The next two sections discuss image management and image storage.
Various types of image storage hardware are described. The chapter ends with a
dis- cussion of things to consider when choosing an archiving system.

Im age Manager
The image manager contains the master database of everything that is in the
archive. It controls the receipt, retrieval, and distribution of the images it stores and
also con- trols all the DICOM processes running within the archive.
The image manager generally runs a reliable commercial database such as
Sybase (Sybase Inc., Dublin, CA) or Oracle (Oracle Corp., Redwood Shores, CA) with
struc- tured query language (SQL). This database contains only the image header
informa- tion, not the image data. The image data are stored on the archive server,
which will be discussed in the next section. The database is mirrored, meaning that
there are two identical databases running simultaneously so that if one goes down,
the system can call on the mirror and continue to run as normal, a very important
feature.
The image manager is also the PACS component that interfaces with the radiol-
ogy information system (RIS) and the hospital information system (HIS). This allows
170 CHAPTER 9 PACS
Archiving

the PACS database to collect additional patient information that is necessary for its
effective operation. Information extracted from these databases will be used in the
prefetching and routing of images to various locations throughout the PACS. The
image manager can also play a key role in populating image information into the
hos- pital electronic medical record (EMR).
As mentioned earlier, the image manager database contains the DICOM header
information, such as the patient name, identification information (ID), examination
date, ordering physician, and location. These fields are organized within the database so
that when someone queries for a study on a workstation, the image manager can
quickly move through these data fields and locate the images that are being queried
(Figure 9-3). The database has pointers associated with each image on the archive
server that point back to the data fields within the database. The following list
summarizes the process:

■ An order is placed in the RIS for a radiology study.

■ The images are acquired and sent to the archive.
■ The image manager strips the image header from each image and assigns a
pointer to each image or series of images.
■ The database files the information in various fields and communicates back to
the RIS to verify certain information.
■ The study is then queried, and the pointers locate the images on the archive
server and send the images to the workstation.

Figure 9-3 The PACS database can be queried using various data points.
 Archiving 171
Components

Ima ge Storage
The image storage or archive server consists of the physical storage device of the
archive system. It commonly consists of two or three tiers of storage. A tier is a
level, layer, or division of something. In an archive server, a tier represents a specific
level of archive: short term, mid term, or long term. Most PACS archive systems are
set up with a short-term tier and a long-term tier. Short-term means being online or
avail- able very quickly, usually within 3 to 5 seconds. Long-term means near line, or
images that must be retrieved from a tape or disk storage device and brought to
redundant array of independent disks (RAIDs). This could take 1 to 5 minutes.

Short-Term Storage
The short-term tier is commonly a redundant array of independent
(inexpensive) disks (RAID) (Figure 9-4). A RAID is composed of several magnetic
disks or hard drives that are linked together in an array (Figure 9-5). The size of
the RAID ranges

Figure 9-4 A redundant array of independent disks.

(Courtesy Sun Microsystems.)
172 CHAPTER 9 PACS
Archiving

Figure 9-5 A RAID array.

(Courtesy Sun Microsystems.)

from several hundred gigabytes to several terabytes. As the individual disk sizes
con- tinue to increase, so does the potential size of the RAID.
In 1988 David Patterson, Garth Gibson, and Randy Katz coined the term RAID
in an article entitled “A Case for Redundant Arrays of Inexpensive Disks (RAID).”
Their presentation introduced five levels of RAID; now there are approximately 11
levels (Figure 9-6), most of which are combinations of the first five. Four RAID levels
that are most commonly used:

■ RAID 0: Data are “striped” across all of the connected disks. “Striping” means
that the data are broken up into pieces, and each disk will have one piece of the
data (Figure 9-7). When the data are called up from the RAID, all of the data are
put together from the disks and presented to the user as a whole.
■ RAID 1: All of the data sent to the RAID are mirrored onto two disks (Figure 9-
8). Mirroring means that all of the data are duplicated and placed onto two
separate disks. This RAID level has full redundancy, meaning that if one disk
goes down, the other one takes over and operation of the system continues. This
is a very expensive system because only half of the total storage is used.
■ RAID 3: The data are striped across all of the disks just like in RAID 0, but there
is one disk that is set aside for error correction. This disk is known as the parity
disk (Figure 9-9).
■ RAID 5: This RAID level is similar to RAID 3 but instead of having the parity
writ- ten to one disk, it is striped along all of the disks within the RAID (Figure
9-10). RAID 5 is the most common level used for a PACS archive because it
provides adequate redundancy and fault tolerance.

The striping of data increases the reliability and performance of the system.
With certain levels of RAID, if one disk fails, the data from that disk can be regener-
ated using the redundancy of data on the other disks. The error correction detects
any transmission errors, and the data will also be regenerated based on the informa-
tion from the other disks. Striping also enhances performance because if all of the
data were on one disk, data added to the disk first would be accessed first, requiring
 Archiving 173
Components

Figure 9-6 RAID levels.

Figure 9-7 RAID 0.

longer wait times for data added to the disk later. Spreading data over several disks
allows all data to be accessed at the same time.

Long-Term Storage
Because RAID is becoming more cost-effective, many hospitals use RAID storage for
both their short-term and their long-term archive. Other long-term storage products
that are still widely used are optical disk, tape, and magnetic disk. Optical disk and
magnetic tape archive solutions use a jukebox (Figure 9-11) to hold the tapes or
disks; the magnetic disk uses an array. The jukebox has controller software that
interfaces
174 CHAPTER 9 PACS
Archiving

Figure 9-8 RAID 1.

Figure 9-9 RAID 3.

Figure 9-10 RAID 5.

 Archiving 175
Components

Figure 9-11 A DVD jukebox.

(Courtesy IBM.)

with the image manager to keep track of exactly where each image is located. The
jukebox controller keeps like studies together as much as possible to minimize
access time. The long-term archive has much higher access times than the short-term
archive, but the price of storage per gigabyte is much less with the jukeboxes.

Optical Disk
Magneto-optical Disk
A magneto-optical disk (MOD) (Figure 9-12) is very similar to a compact disk (CD)
or digital versatile disk (DVD) in that it is read optically with a laser, but the disk
itself is housed within a plastic cartridge. MODs tend to be more reliable than some
of the other long-term storage options. The disks are rather robust and can
withstand many years of reading. They can be read faster than some of their
counterparts. The cost per gigabyte is a bit higher for MODs than for some of the
other long-term storage options, but it is still a viable long-term storage option.

Digital Versatile Disk

Digital versatile disks (DVDs) (Figure 9-13) were first introduced for use in video.
CDs were used by a few early PACS adopters, but they found that the CDs could
not hold enough data to make a CD archive cost and space efficient. DVDs have a
much higher capacity. In 2006, a double-sided, two-layered DVD held 17 GB of
data, whereas a CD held 650 MB. DVDs are the least expensive method for long-
term archiving per gigabyte.

Ultra Density Optical

Ultra density optical (UDO) disk (Figure 9-14) is the new generation MOD.
A UDO disk utilizes blue laser technology in its read and write activities.
Plasmon (Plasmon PLC, Hertfordshire, UK) introduced the first UDO disk in 2004
with a disk
176 CHAPTER 9 PACS
Archiving

Figure 9-12 A magneto-optical disk (MOD).

(Courtesy Plasmon.)

Figure 9-13 A digital versatile disk (DVD).

 Archiving 177
Components

Figure 9-14 An ultra density optical (UDO) disk.

(Courtesy Plasmon.)

capacity of 30 GB (2006 MOD technology was at 9.1 GB), and the capacity is
predicted to increase to 60 GB and then to 120 GB to accommodate industry needs.
Currently, UDO technology operating costs are less than MODs and very competitive
with DVD technology. The tape libraries being offered in 2006 held between 24 and
638 disks.

Tape
Tape (Figure 9-15) libraries provide the greatest scalability of the long-term archive
options. These libraries can grow to hundreds of terabytes, possibly even a petabyte,
and this technology will continue to improve and expand its storage limits. Tape is a
fairly low-cost archive medium that comes in various sizes. These tapes are
contained within a jukebox or library that has multiple drives and a robot arm to
move the tapes in and out of the drives. These libraries can hold between 10 and
1448 tapes in one library (Figure 9-16). Most of the libraries are scalable, meaning
that additional librar- ies can be added to the original.
One of the biggest disadvantages of tape is its unreliability over multiple uses.
The tape can wear after several years of heavy use and may become damaged. Tape
also has a longer access time than its optical counterparts. Tape has greatly
improved over the past few years in its speed and reliability, and it will continue to
be a factor in long-term PACS archiving systems.
There are several types of magnetic tape technologies available:

■ Linear tape open (LTO): LTO technology was developed jointly by Hewlett
Packard (Palo Alto, CA), IBM (Armonk, NY), and Quantum (San Jose, CA) to
make available an open-format tape storage option. Open-format technology
means that users have multiple sources of product and media that enable them
to mix products from various vendors and still maintain compatibility and
function.
■ The LTO format is a high-capacity tape technology. Current LTO-3 technology
holds 400 GB of uncompressed data on a single tape.
■ Digital linear tape (DLT): DLT technology was invented by Digital Equipment
Cor- poration in 1984. It was purchased by Quantum in 1994, and they license the
technol- ogy. DLT tape drives have storage capacities between 40 and 160 GB,
and a newer DLT technology known as super DLT has a capacity of 160 to 300 GB
178 CHAPTER 9 PACS
Archiving
uncompressed.
 Archiving 179
Components

Figure 9-15 A magnetic tape.

(Courtesy Sun Microsystems.)

■ Advanced intelligent tape (AIT): AIT is a high-speed and high-capacity tape

made by Sony (Tokyo, Japan) to compete with the DLT. Sony introduced AIT
in 1996 with a tape capacity of 25 GB; current AIT-4 technology has a capacity
of 200 GB. Sony developed the next generation of AIT tapes, known as SAIT, and
they have an initial capacity of 500 GB. Sony plans for the fourth generation
of SAIT to come out by 2010 with a capacity of 4 TB/tape.

Magnetic Disk
As mentioned earlier in the chapter, as the price of magnetic disk storage (Figure 9-
17) continues to decrease, RAID storage becomes a more feasible option for long-
term storage. When using magnetic disks for long-term storage, the RAID arrays
may be configured into three different but related fashions: direct attached storage
(DAS), network attached storage (NAS), or storage area network (SAN).

■ DAS (Figure 9-18): DAS is coupled to the system just like a short-term RAID. The
DAS storage is connected directly via cable connections and shows up on the
com- puter as different partitions for use. They are typically managed by the
same RAID controller because in essence, the short-term RAID is just being
expanded to have more storage space so that the studies will remain for a
longer period of time.
■ NAS (Figure 9-19): NAS servers are stand-alone RAID arrays that are attached
directly to the network. Multiple NAS servers can be attached to one network to
pro- vide additional fault tolerance, and the load can be balanced throughout the
servers.
■ SAN (Figure 9-20): A SAN is a high-speed, special-purpose network (or subnet-
work) that links different kinds of data storage devices with associated data
180 CHAPTER 9 PACS
Archiving
servers,
 Archiving 181
Components

Figure 9-16 Various tape libraries.

(Courtesy Sun Microsystems.)

such as disk array controllers and tape libraries. SANs are becoming more popular in
health care because of plummeting costs of magnetic disk storage. A SAN can be
used by multiple departments within an institution and provide exceptional
response speed for called-up data. The RAID levels can still be taken advantage
of when they are used in conjunction with a SAN.
182 CHAPTER 9 PACS
Archiving

Figure 9-17 Magnetic disk storage used as a long-term archive.

(Courtesy Sun Microsystems.)

Figure 9-18 A direct attached storage long-term archive.

ARCHIVE CONSIDERATIONS

PACS archives are chosen for many reasons, including system need, system cost, and
system compatibility. Many hospitals do not have the capital funds or the personnel
to implement and operate the complex archive that is needed for a PACS. These
hospi- tals have sought out other alternatives. One such alternative is an application
service provider (ASP). An ASP is a company that provides outsourcing of
archiving and
 Archive 181
Considerations

Figure 9-19 A network attached storage long-term archive.

Figure 9-20 A storage area network.

management functions for a pay-per-use or pay-per-month charge. ASPs give

smaller institutions access to the level of hardware and software they could not
otherwise afford. Moreover, they assume responsibility for the day-to-day
management of the archive system. Many ASP models have a short-term archive
located on hospital prem- ises, and the long-term archive is handled at the off-site
location run by the ASP com- pany (Figure 9-21). The short-term archive may be
leased by the ASP, and the controller will prefetch images from the long-term off-
site storage during the evening and night hours for the next day’s schedule.
182 CHAPTER 9 PACS
Archiving

Figure 9-21 An application service provider model using off-site, outsourced long-
term storage.

Another common use for an ASP is as a disaster recovery mechanism. Disaster

recovery involves making copies of each tape or disk and sending them to another
building or off-site location or by using the ASP model of shipping them to an out-
side company for storage on a pay-per-use policy. Even larger institutions have diffi-
culty purchasing the proper amount of storage for disaster purposes. With proper
disaster recovery, a complete copy of the archive is housed in another location and
immediately available if the front-line archive goes down for any reason. With an
ASP, however, the data may be housed in another state in a large storage silo, and
the duplicated data may not be immediately available. There are many facets to
disaster recovery, but a discussion of them is outside of the scope of this textbook.
The most important thing to know is that backups are completed each day on the
image man- ager database and that there must be some sort of contingency plan
should disaster strike the archive room.
The archive is a complex arrangement of servers, databases, and storage
devices. It is the most integral part of a PACS and is in general the most difficult
piece to fully understand. This chapter presents an overview of the topic but by no
means has presented the information needed to successfully purchase or operate a
PACS archive.
 Chapter Review 183
Questions

SUMMARY

■ The archive is a complex arrangement of computers and storage space that is

the permanent location for digital images.
■ The image manager contains the master database of everything that is in the
archive.
■ The archive server consists of the physical storage devices of the archive system.
■ Most PACS archives are set up with short-term and long-term archive tiers.
■ A short-term tier is commonly a RAID.
■ A RAID is composed of several magnetic disks or hard drives that are linked
together in an array.
■ RAID 5 is the most common RAID level used in PACS archives.
■ Long-term storage devices hold historic images for comparison reading on the
workstations.
■ Tape, optical disk, and magnetic disks are commonly used as long-term archive
solutions.
■ An ASP is a company that provides outsourcing of archiving and management
functions for a pay-per-use or pay-per-month charge.
■ A proper disaster recovery mechanism keeps a complete copy of the archive in
another location that is immediately available in the event that the front line
archive goes down.

CHAPTER REVIEW QUESTIONS

1. What is an image archive?

4. Define RAID, and describe the RAID levels
addressed in the chapter.
2. What are the two major categories of the
image archive and describe their uses?
5. Define long-term archive, and give several
examples of those seen in a radiology depart-
3. Define short-term archive, and give an ment.
example of the most common PACS short-
term archive.
6. What is an ASP, and how can it be used in a
radiology department?
 CHAPTER 10

Digitizing, Printing,
and Burning

PACS Peripheral

Devices Film

Digitizers

Laser Film Digitizers

CCD Film Digitizers
Common Uses of Digitizers

Imagers

Wet Imagers
Dry Imagers
Common Uses of Imagers

CD/DVD Burners

Common Uses of Burners

184 Chapter Review 185
Questions
 OBJECTIVES

1. Explain the differences between laser film 4. Discuss the common uses for imagers
digi- tizers and charge-coupled device in a pic- ture archival and communication
(CCD) film digitizers. system (PACS) environment.
2. Describe the uses of a film digitizer.
5. Identify common uses for compact disk
3. Compare and contrast dry laser (CD)/ digital versatile disk (DVD)
imager tech- nology with wet laser burners in a PACS environment.
imager technology.

K E Y T E R M S

Burner Teleradiolo
Dry gy Wet
imager imager
Film
digitizer
185
186 CHAPTER 10 Digitizing, Printing, and
Burning

PACS PERIPHERAL DEVICES

The previous chapters discussed the digital image acquisition process, picture
archival and communication system (PACS) workstations, and archive systems. This
chapter introduces you to three other components that are common in a PACS: film
digitizers, imagers, and compact disk (CD) burners. Each of these three technologies
plays an important role in the PACS.

F ILM DIGITIZERS

Another way to take a projection radiograph to a digital format other than

computed radiography (CR) and digital radiography (DR) is by using a film digitizer.
The film digitizer (Figure 10-1) scans the analog film and produces numeric signals
for each part of the scanned film. The numbers are fed into a software
application that is

Figure 10-1 Typical film digitizer.

(Courtesy Vidar, Herndon, VA.)
 Film 18
Digitizers 7

attached to the scanner, and the scanner digitally reproduces the image using the
numeric signals that represent each part of the radiograph.
There are two major types of film digitizers, one that uses laser technology and
one that uses charge-coupled device (CCD) technology. Both are equal in quality, but
currently the CCD digitizers are less expensive.

La ser Film Digitizers

A laser film digitizer uses a helium neon laser beam to convert the analog film image
into a digital image (Figure 10-2). A laser inside the digitizer is bounced off a series
of mirrors and scanned across the image. A photomultiplier tube picks up the light
that is transmitted through the film. The laser scans one line at a time, and the
photomul- tiplier picks up a very small area and then moves to the next area. The
electrical signal is then sent to an analog-to-digital converter where the signal is
translated into num- bers based on the optical density of the film and the signal
received. The numbers are then displayed on a monitor based on a look-up table
(LUT) that indicates which shade of gray is associated with each number.
Laser digitizers are considered the gold standard for film digitization, and they
have been around since approximately 1990. These digitizers can scan at various
reso- lutions up to 5K and 12 bit, depending on the application need, and can scan an
image in less than 25 seconds, depending on the scanning resolution. The
disadvantages of laser digitizers include their expense and service needs, including
maintenance, calibration, and quality control (QC) tests.

Lase
r
Io
Radiograp
h

I
Lase
r
bea
m

Scintillation
detector-
photomultiplier
tube

Digital Logarithmic
image
processo
r
Figure 10-2 The process of digitizing a film using a laser film digitizer.
188 CHAPTER 10 Digitizing, Printing, and
Burning

CCD Film Digitizers

A CCD film digitizer uses fluorescent bulbs that shine through the film and a CCD
array that detects the light and transforms it into an electrical signal (Figure 10-3).
The signal is then sent to an analog-to-digital converter and changed into a number
that represents the intensity of light that passed through the film. As with the laser
digitizer, the number is referenced against an LUT, and an image is displayed on a
monitor.
The CCD digitizers are less expensive than the laser digitizers but somewhat
slower. A CCD digitizer can take up to 80 seconds to scan one film through the digi-
tizer, and it can also have problems with extreme light and dark areas on the film.
However, the CCD digitizer image quality has improved over the years, and many
radiologists say that the quality is adequate for their needs.

Comm on Uses of Digitizers

There are many uses for the film digitizer in the modern radiology department. Most
departments list the following reasons for using a digitizer:

■ Teleradiology: Teleradiology is a term used to describe the process of transfer-

ring digitized images for delivery at a distance to radiologists. Many hospitals
use the digitizer to transfer films from off-site clinics to the main department for
pri- mary reading. The films are placed in the digitizer, and the image is
transformed into a digital signal and sent via a network back to the main
department. This saves the radiologist from having to drive to the remote
location to read the few films that have been taken. It is also better patient care
because films will be read much more quickly if sent digitally to the radiologist.
■ Compare outside or old films: If a hospital has a PACS installed and is reporting
the image from a monitor, it is very difficult to compare a film image with the

Fluorescent
bulb

Charged coupled
device

ADC
Digital
image
processor
Figure 10-3 The process of digitizing a film using a CCD film digitizer.
 Imager 18
s 9

image on the monitor. Many hospitals will digitize the patient’s old films so that
a comparison can be done much more easily. Patients also frequently come in
with outside films. These are routinely digitized into the archive so that they can
be referred to at a later date and compared with new digital images.
■ Film duplication: On occasion it is necessary to make duplicate copies of films.
The film can be sent through the digitizer, and then the image can be printed
onto film using a laser film imager.
■ Computed aided diagnosis (CAD): A new technology that is gaining momentum
is CAD. It is most currently used in mammography and chest imaging. The film
is sent through the digitizer, and a computer will analyze the densities seen on
the image and alert the radiologist of questionable densities.

IMAGERS

Imagers, also known as film printers, receive an image from a workstation and print
the image based on printer LUTs and preset print layouts. Both of these parameters
vary for each modality that produces digital images. There are two major types of
imagers that are still in use today: wet (chemical) laser imagers (Figure 10-4) and
dry laser imagers (Figure 10-5).

Figure 10-4 A wet laser imager.

(Courtesy Eastman Kodak Co., Rochester, NY.)
190 CHAPTER 10 Digitizing, Printing, and
Burning

Figure 10-5 A dry laser imager.

(Courtesy Eastman Kodak Co., Rochester, NY.)

Wet Imagers
Wet imagers use chemicals to process the film that has been exposed to the laser.
The laser beam produces an intensity of light that is proportional to the signal being
received to regulate the optical density recorded on the film. The laser emits a red
light, so the film that is used must be red sensitive. As mentioned earlier,
conventional film has silver halide crystals suspended in an emulsion; the wet laser
film is not much different other than being red sensitive so that the laser may etch
the image into the film. Because this film is sensitive to red light, it must be placed in
its film magazine and processed in total darkness. This processing takes place in a
bath of chemicals just like film used in the traditional film/screen department.
Because wet imagers require chemicals, they must be placed in a well-ventilated
area with proper drainage and plumbing. Because of these requirements, fewer
depart- ments install this type of imager. Wet imagers also take up much more space
than the dry imagers, and the cost of chemicals, disposal, and maintenance make
them a less popular choice than dry imagers.

Dr y Imagers
Dry imagers use heat to process the latent image that is etched into the silver
emulsion by the laser. Just like conventional film, dry laser film also has silver within
 CD/DVD 19
Burners 1

its emulsion, but instead of silver halide crystals, the dry film has silver behenate.
The film is exposed with a laser in a fashion similar to the wet imager. The silver
salts are then exposed to heat and turn to metallic silver to create the image on
the film.
Dry imagers have been found to have slightly worse quality than wet imagers,
but the dry imagers take up less space and require no special locations. The dry
imager film quality tends to degrade over time, and it is more sensitive to heat and
humidity than conventional film, especially if the film is stored in a warm
environment. More- over, because the chemicals that make the image are still on the
film after it is pro- cessed, the image can gain more density when stored in a high
heat area. The major advantage to the dry imager is that it only requires an outlet
and a network connection to connect to the departmental modalities.

Com mon Uses of Imagers

Even though the future of radiology is a filmless environment, there will always be
a need for producing a hardcopy film. The following paragraphs outline a few
reasons why film can and will be used in the “filmless” radiology department.

■ Backup: The ability to print just in case the PACS goes down is one of the most
often heard explanations. In most hospital networks, the modalities are set up
to send not only to the PACS but also directly to a laser imager. So if the PACS is
down for some reason, the modality can still print directly to the imager.
■ Difficult PACS locations: When a PACS is installed, there are a few departments
that are difficult to convert to PACS initially, like surgery, orthopedics, and
some- times the emergency room. In surgery, space is at a premium, and it may
be dif- ficult to place a PACS workstation in the surgical suite. In many instances,
films are printed for surgery and placed on a lightbox.
■ Outside physicians: Many referring physicians prefer to see their patient’s images
while reviewing the radiologist’s report. When installing a PACS, one of the last
pieces to be converted is outside physician access so, with imagers, films can be
printed and sent to the physicians as normal.
■ Legal cases: For legal cases, films can be printed to be viewed in court. It may
become more commonplace to have computer access in the courtroom, and at
that time images can be viewed digitally.
■ Teaching purposes: Most hospitals train students at their institution. The printing
of films for training purposes will continue to be a need.

CD/ DVD BURNERS

Early PACS advocates used cost savings to justify purchasing a PACS, but you have
seen that there remains a need for hard copies. Film printing is a costly part of a
PACS because laser film is expensive, more expensive than conventional film. Most
hospitals try to reduce the amount of printing done in the department. One
alternative to printing hard copies is to burn images to an optical disk.
192 CHAPTER 10 Digitizing, Printing, and
Burning

Remember from Chapter 2 that CDs and digital versatile disks (DVDs) are both
thin injection-molded polycarbonate plastic disks. The disk is impressed from a
mold to form microscopic bumps that indicate either a 1 or 0 to the computer. Over
the bumps is a reflective layer of aluminum covered with a clear protective coat of
acrylic. In a DVD there are multiple layers of the polycarbonate plastic. Aluminum is
used behind the inner layers, and gold is used behind the outer layers. The gold is
semire- flective so the laser can penetrate to the inner layers of plastic. With a
burner, the information is burned onto the disk starting in the center and spiraling
out to the edge of the disk. The laser will burn a tiny depression (pit) into the disk to
represent the data being saved. A burned disk will be a series of pits and lands, areas
that were not burned by the laser (Figure 10-6).
All PACS vendors offer the ability to burn images to a CD or DVD for purpose of
sharing the images outside of the PACS. When a disk is burned with the patient’s
images, a digital imaging and communications in medicine (DICOM) viewer is also
burned onto the disk. When the disk is put into a drive, the software automatically
launches and displays the images. The software is generally very intuitive and easy
to use and allows for minor image enhancements such as window/level adjustments
and simple measurements.

Com mon Uses of Burners

These disks can be used in most of the same applications as the printed film with the
exception of using them as a fail-safe mechanism and for those departments that are
in difficult locations. Many referring physicians prefer having the images on disk
rather than film because it takes up less space, can be added directly to the patient’s
office chart, and the images can be manipulated.

Figure 10-6 The process of burning an image to a CD.

 Chapter Review 19
Questions 3

Disks also are much cheaper to produce and send out to physicians. One sheet of
dry laser film is approximately $0.48, whereas a CD is approximately $0.28. The CD
can hold multiple studies, and multiple sheets of film would be needed to print an
entire study. The CD will also be much cheaper to mail than the film. Disks will
become much more common outside of the radiology department as the advantages
are seen by those outside of the department.

SUMMARY

■ A film digitizer scans the analog film and produces numeric signals for each part
of the scanned film.
■ A laser film digitizer uses a helium neon laser beam to convert the analog film
image into a digital image.
■ A CCD film digitizer uses fluorescent bulbs that shine through the film and a
CCD array that detects the light and transforms the light into an electrical
signal.
■ Imagers, also known as film printers, receive an image from a workstation and
print the image based on printer LUTs and preset print layouts.
■ Dry imagers use heat to process the latent image that is etched into the silver
emulsion by the laser.
■ Wet imagers use chemicals to process the film that has been exposed to the laser.
■ A CD/DVD burner can burn images to be shared outside of the radiology depart-
ment. Along with the images, a DICOM viewer is burned to the disk for ease
of viewing.

CHAPTER REVIEW QUESTIONS

1. How does a laser digitizer digitize a film?

5. What is a dry laser imager, and how does it
work?
2. How does a CCD digitizer digitize a film?
6. What are the common uses of film imagers?
3. What are the common uses of a digitizer?
7. How are CD/DVD burners used in a radiology
4. What is a wet laser imager, and how does it department?
work?
This page intentionally left blank
 PART
V

Quality
Control
and
Quality
Managem
ent
 CHAPTER 11

Ensuring Quality in PACS

Quality

Aspects Terms

of Quality

Quality Assurance
Quality Control
Continuous Quality Improvement

PACS Equipment QC

Monitor Quality
Printer Image Quality
Speed
Data QC

PACS CQI

Recognition of Undiagnostic Images

System Up-Time
System Training
196
 OBJECTIVES

1. Describe the differences between quality 4. Discuss the process of daily/weekly QC on

con- trol (QC) and quality assurance laser imagers.
activities. 5. State the common QC activities used
2. Define continuous quality improvement to mea- sure system speed and data
and its uses in a radiology department. integrity.
3. Describe the daily and monthly/quarterly 6. Describe several quality assurance
moni- tor QC activities. activities used in a digital radiology
department.

K E Y T E R M S

Acceptance testing Quality assurance

Continuous quality Quality control
improvement Error Routine
maintenance maintenance
PACS Super user
administrator The Joint Commission
Photometer
197
198 CHAPTER 11 Ensuring Quality in
PACS

QUALITY ASPECTS

When you think of quality, what is the first thing that comes to mind? Is it the
service at a restaurant or the backpack purchased at the beginning of the semester?
Both of these deal with quality in some way: one is people-centered, and the other is
product-centered. Likewise, radiology has both a people-centered quality and a
product-centered quality.
The traditional department with film and chemistry has many quality
procedures that must be followed. Many of these same protocols are used in the
digital depart- ment, but they have been modified to be relevant to digital
equipment and processes. The next section introduces the terms used to talk about
quality within a radiol-
ogy department. The following sections introduce various routines that should be
done in the department to ensure that the picture archival and communication
system (PACS) is functioning properly and that the images are being produced at a
certain quality level. Chapter 12 discusses quality with cassette-based and cassette-
less digital radiographic equipment and processes.

TERMS OF QUALITY

Quality has always been a part of health care, whether as a service or product.
Health care institutions pride themselves on providing the highest quality possible,
and they put many measures into place to ensure that the highest quality is
provided to each patient. The ultimate focus in health care is to improve patient care
and provide a high quality service so that patients will want to return. Most health
care institutions are accredited by the Joint Commission (TJC), formerly know as
the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO).
This accreditation is vol- untary but necessary in many instances to obtain Medicaid
certification, hold certain licenses, obtain reimbursements from insurance
companies, and receive malpractice insurance. Today TJC uses a more all
encompassing term of continuous quality improvement (CQI) or total quality
management (TQM). The next few sections will define these concepts and provide
some basic applications in a digital department.

Quality Assurance
Quality assurance (QA) can be defined as a plan for the systematic observation and
assessment of the different aspects of a project, service, or facility to make certain
that standards of quality are being met. QA activities are focused around people and
ser- vice. In a radiology department there are many processes involved in the day-
to-day activities. For example, once a patient has been checked-in at the front desk,
there is a process that is followed to alert the technologist that a patient is waiting. If
this process is not followed, the patient may have to wait for an extended period
before a technolo- gist arrives to check for waiting patients. This extended wait time
affects patient care in a negative manner, and therefore it will be seen as poor
quality of service. A QA measure should be in place to monitor patient wait times to
 Terms of 19
Quality 9
ensure that the process of alerting a technologist that a patient is waiting is working
properly.
200 CHAPTER 11 Ensuring Quality in
PACS

Most QA activities will produce quantitative data that can be analyzed. These
data can be used to monitor the processes and determine whether the process is
working as it should and whether the standard of quality has been met.

Qu ality Control
Quality control (QC) can be defined as a comprehensive set of activities designed to
monitor and maintain systems that produce a product. QC measures are taken to
ensure that radiologic procedures are performed safely, are appropriate for the patient,
are performed efficiently, and produce a high-quality image. For example, tests are
performed on the radiographic room to make sure that all of the parts are
functioning properly, such as the collimator, generator, and focal spots. All of these
parts make up the whole of the room, and if one part is off, it can cause harm to the
patient or reduce the quality of the examination.
QC measures are required by law to maintain the license for the room or
depart- ment. The data from the various activities are kept by a designated
individual within the department. Most QC activities are part of a QA program, and
the data are used to improve the quality of the processes and department. There are
three major catego- ries of QC test that are used at various times:

■ Acceptance testing: This type of testing is performed before newly installed or

majorly repaired equipment can be accepted by the department. The testing
may be performed by a designated technologist, a radiation physicist, or by
service personnel employed by the hospital. The acceptance testing is used to
determine whether the equipment is performing within the vendor’s
specifications and as promised.
■ Routine maintenance: Routine maintenance is performed to ensure that the
equipment is performing as expected. This type of testing can catch problems
before they become radiographically apparent. This testing may be performed
by a designated technologist, a radiation physicist, or by service personnel
employed by the vendor.
■ Error maintenance: When errors occur in equipment performance, corrective
action must occur. Errors will be detected by poor equipment performance or
poor quality outcomes. These corrections will generally be done by service
personnel employed by the vendor.

Con tinuous Quality Improvement

Continuous quality improvement (CQI) tends to focus on the process rather than
on the people or the service. The belief is that if the process is good, health care
work- ers will follow it, and service will be good. The CQI process does not replace
QA/QC programs. The QA/QC programs focus on maintaining a certain level of
quality, not necessarily improving to a higher quality. CQI focuses on improving the
process or system within which the people function as team members rather than
focus on an individual’s work.
One of the most important concepts to understand with CQI is that all levels of
people within the organization must be involved in the process of improvement.
 Terms of 19
Quality 9

Because CQI focuses not on individuals and their mistakes but rather on the process,
each team member is more apt to participate in improving the organization. It is
very important that everyone participate because if one spoke is not involved, the
wheel will fall off, and the quality cart cannot move forward.

PACS EQUIPMENT QC

When beginning a QC program, care must be taken to document all surrounding

variables so that each quality measure can be repeated without harm to the process.
Documentation is very important in any QC activity, and it must be kept up to date
to make a valid performance measure. As with all quality activities, documentation
is the most difficult part of the process and the easiest part to not complete.
Without the documentation to back up the findings, it will be difficult to prove the
need for repair or update of a system.
The next several sections focus on QC activities that should be monitored in a
PACS environment, including display quality for both monitor and film, processing
speed, network transfer speed, and the data integrity of data that are called back
from the archive. This is not an all-encompassing list. Many vendors have
suggestions for what should be monitored for their systems. It is very important
that you follow the vendor’s list and timetable for these various activities. According
to the American Col- lege of Radiology (ACR) “Technical Standard for Digital Image
Data Management”:
Any facility using a digital image data management system must have documented
policies and procedures for monitoring and evaluating the effective management, safety,
and proper performance of acquisition, digitization, compression, transmission, display,
archiving, and retrieval functions of the system. The quality control program should be
designed to maximize the quality and accessibility of diagnostic information.
The ACR also suggests that all the quality tests described below be carried out with
a Society of Motion Pictures and Television Engineers (SMPTE) test pattern (Figure 11-
1) to ensure continuity of measurements. A test pattern developed by the American
Asso- ciation of Physicists in Medicine (AAPM) Task Group 18 (TG18) (Figure 11-2)
is also becoming more widely accepted for use in these QC tests. The ACR suggests
that QC tasks be performed at least monthly, whereas the AAPM has a much more
rigorous schedule. The AAPM suggests that the testing be performed on acceptance
and annu- ally by a trained physicist, and the daily and monthly/quarterly tests can
be performed by a trained QC technologist or a physicist. If any of the following tests
fails or pro- duces out-of-range readings, corrective action and continued
monitoring should be done. Follow your department’s policy on equipment
maintenance procedures. It may be necessary to contact your radiation physicist to
follow up on your findings.

Moni tor Quality

The monitor is often the weakest link in the digital imaging chain. The monitor has a
direct effect on the quality of the image that is presented to the radiologist for
reading or to the referring physician for review. Unfortunately, it is not cost-
effective to pro- vide the highest quality monitor for all viewing situations. As
202 CHAPTER 11 Ensuring Quality in
PACS
discussed in Chapter 8,
 PACS Equipment 201
QC

Figure 11-1 SMPTE test pattern.

the radiologist workstation will have the highest quality medical grade monitors,
usu- ally 2K or 3K for computed radiography (CR) or digital radiography (DR), 1K or
2K for cross-sectional images, and up to 4K for mammography. As with digital
cameras, the megapixel measurement may also be used to determine the
appropriate monitor. Generally, the physician review workstations and the
technologist QC workstations have high quality commercial monitors. They usually
have a resolution of 1K.
The following QC recommendations for display monitors come from the AAPM
in their document entitled “Assessment for Display Performance for Medical
Imaging Systems.” This document outlines testing to be completed both by
physicists and by technologists/users. The following paragraphs outline the tasks to
be completed by a trained technologist on a daily and monthly/quarterly basis on all
monitors used to view images.

Daily Monitor QC
■ Turn on the monitor, and allow it ample time to warm up.
■ Make sure that the monitor is dust-free on the viewing surface and near the
airflow areas.
202 CHAPTER 11 Ensuring Quality in
PACS

Figure 11-2 AAPM TG18-QC test pattern.

■ Retrieve a QC monitor test pattern (SMPTE or AAPM TG18-QC). (The retrieval

time may also be noted for a later test to be discussed.)
■ General image quality and appearance: Evaluate the overall appearance of the
pattern, and take note of any nonuniformities or artifacts, especially at black-to-
white and white-to-black transitions. Verify that the vertical and horizontal bars
appear continuous.
■ Geometric distortion: Make sure that the borders and lines of the pattern are
clear and straight and that the pattern appears to be centered in the active area
of the display.
■ Luminance, reflection, noise, and glare: Verify that all 16 luminance patches are
clearly visible. If desired, measure their luminance using a luminance meter or
photometer, a device used to measure the luminescence of areas on the
monitor (Figure 11-3). Evaluate the results in comparison to previous
measurements. Make sure that the 5% and 95% patches are clearly visible, and
evaluate the appearance
 PACS Equipment 203
QC

Figure 11-3 A photometer used to measure luminescence.

of low-contrast letters and the targets at the corners of all luminance patches with and
without ambient lighting.
■ Resolution: Evaluate the Cx patterns at the center and corners of the pattern,
and verify that all letters and numbers appear.

Monthly/Quarterly Monitor QC
■ Turn on the monitor, and allow it ample time to warm up.
■ Make sure that the monitor is dust-free on the viewing surface and near the air-
flow areas.
■ Retrieve a QC monitor test pattern.
■ Geometric distortions: Using the TG18-QC test pattern, maximize it to fill the
entire usable display area. For rectangular display areas, the patterns should
cover at least the narrower aspect of the display area and be placed at the
center of the area used for image viewing. The pattern should be examined from
a normal view- ing distance, and the linearity of the pattern should be checked
visually across the display area and at the edges.
■ Reflection: Determine whether there are other light sources like overhead
lights, other monitors, or viewboxes that are reflecting back off of the monitor.
Eliminate or reduce these sources of light if possible, and view test pattern at a
normal viewing distance.
204 CHAPTER 11 Ensuring Quality in
PACS

■ Luminance response: Using the TG18-LN test patterns (Figures 11-4 to 11-6)
and a photometer, measure the luminescence from the center of the monitor for
each pattern, and record each reading. Also take a reading using the photometer
with the monitor in power-save mode or turned off. This will give you a baseline
reading for the ambient luminance coming from the monitor. A cathode ray tube
(CRT) moni- tor should have a luminance reading of greater than 170 cd/m2, and
a liquid crystal display (LCD) should have a luminance reading of greater than
100 cd/m2. There should also be a greater than 250 cd/m2 difference between
TG18-LN-01 and TG18-LN-18 test pattern readings (contrast ratio). Using the
TG18-CT (Figure 11-7) pattern, the half-moon targets in the center and the four
low-contrast objects at the corners of each of the 16 different luminance regions
should be visible. Also the bit- depth resolution of the display should be assessed
using the TG18-MP (Figure 11-8) test pattern. The assessment includes
determining whether the horizontal contour- ing bands, their relative locations,
and grayscale reversals are within limits. Both patterns should be examined
from a normal viewing distance.
■ Luminance dependencies: Nonuniformity—the visual method for determining
display luminance uniformity uses the TG18-UN10 and TG18-UN80 test pat-
terns (Figure 11-9). The patterns are displayed, and the uniformity across the
displayed pattern is assessed. The patterns should be observed from a normal
viewing distance. Angular response may be assessed visually using the TG18-CT
test pattern. The pattern should first be viewed on-axis to determine the
visibility of all half-moon targets. The viewing angle at which any of the contrast
thresholds

Figure 11-4 AAPM TG18-LN-01 test pattern.

Figure 11-5 AAPM TG18-LN-08 test pattern.

Figure 11-6 AAPM TG18-LN-18 test pattern.

Figure 11-7 AAPM TG18-CT test pattern.

Figure 11-8 AAPM TG18-MP test pattern.

 PACS Equipment 207
QC

Figure 11-9 AAPM TG18-UN10 and TG18-UN80 test patterns.

become invisible should be noted. Using the TG18-UNL10 and TG18-UNL80

test patterns (Figure 11-10), luminance is measured at five positions over the
monitor (center and four corners) using a calibrated photometer. The five
readings should be within 30% of one another.
■ Resolution: Using the TG18-QC pattern and the magnifying glass within the
PACS software, examine the displayed Cx patterns at the center and four
corners of the monitor. The line pair patterns in the horizontal and vertical
directions should also be evaluated in terms of visibility, and the average
brightness of the patterns should also be assessed using the grayscale step
pattern as a reference. Note any difference in appearance of the test patterns
between the horizontal and vertical lines. The relative width of the black and
white lines in these patches should also be examined using the magnifying glass.
The resolution uniformity may be determined by using the TG18-CX (Figure 11-
11) test pattern and magnifying glass in the same way that the Cx elements in
the TG18-QC pattern were used.

As mentioned earlier, all annual testing and acceptance testing should be per-
formed by a qualified medical physicist. They follow their own standard set of tests
to make sure that the monitors are performing up to their capabilities.

Print er Image Quality

Besides the PACS, the printed image is another way to distribute images around the
hospital enterprise. As with monitors, there are several steps that should be taken to
ensure that the image being seen is of consistent quality.

Wet Laser Imager

Daily/Weekly QC
■ Monitor each film printed to ensure that it is free from artifacts and that it
matches monitor or desired quality.
■ Print a test pattern from the PACS. Some printers have a built-in test pattern
that can be printed by depressing a button on the printer.
208 CHAPTER 11 Ensuring Quality in
PACS

Figure 11-10 AAPM TG18-UNL10 and TG18-UNL80 test patterns.

■ Observe the printed test pattern for artifacts and changes in density, contrast,
and resolution.
■ Measure the steps on the test pattern using a densitometer, and document your
findings. Create a characteristic curve to compare previous measurements.
■ Monitor the processing mechanism as you would any chemical processor. Note
the temperature, as well as the fixer, developer, and wash levels. Clean the racks
and rollers as appropriate.
■ Make sure that the preventative maintenance schedule is completed in a timely
manner, and maintain documentation of the completion and findings.

Dry Laser Imager

Daily/Weekly QC
■ Monitor each film printed to ensure that it is free from artifacts and that it
matches monitor or desired quality.
■ Print a test pattern from the PACS. Some printers have a built-in test pattern
that can be printed by depressing a button on the printer.
■ Observe the printed test pattern for artifacts and changes in density, contrast,
and resolution.
■ Measure the steps on the test pattern using a densitometer, and document your
findings. Create a characteristic curve to compare previous measurements.
■ Make sure that the preventative maintenance schedule is completed in a timely
manner, and maintain documentation of the completion and findings.

Speed
Speed is always a concern in the radiology department, whether it is the speed at which
patients are brought back for their x-rays or the speed at which the radiologist gets
a final report signed. It is no different in a digital department, but there are other
con- siderations when talking about speed: the processing speed of the workstation
and the image retrieval/transfer rate.
 PACS Equipment 209
QC

Figure 11-11 AAPM TG18-CX test pattern.

Workstation Processing Speed

The workstation processing speed can be measured or documented in many different
ways. The following is a practical way to monitor the speed of your workstation.

■ Determine a study to be used as your test. You must use the same study each
time to ensure there are no variables. Choose a study with several images and a
patient that has several studies.
■ Open the initial test study, and note the loading speed. Page through the images,
and note the loading speed of each image.
■ Choose an image processing function appropriate for the test images that you
have chosen, such as edge enhancement, stitching, or a three-dimensional (3D)
processing function. Perform the function, and note the processing speed. Use
the same tool each time you perform the test to maintain consistency.
■ Open the patient’s next study using the appropriate PACS function. Note the
loading speed of the images.

After acceptance of the workstation, this procedure should be followed weekly

to establish a pattern. If no changes are seen, this procedure can then be done on a
210 CHAPTER 11 Ensuring Quality in
PACS

monthly basis. Anytime the software or equipment is updated, the procedure should
be done on a weekly basis until a pattern is established again.

Image Transfer Speed

Image transfer speed should be monitored from the modality to PACS and from the
archive to a workstation. The following steps are an easy way to monitor these
transfer speeds:

■ Determine a study to be used as your test. You must use the same study each
time to ensure there are no variables. You can also use test patterns that you
have saved on your archive. The procedure should be done on the same day of
the week and at approximately the same time to reduce network traffic
variables.
■ Retrieve the study to the workstation. Note the amount of time it took the entire
study to arrive at the workstation.
■ To test the transfer speed from the modalities, have each modality send their QC
images to the archive, and note the amount of time the transfer takes. Make sure
that the modality sends the exact same image set each time you test.

After acceptance of the system, this procedure should be followed weekly to estab-
lish a pattern. If no changes are seen, this procedure can then be done on a monthly
basis. Anytime the software or equipment is updated, the procedure should be done
on a weekly basis until a pattern is established again.

Data QC
Data Integrity
A constant measure to be monitored is whether all images completed at the
modality make it to the PACS. This is usually caught by the radiologist, but as a
technologist, it is a good practice to monitor this periodically. After initial
installation, you should check on a daily basis to make sure that all of the images
that you sent to the PACS arrived on the PACS. If there are no missing images for
several weeks, this practice can be scaled back to once a week. You can randomly
choose several studies that were sent during the week to determine whether all of
the images made it to the PACS.
Another test for data integrity is to periodically pull up images from the archive
to make sure the same images sent initially are still in the study after archival. This
should also be done on a weekly basis.
After acceptance of the system, this procedure should be followed daily to
estab- lish a pattern. If no changes are seen, this procedure can then be done weekly
and then on a monthly basis. Anytime the software or equipment is updated, the
procedure should be done on a daily basis until a pattern is established again.

Compression Recall
Compression is used to reduce the size of the image files to increase the speed of the
network transfer of the images. Compression protocols need to be established by
your radiologists and radiation physicist. They will determine the level of
 PACS Equipment 211
QC
compression that
 PACS 211
CQI

will be acceptable for your institution. The following steps are a practical way of
observing compression recall of images:

■ Save several versions of the AAPM TG18-QC test pattern on your archive using
different compression ratios as follows:
● No compression
● Lossless compression (2:1 compression ratio)
● Lossy compression (variable compression ratios—use the ratio that your
department uses, if any)
■ Recall all test patterns, and compare the results of no compression, lossless, and
lossy. Determine whether there is any loss of information on the compressed
images. Note any changes in image quality, if any.

PACS CQI

There are many processes used each day in a PACS environment, and each of these
processes should be monitored to make sure that the PACS is functioning up to its
capabilities. Remember that CQI activities revolve around process rather than
people and systems. The next few sections describe several simple CQI activities
that need to be monitored in a radiology department. Many activities that are
monitored before the digital conversion of the department should continue after the
conversion. Each PACS vendor may have different activities that they recommend. All
of these activities should be adhered to so that your PACS will run up to its potential,
and problems can be found before they cause major system downtime.

R ecognition of Undiagnostic Images

One CQI activity that should be monitored is the documentation of undiagnostic
images being forwarded to the PACS. This activity will be primarily carried out by
the radiologists. If a poor quality image is detected by the radiologist, the study and
per- forming technologist are noted, and the information is shared with the lead
technolo- gist or the PACS administrator to follow up with the performing
technologist.
The radiologist may note the areas and reasons for the poor quality image. If the
poor quality image was caused by equipment malfunction, the appropriate QC test
should be carried out, and the appropriate service protocol followed. If the poor
qual- ity image was operator error, additional training or counseling by the
supervisor may be required.

Sy stem Up-Time
Another common QA activity is the monitoring of how often the system is down for
any reason. A log should be kept to note any time that the system is down. Also in
the log note the reason, how long, what had to be done to fix the problem, and who
fixed the problem. If the same problem continues to occur, this log can be used to
prove that either a piece of equipment needs to be replaced or that additional
service is needed.
212 CHAPTER 11 Ensuring Quality in
PACS

Sys tem Training

System training is a very important activity that must never stop. One of the early
misconceptions of installing a PACS is that the vendor applications training would
be sufficient for training all staff that interact with the PACS. This is far from the
truth. The vendor applications personnel are usually on site for 1 to 2 weeks during
initial installation. The vendor applications training is supposed to train several
super users (people who are trained on all aspects of the system and are prepared
to train others) and help set up the system to site specifications.
The super users and the PACS administrator (the person trained to oversee
the PACS) need to set up an ongoing training program. The training program must
include several skill levels, from the radiologist to the technologist to the ancillary
personnel. Each new employee needs to be trained on the system. Each time that a
new version of the software is installed, the training protocol needs to be revised;
retraining of existing personnel may be necessary. Each department also has a list of
skills that are tested and retrained each year. PACS skills should be included in this
annual training. A training record should be kept for each employee to show proof
of skills.

SUMMARY

■ Most hospitals are voluntarily accredited by TJC. This accreditation is necessary

to obtain Medicaid certification, hold certain licenses, obtain reimbursements
from insurance companies, and receive malpractice insurance.
■ QA can be defined as a plan for the systematic observation and assessment of
the different aspects of a project, service, or facility to make certain that
standards of quality are being met.
■ QC can be defined as a comprehensive set of activities designed to monitor and
maintain systems that produce a product.
■ Acceptance testing is performed before newly installed or substantially
repaired equipment being accepted by the department.
■ Routine maintenance is performed to ensure that the equipment is performing
as expected.
■ Error maintenance occurs when errors are detected in equipment performance.
■ CQI tends to focus on the process rather than the people or the service. CQI
focuses on improving the process or system in which people function as
members of a team rather than focus on the individual’s work.
■ The following QC activities should take place on a prescribed basis:
● Daily and monthly/quarterly monitor QC
● Printer image quality
● Speed assessment
● Data QC
■ Most CQI activities that were in place before the conversion to a digital depart-
ment should continue. Others should be developed, such as system up-time and
system training.
 Chapter Review 213
Questions

CHAPTER REVIEW QUESTIONS

1. What are the differences between quality con-

4. What are the quality control activities that
trol and quality assurance activities?
should be performed on the laser imagers in
the radiology department, and how often
2. What is the definition of continuous quality
should these activities be performed?
improvement, and what are its uses in the
radi- ology department?
5. How would system speed and data integrity be
measured as part of the QC program?
3. What are the quality control activities that
should be performed on the computer
6. Describe several quality assurance activities
monitors in the radiology department, and
used in a digital radiology department.
how often should these activities be
performed?
 CHAPTER 12

Total Quality
Management of CR and
DR Systems

Total Quality Management

Quality Control

Standards

Quality Control Schedules and

Responsibilities

Technologist Responsibilities
Service Personnel Responsibilities
Radiation Physicist Responsibilities
 Chapter Review 215
Questions

214
 OBJECTIVES

1. Discuss total quality management (QM) 5. Become familiar with problem-reporting

and its uses in digital imaging. respon- sibilities.
2. Describe the daily, weekly, and monthly 6. Recognize the QM/QC activities to be
quality control (QC) activities assigned to per- formed by the radiation physicist.
a radiologic technologist. 7. Acknowledge personal responsibilities
3. Explain the importance of establishing a for cor- rectly marking images,
repeat analysis database with digital maintaining personal repeat rates, and
imaging. preventing artifacts.
4. State the common QC activities
performed by a service engineer on
digital radiographic equipment.

K E Y T E R M S

Continuous quality Quality control (QC)

improvement (CQI) Total quality management (TQM)
Preventative maintenance
(PM)
215
216 CHAPTER 12 Total Quality Management of CR and DR
Systems

TOTAL QUALITY MANAGEMENT

Quality control (QC) standards for image acquisition, processing, and equipment
maintenance all contribute to the concept of total quality management (TQM) or
continuous quality improvement (CQI), as discussed in Chapter 11. The overall
efficiency and effectiveness of imaging systems are evaluated beyond the mechanics
of producing radiographic images. This chapter introduces the concept of whole
system evaluation, considering image acquisition, processing, and evaluation, as
well as repeat examination analysis, communication issues, and system problem
identification.

QUALITY CONTROL STANDARDS

The American College of Radiology requires compliance with standards of practice

to ensure quality in any imaging system. Three general areas define digital image
quality: contrast, resolution, and noise. These must be monitored to avoid
unnecessary repeat examinations and overexposure to patients and staff. There are
a number of system tests that must be performed by service personnel and/or
radiologic technologists and radiation physicists. With the increased sophistication
of digital radiographic equip- ment, it is critical that these tests be performed in a
consistent and thorough manner. The following sections are in no way an exhaustive
list of activities that should be per- formed. The manufacturer’s suggested list of
systems tests should be performed as outlined in the equipment and service
manuals.

QUALITY CONTROL
SCHEDULES AND
RESPONSIBILITIES

The radiologic technologist is the first line of defense in preventing, recognizing, and
reporting QC issues. Quality control (QC) is defined as a comprehensive set of
activities designed to monitor and maintain a system or piece of equipment. The
complicated and delicate nature of digital equipment necessitates frequent and con-
sistent oversight to avoid image errors and unnecessary patient exposure. The follow-
ing is a schedule for proper computed radiology (CR)/digital radiology (DR) system
maintenance.

Technologist Responsibilities
Daily (Box 12-1)
■ General system inspection, including:
 Quality Control Schedules and 217
Responsibilities
● Cleanliness of cassettes
218 CHAPTER 12 Total Quality Management of CR and DR
Systems

Box 12-1 Daily QC Duties for

Technologists
Inspect and clean cassettes
Inspect hinge and latch
Erase imaging plates
Verify digital interfaces and network transmission Inspect
laser printer

O Are the cassettes free of dirt and debris on all surfaces? Dirt on the
cassette may obscure the laser reader photomultiplier, leaving artifacts
or reader errors.
O Are barcode labels in good condition and able to be read? Labels in
disrepair will compromise the connection of the imaging plate
identification to the patient and examination identification information.
● Hinge and latch inspection
O Are hinges and/or latches in good condition? Broken latches or hinges can
damage readers and will require a service call to get the reader in
working order.
● Erasure of imaging plates
O Have plates been left unexposed for longer than 24 hours? Even cassettes
that have been erased more recently have the potential to record
exposure such as prolonged light exposure or scatter radiation. The safest
procedure is to erase cassettes before use if unsure of the last erasure
performed.
● Verification of digital interfaces and network transmission
O Is the reader communicating with the workstation? Are barcode readers
working properly? Again, it is critical to maintain the link between the
imaging plate and patient information.
● Inspect the laser printer for ink and paper. Make sure the printer is clean and
the output bin is free of obstructions. If the printer can be used manually for
copies, inspect the printer glass for dirt, fingerprints, and so on, and clean
according to the manufacturer’s specifications. Artifacts produced by dirt and
fingerprints can appear and be interpreted as pathology, possibly resulting in
false-positive diagnoses.

Weekly (Box 12-2)

■ Clean and inspect receptors
● Clean CR cassettes as needed, and inspect DR image receptors for dirt or
dam- age. Inspect the entire length of the DR cable for splits or exposure of
wires. If breaks or wear has caused wire exposure, inform service personnel
immedi- ately. In addition to the danger of electrical shock to personnel,
electrical shorts can cause failure of equipment and/or noise on the image.
■ Equipment manufacturers should provide lists of appropriate system tests to be
performed by the technologists. This type of testing may be performed by a
 Quality Control Schedules and 219
Responsibilities

Box 12-2 Weekly QC Duties for

Technologists
Clean and inspect receptors Clean air
intakes of CR reader Clean CRT
screen
Clean computer keyboard and mouse

designated QC technologist rather than by each individual technologist. Examples of

this type of test are:
● Image acquisition testing with phantoms
● Cassette integrity testing with special, standardized cassettes
■ Clean the air intakes on the CR reader.
● Air is used to cool the reader electronics. If dirt and debris are allowed to
clog the intakes, the reader could sustain serious damage. In addition, debris
enter- ing the air intake could obscure the lens of the scanning laser or
reader mirrors and produce artifacts.
■ Clean the cathode ray tube (CRT) screen, keyboard, and mouse.
● With multiple people using digital imaging systems, and because the digital
imaging system makes use of touch screen technology, CRT screens get dirty
very quickly. Multiple users leave multiple fingerprints that, because of the oil
in the skin, attract and retain dust and dirt particles. From a visual standpoint,
it is much easier to view images on a screen not obscured by streaks and
smears. From a health standpoint, many hands on the same surfaces without
proper cleaning can lead to increased transmission of illness. Care must be
taken to properly clean and disinfect these surfaces according to
manufacturers’ guidelines.
■ All problems must be recorded and reported immediately.

Monthly (Box 12-3)

■ Reject analysis
● It is critical that repeat exposures are identified so that data concerning
repeat reason, number of repeats, and the technologist responsible for the
repeat can be analyzed. One issue is that whereas DR systems record the
milliamperage seconds (mAs) and kilovoltage peak (kVp) values directly on
the film, CR sys- tems do not, nor do CR systems identify the technologist
unless that informa- tion is input manually. In cases when the department
does not require manual technologist identification input, it is strongly
recommended that a personal repeat rate log be kept by each technologist.
Figure 12-1 is a sample log. Keep- ing a log helps the technologist see
possible trends in exposure errors. For example, if the repeat reason is
insufficient density (too light), the cause could be poor calibration of the
automatic exposure control (AEC), or it could be poor imaging skills. Either
way, identification of this trend allows the technolo- gist to improve imaging
procedures and better protect the patient. This can be
220 CHAPTER 12 Total Quality Management of CR and DR
Systems

Box 12-3 Monthly QC Duties for

Technologists
Reject analysis
Reject reasons
Positioning errors
Marker errors
Equipment malfunction errors
Clean imaging plates
Artifact identification Problem
reporting

accomplished to a certain extent with a software program. Many vendors have

software to automatically keep repeats in a folder for the QC technologists to
review, eliminating the issue of technologists deleting repeat exposure images.
■ QC out of standard images
● Typically, a technologist is assigned the responsibility of coordinating
analysis of images of suboptimal quality. This may be done in concert with a
radiation physicist, the purpose being to identify equipment and technologist
perfor- mance errors. Figure 12-2 is a sample reject analysis form. This type of
analysis helps determine:

Repeat Exam Log

Technologist: Date: Room # Portable

Repeat Reason
Over collimated

Double exposed

Patient
Underexposed

ID Exam
Overexposed

Wrong exam

exposure

Marker over
Positioning

marker
code
Reprinted

part
Artifact
Motion

Other

Figure 12-1 Sample repeat examination log.

 Quality Control Schedules and 221
Responsibilities

CR/DR Image Analysis Form

Exam/view cm kVp mAs

Patient hx Film CR DR

Room or reader Date Technologist

Area to evaluate Criteria Pass Reject

1. Image identification
Institution name
Patient name or number
Date
2. Radiographic markers and placement
Present and accurate
Location and orientation
Superimposition
3. Collimation and shielding
4. Patient artifacts
5. Imaging equipment, handling, or
processing artifacts
6. Image sharpness, magnification,
minification, and distortion
7. Positioning
Film size and part/receptor Appropriate imaging plate size
alignment Correct central ray placement

Angle Tube/part angle is correct

Rotation Part rotated correctly
Inclusion All anatomy included

8. Exposure
kVp Appropriate for type and
amount of contrast
Scale of contrast Black/white ratio appropriate
Density Overall too dark/too light
Exposure index
appropriate mAs
selection appropriate
9. Equipment Reader error
Histogram error
10. Accept/reject

Comments/action

Figure 12-2 Sample image analysis/reject form.

222 CHAPTER 12 Total Quality Management of CR and DR
Systems

● Reject reasons
O This is fairly easy to identify in DR images because the mAs and
kVp are recorded as part of the image. In CR, images that are out
of the recommended exposure range can be identified, but unless
the technical factors are manually input, there is no way to tell
whether the problem was caused by mAs or kVp errors. Without
the use of side/position markers, there is no way to positively
link an image with the performing technologist.
O Positioning errors should be easy to identify. Again, without input
as to performing technologist, it will be difficult to identify skill
issues. It is strongly recommended that the department put a
procedure in place that accomplishes this, not for punitive
purposes, but for standardization of exposure practices. A major
part of being a professional in the imaging sciences is having the
integrity to accept responsibility for one’s own work. Positioning
errors may also be the cause of incorrect processing, related to
the position of the part on the imaging plate, collimation, or
alignment resulting in poor images even if technique is correct.
Vendors are developing software to minimize this, but software is
no substitute for proper positioning, collimation, and alignment.
O Side/position marker errors may be very difficult to identify.
Because postexposure marking is easily done, technologists may
not see the benefit of using personal identification (ID) markers.
However, this may lead to serious errors that are difficult to
identify. In one case, a technologist performed a portable chest
x-ray on an infant. On processing, she noticed that her personal
marker was on the wrong side of the chest. On investigation, she
discovered that she had marked the chest correctly, but the
infant had situs inversus that was never identified during six
previous examinations because technologists had failed to use
their personal ID markers. There is no substitute for using proper
personal ID markers correctly. Incorrect or lack of use of side
identification markers may result in legal complications if images
are included in a court case. With no blocker for the technologist
to use as an identifier of cassette and image orientation, there
would be no way to prove proper marking without the
technologist ID markers.
■ Clean imaging plates
● Image plates (IPs) should be removed from the cassette and inspected
visually for dirt, hair, lint, scratches, or cracks. Weekly inspection is
recommended, especially for departments with high throughput or frequent
“dirty” case use. It is important that lint-free cotton gloves be worn to avoid
further contaminat- ing the IP. A lint-free cloth, such as a photographic lens
cloth, should be used to gently wipe debris off the imaging plate surface. A
camel hair brush can be used but should be stored so that dust and dirt do
not collect on it. If this is ineffective, cleaning solutions can be used. Use only
cleaning solutions specifi- cally recommended by the manufacturer, and be
sure to follow the material
 Quality Control Schedules and 223
Responsibilities

safety data sheet (MSDS) guidelines provided by the cleaning solution distribu- tor. If
the artifact cannot be removed, the IP will have to be replaced.
● Imaging plate disposal
O Imaging plates contain a small amount of barium, which must be
discarded according to state and U.S. Environmental Protection Agency
(EPA) regulations.
O Disposal must be handled by a licensed disposal company; no other
disposal, such as trashcans, is acceptable. This type of disposal requires
an EPA identification number assigned by the state. Be familiar with
disposal regulations.
■ Artifact identification
● Monthly QC of images will help identify recurring artifacts
caused by debris on IPs, cassettes, laser lenses, and reader
mirrors. Major artifacts should be noted at the time of processing
and reported. Smaller, less intrusive artifacts can be missed or
ignored, resulting in long-term problems.
O Proper problem reporting procedures provide a mechanism through
which recurring quality trends can emerge. For example, if several
reports are received from a particular room that images are excessively
noisy or too light, the room may need to be inspected for system
interference or AEC recalibration. It will also help service personnel
determine what issues exist based on location and frequency.

Se rvice Personnel Responsibilities (Box 12-4)

Although specific responsibilities vary from manufacturer to manufacturer and vendor to
vendor, generally speaking, service personnel have a duty to the consumer to ensure
that equipment is being maintained properly. This is accomplished through a
program of preventative maintenance (PM), which typically takes place
semiannually. Pre- ventative maintenance consists of a series of equipment tests
that are performed by a service engineer. This engineer may be employed by the
hospital or the equipment manufacturer. Some of the PM duties are listed below:

■ X-ray generator, tube, and reader

● Tests are performed to establish accuracy and reproducibility. The code
value at each pixel should accurately reflect the x-ray exposure at that
location. Reproducibility of exposures produced should be 2% within
established expo- sure parameters measured in multiple exposures (Kodak
[Rochester, NY] rec- ommends 20 exposures per test at 80 kVp, filtration,
nongrid, with three levels of exposure at the 0.1 mR, 1.0 mR, and 10 mR
values).
● If obvious low contrast dark or light bands are seen, then average densities
are measured within these bands so that the recalibration can exclude them.
● If high contrast white spots are seen, they usually indicate dust on the screen.
If sharply defined white streaks are seen that are parallel to the slow scan
direc- tion and are identical in size, dust may have accumulated on the light-
collection optics and will have to be cleaned by a service engineer.
■ Phosphor accuracy testing
224 CHAPTER 12 Total Quality Management of CR and DR
Systems

Box 12-4 Service Personnel QC

Responsibilities
Preventative Maintenance
X-ray generator, tube CR
reader
Phosphor accuracy testing
Image processing functions
Image display testing
Reader erasure functions
Spatial frequency response testing

● This is accomplished by using a special standardized cassette that is not used

for daily imaging procedures.
● Exposure is made to the imaging plate, and it is inspected for response
unifor- mity and artifacts.
■ Image processing
● Image processing parameters are tested to ensure that anatomic image
analysis and histogram production are operating correctly. Service personnel
will disable all automatic functions and process an image manually. This
results in particu- lar code displays that allow the service personnel to look
at each image param- eter and evaluate it for processing errors. Test images
should be discarded and not sent to archive storage space.
■ Image display
● Testing the system display verifies correct positioning and image processing
selections. These images are subsampled so most detail is not present. These
images are for image display issues only and should never be used for evaluating
system performance.
■ Screen erasure
● To avoid interference from previous exposures that store light or signal, or
from extraneous light sources in the reader, the erasure function of the
reader must be tested at least once per year.
■ Spatial frequency response testing
● Line-pair testing phantoms are used to determine resolution patterns. These
phantoms encase objects that are at least 0.05 mm in thickness and have pat-
terns at least 10 mm in length. Manufacturers determine guidelines for maxi-
mum and minimum resolution standards.

Rad iation Physicist Responsibilities (Box 12-5)

Schedules for physicist review of digital imaging systems may vary depending on avail-
ability. One physicist may handle multiple medical facilities, visiting each one on a
weekly or monthly basis. Others may be employed by only one facility and be much
more active in determining review procedures. Typical responsibilities include:

■ Semiannual/annual
 Quality Control Schedules and 225
Responsibilities

Box 12-5 Radiation Physicist’s

Responsibilities
Semiannual/Annual QC
Maintain base-line values
Exposure trends
Reject rate analysis QC
record review Service
history analysis

● Review of departmental images to:

O Reestablish baseline values
O Check exposure indicator’s accuracy with calibrated ion chamber
O Determine exposure trends
O Analyze repeat rates
O Review QC records
O Analyze service history

The standard QC tests for filtration, collimation, focal-spot size, kVp calibration,
exposure timer accuracy, exposure linearity, exposure reproducibility, and
protective apparel will remain the same, but the American Association of Physicists
in Medicine (AAPM) has established a set of QC parameters to be followed for
photostimulable phosphor systems. AAPM Report 74 details the daily, weekly,
monthly, semiannual, and annual tests and reports to be performed.

SUMMA
RY QC standards for image acquisition, processing, and equipment maintenance all
■
contribute to TQM, or CQI.
The radiologic technologist is the first line of defense in preventing, recognizing,
■ and reporting QC issues.
Radiologic technologists, service personnel, and radiation physicists each have a
■ set of QC activities that they are responsible to maintain.
 Chapter Review 225
Questions

CHAPTER REVIEW QUESTIONS

1. How is total quality management used in

result if someone other than the service engi-
digital imaging? Are there any new procedures
neer performed these activities?
or pro- cesses that did not exist with
film/screen radiography?
6. What is at risk if proper problem reporting
sys- tems do not exist? How could a lack of
2. What are the daily and weekly activities the
knowl- edge about what to report and to
imaging technologist needs to complete to
whom impact you?
ensure the highest quality imaging?
7. What are the major responsibilities of the
3. What monthly activities are the most impor-
radia- tion physicist?
tant? Are there any that can be skipped? What
would be the consequences of not completing
8. What might happen if nobody is concerned
these activities?
about correctly making images?
4. Why is it important to establish a repeat
9. How would knowing your personal repeat rate
analysis database? What specific information
affect your work?
could be gained from such a database?
[Link] is it important to know how artifacts
5. Why are some activities designated specifically
occur?
for the service engineer? What could be the
This page intentionally left blank
 GLOssARY

acceptance testing testing that occurs to ensure central processing unit (CPU) small chip
equipment or processes are functioning within found on the motherboard that manipulates data sent
acceptable limits from a program; brains of the computer
application service provider (AsP)
company that provides outsourcing of archiving and
management functions for a pay-per-use or pay-per-
month charge archive historical collection of
images stored in PACS archive query software
function that allows historical information to be
gathered from digital storage, such as multiple
examinations, a range of dates, or by pathology
archive server consists of the physical storage
device of the archive system; it commonly consists of
two or three tiers of storage
artifacts avoidable extraneous information on
the image that interferes or distracts from image
quality aspect ratio ratio of the width of the
monitor to the height of the monitor
automatic data recognition processing mode
in which the computer analyzes data according to set
parameters
automatic rescaling occurs when exposure is
greater or less than the optimal amount to produce a
diagnostic image; it is the effort of the computer to “fix”
exposure errors backing layer soft polymer that
protects the back of the cassette
barcode label label attached either to the
cassette or to the imaging plate that identifies the
plate for the purpose of matching the examination to
the plate barium
fluorohalide photostimulable phosphor
located in the imaging plate
basic input/output system (BIOs) contains
a simple set of instructions for the computer to
perform several basic functions, such as boot up, run
hardware diagnos- tics, interpret keyboard signals,
and so on
binary code machine language of 1s and 0s
bit single unit of data
burner device that burns data onto a CD or DVD
bus series of connections, controllers, and chips
that creates the information highway of the
computer
bus topology type of network setup in which each
of the computers and network devices are connected
to a single cable
byte made up of 8 bits and is the amount of memory
needed to store one alphanumeric character
cassette rigid plastic housing for the imaging plate
cesium iodide scintillator (CsI) newer type
of amor- phous silicon detector that uses a cesium
iodide (CsI) scintillator; the scintillator is made by
growing very thin crystalline needles (5 μm wide)
that work as light-direct- ing tubes, much like
fiberoptics
charge-coupled device (CCD) coupling
devices that act as cameras that link phosphor signals
to a signal client-based network similar to a
server-based net- work, in that there is a centralized
computer that controls the operations of the network,
but rather than sending the entire original resource to
the client for processing, the server processes the
resource as requested by the client and returns only
the results back to the client client/server-
based system PACS workflow where the
images are sent directly to the archive server after
acquisition and are centrally located
coaxial cable network communication medium
that is similar to TV cable wiring
collimation type of wire that consists of a center
wire surrounded by insulation and then a grounded
shield of braided wire; the shield minimizes electrical
and radio frequency interference
color layer area within the conductive layer
where electrons are trapped
complementary metal oxide
semiconductor (CMOs)
special type of memory chip that uses a small
rechargeable or lithium battery to retain
information about the PC’s hardware while the
computer is turned off computed radiography
(CR) or cassette-based digital radiography is the
digital acquisition modality that uses storage
phosphor plates to produce projection images
computer programmable electronic device that
can store, retrieve, and process data
conductive layer layer of material that will
absorb and reduce static electricity
continuous quality improvement (CQI)
alternative set of terms for total quality management
that includes maintenance of equipment, image
acquisition, and pro- cessing standards
contrast manipulation conversion of the
digital image using contrast enhancement parameters
detective quantum efficiency (DQE)
measurement of how efficiently a system converts x-
ray input signal into a useful output image
detector size actual physical size, length and
width, of the x-ray detector
DICOM digital imaging and communications in
medicine; it is a global information technology standard
227
228 GLOssA
RY

that allows network communication between modality

film digitizer device that scans hard copy x-ray
and PACS
images and converts them to digital images
digital imaging any imaging acquisition process
fixed mode postprocessing mode in which the user
that produces an electronic image that can be viewed
selects the exposure index: latitude is set by the menu
and manipulated on a computer
selection; no histogram is generated, and there is no
digital radiography (DR) or cassette-less
recognition of imaging plate division; the resultant
systems use an x-ray absorber material coupled to a
image is a direct reflection of the exposure value
flat panel detec- tor or a charged-coupled device to
flat panel detector detector that consists of a
form the image digital versatile disk (DVD)
photo- conductor, which holds a charge on its surface
digital storage device that can hold up to seven
that can then be read out by a thin-film transistor
times more than the CD, which equates to about 9.4
focused grid grid in which the scatter absorbing
(single-sided) to 17 GB (dou- ble-sided) of data; in a
lead lines are tilted so that at a prescribed distance, the
DVD, there are multiple layers of the polycarbonate
lines will converge
plastic
grid frequency number of grid lines per inch
direct capture digital radiography these
grid ratio ratio of the height of the grid line to the
devices convert the incident x-ray energy directly into
width of the interspace material
an electri- cal signal, typically using a photoconductor
hanging protocol how a set of images will be
as the x-ray absorber and a thin-film transistor as the
displayed on the monitor
signal collec- tion area, and send the electrical signal to
hard drive main repository for programs and docu-
the computer for processing and viewing
ments on the computer
direct conversion conversion of x-ray energy to
high-pass filtering technique for the
elec- trical signals without the light-conversion step
enhancement of contrast and edge that amplifies the
disaster recovery complete copy of the archive
frequencies of areas of interest that are known (those
housed in another location and immediately available if
frequencies that can be amplified) and suppresses
the front-line archive goes down for any reason
frequencies outside the area of interest
display workstation generally a display monitor
histogram graphic representation of all of the digi-
where postprocessing occurs or where images can be
tally recorded signals of a digital x-ray exposure
viewed distributed system PACS workflow
HL-7 health level 7; standard protocol used for medi-
where the acqui- sition modalities send the images to a
cal data systems
designated reading station and possibly review
hospital information system (HIs)
stations
information system used throughout the hospital,
dot pitch measurement of how close the dots
includes direct patient care information, billing
are located to one another within a pixel
systems, and reporting systems
dry imager printer that uses heat to develop the
image annotation software function that allows
film edge enhancement enhancement occurs
text or markers to be digitally added to an image
when fewer pixels in the neighborhood are included
image manager contains the master database of
in the signal average; the smaller the neighborhood,
everything that is in the archive
the greater the enhancement
image orientation identification of the top or
error maintenance correction to equipment
side of an image
after errors have occurred
image sampling amount of information gathered
exposure index (EI) term used by Kodak to
from pixel storage
express exposure values
image stitching process of “sewing” together
exposure indicator number numerical
multiple images to form one continuous image
representa- tion of the amount of exposure, usually the
image storage process of sending the digital
mean value fiberoptic cable network
image to PACS or CD
communication medium that uses glass threads to
imaging plate thin piece of plastic with several
transmit data on the network in the form of light
layers of material that capture and store image data
field effect transistor (FET) device within an
indirect capture digital radiography
imaging detector that isolates each pixel element and
devices that absorb x-rays and convert them into light;
reacts like a switch to send the electrical charges to the
the light is then detected by an area-charge-coupled
image processor file room workstation
device or thin- film transistor array in concert with
workstation found in the radi- ology file room that
photodiodes, and
may be used to burn CDs or print films for outside use
 GLOssA 229
RY
then converted into an electrical signal that is sent to
multiple manual selection mode area of
the computer for processing and viewing
interest is selected by the technologist, and the image
indirect conversion two-step process in which x-
is derived from the selected areas imaged in
ray photons are converted to light and then the light
semiautomatic mode navigation functions
pho- tons are converted to an electrical signal
options available on the worksta- tion that allow
kVp kilovoltage peak
movement through menus, menu options, image
laser amplification of stimulated emission of
processing choices, as well as movement through a
radiation, a device that creates and amplifies a narrow,
series or stack of images and/or patient image folders
intense beam of coherent light
network two or more objects sharing resources
latitude amount of error that can be made in
and information; interconnected computers,
exposure factor choice and still result in the capture of
terminals, and servers connected by communication
a quality image
channels sharing data and program resources
level image manipulation parameter that changes
network bridge created so that larger networks
screen image contrast usually through the use of a
can be segmented or broken up into smaller networks
mouse
to reduce traffic within that network
local area network (LAN) small area
network hub central meeting point where cables
networked with a series of cables or wireless access
from several devices can come together and share
points so that the computers can share information
information throughout the group; it is a simple
and devices on the same network
boxlike device with several wiring ports available to
logarithm of the median exposure (lgM)
receive and pass on data to various pieces of
term used by Agfa to express exposure to the imaging
equipment; the hub sends all infor- mation to every
plate
device connected.
look-up table (LUT) reference histogram of the
network interface card (NIC) interface
lumi- nance values derived during image acquisition
between the computer and the network medium
low-pass filtering result of averaging each pixel’s
network protocol agreed-on set of rules for
fre- quency with surrounding pixel values to remove
network communication
high frequency noise; the result is a reduction of noise
network router device that can read portions of
and con- trast; useful for viewing small structures such
the messages and direct them to their intended target,
as fine bone magnetic disk storage short-term
even if the device is on a separate network and uses a
magnetic disk storage, usually found in arrays (RAID)
different network protocol
magneto-optical disk (MOD) very similar
network switch similar to a hub but it sends data
to a CD or DVD in that it is read optically with a
only to those devices to which the data are directed
laser, but the disk itself is housed within a plastic
Nyquist theorem when sampling a signal such as
cartridge magnification enlargement of an image
the conversion from an analog to a digital image, the
in all dimen- sions without loss of sharpness
sam- pling frequency must be greater than twice the
manual send computer function that allows
band- width of the input signal so that the
images to be sent to specified reading stations
reconstruction of the original image will be nearly
mAs milliamperage seconds
perfect
matrix rectangular or square table of numbers that
operating system software that controls the
represent the pixel intensity to be displayed on the
com- puter hardware and acts as a bridge between
monitor memory used to store information being
applications and the hardware
currently processed within the central processing unit
PACs picture archival and communication system;
mesh topology network that has multiple
consists of digital acquisition, display workstations, and
pathway interconnecting devices and networks storage devices interconnected through a network
modulation transfer function ability of a PACs administrator the person trained to
system to record available spatial frequencies oversee the PACS
moiré grid line or image noise pattern that occurs patient demographics input information
when either the alignment of the grid to the laser scan regarding pat- ient age, identifying number, ordering
direction is incorrect or when spatial frequency is physician, and so on peer-to-peer network each
greater than the Nyquist frequency; a wraparound
computer on the network is considered equal; no
image will result motherboard largest circuitry
computer has ultimate control over another
board inside the com- puter; it contains many
phosphor center see color layer
important small components to make the computer
phosphor layer layer of photostimulable
function properly
230 GLOssA
RY
phosphor that “traps” electrons during exposure;
usually made of
 GLOssA 231
RY
phosphors from the barium fluorohalide family (e.g., bar-
resolution number of pixels contained on a display
ium fluorohalide, chlorohalide, or bromohalide crystals)
review workstation workstation used by other
photometer device used to measure the
health care personnel to view radiology images
luminescence of areas on the monitor
ring topology network in which the devices are
photomultiplier electronic device that amplifies
con- nected in a circle
light energy
routine maintenance synonymous with
photostimulable luminescence (PsL) light
preventive maintenance; maintenance of equipment
produced by a phosphor when struck by light or x-ray
that occurs before problem occurrences
photons photostimulable phosphor
s, sensitivity number term used by Fuji Medical
phosphor that produces light when stimulated by light
to express exposure
or x-ray photons
semiautomatic mode postprocessing mode in
picture archival and communication
which the latitude value of the histogram is fixed, and
system net- worked group of computers, servers,
only a small reading area is used; there is no
and archives that can be used to manage digital images
collimation detec- tion, and the proper kV must be
pixel basic picture element on a display
used to maintain subject contrast because the latitude
port collection of connectors sticking out of the back
value does not change server computer that
of the computer that link adapter cards, drives,
manages resources for other computers, servers, and
printers, scanners, keyboards and mice, and other
networked devices
peripherals that may be used
server-based network there is a centralized
power supply delivers all electricity and
computer (server) that controls the operations, files,
provides connections to power devices in the computer
and some- times the programs of the computers
preventative maintenance (PM) periodic
(clients) attached to the network
testing of equipment and materials before problem
shuttering used to blacken out the white
occurrence protective layer very thin, tough,
collimation borders in a digital image, effectively
clear plastic cover- ing in the imaging plate for
eliminating veil glare
protection of the phosphor layer
smoothing also known as low-pass filtering, the
quality assurance another term for quality
result of averaging each pixel’s frequency with
manage- ment, which is now considered antiquated;
surrounding pixel values to remove high frequency
typically focuses on the person rather than the process
noise
quality control (QC) subdivision of quality
softcopy reading images on the computer without
manage- ment that focuses on equipment functions
hardcopy films
quality control (QC) station dedicated
spatial frequency resolution amount of detail
computer and monitor for the purpose of reviewing
or sharpness in a digital image
digital images quantum mottle failure of an
speed in conventional radiography, speed is deter-
imaging system to record densities usually caused by
mined by the size and layers of crystals in the film and
a lack of x-ray photons quantum noise recording
screen; computed radiography system “speeds” are a
error in the digital image radiology information
reflection of the amount of photostimulable lumines-
system (RIs) information system used in the
cence given off by the imaging plate while being
radiology department for ordering examinations and
scanned by the laser
reporting results
star topology network that has the devices
raster zigzag electron scanning pattern
connected to a central hub or switch
reading station computer and monitor generally super user someone trained within the hospital
used by the physician interpreting the digital images to help troubleshoot and teach others to use the PACS
redundant array of independent disks
support layer semirigid material in the imaging
(RAID) composed of several magnetic disks or hard
plate that gives the imaging sheet some strength
drives that are linked together in an array
system architecture hardware and software
reflective layer layer in the imaging plate that
infra- structure of the system’s workflow
sends light in a forward direction when released in the tape magnetic tape cartridges used for long-term
cassette reader; this may be black to reduce the spread
stor- age archives
of stimu- lating light and the escape of emitted light;
teleradiology moving images via telephone lines
some detail is lost in this process
to and from remote locations
refresh rate measure of how fast the monitor
The Joint Commission organization that
rewrites the screen or the number of times that the
accredits health care organizations, such as hospitals,
image is redrawn on the display each second
232 GLOssA
RY
clinics, and labs
 GLOssA 233
RY
thick-client computer that can work independently
viewable area measured from one corner of the
from the network and can process and manage its own
dis- play to the opposite corner diagonally
files thin-film transistor (TFT) photosensitive
web-based system very similar to a
array, made up of small (about 100 to 200 μm) pixels,
client/server sys- tem with regard to how the data
converts the light into electrical charges
flow, but the biggest difference is that not only are the
thin-client device that is found on a network
images held centrally but so is the application software
that requests services and resources from a server
for the client display wet imager printer that
tier level, layer, or division of something
uses chemicals to develop the film
topology physical (geometric) layout of the
wide area network (WAN) network that
connected devices on a network
spans a large area, city, state, nation, continent, and/or
total quality management (TQM) see
world window image manipulation parameter that
continuous quality improvement
changes screen image brightness usually through the
twisted-pair wire network communication
use of a mouse
medium that consists of four twisted pairs of copper
wireless network communication medium that uses
wire that are insulated and bundled together with an
either infrared or radio frequencies as its means of
RJ-45 termination
communication
ultra density optical disk (UDO) new
workflow amount of work or examinations
generation MOD; uses blue laser technology in its read
completed over a period of time
and write activities
This page intentionally left blank
 ABBREVIATION
TABLE

μGy microgray HIPAA Health Insurance Portability and

3D three-dimensional Accountability Act
AAPM American Association of Physicists in HIS hospital information system
Medicine HL-7 health level 7
AC alternating current Hz hertz
ACR American College of Radiology IDE integrated drive electronics
AEC automatic exposure control IP internet protocol
AGP accelerated graphics port IP image plate
AIT advanced intelligent tape JPEG joint photographic expert group
a-Si:H amorphous selenium keV kilo-electron-volt
ASP application service provider kVp kilovoltage peak (prime)
BIOS basic input/output system L latitude
C7-T1 refers to the junction of the seventh L5/S1 refers to the junction of the fifth
cervical vertebra and the first
lumbar vertebra and the first section
thoracic vertebra
of the sacrum
CAD computed aided diagnosis LAN local area network
cat 5 category 5 LCD liquid crystal display
CCD charge-coupled device lgM logarithm
CD compact disk lp/mm line pairs per millimeter
cm centimeter LTO linear tape open
CMOS complementary metal oxide LUT look-up table
semiconductor
mAs milliamperage seconds
CPU central processing unit
MB megabyte
CQI continuous quality management
MIP maximum intensity projection
CR computed radiography
MOD magneto-optical disk
CRT cathode ray tube
MPR multiplanar reconstruction
CT computed tomography
mR milliroentgen
DAS direct attached storage
MRI magnetic resonance imaging
DC direct current
MSDS material data safety sheets
DICOM digital imaging and communications
MTF modulation transfer function
in medicine
NAS network attached storage
DLT digital linear tape
NEMA National Electrical Manufacturers
DQE detector quantum efficiency
Association
DR digital radiography
NIC network interface card
DSA digital subtraction angiography
nm nanometer
DVD digital versatile disk
OID object image distance
EI exposure index
OS operating system
EMR electronic medical record
PACS picture archiving and communications
EPA Environmental Protection Agency
system
eV electron volt PC personal computer
FET field effect transistor
PCI peripheral component interconnect
GB gigabyte
PM preventative maintenance
GUI graphical user interface
PSL photostimulable luminescence
233
ABBREVIATION TABLE,
CONT.
SQL structured query language
QA quality assurance SSD shaded surface display
QC quality control TCP transmission control protocol
RAID redundant array of independent disks TFT thin-film transistor
RAM random access memory TJC The Joint Commission
RF radio frequency TQM total quality management
RIS radiology information system UDO ultra density optical disk
S (number) sensitivity UID unique identifiers
SAN storage area network USB universal serial bus
SCP service class provider VRT volume rendering technique
SCSI small computer system interface WAN wide area network
SCU service class user
SOPs service/object pairs
23 ABBREVIATION
4 TABLE

Index
A
C Component role classification, of network, 43
AAPM (American Association of Physicists in client-based, 43, 58
Cable
Medicine), 200, 201, 202f, 211 peer-to-peer, 44, 45f
coaxial, 48f
Acceptance tests, 199 server-based, 46, 46f
fiberoptic, 48, 49f
Acquiring and forming Components. See Hardware components
of image, 67 CAD (computed aided diagnosis), 189
Cassette, 64, 65f, 66f Compression recall, 210
of imaging plate, 67 Computed aided diagnosis. See CAD
Cassetteless image acquisition
Acquisition. See Cassetteless image acquisi- Computed radiography. See CR
equipment and
tion; CR image acquisition Computed tomography scanner. See CT
CCD relating to, 103, 104, 105f, 106
ACR (American College of Radiology), 55, scanners
chapter review questions for, 109
200, 216 Computers, 20, 20f
CR relating to, 102, 106
Advanced Micro Devices. See AMD chapter review questions for, 39
summary of, 108
Advanced workstation functions, of hardware components of, 21
PACS, 160 potential errors of, 108
Cathode ray tube. See CRT monitors for, 33
for reading station, 161 OS relating to, 36
CCD (charged coupled device), 7, 8,
for technologist QC station, 151, 152f, 163 in radiology department, 38
83, 187
Algorithms application, improper, 120 summary of, 38
cassetteless equipment and image
Aliasing, 113, 115f types of
acquisition relating to, 103, 104,
AMD (Advanced Micro Devices), 24 server, 47
105f, 106
American Association of Physicists in thick-client, 47
CCD film digitizers, 188, 188f
Medicine. See AAPM thin-client, 47
CD (compact disk), 28, 177f, 186f, 192
American College of Radiology. See ACR typical components of, 47, 47f
CD-burning option, 160
Amorphous silicon detector, 104 workings of, 20
Analog, 72 CD/DVD burners, 141, 192, 192f
common uses of, 141 Conductive layer, of imaging plate, 65
Annotations, 156, 157f Construction, of imaging plate, 64
CD/DVD drive, 31, 31f, 32
image, 123, 125f Continuous quality improvement. See CQI
CD-ROM, 28, 31
Application interfacing, 54 Contrast manipulation, 119, 119f
Central processing unit. See CPU
Application service provider. See Conventional radiography, 4
Cesium iodide detector. See CsI detector
ASP Archive query, 127 CR, DR and, comparison of, 8, 10t, 11f
Cesium iodide scintillator. See CsI scintillator
Archive servers, 137, 171 Conversion
Charged coupled device. See CCD
Archives, 137, 138f, 168. See also PACS direct, 102
Classification measurements, of monitors,
National, 168f indirect, 103, 103f, 104
33–34
Artifacts, 90. See also Imaging plate artifacts CPU (central processing unit), 21, 24, 24f, 28
Client-based network, 46
electronic memory, 108 CQI (continuous quality improvement), 198,
Clients. See Thick-client; Thin-client
ASP (application service provider), 180, 199, 211
Client/server-based systems, 141,
182, 182f CR (computed radiography), 5, 6, 6f, 7f, 64
142f
Aspect ratio, 34 cassetteless equipment and image acquisi-
advantages of, 141
Atoms, 68 tion relating to, 102, 106
disadvantages of, 141
Automatic data recognition, conventional, DR and, comparison of, 8,
CMOS (complementary metal oxide semicon-
89 Automatic rescaling, 115 10t, 11f
ductor), 21, 27, 28, 106
Coaxial cable, 48f QC relating to. See QC schedules and
Collimation, 86, 89 responsibilities
B
Color layer, of imaging plate, 66 reader functions relating to, 112
Background removal, 122, 122f CR equipment, 64
Common network topologies, 53
Backing layer, of imaging plate, cassette, 64, 65f, 66f
Communication. See DICOM; Network;
66 Barcode label, 67, 68f, 69f chapter review questions for, 77
PACS
Barium fluorohalide, 64 imaging plate, 64, 67f, 112
Communication chain, person-to-person, 42f
Basic input/output system. See BIOS reader, 68, 70f
Communication medium, 48
Binary code, 20, 21f, 22f summary of, 76
BIOS (basic input/output system), 21, 25 coaxial cable, 48
fiberoptic cable, 48, 49f CR image acquisition, 80
Bit, 20 artifacts, 90
twisted-pair wire, 48, 49f
Bit depth, 72 chapter review questions for, 99
wireless connections, 49, 50f
Box, 21, 23f exposure, 80
Compact disk. See CD
Burners. See CD/DVD burners imaging plate artifacts, 90–91f, 93f
Comparison of conventional radiography, CR,
Bus topology, 25, 53, 53f operator errors, 96, 96f, 97f
Byte, 20 and DR, 8, 10t, 11f
Complementary metal oxide semiconductor. plate reader artifacts, 92, 93f, 94f, 95f
See CMOS

Page references followed by “f” indicate figures and by “t” indicate tables.
235
236 INDE
X

CR image acquisition (Continued) Exposure indicator number, 87

DR (Continued)
printer artifacts, 96
direct capture, 7, 106
summary of, 98
indirect capture, 7, 106
CR image sampling, 112
QC relating to. See QC schedules and
CR/DR Image Analysis Form, 220f
responsibilities
CRT (cathode ray tube), 33, 34, 35f,
summary of, 15
145,
DR image sampling, 113
147f, 218
aliasing, 113, 115f
CsI (cesium iodide) detector, 104, 107
automatic rescaling, 115
CsI (cesium iodide) scintillator, 104,
latitude, 116
105f
LUT, 115, 116f
CT (computed tomography) scanners, 4, 5f,
Dry imagers, 190, 190f
14f, 135
Dry laser imager, 208
D DVDs (digital versatile disk), 175, 176f,
192, 192. See also CD/DVD burners;
DAS (direct attached storage), 178, 180f CD/DVD drive
Data QC, 210
Data recognition. See Automatic data recogni- E
tion; Exposure data recognition;
Edge enhancement, 120, 121f
Image data recognition and preprocessing
EI (exposure index), 87, 88t
Demographics, of patients, 125
Electronic memory artifact,
Detective quantum efficiency. See DQE
108
Detectors
Enhanced visualization image processing.
amorphous silicon, 104
See EVP
CsI, 104, 107
Enhancement functions, image manipulation
flat-panel, 102, 102f
and, of PACS, 156
size of, 106
Equipment. See also Cassetteless image acqui-
DICOM (digital imaging and communications
sition; CR equipment
in medicine), 12, 13, 14, 134, 136f, 169,
selection of, 82
169f, 170, 192
grid, 84, 85f
medical imaging’s use of,
imaging plate, 82, 84f
54 standard, parts of, 57t
technical factors and,
Digital imaging, 4. See also DICOM
107
historical development of, 4
Equipment QC, PACS relating to, 200
Digital radiographic image processing and
data QC, 210
manipulation, 112
compression recall, 210
chapter review questions for, 129
integrity, 210
summary of, 127
monitor quality, 200
Digital radiography. See DR
daily, 201
Digital versatile disk. See DVDs
monthly/quarterly, 203
Digitization, of signal, 72
printer image quality, 207
Digitizers. See Film digitizers
speed, 208
Direct attached storage. See DAS
image transfer, 210
Direct capture digital radiography, 7, 106
workstation processing,
Direct conversion, 102
209 Erasure, of image, 75f, 75
Disaster recovery, 182
Error maintenance, 199
Disk. See CD; Image storage; RAID
Errors
Display workstations, PACS relating to,
operator, 96, 96f, 97f
145, 145f
potential cassetteless image acquisition,
advanced functions of, 160
108 EVP (enhanced visualization image
fundamentals of, 135, 137f, 146f
process-
stations
ing), 116, 116f
file room/image management, 153, 153f
Exposure, 80
physician review, 149, 150f
collimation, 86, 89
radiologist reading, 149, 149f, 150f
equipment selection, 82
technologist QC, 151, 152f, 163
image data recognition and preprocess-
Distributed systems, 142, 143f
ing, 89
advantages of, 143
indicators of, 87
disadvantages of, 143
Dot pitch, 34 part selection, 80, 80f, 81f
DQE (detective quantum efficiency), 106 side/position markers, 86
technical factors, 81
DR (digital radiography), 4, 5, 8, 8f, 102, 104
kVp, 81
chapter review questions for, 15
mAs, 81, 82, 82f
CR, conventional radiography and,
comparison of, 8, 10t, 11f Exposure data recognition, 89
Exposure index. See EI
 INDE 237
F BIOS, 21, 25
X
FET (field-effect transistor), box, 21, 23f
102, 103 Fiberoptic cable, 48, bus, 25, 53, 53f
49f CD/DVD drive, 31, 31f, 32
Field-effect transistor. See FET CMOS, 21, 27, 28
File room/image management CPU, 21, 24, 24f, 28
stations, 153, 153f hard
Film digitizers, driv
186, 186f e,
CCD, 188, 30,
188f 31f
common me
uses of, mor
188 y, 26
laser, motherboard, 21, 23f
187, NIC, 28, 29f
187f peripherals, 32
Film-based workflow, ports, 27
138, 139f Filtering power
high-pass, 120 supply, 28,
low-pass, 120 30f sound
spatial frequency, 120 card, 28
Fixed mode, 90 of network. See Network
Flat-panel detectors,
102, 102f direct
conversion, 102
indirect conversion,
103, 103f, 104 Flip and
rotate, 156, 157f
Fluoroscopy, 5
Focused grids, 86
Forwarding, preprocessing, and
processing, of image, 75

G
Geographic classification, of
network, 43 LAN, 43, 44f,
48
WAN, 43, 45f
Graphical user
interface. See GUI
Grid
equipment
selection
relating to,
84, 85f
focused, 86
selection
of, 84
frequency,
84
ratio, 85
size, 86
Grid
frequency, 84
GUI (graphical user interface), 37

H
Hanging
protocols, 154,
155f Hard drive,
30, 31f
Hardware
components
of computer, 21
238 INDE
X

Health Insurance Portability and Accountabil-

Imagers (Continued) Magnetic disk storage (Continued)
ity Act. See HIPPA
wet, 189f, 190 SAN, 178, 181f
High resolution, 82
Imaging. See DICOM; Digital imaging; MRI Magnetic resonance imaging. See MRI
High-pass filtering, 120
Imaging manager, PACS relating to, 169 Magnetic tape, 177, 178f
HIPPA (Health Insurance Portability and
Imaging plate, 64, 67f, 112 Magneto-optical disk. See MOD
Accountability Act), 160
construction of, 64 Magnification, 123, 126f
HIS (hospital information system), 58, 169
equipment selection relating to, 82, 84f Magnify, 157, 158f
Histogram, 89, 112, 113, 114f
image, acquiring and forming of, 67 Maintenance. See QC tests
HL-7, 58
layers of, 64, 66–67f Manipulation
Hospital information system. See HIS
reader relating to, 69, 71f, 72f contrast, 119, 119f
I resolution of digital radiographic image processing
high, 82 and, 112
IDE (integrated drive electronics) port, 27, 28 standard, 82 image. See Image
Image Imaging plate artifacts, 90–91f, manipulation Manual send, 127
acquiring and forming of, 67 93f operator errors, 96, 96f, Markers
erasure of, 75, 75f 97f moiré, 84
preprocessing, processing, and forwarding plate reader artifacts, 92, 93f, 94f, side/position, 86
of, 75 95f printer artifacts, 96 mAs (milliamperage seconds), 81, 82, 82f
undiagnostic, recognition of, 211 Imaging plate sensitivity, 88t Matrix, 33
Image acquisition, 135, 137f. See also Cas- Indirect capture digital radiography, 7, 106 pixel, 83f, 146
setteless image acquisition; CR image Indirect conversion, 103, 103f, 104 Matrix size, 102
acquisition Integrated drive electronics port. See IDE port Maximum intensity projection. See MIP
Image annotation, 123, 125f Integrity, 210 Measurements, 158, 159f
Image data recognition and preprocessing, 89 Intel, 24, 25f classification, of monitors, 33–34
automatic data recognition, 89 Internet protocol. See IP Memory, 26. See also Electronic memory
fixed mode, 90 IP (Internet protocol), 52 artifact; RAM
multiple manual selection mode,
Memory chip, 26f
90 semiautomatic mode, 89 J Mesh topology, 54, 56f
Image formation, latent, 9, 10, 11f
The Joint Commission. See TJC Microphones, 33
Image management, 125 Microprocessors, 24
Jukebox, 169f, 173, 175f, 177
archive query, 127 Microsoft-Disk Operating System. See
functions, PACS relating to, 137f, MS-DOS
K
158, 160f Milliamperage seconds. See mAs
manual send, 127 Keyboard, 32
MIP (maximum intensity projection),
patient demographic input, 125 Kilovoltage peak selection. See kVp
161, 162f
Image management stations, 153, 153f kVp (kilovoltage peak selection), 81, 106,
MOD (magneto-optical disk), 175, 176f
Image manipulation. See also Digital radio- 107, 112
Modes
graphic image processing and manipula- fixed, 90
tion; Processing system, basic functions L
multiple manual selection, 90
of, image manipulation as LAN (local area network), 43, 44f, 48 semiautomatic, 89
enhancement functions and, of PACS, 156 Laser, 68, 70f, 71f semi-X, 90
annotations, 156, 157f used to read imaging plate, 69, 71f, 72f Modulation transfer function. See MTF
flip and rotate, 156, 157f Laser beam formation, 68, 69 Moiré markers, 84
measurements, 158, 159f Laser film digitizers, 187, 187f Monitors, 33
pan, zoom, and magnify, 157, 158f Latent image formation, 9, 10, 11f advantages and disadvantages of, 36, 37t
window/level, 156, 156f Latitude, 116 classification measurements of, 33–34
Image orientation, 123 LCD (liquid crystal display), 33, 34, 35f, CRT, 33, 34, 35f
Image processing parameters, 118 145, 147f LCD, 33, 34, 35f, 145, 147f
Image quality, of printer. See Printer image Level, 120, 156, 156f 1K square, 145, 147, 148f, 200
quality lgM (logarithm of median exposure), 88 plasma displays, 36, 36f
Image sampling. See CR image sampling; DR Library. See Tape libraries quality of, 200
image sampling Liquid crystal display. See LCD 2K portrait, 145, 148f, 200
Image stitching, 123, 124f Local area network. See LAN Motherboard, 21, 23f
Image storage, 171 Logarithm of median exposure. See lgM Mouse, 32
long-term, 173 Long-term storage, 173 MPR (multiplanar reconstruction), 161,
magnetic disk, 178, Look-up table. See LUT 161f MRI (magnetic resonance imaging), 4,
180f magnetic tape, Low-pass filtering, 120 64, 135
177, 178f optical disk, LUT (look-up table), 115, 116f, 187, 188, 189 MS-DOS (Microsoft-Disk Operating
175 System), 37
short-term, 171 M
MTF (modulation transfer function), 118,
Image transfer speed, 210 Macintosh OS, 36 118f Multiplanar reconstruction. See MPR
Imagers, 189 Magnetic disk storage, 178, 180f Multiple manual selection mode, 90
common uses of, DAS, 178, 180f Multiuser OS, 37
191 dry, 190, 190f NAS, 178, 181f
 INDE 239
X

N
P Plasma displays, 36, 36f
NAS (network attached storage), 178, Plate reader artifacts, 92, 93f, 94f, 95f
PACS (picture archival and communication
181f NASA, 106 PM (preventive maintenance), 222
National Archives, 168f system), 4, 5, 12, 13f, 38, 46, 56, 57, 75,
107, 120, 127 Ports, 27
Navigation functions, of PACS, 154, 154f IDE, 27, 28
administrator for, 212
NEMA (National Electrical Manufacturers parallel, 27, 27f
Association), 55 advanced workstation functions of, 160
archive considerations of, 180 SCSI, 27, 28
Network, 42, 42f serial, 27
archiving components of, 168, 169f, 170f
application interfacing relating to, USB, 27, 27f
image storage, 171
54 bridge, 51 Potential cassetteless image acquisition
imaging manager, 169
cabling. See Cable errors, 108
chapter review questions for, 15, 165, 183
chapter review questions for, 59 Power supply, of computers, 28,
common functions of, 154
classifications of, 43 30f Preprocessing
hanging protocols, 154, 155f
component role, 43 image data recognition and, 89
image management functions,
geographic, 43 processing, forwarding and, of image,
137f, 158, 160f
communication of, 52 75
image manipulation and enhancement
model of, 52 Preventive maintenance. See PM
functions of, 156
protocol, 52 Printer artifacts, 96
navigation, 154, 154f
connectivity of, 48 Printer image quality, 207
study navigation, 155
communication medium, 48 dry laser imager, 208
display workstations relating to,
network bridge, 51 wet laser imager, 207
145, 145f
network hub, 50 Processing, preprocessing, and forwarding, of
equipment QC relating to, 200
network router, 51 image, 75
fundamentals of, 134, 134f
network switch, 51 Processing system, basic functions of, image
archive servers, 137, 171
NIC, 50 manipulation as, 120
display workstations, 135, 137f, 146f
hub, 50 background removal or shuttering,
image acquisition, 135, 137f
protocol relating to, 52 122, 122f
workflow, 138
router, 51 image annotation, 123, 125f
peripheral devices of, 134
summary of, 58 image orientation, 123
CD/DVD burners, 141, 192, 192f
switch, 51 image stitching, 123, 124f
chapter review questions for, 143
topologies of, 53 magnification, 123, 126f
film digitizers, 135, 186f
common, 53 window and level, 120
imagers, 138
typical components of, Protective layer, of imaging plate, 64
summary of, 142
47 computers, 47, 47f Protocols
quality of. See Quality, of PACS
network communication, 52 hanging, 154, 155f
summary of, 15, 164, 183
network connectivity, 48 network, 52
system architecture of, 141
Network attached storage. See NAS PSL (photostimulable luminescence), 74
client/server-based, 141, 142f
Network interface card. See NIC
distributed, 142, 143f
NIC (network interface card), 28, Q
web-based, 144, 144f
29f, 50
terms of quality of, 198 QA (quality assurance), 198
Nyquist theorem, 113
uses of, 14 QC (quality control), 199, 216, Data QC;
workflow, generic, 140, 140f Equipment QC, PACS relating to;
O Pan, zoom, and magnify, 157, 158f TG18-QC test patterns
Parallel port, 27, 27f QC schedules and responsibilities,
OID (object-image distance), 120
Patient demographics, 125 216 of radiation physicist, 223, 224
1K square monitor, 145, 147, 148f, 200
Peer-to-peer network, 44, of service personnel, 222, 223
Operating system. See OS
45f of technologist, 216
Operator errors, 96, 96f, 97f
Peripheral devices, of PACS, 134 QC standards, 216
Optical disk storage, 175
Peripherals, of computer hardware compo- QC station, 75, 127, 149
DVDs, 175, 176f, 192
nents, 32 functions of, 118
MOD, 175, 176f
Person-to-person communication chain, 42f contrast manipulation, 119, 119f
UDO, 175, 177f
Phosphor center, 67 image processing parameters, 118
Oracle, 169
Phosphor layer, of imaging plate, 64, 81 spatial frequency filtering, 120
OS (operating system),
Photometer, 202, 203f spatial frequency resolution, 120
36 Macintosh, 36
Photomultiplier, 69 for technologist, 151, 152f, 163
MS-DOS, 37
Photostimulable luminescence. See PSL QC tests, 199
multiuser, 37
Photostimulable phosphor, 64 acceptance, 199
real-time, 36
Physician review stations, 149, 150f error maintenance, 199
single-user, multitask, 37
Picture archival and communication system. routine maintenance, 199
single-user, single-task, 36
See PACS Quality assurance. See QA
UNIX/Linux, 36, 38
Pixel, 33, 72, 73f, 146 Quality control. See QC
Windows, by Microsoft, 36
size of, 107 Quality control station. See QC station
Pixel matrix, 83f, 146
240 INDE
X

Quality of PACS
RIS (radiology information system), 58, 140, Super users, 212
aspects of,
138, 140, 149, 169, 170 Support layer, of imaging plate, 66
198
Rotate and flip, 156, 157f Sybase, 169
chapter review questions for, 213
Routine maintenance, 199 System training, 212
CQI, 198, 199, 211
system training, 212 System up-time, 211
S Systems. See BIOS; HIS; OS; PACS; Process-
system up-time, 211
S (sensitivity number), 87 ing system, basic functions of, image
undiagnostic images, recognition
of, 211 SAN (storage area network), 178, manipulation as; RIS; Stand-alone system
equipment relating to, 181f Scanners, 33. See also CT
scanners Scintillator T
200 summary of, 212
terms of, 198 CsI, 104, 105f Tape. See Magnetic tape
CQI, 199 rare-earth, 104 Tape libraries, 175, 178, 179f
QA, 198 SCP (service class provider), 56, 57 TCP (transmission control protocol), 52
QC, 199 SCSI port, 27, 28 TCP/IP, 54, 55
Quantum mottle, 82 SCU (service class user), 56, 57 Technical factors
Quantum noise, 82 Segmentation, 89 equipment selection and, 107
Semiautomatic mode, 89 exposure relating to, 81
R Semi-X mode, 90 Technologist
Sensitivity number. See QC station of, 151, 152f, 163
Radiation physicist responsibilities, 223, 224
S Serial port, 27 responsibilities of, 216
Radiography. See Conventional radiography;
Server-based network, 46, 46f daily, 216, 217
CR; DR
Server-based/client systems, 141, monthly, 218, 219
Radiologist reading stations, 149, 149f,
142f Servers, 47 weekly, 217, 218
150f Radiology department, computers in,
archive, 137, 171 Teleradiology, 5, 188, 144
38 Radiology information system. See RIS
Service class provider. See SCP Test patterns
RAID (redundant array of independent
Service class user. See SCU SMPTE, 200, 201f
disks), 171–171f, 173–174f, 178
levels of, 172 Service personnel responsibilities, 222, 223 TG18-QC, 200–202f, 203, 204, 207,
Service-object pairs. See SOP 207f, 211
RAM (random access memory),
Shaded surface display. See Tests. See QC tests
26 Random access memory. See
SSD Short-term storage, 171 TFT (thin-film transistor) array, 7, 8, 102,
RAM Rare-earth scintillator, 104
Shuttering, 86, 87f, 122, 122f 103, 104f, 106, 107
Raster pattern, 69
Side/position markers, TG18-QC test patterns, 200–202f, 203, 204,
Ratio
86 Signal, digitization of, 207, 207f, 211
aspect, 34
72 Single-user Thick-client, 47
grid, 85
multitask OS, 37 Thin-client, 47
Reader, 68, 70f. See also Plate reader
single-task OS, 36 Thin-film transistor array. See TFT array
artifacts image
Smoothing, 120 Tier, 171
erasure of, 75, 75f
SMPTE test pattern, 200, 201f TJC (The Joint Commission), 198
preprocessing, processing, and
Softcopy, 135 Topologies, 53
forwarding of,
SOP (service-object pairs), 56, 57 common, 53
75 laser, 68, 70f, 71f
Sound card, 28 bus, 25, 53, 53f
used to read imaging plate, 69, 71f,
Spatial frequency filtering, 120 mesh, 54, 56f
72f signal, digitization of, 72
edge enhancement relating to, 120, 121f ring, 53, 54f
spatial resolution, 73, 74f
smoothing relating to, 120 star, 54, 55f
speed, 74
Spatial frequency resolution, 120 network, 53
Reader functions, CR relating to, 112
Spatial resolution, 73, 74f, 102 Total quality management. See TQM
Reading stations, 161
Spatial resolution reader, 73, 74f TQM (total quality management), 198, 216
for radiologist, 149, 149f,
Speakers, 33 chapter review questions for, 225
150f Real-time OS, 36
Speed, 74. See also Equipment QC, PACS quality control schedules and responsibili-
Recognition. See also Automatic data recogni-
relating to ties, 216
tion; Exposure data recognition; Image
SSD (shaded surface display), 161, quality control standards, 216
data recognition
163f Stand-alone system, 142 summary of, 224
of undiagnostic images, 211
Standard resolution, 82 Transistor. See FET; TFT array
Redundant array of independent disks.
Star topology, 54, 55f Transmission control protocol. See TCP
See RAID
Reflective layer, of imaging plate, 65 Stations. See also Display workstations, Twisted-pair wire, 48, 49f
Refresh rate, 34 PACS relating to; QC station 2K portrait monitor, 145, 148f, 200
Repeat examination log, physician review, 149, Typical components
219f Resolution, 33 150f reading, 161 of computers, 47, 47f
high, 82 for radiologist, 149, 149f, of network, 47
spatial, 73, 74f, 102 150f Storage. See Image storage computers, 47, 47f
standard, 82 Storage area network. See SAN network communication, 52
Ring topology, 53, 54f Study navigation, 155 network connectivity, 48
 INDE 241
X

U
Volume rendering technique. See Windows, by Microsoft, 36
UDO (ultra density optical) disk, 175, 177f VRT VRT (volume rendering Wireless access point, 49
UIDs (unique identifiers), 57 technique), Wireless connections, 49, 50f
Ultra density optical. See UDO 161, 162f Workflow, 138
disk Ultrasound. See US film-based, 138, 139f
Undiagnostic images, recognition of, 211 generic PACS, 140, 140f
W
Unique identifiers. See UIDs Workstation processing speed, 209
UNIX/Linux OS, 36, 38 WAN (wide area network), 43,
Workstations. See Display workstations, PACS
US (ultrasound), 64 45f Web-based systems, 144,
relating to
USB port, 27, 27f 144f
advantages of, 144
V disadvantages of,
Z
144 Wet imagers,
Viewable area, 34
189f, 190 Wet laser Zoom, 158f, 157
imager, 207
Wide area network. See WAN
Window, 120, 156, 156f