Presentation to NNOHA in Nashville


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Presented to NNOHA National Conference in Nashville, November, 2009.

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  • PACS serve to receive and store images from the modalities and distributes them to clinicians and radiologists for interpretation. Benefits : Within seconds after an image is acquired it can be viewed. No film loss. Thousands of images are handled effectively and efficiently Images can be transferred between dental offices and hospitals in regions, states, and countries readily and quickly. Decades of images can be archived economically and can be retrieved immediately. Teleradiology allows virtually immediate communication between clinicians.
  • Back in the 90’s you would see an occasional article about digital photography and duplication of x-rays. Now there are literally hundreds of articles showing up in tech and healthcare online journals, blogs, as well as print media touting digital x-ray imaging and PACS. Digital imaging modalities are increasing in sophistication. Witness CBCT or Cone-Beam CT based imaging with 3-D capability. These changes are driving the system because of the need for archiving and retrieval of more complex digital images. But the study by Park, et all referenced in this slide in Korea Med and originally published in the Korean J of Oral and Maxillofacial Radiology in 2004……regarding full PACS implementation in Korea, it is suggested that with respect to dentistry there is a long way to go towards the goal of a digital transformation. As of 2003, only 4 installations out of a total of 110 hospitals in Korea had Dental PACS. In the US approximately half of the dental schools now utilize PACS with a smaller percentage having DICOM compliant PACS. The number of PACS in the Dental Public Health Sector (public dental health clinics, prisons, etc) is unclear but there appears to be a growing need.
  • This need may also be driven by Educational Standards in the US. In the Hillenburg study, 10 questions regarding the future of e-learning were distributed to 33 dental administrators. Results – virtually all agreed that this type of learning would be important in future dental education. Financial resources, among other factors, were listed as a major challenge for implementation of software systems. One of their conclusions was that collaborations of many types will be necessary and desirable to bring e-learning to fruition.
  • This citation references some of the initial literature that came out in 1995…..this was a review article and the author concluded that digital radiography was no longer an experimental reality. He also noted that task-specific image processing and sensor-independent archiving are important advantages that digital radiography has over conventional film-based systems.
  • Current studies and articles reflect the sophistication of current Digital Trends. This slide references a more recent article that followed a study assessed the effect of grey level information that is provided by various digital radiography systems. They found that every modality has its own way of saving and converting the images into DICOM data…..and is either sent with a reduced grey level range due to windowing or with the initial 10-12 bit grey range levels. They concluded that the loss of image quality due to image transfer from the modality to a PACS can lead to information loss which can effect diagnostic information. The take away here is that the purchaser of a Digital system and PACS with DICOM compliance needs to be aware that there may be distinct differences between systems with respect to image quality.
  • Here is a study that looks at caries assessment when phosphor plates are compared with film radiography. I want to draw your attention to the last bullet point related to sensitivity and specificity.
  • And on this slide two studies are cited that look at the additional tweaking of digital imaging that is purported to improve diagnostic acuity for caries. These references are pointed out to emphasize that as the technology advances, new and potentially useful advances in image manipulation are going to further increase sophistication of digital solutions.
  • Now lets take a look at Industry Standards as they apply to PACS. There are four major components.
  • DICOM means ‘Digital Communication in Medicine’ This is the ‘standard in medicine for………..’ It provides for: -Integration with all DICOM Modalities, Devices At this point I would like to make a plug for the company I work with….. -EBM is the DICOM Expert -Tested with vendors such as Aloka (Ultrasound), Sony (Filmstation), GE (CT), Hologic (Mammo) AND Planmed (Mammo), and Dexis/Dentrix (Schein) -Vast DICOM Library to integrate with various devices
  • Industry Standards DICOM – Digital Communication in Medicine -Integration with all DICOM Modalities, Devices -EBM is the DICOM Expert -Tested with vendors such as Aloka (Ultrasound), Sony (Filmstation), GE (MI) DICOM is the standard in Medicine. The American Dental Association (ADA) has been a member of the Digital Imaging and Communication in Medicine (DICOM) Standard Committee since 1996 In 2000, the ADA resolved to strive for interoperability of digital dental images, using the DICOM Standard as the backbone of the effort. ADA Working Group 12.1 was tasked with development of specifications and also with educating the dental profession concerning digital image interoperability….with Dr Brent Dove of the University of Texas-San Antonio as director. DICOM-related interoperability demonstrations are now a part of the ADA Annual Congress, in the form of seminar and as a noncommercial exhibit.
  • These are the basic qualifiers for the DICOM communication standard ……..
  • Do you get the picture…..DICOM is a very robust standard but one that facilitates communication. Images can be transmitted more easily and with greater information attached than what can be attached via standard films.
  • This slide demonstates some of the many DICOM tags that identify an image…..
  • This slide demonstates some of the many DICOM tags that identify an image…..
  • This slide demonstates some of the many DICOM tags that identify an image…..
  • This slide demonstates some of the many DICOM tags that identify an image…..
  • HL7 – Health Level 7 -Enables communication between different medical practice systems – billing, patient tracking, reporting
  • Integrating the Healthcare Enterprise -Compliance with IHE Integration Profiles: -Scheduled Workflow -Consistent Presentation of Images -Access to Radiology Information -Key Image Note (KIN) -Portable Data for Imaging (PDI) -Mammography Integration (MI)
  • And of course there is HIPPA. HIPPA compliance is particularly important in the transfer of images between workstations and clinicians. To have full DICOM and HIPPA compliance, a digital x-ray must have 128 bit encryption. This is provided by DICOM compliant PACS. This means that if your clinic is copying standard x-rays via a scanning machine or jpeg photo for sending over the WEB your clinic is not HIPPA compliant.
  • So when you have DICOM compliance in a PACS system this slide demonstrates the potential result. There can be three isolated clinics connected by the Web with HIPPA compliant image sharing. There can be multiple modalities at each clinic able to share images immediately with the other clinics and dentists or physicians. Archiving of images can occur at a central location. And the end result is cost savings and improvement in diagnostic efficiency and the quality of patient care.
  • Now lets take a more detailed look at one DICOM compliant PACS – EBM’s Pangea Dental Solution.
  • The Pangea Dental Solution is composed of several functional components that can be added or subtracted depending on the needs of the facility/clinic.
  • Supoorts DICOM storage Commitment: Guarantees the image is stored to the PACS SCU : capablity to store DICOM to the PACS
  • If pulling up images patient name can be hidden…..allows copy and paste……
  • Workflow that the UW system will employ with Pangea Dental soluton
  • Highlights Hang images from multiple vendors Customizable Eliminate double read Streamline workflow Single point of deployment with high accessibility Multimodality Standardized VS Optional Comply with IHE Integration Profile Image Manager, Image Display & Print Composer
  • Hanging Protocol Pangea Hanging protocol allows users to hang their images without limit.
  • This slide shows some of the analysis features of Pangea Dental.
  • This slide shows one of the analysis features of Pangea Dental. The two films are different for demonstration purposes but the user would be able to pull up two bitewings 6 months or 1 year apart and evaluate in them with a double zoom for potential interproximal caries. This is a unique feature of the software.
  • Another unique feature is the ability of the software to calculate dimensions. This, of course, is not as possible with standard plain film imaging. As you can see the area can be calculated with averages displayed along with minimum and maximum values and the standard deviation. This feature has clinical and research relevance.
  • .
  • One of the most exciting features of having a PACS and particularly Pangea Dental……is that it allows a dentist in his/her office to view and access with all the functionality that the radiologist has at his/her disposal sectional TMJ, Implant, and Surgical studies. The analysis features are intuitive and easy to use. As with dental views they are available within a short time after the image is taken. Published research indicates that the measurement instruments that are used in analysis are accurate and reliable. Research Ideas for Endodontics: Does use of CBCT in analysis of root structure improve endodontic efficacy? Does use of CBCT improve recovery of broken instruments? Is CBCT accurate in predicting the length of the root canal? The use of CBCT in defining the degree of overfill, if it occurs. Case studies in Endo using CBCT
  • There is an issue with DICOM and 3d imaging.
  • For the serious institution that is considering the purchase of a PACS The four important factors that need to be defined are listed on this slide.
  • Keeping in mind the strategic goals of the clinic Is there a need for increased doctor efficiency Is there a need to improve annotation capability and efficiency Is it important to have communication with associated medical or hospital facilities Is there a need for DICOM standard to facilitate insurance billing and interoffice viewing of images Is there a need for gaining office space by eliminating developing rooms or gaining counter space through the elimination of a large developer.
  • In terms of Financial Issues there are two main considerations: Reduction in cost associated with non-digital film procedures 2. Income generation by using PACS On the Cost side, there is elimination of cost associated with film, chemistry, mounts and film jackets….estimated to be about $4000.00 for the average clinic. There is savings related to the need for reduced storage of images, reprints, retakes, film processor maintenance and also the square footage associated with a developing room. There is considerable savings associated with the retrieval of images and lost films – estimated to be 7% in a general practice.
  • On the flip side of the issue PACS are likely to increase income in several ways: There will be increased Dr efficiency in reading films and providing treatment plans The community perception will be that the clinic is using state of the art systems There is likely to be improved acceptance of treatment plans based on digital display Referrals will increase from the practice and from hospitals and medical clinics that can be communicated with via DICOM transfer of images and data.
  • A good reference
  • If there is a need for communication between Dental and Medical facilities the system must be DICOM Compliant. Try to select a system that provides the greatest functionality at the lowest cost. Look carefully at the features that are actually included in the software package. Evaluate for add-ons that add extra cost that may not be necessary. Integration issues and charges by some PACS vendors can add considerable cost if new equipment is added to a facility. A company that provides timely service and support, including timely upgrades and a reasonable warranty. Look at service response time….from internet connectivity to in person response. Select a company with a long history of PACS involvement and digital involvement. Remember that the cost of migrating data if a change is made can be high. Select a company that adheres to international standards. Buy a PACS that is scalable so you can add on modalities or features at a reasonable cost. This provides flexibility in the system. Try to select a PACS that is modality and EDR independent. That will provide integration with a wide array of acquisition modalities. Check on the level of training that is offered by the company. And finally, look for a 99.9 % uptime guarantee as time lost from a down server can be frustrating and costly.
  • Presentation to NNOHA in Nashville

    1. 1. Electronic Dental Records and PACS in the Dental Community Health Sector NNOHA Presentation 11/04/09 Jeff Burgess DDS MSD
    2. 2. Marc Capots Special Markets Technology Manager Henry Schein Special Markets Equipment Jeff Burgess DDS MSD Boarded in Oral Medicine Vice President of Sales and Marketing EBM Technologies
    3. 3. PACS
    4. 4. PACS
    5. 5. PACS
    6. 6. PACS
    7. 7. PACS
    8. 8. Svanaes, Moystad, Larheim: Approximal caries depth assessment with storage phosphor versus film radiography. Evaluation of the caries-specific Oslo enhancement procedure. Caries Res. 2000 <ul><li>120 extracted human teeth </li></ul><ul><li>Storage Phosphor plates with Digora scanner versus Ektaspeed Plus film </li></ul><ul><li>240 Proximal surfaces for caries, 9 observers, 5 point confidence scale </li></ul><ul><li>Ratings compared with the histological state </li></ul><ul><li>Pooled sensitivity and specificity values: </li></ul><ul><ul><li>.48/.94 with film, .61/.86 with phosphor image </li></ul></ul>Digital Sensors PACS
    9. 9. <ul><li>Gakenheimer DC: The efficacy of a computerized caries detector in intraoral digital radiography. JADA 2002 </li></ul><ul><li>Navarro F, Puy L, Godoy G: Diagnostic performance of radiovisiography in combination with a diagnosis assisting program versus conventional radiography with radiovisiography in basic mode and with magnification. Med Oral Pathol Oral Cir Bucal, 2008. </li></ul>Caries Detection PACS
    10. 10. Industry Standards <ul><li>DICOM – Digital Communication in Medicine </li></ul><ul><li>HL7 – Health Level 7 </li></ul><ul><li>IHE – Integrating the Healthcare Enterprise </li></ul><ul><li>HIPPA </li></ul>
    11. 11. Industry Standards DICOM – Digital Communication in Medicine Standard in Medicine for handling, storing, printing and transmitting medical information in medical images DICOM <ul><li>Includes a file format definition and network communications protocol </li></ul><ul><li>Enables integration of scanners, servers, workstations, printers, and network hardware </li></ul>
    12. 12. Industry Standards <ul><li>DICOM – Brief History </li></ul><ul><li>1985 – First Standard Released </li></ul><ul><li>1988 Second Version Released </li></ul><ul><li>1992 First Large Scale Deployment by the US Army and Air Force </li></ul><ul><li>1993 Third Version – 3.0 </li></ul><ul><li>Now recommended using release year: “the 2007 version of DiCOM” </li></ul><ul><li>IHE (Integrating the Healthcare Enterprise) + HL-7 completes workflow interoperability </li></ul>
    13. 13. Industry Standards <ul><li>DICOM </li></ul><ul><li>Store </li></ul><ul><li>Storage Commitment </li></ul><ul><li>Query/Retrieve </li></ul><ul><li>Modality Worklist </li></ul><ul><li>Modality Performed Procedure Step </li></ul><ul><li>Printing </li></ul><ul><li>Storage in Off-Line Media </li></ul>
    14. 14. Industry Standards <ul><li>DICOM </li></ul><ul><li>Store </li></ul><ul><ul><li>Used to send images or other persistent objects (such as reports, lab results, patient photos) to a PACS workstation. </li></ul></ul>
    15. 15. Industry Standards <ul><li>DICOM </li></ul><ul><li>Storage Commitment </li></ul><ul><ul><li>This is used to confirm that an image has been permanently stored by a device such as a disk or back-up media or server. This makes it safe to delete the images locally. </li></ul></ul>
    16. 16. Industry Standards DICOM Query/Retrieve This function allows a workstation to find the lists of images and other ‘objects’ and then retrieve them from a PACS
    17. 17. Industry Standards DICOM Modality Worklist This enables an acquisition device (a modality - x-ray machine) to obtain details of patients scheduled examinations so that the information doesn’t have to by entered multiple times.
    18. 18. Industry Standards DICOM Modality Performed Procedure Step This function enables the modality to send a report about an examination which includes data like when it was acquired, beginning time, end time, dose delivered, etc.)
    19. 19. Industry Standards DICOM
    20. 20. Industry Standards DICOM More About DICOM If an acquisition device company says that it is DICOM compliant you should be able to request its DICOM conformance statement. If it does have one, it is not DICOM compliant.
    21. 21. Industry Standards DICOM More About DICOM Just because an image is DICOM compliant does not mean that it can be sent to a medical facility. There must be a functioning DICOM server to make this a true enterprise system.
    22. 22. Industry Standards DICOM More About DICOM For more Information about DICOM, visit:
    23. 23. Industry Standards HL7 – Health Level 7 <ul><li>Founded in 1987 </li></ul><ul><li>Global authority for healthcare information interoperability and standards </li></ul><ul><li>57 Countries </li></ul><ul><li>2,300 members represent 500 corporate members – 90% of the information system vendors. </li></ul><ul><li>Supports clinical practice and the management, delivery, and evaluation of health services. </li></ul><ul><li>ADA signed an Associate Charter Agreement September 2009 to develop dental IT standards </li></ul>
    24. 24. Industry Standards IHE – Integrating the Healthcare Enterprise IHE Connectathon Results Browser Oct 11, 2009 ... Browse the results of the IHE (Integrating the Healthcare Enterprise) connectathons that have taken place in Europe, Japan and North America ... connectathon -results. ihe <ul><li>An initiative by healthcare professionals and industry to improve the way computer systems in healthcare share information </li></ul><ul><li>Several hundred products support one or more IHE Profiles </li></ul><ul><li>Integration Profiles describe clinical information management use cases and specify how to use existing standards (HL7, DICOM, etc,...) to address them </li></ul><ul><li>Integration Statements, Technical Frameworks, Connectathons, Showcases </li></ul>
    25. 25. Industry Standards On April 14, 2003, the privacy rules promulgated under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) changed the way that certain health record custodians (called “covered entities”) will respond to a request for disclosure of a person’s &quot;protected health information&quot; (PHI). HIPPA – Health Insurance Portability and Accountability Act Requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers
    26. 26. Yeoh & Muranaka Medical Center, based in Honolulu, Hawaii facilitates three outpatient imaging clinics. <ul><li>Imaging Center </li></ul><ul><li>Exams per year : 50,000 </li></ul><ul><li>4 Radiologists </li></ul><ul><li>Serves pop. Of 900,000 </li></ul><ul><li>EBM Solution </li></ul><ul><li>UniSight™ </li></ul><ul><li>UniWeb™ </li></ul><ul><li>EBM PACS Server™ </li></ul><ul><li>Imaging Devices </li></ul><ul><li>2 CT </li></ul><ul><li>4 US </li></ul><ul><li>2 BMD </li></ul><ul><li>4 DR </li></ul><ul><li>1 MR </li></ul>Case Study: USA
    27. 27. The EBM Pangea Dental Solution
    28. 28. The EBM Pangea Dental Solution UniGate® Workstation ‘ To communicate with the non-DICOM devices’ UniSight® Workstation EBM Pacs Server® UniWeb® Workstation Pangea Dental
    29. 29. The EBM Pangea Dental Solution <ul><li>Supports DICOM Worklist </li></ul><ul><li>Supports DICOM Dental Tag </li></ul><ul><li>Supports DICOM MPPS (Modality Procedure Performed Status) </li></ul><ul><li>Supports DICOM Storage Commitment </li></ul><ul><li>Allows conversion of non-digital images to DICOM standard </li></ul>UniGate® Workstation ‘ To communicate with the non-DICOM devices’
    30. 30. The EBM Pangea Dental Solution <ul><li>Acts as QC Station to Preview Images </li></ul><ul><li>DICOM Print function </li></ul><ul><li>DICOM Portable Media Function (for CD/DVD Burner) </li></ul><ul><li>Conversion of Images between DICOM and non- DICOM </li></ul><ul><li>Supports DICOM Store (SCU/SCP) Function </li></ul><ul><li>Supports DICOM Storage Commitment </li></ul>UniSight® Workstation
    31. 31. The EBM Pangea Dental Solution <ul><li>Stores DICOM images </li></ul><ul><li>Keeps a log of image modifications and deletions </li></ul><ul><li>Keeps a log of image query and retrieval by all users </li></ul><ul><li>Logs problems </li></ul><ul><li>Sends out SMS or email to headquarters (engineers) when a problem occurs </li></ul><ul><li>Provides a log that helps track the image route between the modality and the server </li></ul>EBM Pacs Server®
    32. 32. The EBM Pangea Dental Solution <ul><li>Allows WEB Access to review Image (Internet Explorer) </li></ul><ul><li>Web Access to DICOM Objects (WADO) </li></ul><ul><li>Robust Viewing Tools </li></ul><ul><li>Scalable Concurrent License </li></ul><ul><li>Used for Teaching </li></ul>UniWeb® Workstation
    33. 33. HL7/non-HL7 Broker (EBM) DICOM Worklist Server (EBM) EBM PACS Server/ Pangea Dental HIS/RIS with HL7/non-HL7 UniGate (EBM) Teleradiology Acquisition modalities support DICOM worklist Clinicians Communication DICOM Printing Diagnostic/Viewing Station Acquisition modalities Non-DICOM
    34. 34. Hanging Protocol Multimodality – Device Neutral Web Based DICOM 3.0 Standards Pangea Dental Highlights Integration with RIS Systems Dynamic Analysis Functions
    35. 35. Hanging Protocol Pangea Dental Hanging Capability <ul><li>Flexible </li></ul><ul><li>Customizable </li></ul><ul><li>Supports mouse dragging for tooth selection </li></ul><ul><li>Supports image display of selected study date results </li></ul>
    36. 36. Pangea Dental DICOM Tags
    37. 37. Pangea Dental Analysis Functions PACS software provides many analytic features that plain films cannot duplicate.
    38. 38. Pangea Dental Analysis Functions The ZOOM function allows the viewing of two or more images taken over time to document potential change.
    39. 39. Pangea Dental Analysis Functions The measurement functions allow for a gross calculation of the length, ratio, area, angles and a value based on the density of the location (area or single point) being viewed
    40. 40. Pangea Dental Analysis Functions In this case the length of the maxillary sinus and a TMJ defect is calculated. There are many more analytical features associated with Pangea Dental
    41. 41. Pangea Dental Analysis Functions CBCT Images
    42. 42. Pangea Dental – CBCT Images
    43. 43. Pangea Dental – CBCT Images Sectional Images can be reformatted into axial, coronal, sagital, and 3D views
    44. 44. Pangea Dental Analysis Functions Export/Import to DICOM Portable Media CD/DVD Viewer On CD®
    45. 45. Pangea Dental System Requirements <ul><li>Needs assessment </li></ul><ul><li>Financial issues </li></ul><ul><li>Creating a request for proposal </li></ul><ul><li>Selecting a vendor </li></ul>
    46. 46. Pangea Dental System Requirements <ul><li>Needs assessment </li></ul><ul><ul><li>should be consistent with the goals of the clinic or institution </li></ul></ul>
    47. 47. Pangea Dental System Requirements <ul><li>Doctor Efficiency </li></ul><ul><li>Improved Annotation Capability </li></ul><ul><li>Medical Communication </li></ul><ul><li>Insurance Billing </li></ul><ul><li>Office Space </li></ul>Needs Assessment
    48. 48. Pangea Dental System Requirements <ul><li>Cost Reductions </li></ul><ul><ul><li>Savings on development costs </li></ul></ul><ul><ul><li>Savings related to storage </li></ul></ul><ul><ul><li>Savings in assistant time </li></ul></ul>Financial Issues
    49. 49. Pangea Dental System Requirements <ul><li>Increased Income </li></ul><ul><ul><li>Efficiency </li></ul></ul><ul><ul><li>Community Perception </li></ul></ul><ul><ul><li>Improved consultation acceptance </li></ul></ul><ul><ul><li>Referrals </li></ul></ul>Financial Issues
    50. 50. Pangea Dental System Requirements <ul><li>PACS, A Guide to the Digital Revolution, Second Edition. Springer. Keith Dreyer, David Hirschorn, James Thrall, Amit Mehta, Editors. 2006. </li></ul>Creating a Request for Proposal
    51. 51. Pangea Dental System Requirements <ul><li>DICOM Compliance </li></ul><ul><li>Features </li></ul><ul><li>Service/Support </li></ul><ul><li>History </li></ul><ul><li>International </li></ul><ul><ul><li>Standards </li></ul></ul>Selecting a Vendor <ul><li>Scalable Software </li></ul><ul><li>Modality Independent </li></ul><ul><li>Reliability </li></ul><ul><li>Training </li></ul>
    52. 52. Take Home Points <ul><li>DICOM Compliant PACS are the future of Dental Imaging communication </li></ul><ul><li>A DICOM Server is going to be necessary for true browser based teleradiology and web based communication with Medical EMRs </li></ul><ul><li>Discuss carefully with your EDR provider whether they can integrate or are integrated with a true PACS company that has a DICOM Server. </li></ul>