Iranian Journal of Radiology
Volume:4 Issue: 2, Winter 2007

We give a historical review of PACS development during the past 25 years. The first 10 years was mainly in laboratory research and development. The second 10 years was in clinical usage and workflow analysis. During the past five years, research and development have been in developing the concept of imaging informatics, and CAD and PACS integration. The future trend will be in using images to bridge the gap between diagnosis and therapies including surgery, radiation treatment, and image-guided target drug delivery.

This presentation will be in two parts: PACS implementation strategy and clinical implementation. A PACS consists of many imaging modalities and ICT (information and communication technology) components to form an integrated system for clinical practice in radiology departments, medical centers, and healthcare enterprises. During the past 25 years, many hospitals and manufacturers in the United States and abroad have researched and developed PACS implementation strategy of varying complexity loosely categorized into five models according to methods of implementation in clinical environment. The advantages and disadvantages of these models will be discussed in details first, in-cluding.1- The home-grown model 2- Two-team effort model3- Turnkey Model4- Partnership Model5- Application Service Provider (ASP) Model.The second topic will be in PACS clinical implementation, acceptance, data migration and system evaluation. Panning to install a PCAS needs to consider:1- Cost analysis2- Current film-based operation3- From film-based to uture digital-based operation4- Template for PACS RFP (Request for Proposal)5- Preparing for PACS implementation6- Check list during implementation7- System acceptance8- PACS system evaluation

Digital techniques in radiology have many advantages for radiologists, radiographers, patients, clinicians and hospital-operators from many perspectives: diagnostic quality, dose reduction, access to old and new images and reports via PACS, HIS and RIS.Radiologists concentrate more and more on organs and pathology (super) specialties rather than in modalities. Organ based radiology requires the integration of all modalities and has to cover large geographical regions to deliver expertise, as there few top-experts. This is only possible in the digital world of HICT (Health Information and Communication Technology), where digital detectors are the first step in a long chain of informatics.Today most of the diagnostic imaging modalities (CT, MRI, US, PET,..) used in radiology are digital except plain film imaging. In order to digitize plain x-ray (also called General Radiology) there is choice between Computed Radiography (CR) based upon storage phosphor screens and DR (Digital Radiography) based on "flat or panel" detectors. A large spectrum of applications and price ranges is available on the market.Technology: Both CR and DR rely on conversion and storage of x-ray energy in "pixel"-like elements in the detector. These detectors are linear (film is S-curved) and have a enormous dynamic range (1 in 100.000) so no information is lost and they resist over- and under-exposure up to 4 times.- In CR x-ray energy is stored into the phosphor-crystals and converted into visible light after stimulation by (laser) light which is in turn captured and digitized by an optical system. Pixels (in size between 50 and 150 µm) are one after one stimulated and translated into a digital image of millions of points. - In DR systems x-ray energy is converted in 2 or 3 steps into electrical charge that is stored in every pixel of the detector. These charges are digitized row after row to make a digital image. The conversion of the x-rays is done by a "scintillator" or phosphor, known from screens and image amplifiers. There are 2 groups of DR: the first group is amorphous selenium + TFT pixel backplane and the second is a scintillator + TFT pixel backplane. The first directly converts x-ray into charge (2 steps) and the latter first converts x-rays into light and light into charge in a photodiode in each pixel. Of course the DR technology is complex and difficult to manufacture in the large formats needed in radiology (14"x17") and explains the high price/unit (>200 k$).DR can only be justified in a limited number of situations: high throughput (like chest), high labor-cost and lack of radiographers, radiation-dose regulations.The technical nature of DR is very sensitive to environmental conditions like vibrations (mobile applications) and temperature (Selenium has to be air-conditioned) and the portable models are still bulky and costly to put under the bed patients. However, in the future DR prices are expected to come down- There are numerous combined systems: lens or fiber coupled CCD systems guiding the x-ray image into a small (and cheap) CCD with a bad image quality.Slit/slot methods moving a small bundle of x-rays and a line-detector over the patient during several seconds exhausting the tube and the patient....There is no perfect system: most have some advantages and some drawbacks and all of them are compromises between quality and price. Today CR based on powder phosphors is still the best solution in a starter situation where cost and a broad range of ap-plications are important, because it replaces all types of film-screen cassettes by 1 CR cassette, without changes to the x-ray modality and the workflow. Immediately it allows lower doses and a decrease in repeat rates to <1% at a high image quality (with multi-frequency image processing like Agfa Musica).CR readers are offered in a wide range of sophistication and prices matching most of the needs and budgets of radiology practices.For special cases like pediatrics and mammography, low-dose high resolution Needle phosphor CR technology can compete with DR at a lower price.CR technology has proven to be cost-efficient on itself in radiology, DR has not yet. Although digital detectors improve the diagnostic quality along with the improved image quality, the real value of digital images is in the hospital-wide (and even further) availability of digital information at the level of PACS, RIS and HIS.

Kodak offers an extensive family of CR. Systems and options flexible enough to support nearly any environment, workflow, or application. Two out of five CR systems in USA and Canada are Kodak.Fast, reliable, and easy to use, these systems deliver remarkable image quality and state-of-the-art image processing-for the productivity and performance you need to control costs and maximize return on your investment.Kodak CR''s key strengths are, easy to use, intuitive customer interface, advanced software options for enhanced productivity image quality and statistical analysis. New option includes Low Exposure Optimization Software. All in one design CPU, UPS, SW, monitor, bar code reader, rigid image plates and 100% non-contact scanning. Our Kodak cassettes have been laboratory tested to withstand 45 000 actuations without fail liar. It also supports Mammography Feature which is now FDA ap-proved. Our CR options include Remote operations panel. Wall-mounted touch-screen panels allow radiographers to perform most CR system functions away from the main unit. Network up to ten remote operations panels to a single Kodak DirectView CR system. Or network one panel to as many as eight CR systems. EVP optional software takes Kodak Direct-View CR system image quality and user diagnostic confidence to new levels with a technological breakthrough that extends image latitude without loss of detail contrast. Kodak V3 optional software improves image presentation and saves time in entering exam and patient data. Use the package to automatically detect and suppress grid-line artifacts, enable true size printing, preload procedure mapping and exam protocols-and more. Kodak DirectView Remote Patient Data entry software improves productivity and workflow by allowing personnel to enter patient data at any networked PC. Kodak DirectView Long-Length Imaging System enables capture of vertical long-bone CR images- full leg and full spine-with a 800/900 system. Automatic stitching software delivers the largest single exposure-up to 17 *51 in. long-with few, if any visible seams. Kodak DirectView Total Quality tool enables technologists to perform objective system tests and QA measurements for optional CR system CR system function. The x-ray phantom software is fully automated. Kodak self-calibrating digitizers provide high-performance for teleradiology, digital arc-hiving, and CAD applications. Masterpage Workstation is a innovative and flexible workstation adds even greater functionality to Kodak CR systems. It provides a range of features from QA, automatic intelligent printing, CD production to applications like Orthopedic templating Cardiac viewing and image distribution.

KODAK DIRECTVIEW DR 9500 System. The flexibility of a dual detector system in a unique, sin-gle detector design. The DR 9500 easily moves "around" the patient, making it ideal for all horizontal, upright and angled projections, and added convenience for patients - particularly those with limited mobility. KODAK DIRECTVIEW DR 7500 System New-generation system provides the ultimate in digital radiography flexibility. Modular components ena-ble you to easily configure a DR system to fit your space, applications, workflow - and budget.Highest operator comfort:• Auto tracking (tube, table, wall stand, both direc-tions)• Automatic, perpendicular centring to detectors center for table and wall stand• Auto positioning (choice of 16, customer programmable tube-detector positions)• Manual or full motorised up and down motion and motorised detector tilt capability• Overhead tube system optional motorised, standard length rail system (5x3m)• Floor mounted or with floor rails equipped DR 7500WM wall stand• Moveable, motorised table with floating top tableScaleable: • degree of motorisation, degree of automatic func-tionsKODAK DIRECTVIEW DR 3000 System This powerful multipurpose system is designed to handle a full range of general radiography procedures. With its simple design, space saving footprint, and advanced "ease of use" features, this system can enhance departmental workflow, productivity, and the quality of patient care.

‘APAX VIEWER'' is software that enables you to see the various medical images. It allows doctors in each clinical part to inquire about the medical images and helps them to diagnose their patient''s illness more correctly. Its function related to the management of the database helps the doctors to prepare for the education, research and conference as well as to save the images into their personal computers. And it also can help the doctors to manage effectively the patient''s data of diagnosis and treatment, connected with the Hospital Infor-mation System (HIS).Enterprise PACS communicates with global medical system by LAN or WAN. Images from any modality can be exchanged across your enterprise network to give everyone who needs access anytime.Enterprise PACS gives you some merits such as:- Fast data exchanges between multiple modalities, archives, and workstations - Convenient image accesses across wide and local area networks to break down the barriers of communication between your central location and private practice offices - Expandable technology that grows with your needs, no matter where those needs arise WebPACS, Seoul C&J Inc. solution for Enterprise PACS, based on clinical version of APAX Viewer- designated for clinic doctors. It usually uses a single monitor. Some functions are limited than Di-agnostic version that is a viewer for diagnosticians.The user does not need any software installed in his/her Computer. He/she connects to WebPACS Server using website address. The clinical version of APAX Viewer will be downloading and installing through ActiveX control. The user can select Database and Enter predefined Username and Password. He/she can view images of any patient in worklist that put by WebPACS administrator on WebPACS Server, instantly.

To reach to the optimum benefits of the PACS, we need to consider many things as followings:We need a clear vision and mission about the usage and benefits of the PACS and also a clear data about the quality, quantity and extending the soft-ware that we will need in the future.Before installing the PACS, we must know the benefits of supplementary products and tools such as necessary hardware, network, internet, appropriate OS (especially for the servers), educated personnel, security of the system and data, disaster recovery plan which they are playing very important roles in performance and quality of the system.We should be aware of our needs about the integration of PACS and RIS/HIS, using the TeleRadiology, DICOMizer, standard reports as Structured Report (SR), image processing and computer aided diagnostic tools, stability of PACS and DICOM servers.We should be aware of the importance of software licenses and copyrights and also support the PACS, OS, Databases and other components especially when we want to store significant information and connect it through Internet.The budget of the system not only depends on the PACS software but also includes the price of hard-ware, network, image processing components, maintenance, upgrading, original OS, database and other supplementary tools.We are very proud to have ability for designing and producing these strategic and high technical products for the first time in open source platform in our region. We hope that you support the Iranian products and help us to improve our work for better competition with the best foreigner PACS

Accurate and precision tumor treatment in radiotherapy is one of the critical problems for cancer therapy. Before foundation of DICOM, planning done through inaccurate and 2D methods using simple images that are contoured using a digitizer device on hard copy images of CT or X-ray. Body, tumor and normal contours made by user. After introducing DICOM, medical physicists and oncologists try to plan based on DICOM files which acquired, archived and delivered by PACS.CorePLAN is a representative product of Seoul C&J, Inc. for treatment planning based on PACS. This product is a convenient and comprehensive radiation therapy planning system that supports 3D conformal treatment, multi-plan, IMRT (Intensity Modulated Radiation Therapy) with useful intelligent functions and automatic registration suite. CorePLAN provides accurate dose calculations based on the collapsed cone convolution method, which is proven by the KFDA. The accuracy of its algorithms was confirmed through numerous clinical tests and achievement of treating over 700 patients. CorePLAN demonstrates excellent accuracy, and its high-speed calculation is as fast as that of 2D algorithms. This is a result of the implementation of new technologies and rigorous optimization based on PACS.Some CorePLAN features are:-Automatically detecting and contouring the body, contouring desired regions easily with a single click.-Digitizer for making Images that is contoured using a digitizer device.-Film Scanner to producing digitalized images through a film scanner device. -DICOM QNR that combines with other DICOM-compatible applications is done through DICOM query and retrieval methods. -DICOM 3.0 standard which support DICOM-RT standard.-DICOM Server that used while linked with PACS system and others. -CoreFusion which is a convenient and accurate registration system that supports every important medical modality (CT, MR and PET) for excellent tumor contouring and visualization for treatment follow up, which supports automatic, marker-based and manual registration.

Link Data Processor Medical Engineering Co., Tehran, IranThere is need of using patient''s past-deciphered re-sults and images for accurate diagnosis of disease and treatment follow up. ‘APAX VIEWER'' is software that enables you to see the various medical images. Its function related to the management of the database helps the doctors to prepare for the education, research and conference as well as to save the images into their personal computers. And it also can help the doctors to manage effectively the patient''s data of diagnosis and treatment, connected with the Hos-pital Information System (HIS).Diagnostic version of APAX viewer is a viewer for diagnosticians that uses multi monitor of portrait type, which requires 2 to 4 monitors, optimized to diagnose.One of the features of APAX is Patient Time Table or MIH (Medical Image History) that display the patient''s past-deciphered results and images which all images have the same Patient ID. It shows images in 3Months, 6Months, 1Year, 2Years, 3Years, 4Years and 5Years ago and can open each exam or series as selected.APAX has 4 viewing modes: Compare (comparing images of old exams), Exam (comparing exams of one patient), Series (comparing series of one patient) and Normal (viewing one patient).2 or 4 monitors provide for easy and rapid side-by side comparison viewing of images, regardless of whether they are different representations of the same image or two images of the same patient that were obtained at different times. Radiologist can dictate the interpretation on the same workstation and save it as file in patient database. Also he can type his/her report or interpretation on APAX Radiology Information System (RIS) or other RIS on the same workstation instantly. All APAX icons are gray which are compatible with gray scale medical monitors.Above features cause APAX to be ergonomic for using by Radiologists.

About Barco: Barco, the global market leader in visualization solutions for Picture Archiving and Communications Systems (PACS), has been developing visionary medical imaging solutions for more than 15 years. Designed to help healthcare professionals meet a wide spectrum of imaging needs, Barco''s solutions range from premium, high-resolution diagnostic display systems to innovative advanced visualization and analysis software.The company''s reputation and commitment to quality and service have earned the trust of customers from all over the world, who partner with Barco to meet their most demanding imaging challenges. A strong emphasis on support is the cornerstone of Barco''s customer commitment. Barco''s development and production process is supported by a worldwide network of research, development and support services.Barco''s Medical Imaging division is ISO 9001:2000 & ISO 13485 certified.

Multi media dry imager and printer: CodonicsCodonics, a privately held corporation headquartered in Cleveland, Ohio, has been pioneering medical hardcopy solutions for over a decade, and is the industry leader in multi-media imagers. The first to introduce color DICOM printers, we are now represented in over 80 countries by thousands of people with over 25,000 installations worldwide. Now, Codonics revolutionizes the medical industry with the introduction of the Horizon Multi-media imager. Horizon instantly delivers diagnostic film, stunning color prints, and cost-saving white films. This all-in-one imager is an enormous breakthrough in performance, cost and quality for healthcare facilities. Horizon''s unprecedented variety in printing options creates a new freedom of choice and allows users to match the output with the need, resulting in solutions capable of immediately reducing costs, minimizing waste and maximizing workflow. Horizon packs this all into one compact device, weighing less than 70 pounds and taking up less than two feet of desk space, eliminating costly sitting requirements. Codonics delivers a lot more than state-of-the-art medical imagers. Our focus is providing a greater value to your radiology department. Codonics was the first to introduce an exclusive medical-intended film alternative, DirectVista Paper. Printed the same way as our diagnostic film with no toners, wax or ribbons to ever replace, white film can be room light viewed and is preferred by referring physicians. Codonics implements design and test methodologies used in the aerospace industry to deliver the most reliable products in the world with the industry''s lowest service and maintenance costs. The small size and light weight of Codonics imagers allow for further ground breaking innovation in the area of medical imager service. Codonics provides a replacement unit if any problem cannot be solved by our 24/7 technical support team. This revolutionary Sunrise Express Warranty (or ''swap'' service) provides greater uptime and a lower total cost than traditional on-site service plans.Medical disc publisher: Virtua The Codonics Virtua XR Medical Disc Publisher is the world''s fastest medical disc recording system. With unprecedented speed, it records over 60 CDs or 30 DVDs an hour. Virtua XR is specifically designed for today''s high-volume imaging applications such as breast MR, PET/CT, MRI and CTA. It is the only CD/DVD recorder that keeps up with today''s multi-modality environments where imaging systems can send tens of thousands of images an hour. Setting the standard for medical disc recording systems, customized discs are recorded and ready to leave with the patient without any interruption in workflow. All Virtua models feature a compact design that includes an advanced processor for receiving and managing studies, a robotic disc recorder and printer, and a world-class touch screen interface. The built-in printer produces brilliant, full-color disc labels that can be easily created by the customer or through Codonics exclusive label design service. Not only is Virtua the fastest, most compact, and user-friendly system on the market, it also happens to be the most affordable. You''ll wonder how you ever got along without it. Codonics goal is to provide the medical industry with faster, more versatile and economical imaging solutions than ever before, keeping pace with the demands of tomorrow. Our unique perspective on imaging has been brought to life through our innovative product line - "We bring the future into focus."

The trend towards filmless imaging has, ironically, created growing physician demand for hard-copy images. PACS may improve report turnaround time, increase radiologist'' efficiency, and eliminate film, but it has failed to satisfy many referring physicians. They don''t want to search databases, worry about infrastructure, deal with CD''s or have their office bandwidth choked by huge images files. Consequently, hospitals and clinics are seeking inexpensive ways to produce non-diagnostic prints of sufficient quality that physicians can use for treatment planning and consultation with colleagues and patients. Ideally, it should be easy to incorporate into patients records.aycan''s xray-print solution lets you print radiological and other medical images on plain paper at near film quality. It fits seamlessly into both traditional and PACS workflows to provide a low-cost solution for sharing imaging with referral physicians and patients.• 90% cost reduction - off current hard copy medical imaging cost. • Operated like a film camera - no difference in operation of a paper printer vs. a film laser camera (no time intensive special training, same workflow). • Easy file and store - paper can be easily filed and stored with other patient records.. • Use of color - images such as 3-D, US and NM can be printed in color. • No light sensitivity - unlike film, paper prints are not degradable by direct sunlight.• The aycan xray-print software includes DICOM Presentation Look-Up tables (PLUT), which allows you to set defaults and adjust image quality settings (brightness, grey scale, contrast etc.) for each modality.• Requested Image Size Lets you print images in true size.• RGB and CMYK Color Correction modes Real time preview window Gives you a preview of your adjustments before you actually print.• System Recovery aycan xray-print boots directly from CD with every restart of your system and corrects eventual damages immediately. In case of a complete hard disk failure you can restore your system within

Since 1998, the worldwide interoperability initia-tive "Integrating the Health Care Enterprise" (IHE) has started the process of innovating the clinical and organizational workflow inside and among the Healthcare Enterprises. The process has had a strong impact in Radiological Procedures and nowadays is introducing a new way of thinking in developing and managing all the systems involved.Even the old monolithic concept of Radiological Workstation is changing toward a new composite one. The new vision follows strictly the concept of a collection of IHE "actors" and thus the workstation is a combination of different bricks (the actors), each one with its own features and role. The clinician, with the consultancy of administrative staff and clinical engineers when needed, is able to choose the "workstation system" that fits exactly his particular needs in his clinical practice. Besides these interesting aspects, IHE has regulated the access to information stored outside the hospital, as for example that recorded in the "Med-ical Imaging Resource Centers" (MIRC) Servers, or on a variety of "Electronic Health Record" (EHR) systems: Furthermore, IHE has offered original integration profile solutions for the remote exchange of the data themselves, as the Cross-Enterprise Document Sharing (XDS) profile. These features are already available in some workstations "of the future", as for example O3-RWS by our O3 Consortium.A workstation that implements these features or roles, allows the clinician to have all the relevant patient''s information on the workstation at the same time, regardless it has been taken from the patient''s clinical history, or from literature of spe-cial cases or from a local PACS. The availability of all these data jointly helps improving a safe health care of the patient.In the near future, the next step of the IHE process will be the introduction of a different way of reporting. The integration profile called "Reporting Workflow" (RWF) has been defined in details by IHE and it has been already implemented in some workstations as the above cited O3-RWS. RWF, together with the new state-of-the-art methods for building up a "Structured Report" (see the wonderful work done in Tehran in this field by the group of Dr. Fatehi), seems to be really promising, as a powerful tool for the entire healthcare providers'' staff.

Most of physicians choose the PACS by its viewer. DICOM Image viewers, the programs that run in workstations, facilitate accessing to the digital im-ages via a DICOM network. A good workstation should be equipped with professional monitors and other hardware requirements. A wide range of DICOM image viewers are available from simple 2D viewers which offer means of manipulating the im-ages (rotate, zoom, brightness, contrast and others) to 3D or 4D programs with sophisticated features such as multimodality image fusion, vessel segmentation and computer aided diagnostic tools.These programs can be categorized to client-based and web-based viewers. Despite the client-based viewers, which are heavy-weighted programs, equipped with strong features, web-based viewers are usually light-weighted with essential imaging features and suitable for TeleRadiology. Accessing to the digital images via the Internet is the main propose behind a web-based viewer. Web-based viewers may be used for remote consulting when a city or region lacks of native specialists.An image viewer as a part of PACS should be in conformance with DICOM standard as communication protocol instated of customized networking. This issue allows the viewer to communicate with any DICOM server and operate as an independent module. Structured Report (SR) editor is an essential part of a DICOM viewer. This kind of reporting benefits the archiving system because of small data size in comparison with keeping reports as scanned images or Secondary Capture Images (SC). Also, connection of DICOM viewer to RIS/HIS is important and as our previous experiences in RIS/HIS we connected Payvand DICOM viewer to the RIS/HIS. Payvand DICOM viewer has a lot of features and abilities, but for reaching to the high performance image processing by BARCO-EPD collaboration contract, we integrated our DICOM viewer to the VOXAR 3D and now our users have advanced 3D, vessel, cardiac and colon processing, PET CT Fusion and 3D Enterprise solutions.

‘APAX VIEWER'' enables you to see the various medical images. It allows doctors in each clinical part to inquire about the medical images and helps them to diagnose their patient''s illness more cor-rectly. Its function related to the management of the database helps the doctors to prepare for the education, research and conference as well as to save the images into their personal computers. And it also can help the doctors to manage effectively the patient''s data of diagnosis and treatment, con-nected with the HIS.APAX Viewer''s features:1- Holds HL7. 2- Improved image quality through non-linear lookup tables, window leveling preset auto-matching. 3- Various image processing tools.4- Optimized medical image searching using MIH (Medical Image History).5- Record and Dictation supported.‘APAX SERVER'' connects RIS to modalities, acquires images, archives images and interpretations with or without compression using multiple storage spaces through following features:1-‘APAX Acquisition Server'' acquires images and saves and transmits them to the database (exam and image information and deciphering results received through RIS I/S). 2-‘APAX RIS Broker'' receives patient and order information from RIS, and sends to each modality. 3-‘APAX Archiving Server'' stores acquired data with or without compression in the Short-term Storage (Hard disk,. ..) and when it passes defined days it will be moved to the Long-term Storage (Tape Drives,. ..) with or without compression.4-‘APAX Storage Server'' checks multiple-storage spaces any time, and assists Acquisition Server selecting a suitable storage space to store.5-‘APAX DB Gateway'' relays to DB requests between the Client and DB Server when the main DB server is ‘Oracle'' and a client''s PC is not installed the Oracle client program.6-‘APAX Secondary Capture System'' acquires data from non-DICOM modalities, converts to DICOM and sends to DICOM server by SONO-Link(endoscopy, ultrasound), CTLink(CT, MRI, RF) and SCANLink(x-ray film scanned by film digitizers) programs.

PACS has evolved from a technical difficult and expensive radiology based business towards the main driver in digital diagnostic imaging in healthcare. Emerging countries will not repeat this evolution but have to jump on the bandwagon of enterprise PACS the motor behind healthcare informatics. PACS will use rather of-the-shelf technologies like internet1+2, commercial storage and communication solutions than special "homemade" technology. PACS will evolve from a local image-data center towards a regional and even countrywide medical imaging expertise and knowledge network. This will increase the role of the organ-based specialized radiologists in the diagnosis and treatment of patients.Developments: There exist 3 levels of PACS deployment with increasing technical complexities. At least all of them require a minimum of RIS and HIS to make them useful.• Modality based PACS: supported by modality vendors and of increasing importance by the new 3-4D image processing. Here all processing and storage is located around the MRI and CT. It has value for the radiologist but is not helping clinicians and it is costly because it has to be repeated for every modality and every vendor. • Departmental PACS: integrates all modalities into 1 type of workstation, storage and communication, but communication towards clinicians and other hospitals is based on film, CD ROM or a kind of simple LAN. This has a very high cost and only helps the radiologist. The use of DICOM standards is mandatory.• Enterprise PACS is the imaging part of a hospital-wide informatics strategy (called HIS) leading to an EMR (Electronic Medical Record), EPR (Electronic Patient record) or EHR (Electronic Health record), where neither paper nor film is used. All medical specialties (including the image-rich cardiology) are integrated into one system, improving treatment speed and quality. The main decision-takers are governments, health authorities, health insurances, and hospital chains. It is often used as a competitive and marketing advantage. HL7 is now the dominant standard. Several enterprise PACS can be integrated into a multisite-PACS (even on remote distances) allowing doctors and patients to go wherever into the system. This approach requires new standards like the Master Patient Index (MPI) and a lot more intelligence and integration of the (multi-vendor) systems. The final goal of enterprise PACS is to look for knowledge, EBM and use of the semantic web in order to improve the treatment of patients even in remote locations.Finally all PACS levels have to evolve towards enterprise PACS, integrated in a HIS, and images will be part of a kind of EPR. Modality and departmental PACS must be upgraded towards a hospital-wide PACS in a cost-efficient way without compromises about speed and capacity. Internet technology, database are integral parts of the solution.Companies offering PACS should have this approach in their roadmap, rather than short term throw-away offers. RFPs have to written in respect to future upgrades towards enterprise PACS just to avoid dead-end streets and costly disappointments.

History of Distributor: We are PDP Co. (Pardazesh Danesh Pezeshki) founded in 1998 with more than 8 years Experiments in Diagnostic Medical Imaging Market. we launched our New Division in 2002 for Digital Imaging and Softcopy under name of PDP View. We studied our market demands and PACS Provider Companies for 2 years and finally we signed the Contract with the first leader German PACS Provider named dicomPACS ®. We are the only company who their 3 engineers well trained in the PACS provider company and Certified for sales and after sales services. dicomPACS ® History: dicomPACS ® software house, was founded in Germany in 1991 - 16 years experiences -The company''s main business is the development, design, sale, installation and support of medical In-formation Technology systems, concentrating on total digital solution including: • Complete digital Image processing solutions (PACS)• Provider and supplier of all necessary digital equipment like CR and Film Digitizers dicomPACS and Kodak relationship: Due to dicomPACS High quality and good price, Not expensive as Kodak original PACS, dicomPACS is the partner and PACS Provider for Kodak CR, DR and Laser Imagers in Germany, Iran and many other countries. Introducing dicomPACS: The company''s customers are Hospitals and Clinics. dicomPACS is a market leader in Germany with about 5000 PACS workstations during last 15 years an dit has Worldwide activities in more than 30 countries. so it is very professional in responding to change client requirements and client specific pro-gramming. • Company philosophy: To achieve an honest and transparent working with customers • Company To be the best and to guarantee its customers a tailor-made, optimal solution• The company is certified in accordance with ISO 13485:2003 and the CE Mark, MED CERT. (Medical Certificate) and FDA dicomPACS Main Features• Close co-operation with doctors to develop this software• Easy to adapt to any size of practice or hospital based on your needs• For all types of medical image data and modalities• Specially designed for needs of Radiologists • Connection via DICOM or video signal or Non Standard Analog • Acquisition, archiving, diagnosis and communication• Wide range of tools, features and add-ons e.g.Windowing, zoom, filters, planning, 3D reconstruction• Has extremely favourable price-performance ratio • User-friendly, intuitive and self-explanatory structure very little training requireddicomPACS Technical Features• Object orientated programming in JAVA, minimal risk• Flexible installation under Windows, UNIX, LINUX, Mac• And Highest level of security, speed and compatibility on the basis of SQL database technology and consistent archiving of images and documents in DICOM format.

This presentation offers an understanding of the rapidly changing medical market and devices, and provides ways for Medical Informatics Systems to keep up with this rapidly changing environment. The Infinitt Company of South Korea as one of the pioneers in the field of imaging informatics will present its three major solutions to meet these new trends. The Infinitt G3 will be presented as fully web-based RIS/PACS solution with advanced 3D capabilities all operating on a single platform, i.e. a solution for simultaneous fusion of RIS, PACS and 3D functions.The Infinitt Star PACS is presented as an on-demand PACS solution, which can operate in a web-based environment for easier image distribution, remote conferencing and Teleradiology practices. Infinitt Rapidia, which is a 3D imaging technology, that visualizes 3D images out of a large quantity of 2D images is presented as a tool to support diagnostic and surgery demands.

The Hipax Diagnostic Workstationis a completely new generation of Hipax viewer software, specially developed to cope with very big image series. The new viewer concept allows an optimal workflow.The images can already be processed while the se-ries is still loaded - the loading process is carried out in the background, unnoticed by the user and without loss of performance.The different image processing functions can be used in maximum speed even on very big image series. The multiplanar reconstruction opens additional possibilities for radiologists to evaluate images.Features• Extremely fast performance for big image series• Optimised workflow• Parallel processing (loading and image processing at the same time)• SQL based database• Scalable: Single user workstation to PACS• Available in various languages

PACS is in daily use in many hospitals and shows a reasonably good degreeof functionality when dealing with radiological images.However, there are still some unresolved problems when PACS is asked tomanage ultrasonographic images. These images are markedly different withrespect to the other diagnostic images. They are dynamic, and multiframehas to be supported. They may include colour areas, and special LUT andwindow/level have to be foreseen. They display on the same screendifferent dimensions of data (e.g. a space - measured in cm - and avelocity - measured in cm/sec).Most PACS workstations are unable to cope with the specific requirementsfor optimally displaying ultrasonographic images.In this talk the specific issues of ultrasonography that are relevant forPACS will be discussed.

Typically a PACS network consists of a central server or servers that store a database containing the images connected to one or many clients via a LAN, WAN or internet which provide or utilize the images.The core part of a PACS network is called DICOM server. Its purpose is to receive DICOM images from any node in the network such as different modalities, or to list studies on a workstation and directly retrieve the ones of interest. For choosing the PACS quality, security and accessories of PACS & DICOM server has a main role.Using the PACS for small clinics up to the big hospitals is quite different. Be sure that your PACS system can handle different modalities and users simultaneously. User authentication and authorization is necessary for any secure system especially when the system designed to be accessed from different nodes and users in a network. However, no direct solution is anticipated in DICOM standard for this issue. Payvand PACS offers a tricky solution for authenticating users and authorizing their access to the studies.Protecting a data for reduction of hacking is very important in medical field especially when our server is attached to the internet, so we used many other protections in addition to user define like: fire wall, user log files, and users online observing, and storing the entire modified file in the separate database. So if the authorized user by mistake changed any images the admin can restore original images. Store and retrieve of reports as a structural report (SR) is very important. Different OS platforms haven''t same strength, when we need store huge data, or high perfor-mance and security; the Linux OS is our choice for the servers. This system has a lot of security and accessories fea-tures and it''s the first PACS system design and built in open sources platform (Like Linux, MYSQL...) in the Meddle East and CRS Region.

In this talk, one of the most efficient, and reliable integrated tools for CD/DVD production workflow, called Medical Archive Recording System (MARS) by ETIAM Company, France, which is a leader in multimedia connectivity for healthcare in Europe, is going to be introduced. This tool is used to record all patient studies, route the studies to printers and PACS automatically, print key images and associated reports and log all study production for automated post processing/archiving. Its benefits vary from multi-departmental system to highly customizability, IHE compliancy, high productivity, inclusion of workflow manager and web interface.An automated user-friendly DICOM viewer is in-cluded in this tool, which is used to display reports and key image. It also allows comparing several stu-dies on several discs.The viewer supports all DICOM objects including compressed images such as JPEG, JPEG 2000, RLE etc. and video added-value non-image DICOM ob-jects.The ETIAM MARS is offered in two versions: MARS 15d for medium productions and MARS 20d for medium to large productions. Some of the new features that are added are supports for Windows Vista, support of new DICOM objects (enhanced CT, MR, XA, Encapsulated PDF. ..) IHE PDI update, creation of object keys for key images; importing non-standard reports form files and many other features.The tool enables users to create, verify and index CDs and DVDs by simply sending studies from any DICOM node.

‘APAX VIEWER'' is software that enables you to see the various medical images. It allows doctors in each clinical part to inquire about the medical images and helps them to diagnose their patient''s illness more correctly. Its function related to the management of the database helps the doctors to prepare for the education, research and conference as well as to save the images into their personal computers. And it also can help the doctors to manage effectively the patient''s data of diagnosis and treatment, connected with the Hospital Infor-mation System (HIS).‘APAX SERVER'' is software that connects RIS to modalities, acquires images, archives images and interpretations with or without compression using multiple storage spaces.APAX Acquisition Server is a product that combined these functions into a single module, and provides flexibility by being compatible with any other device. Images managed with DICOM Server can be viewed through APAX Viewer.The DB composition is made up of exam information, image information, and deciphering results received through RIS I/F. Images are saved using 30:1 lossy compression (Wavelet) to maximize storage space, and the saved images and exam information are automatically deleted due to aging. To search deleted images, inquiry them through DICOM Query and import the images.Archiving Server is for limited storage. The data, which is acquired recently, is stored in the Short-term Storage and when it passes defined days it will be moved to the Long-term Storage. The Short-term Storage used fast device (hard disks), while the Long-term Storage used cheap devices.APAX Storage Server checks multiple storage spaces any time, and assists Acquisition Server se-lecting a suitable storage space to store.APAX can compress data in Short-term and Long-term storage devices using Jpeg compression types (Lossy, Lossless, 2000 Lossy, 2000 Lossless) to reduce image size, which leads to increase storage capacity

Avajang ICT Group is a leading name in the IT distribution business and Solution Provider in the Middle East and especially in IRAN with 12 years of Experience and about 300 Employees, with care-fully selected high quality products.Avajang is proudly distributing and providing solu-tions via the most famous brands like Gigabyte Technology, NEC, Kaspersky Lab, AMD, Logitech, Teac, Kingmax and so on.Avajang Includes 5 Companies as below:• Golden Systems Electronics• Avajang System• Avajang Retail • Avajang Hardware• Avajang ServiceIn response to ICT market demands and in continuation of its activities in IT field, Avajang has changed to a separated independent company in one Group in order to take more positive steps in this regard.While studying the demands of Iranian market and by selecting a wide range of products having compatible quality with global standards from well-known manufacturers, Avajang System is trying to provide total solutions and proper reasonable response to all demands of Iranian IT users for SOHO, Corporate, and Enterprises use.Nowadays, ICT (Information and Communication Technology) has deep Influence on different parts of Medicals. Information always would be the most important part of integrated systems. The quality, Availability, Reliability, and Integrity of information should be supported.As PACS (Picture Archiving and Communication System) in the ICT speech means processing huge amount of data in the small piece of time, needs a hardware platform, which supports PACS in all levels of Data Processing, Image Processing, data Storage and Data Backup/Restore recovery systems.Fortunately Avajang System in cooperate with NEC provides an integrated hardware platform which supports not only data processing, image processing and huge scalable with acceptable transfer rate of data storage, but also supports High Availability, Clustering, Load balancing with reliable data recovery systems with competitive cost of the other brands in this level.

Medal Electronic (ME) Engineering Company provides high quality systems, software and services in medical image management, processing and visualization. We assist health care professionals to improve and extend the efficiency of their practices with cost effective solutions. ME is the developer of several medical software including MEDAL-PACS, 3D-Sonosoft, Analytical-Electrophoresis, CBONE and Rhino-Plus. ME is also the exclusive distributor of PACSPLUS in Iran. PACSPLUS is an international, standard, scalable and enterprise PACS solution. PACSPLUS is of ISO, CE and FDA-510 approvals. It is now operational in more than 1000 clinical environment throughout the globe. We discuss about the key features of PACSPLUS system for dealing with real world challenge in PACS as well as the PACS solu-tions needed to fulfill the demands of the clinicians in Iran. Our experience in developing high-end medical software confirms our capability in providing the PACSPLUS as an ultimate PACS solution in Iran.

Best Performace: With our Hipax Cluster PACS Server solution we are introducing the parallel computing concept as an extremely fast software system to the PACS world. In contrast to the common PACS servers, the Hipax Cluster PACS software is not only restricted to one or two computers, but can be used on a couple of servers controlling each other.Thus, the same services can be run simultaneously on different computers. The scalable system can also be expanded subsequently without lost of per-formance by adding further processors or Hipax server units, for example, if new clients or modalities are to be connected.Maximum Failure Security: The Cluster Server concept offers high failure security. If one of the server PCs breaks down, the services can be assumed by another Hipax server unit, temporarily. If the overload of one of the server PCs is imminent, the services will be carried out by another Hipax unit (load balancing). To increase the security, e.g. against fire, the single Hipax servers can also be located separately. This concept offers maximum security, flexibility, performance, redundancy and scalability.The Hipax Cluster PACS Server is easy to be administrated using a web interface. In the case of a system failure (e.g. overloading, breakdown of a server PC) the system administrator receives a mes-sage via Email and is so enabled to solve the problem.Features• Based on SQL database• Different services running on separate PCs• The Hipax Server unis are coordinated and able to control each other• Exponentiates the power of a cluster server to the whole PACS (more processors)• Scalable to the demands• Maximum performance• Load balancing for optimum efficiency• Maximum failure security because of expo-nentiated redundancy• Warning Email automatically sent to the system administrator in the case of failure• Web interface for system configuration• Maintenance without shut down the system• Very easy central administration• Flexible grant of image access authorisation• Latest non-proprietary open standards, including TCP/IP, DICOM, IHE, HL7

Correct data communications with the Imaging Center Departments and HIS is very important in all over the world; in other countries they estab-lished some parts of this connection throw out HL7 standards. At this time none of HIS/RIS software''s in Iran supports this standard, and as well we need to connect these systems at the modalities acquisi-tion segment, which HL7 doesn''t support it.With due attention to EPD Co. experiments in de-sign and Produce of RIS/HIS and PACS and our basic knowledge about HL7 V3, linking these systems together are very important for us. So in the first step, we connect them together over Payvand systems and in the second step we create a standard solution as a service under windows platform for connecting different RIS/HIS to the PACS.This Service is a DICOM-based standard solution that directly links RIS/HIS systems to PACS in workstation level. It transfers patient demographics and study information from RIS systems to PACS by Modality Request. Also radiologists can use this service to get their work list by Dicom Viewer directly. We can denote some benefits of this service as possibility to keep track patient file over the RIS/HIS, eliminating data entry at the modality and in consequence, increasing speed and simplicity of imaging procedure, enabling exams to start on time and assuring that the exam data is cataloged correctly when sent to a PACS.EPD Co. Work list Service runs in the background of Windows operating system. First, it opens a network socket and then answers to all requests from Modalities and DICOM Viewers. The RIS operators work with this service indirectly when they enter patient information. Also this service is not relative to any RIS/HIS and PACS system, so medical imaging centers can use this service with any windows-based RIS/HIS.

Noor Medical Imaging Center was using a viewing station as Dicom-Server when all imaging devices like Spiral CT and MRI was sending their images to this computer. Therefore, other viewers in PACS network could access to images of server via Di-com-Query and imported them to their computer for diagnosis. In this plan a single computer received images from two imaging sources and compressed them for archiving. Meanwhile if another viewer had a request, it should search patients and sent images to that computer.Considering capacity limitations, images must be removed to CD. Hence, if physician wanted to access to the older images, he/she must wanted computer administrator to retrieve images from CD to server. Considering all above problems we planed a Di-com-Server with these futures: 1) Each imaging device must send images to its own unique archiving computer (we named it DicomX). 2) Capacity of each DicomX could be increased via adding new hard disks. 3) For DVD backing up, images must send from DicomXs to Query-Server computer 4) Query-Server stored patient information in its Database for searching services. 5) DicomXs must re-send each received images to predefined viewers for eliminating of query of new studies. That design was working well until installation of MSCT with arising of two problems: 1) DVD backup manner didn''t work, as computer administrator couldn''t write many DVDs and reconstruction of damaged HDD from DVDs is not applicable 2) Internal networking traffic between DicomXs and Query-Server was still high. For solv-ing the problem, we stored Dicom images on two hard disks in each DicomX. One for archiving and another for backing up, instead of using DVDs. Therefore, DicomX just send patient information to Query-Server for reducing of network traffic. In our work, Viewing Stations just are used as Diagnostic Computers and multi-processor Dicom-Server satisfies archiving needs.

This presentation will discuss four topics: • HIS/RIS/PACS integration• Medical image and data Standards• IHE (Integrating the Healthcare Enterprise) Pro-files• ePR (electronic Patient Record)PACS is an imaging management system that requires pertinent data from other medical information systems for an effective operation. Among these systems are hospital information system (HIS), and radiology information system (RIS). A voice recognition (VR) system can also be used to generate a radiology report as a direct output of the RIS which can be considered as a component of RIS. Many functions, for examples, image routing, prefetching, automatic grouping, etc. in the PACS server and display workstations rely on data extracted from both HIS and RIS. This presentation first discusses the infrastructure and functions of HIS, RIS, VR and data which are important to PACS operation, and their interfaces. HIS and RIS follow HL-7 (Health Level 7) data format and TCP/IP communication standards, PACS uses DICOM (Digital Imaging and Communication in Medicine) image format and communication standard. The success of PCAS, HIS, and RIS interface rely on the conformance to these standards of each information system during system operation. To interface HIS and RIS with PACS, certain guidelines are necessary including:(1) Each system (HIS, RIS, PACS) remains unchanged in its configuration, data, and functions performed.(2) Each system''s hardware and software are ex-tended to allow for communication among systems.(3) Only data are shared; original system functions remain local. For example, RIS functions should not be performed at PACS or HIS workstation, or images should not be viewed at RIS workstation. Keeping each system specific and autonomous would simplify the interface process, since a complete database updates is difficult to perform at a global level.Based on these guidelines, successfully interfacing HIS, RIS, and PACS should follow these steps:(1) Identify the subset data that would be shared by other systems. Set up access rights and authorization for each system.(2) Convert non standard subset textual data to HL 7. This step, composing of designing a high level presentation, solving data inconsistencies, and naming conventions, can be accomplished by using a common data model and data language for all systems, and by defining rules of correspondence between various data definitions among systems.(3) Define communication protocol of data transfer, i.e., TCP/IP or DICOM.In general, medical imaging industry conforms to the aforementioned standards as well the IHE (Integrating the Healthcare Enterprise) profiles for integration of HIS, RIS and PACS. IHE is an evolving set of well defined clinical workflows under various clinical operation environments including radiology, pathology, surgery, and oncology. IHE profiles allow healthcare providers integration capability in order to work efficiently in providing optimal patient care. Essences of IHE will be highlighted.Electronic medical record (eMR) or electronic pa-tient record (ePR) is the ultimate patient oriented information system in a healthcare enterprise. In an even broader sense, if the ePR includes health record of an individual, then it is called eHR (Electronic Health Record). Although the development of a universal ePR as a commercial product is still years away, its eventual impact to the healthcare delivery system should not be underestimated. Currently most ePR is Web-based and application oriented and geared its design to a certain clinical subspecialty, for examples, outpatient radiology service, spinal surgery, CAD (Computer-aided diagnosis) server, etc. ePR with images distribution is necessary for wider range in clinical usage, its infrastructure and functionalities will be discussed.

Correct data communications with the Imaging Center Departments and HIS is very important in all over the world; in other countries they estab-lished some parts of this connection throw out HL7 standards. At this time none of HIS/RIS software''s in Iran supports this standard, and as well we need to connect these systems at the modalities acquisi-tion segment, which HL7 doesn''t support it.With due attention to EPD Co. experiments in de-sign and Produce of RIS/HIS and PACS and our basic knowledge about HL7 V3, linking these systems together are very important for us. So in the first step, we connect them together over Payvand systems and in the second step we create a standard solution as a service under windows platform for connecting different RIS/HIS to the PACS.This Service is a DICOM-based standard solution that directly links RIS/HIS systems to PACS in workstation level. It transfers patient demographics and study information from RIS systems to PACS by Modality Request. Also radiologists can use this service to get their work list by Dicom Viewer directly. We can denote some benefits of this service as possibility to keep track patient file over the RIS/HIS, eliminating data entry at the modality and in consequence, increasing speed and simplicity of imaging procedure, enabling exams to start on time and assuring that the exam data is cataloged correctly when sent to a PACS.EPD Co. Work list Service runs in the background of Windows operating system. First, it opens a network socket and then answers to all requests from Modalities and DICOM Viewers. The RIS operators work with this service indirectly when they enter patient information. Also this service is not relative to any RIS/HIS and PACS system, so medical imaging centers can use this service with any windows-based RIS/HIS.

‘APAX VIEWER'' is software that enables you to see the various medical images. It allows doctors in each clinical part to inquire about the medical images and helps them to diagnose their patient''s illness more correctly. Its function related to the management of the database helps the doctors to prepare for the education, research and conference as well as to save the images into their personal computers. And it also can help the doctors to manage effectively the patient''s data of diagnosis and treatment, connected with the Hospital Infor-mation System (HIS).‘APAX SERVER'' is software that connects RIS to modalities, acquires images, archives images and interpretations with or without compression using multiple storage spaces.APAX Acquisition Server is a product that combined these functions into a single module, and provides flexibility by being compatible with any other device. Images managed with DICOM Server can be viewed through APAX Viewer.RIS Information exchange using the DICOM standards, the modality and your review stations can share scheduling and reporting information to accelerate workflow.RIS Broker receives patient and order information from RIS, and sends to each modality. While RIS Broker obtains information from RIS, it parses or-der information and makes the DICOM worklist. Then each modality gets information from RIS Broker with the standard DICOM agreement.Radiologist can dictate the interpretation on the same workstation and save it as file in patient database. Also he can type the report on APAX indoor Radiology Information System (RIS) on the same workstation instantly.The DICOMDIR Autorun CD has the report as well as images. So Hospitals, patient and insurance companies can have a copy of integrated image and report for registering in patient history for their special own aims.

This presentation offers an explanation of the necessity for RIS/PACS integration, provides ways for achieving integration of RIS/PACS, and explains how INFINITT, an innovative Korean medical imaging Informatics Company supports integration between RIS/PACS... This solution is fully web-based RIS/PACS with advanced 3D capabilities all operating on a single database, which features a simultaneous fusion of RIS, PACS and 3D functions. Designed specifically in a web environment, this innovative product enables access even from a remote site as it streamlines the radiology workflow. Enhanced structured reports and GSPS (Grey Scale Presentation State) functions, advanced hanging protocols, background DICOM service processing and roaming user profiles and streamlined routine reading processes are other features of this solution.This solution is compliant with DICOM, HL7, IHE and HIPPA industry standards while ensuring high level of scalability and integration capability

Lung cancer is one of the most lethal kinds of the cancer worldwide. Computed Tomography (CT) has been shown as the most sensitive imaging modality for detecting small pulmonary nodules. To support radiologists in the challenging task of interpreting screening lung CT scans, we have developed a CAD system for the automated detection of the pleural nodules. In this study, we introduce a 3-step region of interest (ROI) hunter algorithm for the initial selection of the nodule candidates. We applied a combination of the 3D directional-gradient concentration method and the 2D morphological opening procedure on the pleural surface already segmented by an iso-surface triangulation technique called marching-cubes algorithm. Then within each ROI a nodule segmentation technique based on the morphological opening is applied to determine the 3D shape of the nodule candidate. Thirteen geometrical and textural features are extracted from the segmented nodules and then classified by a three-layered feed-forward neural network which was trained by the cross-validation method.This method has been validated on 102 pleural no-dules with diameter greater than 5 mm in 42 CT scan. Our CAD system achieved sensitivity values in the range of 80-85% at 35-43 FP/scan, corresponding approximately to 0.12-0.14 FP/slice and has the ability to reject more than the 93% of the FP findings generated by the ROI hunter. The average area Az under the ROC curve obtained was 0.91. The CAD system we proposed in this study has demonstrated a significant potential as a useful diagnostic aid in assisting the radiologists in the accurately identifying the pleural nodules on thoracic CT images. Current efforts are focused on further reducing the amount of false-positive findings generated by the system.

Noticeable development in achieving data from patients is acquired by means of designing a system that connects these systems: imaging, archive and monitoring systems. When several imaging devices work based on DICOM standard; they can connect to each other without any interface. There are many applications for DICOM standard in radiotherapy; however its main usage is in imaging. It has other applications such as RT Structure Set, RT Dose, RT Plan and RT Brachy Treatment. Now DICOM is a complete and widespread standard to use in radiotherapy. Most of the radiotherapy machines have ability to use DICOM. Before installing a new Linac, it is necessary to predict all aspects of DICOM standard in this device. Therefore, as regards to entrance of 12 Linac to Iran, it is important to have enough knowledge about it. This article is a review about development of DICOM in radiotherapy. We try to stress on DICOM applications and abstain from technological agenda.

Appropriate electronic medical report-making soft-wares help physicians to personally generate records for paper printing and ePR access. Flat data-sheets with check-boxes that have been already used in traditional medical paper reports, do not satisfy today''s physician demands for more professional reports.Alternatively, Structured Reporting (SR) as the modified version of flat check-box based reporting method is being selected. In this method, items are nested in a hieratical tree so that each reporting item includes several substitutions. Hence, computer generates professional sentences with logical pre-defined combination of selected items. In our work, on the basis of SR method, we provided solution for reporting of Endoscopy procedures that is accepted by several Gastroenterologists as a proper software. In addi-tion, successful results in generation of ePRs using SR are newly achieved in Cardiology.

Plans for human resource developing are one of the most important aspects of development in their common meaning and learning is the most funda-mental way of their certainty. Like the communication and information technology which is the complement of daily activity process of organizations reconstruction (including electronical banking, electronical comers, electronical post, electronical government...), elec-tronical learning or training realm are also promises of far-fetched goals performance. Now a day, it does not seem to be a prominent limitation by elimination of time, place and learners age that was a far goal in tow decades ago. On the other hand, traditional educational methods will not respond to the expansive requirement of high growing skills and information-based technology. Although traditional educational system has characteristics that ignoring them reduces the influence of learning and can be the cause of abnormality.

The utilization of PACS is expanding in numerous parts of worlds. The witnesses and contexts show the lack of suitable expansion of this knowledge in Iran, so I decided to review the situation of PACS in Iran in form of master thesis of medical IT. Following cases are considered in this study:a) Considering of companies about internal produc-tions or external produces sale: by main considering about active company in PACS field in Iran, it be-comes obvious that just 2 Iranian companies are active in production of PACS at this time, one of them considered to external products, and in this time just one medical informatics company cooperation still has activity about internal production in this field. More than 10 companies are active as legal and illegal representation in dif-ferent PACSes installation.b) Review and attitude to PACS in Iran: this work is accomplished by providing questionnaire and sending it to more than 50 different radiology centers. Among 37 centers that returned questionnaire, only 12 centers had PACS. 48.6% of these centers did not consider any PACS, 43.8% did not have any tendency to consider PACS, and only 32.4% of these centers probably will provide CR in 2 years later.The attitude effect of radiologists, managers and physicians in PACS expansion in order is 88.2%, 90.0% and 92%. There is direct correlation with the PACS inspection & number of DICOM output devices (p=0.002) and competition between Imaging Centers (p=0.034).

Nonlinear dynamics, chaos theory and fractal geometry have been widely used to study biologic systems and there are many applications regarding using them in biomedical sciences. Fractal image analysis which provides a new approach to quantify the properties of images and describe them as fractal dimension and multifractal spectra is one of the novel methods to explore complex images in a scale-independent format as a whole. In this paper the fractal analysis of radiological images as a new diagnostic quantitative procedure has been introduced via different examples. Several mathe-matical methods for calculating the multifractal spectrum of radiological images are discussed. It is shown that quantifying the characteristics of radiological images as fractal dimensions can help to develop a diagnostic tool for radiologists to reduce the errors in their diagnoses.

Technological advances in medical imaging in the past two decades have enable radiologists to create images of the human body with unprecedented resolution. MRI, PET,... imaging devices can quickly acquire 3D images. Image fusion establishes an anatomical correlation between corresponding images derived from different examination. This fusion is applied either to combine images of different modalities (CT, MRI) or single modality (PET-PET).Image fusion is performed in two steps:1) Registration: spatial modification (eg. translation) of model image relative to reference image in order to arrive at an ideal matching of both images. Registration methods are feature-based and intensity-based approaches.2) Visualization: the goal of it is to depict the spatial relationship between the model image and refer-ence image. We can point out its clinical application in nuclear medicine (PET/CT)

Proposing automated algorithms for quantitative analysis of facial images based on facial features may assist surgeons to validate the success of nose surgery in objective and reproducible manner. In this paper, we attempt to develop automatic procedures for quantitative analysis of rhinoplasty operation based on several standard linear and spatial features. The main processing steps include image enhancement, correction of varying illumination effect, automatic facial skin detection, automatic feature extraction, facial measurements and surgery analysis. For quantitative analysis of nose surgery, we randomly selected 100 patients from the database provided by the ENT division of Imam Hospital, Tehran, Iran. The frontal and profile images of these patients before and after rhinoplasty were available for experiments. For statistical analysis of nasal two clinical parameters, i.e., Nasolabial Angle and Nasal Projection ratio are computed. The mean and standard deviation of Nasolabial Angle by manual measurement of a specialist was 95.98˚(±9.58˚) and 111.02˚(±10.07˚) before and after nose surgery, respectively. The proposed algorithm has automatically computed this parameter as 94.12˚ (±8.86˚) and 109.65˚ (±8.86˚) before and after nose surgery. In addition, the proposed algorithm has automatically computed the Nasal Projection by Good''s method as 0.584(±0.0491) and 0.537(±0.066) before and after nose surgery, respectively. Meanwhile, this parameter has manually been measured by a specialist as 0.576(±0.052) and 0.537(±0.077) before and after nose surgery, respectively. The result of the proposed facial skin segmentation, feature detection algorithms, and estimated values for the above two clinical parameters in the presence of the mentioned datasets declare that the techniques are applicable in the common clinical practice of the nose surgery.