Digital Endoscopy: Challenges for Enterprise Imaging

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PACS has the potential to serve the needs of the entire diagnostic imaging enterprise; providing archival and connectivity capabilities to deliver image information anywhere across the healthcare continuum. Although PACS has predominantly lived within the purview of radiology, many other diagnostic imaging specialties are now able to produce native DICOM images, or have conversion tools available that convert captured images into the DICOM format for PACS purposes.

As such, many of the medical specialties outside radiology—including cardiology, orthopedics, radiation therapy, pathology, dentistry, ophthalmology, virology, microbiology and hematology—want to harness the power of PACS for storing and distributing images generated by their departments. Of particular interest for many clinicians is the capability for using PACS to store and transmit digital endoscopy data.

Endoscopy is perhaps one of the most widely used visible-light image capture tools in medicine, and almost all of the latest generation of equipment is digital and support DICOM. Gastrointestinal specialists use the technology to perform colonoscopy, esophagogastroduodenoscopy, proctosigmoidoscopy, and endoscopic retrograde cholangiopancreatography (ERCP) studies.

Rhinoscopy and bronchoscopy exams are commonly conducted for the respiratory tract; with panendoscopy (the combination of laryngoscopy, esophagoscopy and bronchoscopy) also ordered for patient studies. Cystoscopy is performed for urinary tract disorders. Gynecologists conduct colposcopy, hysteroscopy, falloscopy, and some laparoscopy exams, while obstetricians utilize the technology for amnioscopy and fetoscopy. Orthopedic specialists utilize arthroscopy, and thoracic specialists use endoscopic tools for thoracoscopy and mediastinoscopy studies.

Visible light, for the capture of microscopy and endoscopy images, has been part of the DICOM standard since 1999. The DICOM-VL specification delineates how to store preparation procedures and image-acquisition conditions in the image headers, which allows for display of these images on a DICOM viewing station, as well as integration of the data into an enterprise-wide PACS image management architecture.

At first glance, it would seem that the pieces are in place for bringing digital endoscopy onto the enterprise PACS; however, according to a pair of healthcare informatics pioneers who have set themselves this task, there are still issues remaining to be resolved.

Integration takes more than DICOM

In a presentation on enterprise PACS made at the 2005 Society for Computer Applications in Radiology (now the Society for Imaging Informatics in Medicine) annual conference in Orlando, Fla., Gary Wendt, MD, vice chair of informatics and enterprise director of medical imaging at University of Wisconsin-Madison, stated: “Perhaps the biggest problem with expanding PACS is the lack of informatics standards in other departments.”

Bringing digital endoscopy effectively onto an enterprise image management system is not based solely on the modality’s capability to generate images that are compliant with the DICOM-VL standard. According to Wendt, who has been part of bringing several specialties’ endoscopy studies onto the University of Wisconsin-Madison enterprise PACS; workflow and informatics issues play a key role in successful integration.

Endoscopic images are captured during an invasive procedure, so technologists performing the exam need easy access to the informatics system, according to Wendt. His facility has found that most user-friendly and least procedure-intrusive options for image and data entry are a foot pedal or touch-screen mechanism.

In addition, technologists need a way to quickly upload patient demographics and the capability to easily annotate the anatomical location of the images being captured, he says. In addition, interpreting clinicians should have the capability to identify key images or cine sequences in the endoscopy procedure that illustrate the findings of their diagnostic report.

“Post-procedure images can be easily confused; the right main stem bronchus looks like the left, so unlabeled images are of minimal clinical value,” Wendt says. “Also, key image selection permits endoscopy physicians to include the clinically relevant portion of the exam in their report, rather than the entire sequence of images obtained during the exam.”

Many times, endoscopy procedures are performed on conscious or minimally sedated patients, he notes.