Common object request broker architecture (CORBA)-based security services for the virtual radiology environment.

The US Army Great Plains Regional Medical Command (GPRMC) has a requirement to conform to Department of Defense (DoD) and Army security policies for the Virtual Radiology Environment (VRE) Project. Within the DoD, security policy is defined as the set of laws, rules, and practices that regulate how an organization manages, protects, and distributes sensitive information. Security policy in the DoD is described by the Trusted Computer System Evaluation Criteria (TCSEC), Army Regulation (AR) 380-19, Defense Information Infrastructure Common Operating Environment (DII COE), Military Health Services System Automated Information Systems Security Policy Manual, and National Computer Security Center-TG-005, "Trusted Network Interpretation." These documents were used to develop a security policy that defines information protection requirements that are made with respect to those laws, rules, and practices that are required to protect the information stored and processed in the VRE Project. The goal of the security policy is to provide for a C2-level of information protection while also satisfying the functional needs of the GPRMC's user community. This report summarizes the security policy for the VRE and defines the CORBA security services that satisfy the policy. In the VRE, the information to be protected is embedded into three major information components: (1) Patient information consists of Digital Imaging and Communications in Medicine (DICOM)-formatted fields. The patient information resides in the digital imaging network picture archiving and communication system (DIN-PACS) networks in the database archive systems and includes (a) patient demographics; (b) patient images from x-ray, computed tomography (CT), magnetic resonance imaging (MRI), and ultrasound (US); and (c) prior patient images and related patient history. (2) Meta-Manager information to be protected consists of several data objects. This information is distributed to the Meta-Manager nodes and includes (a) radiologist schedules; (b) modality worklists; (c) routed case information; (d) DIN-PACS and Composite Health Care system (CHCS) messages, and Meta-Manager administrative and security information; and (e) patient case information. (3) Access control and communications security is required in the VRE to control who uses the VRE and Meta-Manager facilities and to secure the messages between VRE components. The CORBA Security Service Specification version 1.5 is designed to allow up to TCSEC's B2-level security for distributed objects. The CORBA Security Service Specification defines the functionality of several security features: identification and authentication, authorization and access control, security auditing, communication security, nonrepudiation, and security administration. This report describes the enhanced security features for the VRE and their implementation using commercial CORBA Security Service software products.

Security model for picture archiving and communication systems.

The modern information revolution has facilitated a metamorphosis of health care delivery wrought with the challenges of securing patient sensitive data. To accommodate this reality, Congress passed the Health Insurance Portability and Accountability Act (HIPAA). While final guidance has not fully been resolved at this time, it is up to the health care community to develop and implement comprehensive security strategies founded on procedural, hardware and software solutions in preparation for future controls. The Virtual Radiology Environment (VRE) Project, a landmark US Army picture archiving and communications system (PACS) implemented across 10 geographically dispersed medical facilities, has addressed that challenge by planning for the secure transmission of medical images and reports over their local (LAN) and wide area network (WAN) infrastructure. Their model, which is transferable to general PACS implementations, encompasses a strategy of application risk and dataflow identification, data auditing, security policy definition, and procedural controls. When combined with hardware and software solutions that are both non-performance limiting and scalable, the comprehensive approach will not only sufficiently address the current security requirements, but also accommodate the natural evolution of the enterprise security model.

Picture archiving and communication systems project management using web-based tools.

As the technology of picture archiving and communications systems (PACS) improves and implementation becomes more widespread, the project management of deploying substantially large, multiple-facility systems becomes an integral part of success. A successful deployment requires project support from the initial planning and surveying to the final acceptance, even encompassing support during active use of the PACS. The sharing of information between project stakeholders of a PACS implementation can be daunting at times, but with the flexibility of the worldwide web, this aspect can be eased. This report speaks to the tools and usability of the worldwide web to disseminate project management information for planning, implementation, and support of any PACS implementation--anywhere. This sharing of knowledge prepares the end user for what will be available for them when the complete systems is in place, allowing for a smoother migration to PACS.

Planning factors for developing an enterprise-wide picture archiving and communication system maintenance program.

Picture archiving and communication system (PACS) maintenance on an individual site basis has historically been a complex and costly challenge. With the advent of enterprise-wide PACS projects such as the Virtual Radiology Environment (VRE) project, the challenge of a maintenance program with even more complexities has presented itself. The approach of the project management team for the VRE project is not one of reactive maintenance, but one of highly proactive planning and negotiations, in hopes of capitalizing on the economies of scale of an enterprise-wide PACS maintenance program. A proactive maintenance program is one aspect of life-cycle management. As with any capital acquisition, life-cycle management may be used to manage the specific project aspects related to PACS. The purpose of an enterprise-wide warranty and maintenance life-cycle management approach is to maintain PACS at its maximum operational efficiency and utilization levels through a flexible, shared, yet symbiotic relationship between local, regional, and vendor resources. These goals include providing maximum operational performance levels on a local, regional, and enterprise basis, while maintaining acceptable costs and resource utilization levels. This goal must be achieved without negatively impacting point of care activities, regardless of changes to the clinical business environment.

Coping with PACS downtime in digital radiology.

As radiology departments become increasingly reliant on picture archiving and communication systems, they become more vulnerable to computer downtime that can paralyze a smoothly running department. The experiences and strategies developed during various types of picture archiving and communication system (PACS) downtime in a large radiology department that has completely converted to soft copy interpretation in all modalities except mammography are presented. Because these failures can be minimized but not eliminated, careful planning is necessary to minimize their impact.

Photostimulable storage phosphor image acquisition: evaluation of three commercially available state-of-the-art systems.

Photostimulable storage phosphor (PSP) image acquisition systems have been available for several years. The technology has had the opportunity to mature; however, there has not been an independent comparison of recently marketed commercial systems. For this study, three computed radiography (CR) systems using PSP technology (Kodak CR System 400 with autoloader [Eastman Kodak, Rochester, NY], Fuji FCR AC-3CS [Fuji Medical Systems, Stamford, CT], and Agfa ADC Compact [Bayer Corp, Ridgefield Park, NJ]) were connected to an IBM RadWorks diagnostic radiology workstation (IBM Corp, White Plains, NY) and evaluated for conformance to their performance specifications using guidance provided in the most recent draft acceptance testing protocol from Task Group No. 10, American Association of Physicists in Medicine. In addition, the physical requirements (e.g., space and power) and connectivity to another manufacturer's diagnostic workstation were examined. X-ray technologist comfort with each PSP imaging system and an assessment by our supporting biomedical equipment maintenance activity of their ability to service each PSP imaging system were also considered.

Technology assessment and requirements analysis: a process to facilitate decision making in picture archiving and communications system implementation.

In a time of decreasing resources, managers need a tool to manage their resources effectively, support clinical requirements, and replace aging equipment in order to ensure adequate clinical care. To do this successfully, one must be able to perform technology assessment and capital equipment asset management. The lack of a commercial system that adequately performed technology needs assessment and addressed the unique needs of the military led to the development of an in-house Technology Assessment and Requirements Analysis (TARA) program. The TARA is a tool that provides an unbiased review of clinical operations and the resulting capital equipment requirements for military hospitals. The TARA report allows for the development of acquisition strategies for new equipment, enhances personnel management, and improves and streamlines clinical operations and processes.

Virtual management of radiology examinations in the virtual radiology environment using common object request broker architecture services.

In the Department of Defense (DoD), US Army Medical Command is now embarking on an extremely exciting new project--creating a virtual radiology environment (VRE) for the management of radiology examinations. The business of radiology in the military is therefore being reengineered on several fronts by the VRE Project. In the VRE Project, a set of intelligent agent algorithms determine where examinations are to routed for reading bases on a knowledge base of the entire VRE. The set of algorithms, called the Meta-Manager, is hierarchical and uses object-based communications between medical treatment facilities (MTFs) and medical centers that have digital imaging network picture archiving and communications systems (DIN-PACS) networks. The communications is based on use of common object request broker architecture (CORBA) objects and services to send patient demographics and examination images from DIN-PACS networks in the MTFs to the DIN-PACS networks at the medical centers for diagnosis. The Meta-Manager is also responsible for updating the diagnosis at the originating MTF. CORBA services are used to perform secure message communications between DIN-PACS nodes in the VRE network. The Meta-Manager has a fail-safe architecture that allows the master Meta-Manager function to float to regional Meta-Manager sites in case of server failure. A prototype of the CORBA-based Meta-Manager is being developed by the University of Arizona's Computer Engineering Research Laboratory using the unified modeling language (UML) as a design tool. The prototype will implement the main functions described in the Meta-Manager design specification. The results of this project are expected to reengineer the process of radiology in the military and have extensions to commercial radiology environments.

Meta-manager: a requirements analysis.

The digital imaging network-picture-archiving and communications system (DIN-PACS) will be implemented in ten sites within the Great Plains Regional Medical Command (GPRMC). This network of PACS and teleradiology technology over a shared T1 network has opened the door for round the clock radiology coverage of all sites. However, the concept of a virtual radiology environment poses new issues for military medicine. A new workflow management system must be developed. This workflow management system will allow us to efficiently resolve these issues including quality of care, availability, severe capitation, and quality of the workforce. The design process of this management system must employ existing technology, operate over various telecommunication networks and protocols, be independent of platform operating systems, be flexible and scaleable, and involve the end user at the outset in the design process for which it is developed. Using the unified modeling language (UML), the specifications for this new business management system were created in concert between the University of Arizona and the GPRMC. These specifications detail a management system operating through a common object request brokered architecture (CORBA) environment. In this presentation, we characterize the Meta-Manager management system including aspects of intelligence, interfacility routing, fail-safe operations, and expected improvements in patient care and efficiency.

Incidence and methods of diagnosis of musculoskeletal injuries incurred in Operations Desert Shield and Desert Storm.

RATIONALE AND OBJECTIVES: The authors studied the incidence and distribution of orthopedic injuries sustained in Operation Desert Shield and Desert Storm by evaluating whether existing diagnostic imaging modalities were sufficient to diagnose the types of musculoskeletal injuries incurred. The authors also sought to determine if a dedicated extremity MR scanner would provide monetary benefits and enhance military readiness. METHODS: The authors retrospectively reviewed data on all musculoskeletal injuries incurred in Desert Shield/Desert Storm to determine the total number of injuries, proportion of orthopedic injuries, number of soft-tissue orthopedic injuries, and the country where the diagnosis was established. The authors also determined the number of patients, duration, and economic impact of the evacuation process. RESULTS: There were 1011 fractures and 1177 soft-tissue injuries; 408 soft-tissue injuries were diagnosed in the Persian Gulf countries, and 769 diagnosed in the United States and Germany. The average time to evacuate these 769 patients was 21 days with an estimated replacement cost of $836,885. CONCLUSIONS: Musculoskeletal soft-tissue injuries comprised 34% of the overall injuries in the Persian Gulf War, and twice as many patients required evacuation for diagnosis as were diagnosed locally using existing imaging modalities. A dedicated extremity magnetic resonance scanner in the battlefield would obviate many evacuations and hence be of both monetary and military readiness benefit.

Gadopentetate dimeglumine-enhanced chemical-shift MR imaging of the breast.

Standard T1-weighted MR images enhanced with gadopentetate dimeglumine show relatively minimal enhancement of breast lesions due to the high background signal from fat in the breast. Strongly enhancing lesions may become isointense relative to the fat signal and become invisible or indistinct after contrast administration. Fat-suppressed chemical-shift imaging (CSI) combined with administration of gadopentetate dimeglumine improves lesion detection and characterization in other areas of the body where a strong lipid signal is present. We evaluated this technique in the breast. Twenty patients with mammographic lesions were studied with standard unenhanced T1- and T2-weighted images and enhanced T1-weighted images, as well as with CSI before and after administration of gadopentetate dimeglumine. The series were ranked independently for border and matrix characteristics. The border was assessed for a smooth, irregular, or spiculated margin. The matrix or internal substance was evaluated for visibility and type of enhancement, homogeneous or inhomogeneous. The enhanced CSI images were superior to all other images in the depiction of border and matrix characteristics. Of 20 patients, a corresponding mass was detected on MR in 14. In two of the 14 patients, the lesion was seen only in the enhanced CSI images. Chemical-shift artifacts on enhanced T1-weighted images obscured border detail in several cases. Enhanced CSI improves visualization of breast lesions as compared with conventional MR imaging with or without enhancement. The enhanced CSI technique produces differential enhancement between glandular tissue and lesions while suppressing the signal from fat. This improves the visualization of border and matrix characteristics and depicts lesions that otherwise might be obscured.

Leiomyoma of terminal ileum producing a false-positive Meckel's scan.

A case of positive Meckel's diverticulum scan caused by a leiomyoma of the terminal ileum is reported. The early appearance of activity on the perfusion study aided in recognition of a false-positive scan.

Radionuclide thyroid angiography and surgical correlation. A five-year study.

Only 15% to 25% of cold nodules on conventional static thyroid scans are malignant. Radionuclide angiography of the thyroid and conventional static scans using sodium pertechnetate Tc 99m were performed on 114 patients who underwent thyroid surgery within a five-year period. The combined use of radionuclide angiography and conventional static scans increased the specificity for the diagnosis of thyroid carcinoma from 42% to 79% over static scans alone. The incidence of carcinoma in solitary cold nodules in our population was increased from 26% on static scans to 60% if the lesion was hypervascular on radionuclide angiography. Eighty-seven percent of hypervascular solitary cold nodules were neoplasms (carcinomas and adenomas). Hypervascularity as demonstrated by radionuclide angiography is predictive of thyroid neoplasia. The finding of a hypervascular, solitary cold nodule makes a recommendation for surgery predictive and reasonable.

The predictive value of myocardial radioisotope scanning in animals treated with doxorubicin.

Thirty-four New Zealand white rabbits were treated with doxorubicin and imaged weekly with Tc-99m pyrophosphate to define the value of abnormal myocardial images in predicting doxorubicin-induced cardiac toxicity. Increased myocardial uptake was detected in most animals on sustained treatment with doxorubicin. A greater proportion of the heart was involved with doxorubicin-related histologic changes in animals with strongly positive myocardial images than in treated animals with moderately positive or normal scans. The myocardial images returned to normal levels 2--6 wk after doxorubicin was discontinued. Five of seven rabbits that received doxorubicin after they had three moderately positive myocardial scans, died from congestive heart failure. Three rabbits whose doxorubicin was discontinued because of scan findings, survived for 6 wk or more before dying from renal failure. The three rabbits who received the highest total dose of doxorubicin died of renal failure without developing abnormal myocardial scans.

Myocardial imaging with Cc-99m pyrophosphate in patients on adriamycin treatment for neoplasia.

Technetium-99m pyrophosphate was utilized for myocardial imaging in 15 patients on adriamycin treatment for neoplasia. We have noted abnormal accumulation of the pyrophosphate in several patients, particularly in those in whom the so-called poor-risk factors were operative, namely prior radiation, cyclophosphamide therapy, and ischemic heart disease.

Infantile hepatic hemangioendotheliomas associated with hemihypertrophy.

An infant presented with congenital hemihypertrophy, hepatomegaly, and a low thoracic paraspinal mass. Liver scan showed multiple defects in the uptake of radioisotope. Surgical exploration revealed multiple infantile hemangioendotheliomas of the liver and a paraspinal hemangioendothelioma. In review of 69 reported cases of infantile hemangioendothelioma of the liver and viscera, there has been no previous note of hemihypertrophy associated with this abnormality.