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RC626 Using the Medical RC626 Using the Medical Image Resource Center Image Resource Center (MIRC) Software (Basic (MIRC) Software (Basic Imaging Informatics)Imaging Informatics)
Adam E. Flanders, MDThomas Jefferson University HospitalPhiladelphia, Pennsylvania
Using MIRC for Using MIRC for Departmental Teaching Departmental Teaching Files Files
Your SpeakersYour Speakers
RC626A – Using MIRC For RC626A – Using MIRC For Departmental Teaching Files Departmental Teaching Files Adam E. Flanders MDAdam E. Flanders MD
RC626B – Using MIRC to Create RC626B – Using MIRC to Create Medical School and Resident Training Medical School and Resident Training ProgramsPrograms Krishna Juluru, MDKrishna Juluru, MD
RC626C – New Developments in RC626C – New Developments in RSNA MIRC ToolsRSNA MIRC Tools John Perry John Perry
Segment ObjectivesSegment Objectives
Features of a digital teaching file.Features of a digital teaching file. The MIRC solutionThe MIRC solution MIRC design features.MIRC design features. TJUH configuration(s) of MIRC TJUH configuration(s) of MIRC
software.software. Challenges of departmental DTF Challenges of departmental DTF
deployment.deployment.
What is a Teaching File?What is a Teaching File?
An organized repository of clinical An organized repository of clinical images and documentation.images and documentation.
Used primarily to supplement learning Used primarily to supplement learning process for trainees.process for trainees.
Source material for lectures, Source material for lectures, publications.publications.
Film library modelFilm library model Shelves of cases (film jackets)Shelves of cases (film jackets) Organized by anatomy, disease, ACR codes.Organized by anatomy, disease, ACR codes.
What are the Qualities of a What are the Qualities of a “Great” Radiology Teaching “Great” Radiology Teaching
FileFile High quality ImagesHigh quality Images Comprehensive supplemental Comprehensive supplemental
Information:Information: path reports, path images, discussion etc.path reports, path images, discussion etc.
OrganizationOrganization Indexed and searchableIndexed and searchable Fresh content.Fresh content. Easily accessed from anywhere.Easily accessed from anywhere. Easy to navigate.Easy to navigate. SecureSecure
Problems with Film-Problems with Film-Based TFBased TF Limited access.Limited access.
Typically, a lot of work to Typically, a lot of work to submit a case.submit a case. Difficult to solicit Difficult to solicit
“voluntary” contributions.“voluntary” contributions. Difficult to keep Difficult to keep
organized.organized. Missing or misfiled cases Missing or misfiled cases
or films.or films. Need a librarian/policemanNeed a librarian/policeman Securing files = limited Securing files = limited
access.access. Searching file is Searching file is
problematic.problematic. Inconvenient to use for Inconvenient to use for
decision support.decision support. Difficult to Difficult to
update/maintain – update/maintain – keeping material keeping material current.current.
Analog to Digital Analog to Digital TransformationTransformation
Inexpensive digital cameras / Inexpensive digital cameras / scanners.scanners.
Retirement of hard copy Retirement of hard copy (film)(film)
Proliferation of PACS.Proliferation of PACS. Proliferation of workstations.Proliferation of workstations.
Digitizing Analog ImagesDigitizing Analog Images
Digitizing Analog ImagesDigitizing Analog Images
Digital Camera on PACS or ViewboxLaborious but effective!
Personal Image Personal Image Storage Storage
SolutionsSolutions
Digitized Images: Big Step Digitized Images: Big Step Forward!Forward!
AdvantagesAdvantages Lightweight and reusableLightweight and reusable No deterioration, loss, resistant to theft.No deterioration, loss, resistant to theft. ModifiableModifiable Easy to adjust, crop, contrast, brightnessEasy to adjust, crop, contrast, brightness Easy to add annotation.Easy to add annotation.
ProblemsProblems Access remained limited.Access remained limited. Organization!Organization! Large collections, difficult to find images Large collections, difficult to find images
without meticulous labeling methodswithout meticulous labeling methods Sharing material?Sharing material?
Where to Put Your Images? - Personal Where to Put Your Images? - Personal DTFDTF
Copy images Copy images into folders into folders labeled labeled appropriatelappropriately.y.
Nested file Nested file structurestructure
Need to Need to open open content in content in another another application application for use.for use.
Not very Not very versatileversatile
Personal Teaching FilesPersonal Teaching Files Thousands of radiologists have amassed Thousands of radiologists have amassed
“personal” collections of images.“personal” collections of images. Solutions include cases on email, upload Solutions include cases on email, upload
of cases to free digital photo services (ie of cases to free digital photo services (ie Google, Picassa, Shutterfly, Flikr etc.)Google, Picassa, Shutterfly, Flikr etc.)
Generally used by a single user.Generally used by a single user. Accessible from a single computerAccessible from a single computer Image collections are limited in scope.Image collections are limited in scope. Difficult to enhance content.Difficult to enhance content. Not readily sharableNot readily sharable
Personal DTF Organization Personal DTF Organization with Picassawith Picassa
The Next PhaseThe Next Phase Web browser is the most appropriate Web browser is the most appropriate
vehicle for delivery of educational content.vehicle for delivery of educational content. Browsers are designed to display written and Browsers are designed to display written and
visual content efficiently.visual content efficiently. Including multimedia.Including multimedia.
Early DTF contained “static” web pages.Early DTF contained “static” web pages. Laborious to produce.Laborious to produce.
Modern DTF coupled to a database Modern DTF coupled to a database generates content dynamically (“on-the-fly”).generates content dynamically (“on-the-fly”). Easier to modifyEasier to modify More conducive to search mechanismsMore conducive to search mechanisms
Components of a Modern Components of a Modern DTFDTF
FileserverFileserver DatabaseDatabase WebserveWebserve
rr
Fileserver
Database
Webserver
Ethernet
What Do People Want?What Do People Want?
Radiologists want a simple method Radiologists want a simple method to create teaching materials from to create teaching materials from their existing PACS systems.their existing PACS systems.
Ease of useEase of use Time efficientTime efficient Simple to accessSimple to access Scalable in terms of size & Scalable in terms of size &
complexity.complexity.
What Is Available NOW?What Is Available NOW?
Commercial turnkey systems available Commercial turnkey systems available for a price which will provide:for a price which will provide: Method to save images & data from Method to save images & data from
PACS.PACS. Storage local or off-site for your casesStorage local or off-site for your cases Web server to display casesWeb server to display cases
Organizational repositories (e.g. ACR Organizational repositories (e.g. ACR Case-In-Point, Aunt Minnie etc.)Case-In-Point, Aunt Minnie etc.)
You can develop your own…You can develop your own… Or there is MIRC!!!!Or there is MIRC!!!!
What Does The MIRC What Does The MIRC Software Suite Do For Me?Software Suite Do For Me?Medical Imaging Resource Center
Da’ AnswerDa’ Answer
Set of software tools that allow you to Set of software tools that allow you to create, index, search and display create, index, search and display teaching materials.teaching materials.
Repository for this content.Repository for this content. Ability to selectively share this Ability to selectively share this
material in a consistent manner material in a consistent manner withinwithin your institution on your local your institution on your local intranet or intranet or worldwideworldwide on the internet. on the internet.
MIRC factoidsMIRC factoids An RSNA sponsored initiative.An RSNA sponsored initiative. Software toolkit that can be used for creation of Software toolkit that can be used for creation of
teaching repositories and clinical trials databases.teaching repositories and clinical trials databases. Built on open-source principles.Built on open-source principles. No proprietary technology.No proprietary technology.
Uses available standards DICOM, XML, HTTP, JSP, JavaUses available standards DICOM, XML, HTTP, JSP, Java Software is free-of-charge, no licensing.Software is free-of-charge, no licensing. Software designed to operate on most common Software designed to operate on most common
operating systems incl. Windows, Apple OSX and operating systems incl. Windows, Apple OSX and Linux.Linux.
PACS vendor neutral.PACS vendor neutral.
MIRC FeaturesMIRC Features Individualized file storageIndividualized file storage Multiple document “templates”Multiple document “templates” Multiple methods to author contentMultiple methods to author content Multiple methods to display contentMultiple methods to display content Web-based DICOM viewer.Web-based DICOM viewer. Web-based editor.Web-based editor. DICOM receiver (DICOM SCP)DICOM receiver (DICOM SCP) DICOM anonymizerDICOM anonymizer Administrative control of viewing, editing, Administrative control of viewing, editing,
deletion.deletion. Scalable and expandable from one author/PC to Scalable and expandable from one author/PC to
hundreds.hundreds. Easy to install & configure.Easy to install & configure.
Scalability of MIRCScalability of MIRC MIRC has the unique ability to scale from MIRC has the unique ability to scale from
one computer / one user to many one computer / one user to many computers / many users.computers / many users.
Potential configurations include:Potential configurations include: One MIRC repository for one or more users.One MIRC repository for one or more users. Multiple MIRC repositories in one or many Multiple MIRC repositories in one or many
institutions.institutions. Software enables development of Software enables development of
cooperative libraries.cooperative libraries. Each library is individually administered yet Each library is individually administered yet
portions can be made accessible to all.portions can be made accessible to all.
MIRC Software Supports MIRC Software Supports Many Storage Formats.Many Storage Formats.
Images: DICOM, GIF, JPEG, Images: DICOM, GIF, JPEG, PNGPNG
Hyperlinks to other web Hyperlinks to other web content.content.
Virtually any content that is Virtually any content that is displayable in a web browser.displayable in a web browser.
Pointers to other files for Pointers to other files for downloading.downloading.
Display support for other types Display support for other types in the future…in the future…
Key MIRC Server Key MIRC Server ComponentsComponents
Storage Service (Warehouse for material)Storage Service (Warehouse for material) A cooperating information library.A cooperating information library. IndexIndex: the library’s card catalog.: the library’s card catalog. ServerServer: the library’s shelves.: the library’s shelves. Responds to MIRCquery using the Responds to MIRCquery using the
MIRCqueryresponse schema.MIRCqueryresponse schema. Query Service (“Google-like” search Query Service (“Google-like” search
portal)portal) An entry point into the MIRC community for a user An entry point into the MIRC community for a user
on the Internet.on the Internet. Creates queries using Creates queries using MIRCquery schemaMIRCquery schema..
MIRC TF Configuration MIRC TF Configuration ScenariosScenarios
Private ModePrivate Mode Departmental Departmental
ModeMode Division ModeDivision Mode Worldwide ModeWorldwide Mode VariationsVariations
MIRC TF ScenariosMIRC TF ScenariosPrivate (selfish) ModePrivate (selfish) Mode
My Stuff
Single-user Single-user contributorcontributor
Single-user Single-user accessaccess
No sharing No sharing of contentof content
MIRC TF ScenariosMIRC TF ScenariosDivisional / Semi-Private ModeDivisional / Semi-Private Mode
Each division or key Each division or key individual maintains a individual maintains a server.server.
Division is responsible Division is responsible for maintaining their for maintaining their content.content.
All or a portion of All or a portion of content can be made content can be made public.public.
Any individual can Any individual can access public records access public records on other MIRC on other MIRC servers within servers within institution.institution.
Much more difficult to Much more difficult to administer.administer.
MIRC TF ScenariosMIRC TF ScenariosDepartmental ModeDepartmental Mode Multiple users or Multiple users or
divisions contribute divisions contribute to a single to a single departmental MIRC departmental MIRC server.server.
All users have All users have controlled access.controlled access.
All can view public All can view public cases.cases.
Only owners can Only owners can modify data.modify data.
Private cases are Private cases are supported.supported.
One server to One server to manage for all manage for all content.content.
Easier to administer.Easier to administer.
BIG MIRC
NeuroNeuro NMNM ChestChest
CTCT Body Body MRMR
MammMammoo
CVIRCVIR MSKMSK PrivatePrivate
Neuro
MSK
Mammo
User
MIRC TF ScenariosMIRC TF ScenariosWorldwide ModeWorldwide Mode
Multiple MIRC Multiple MIRC sites sites (“MIRClets”) (“MIRClets”) expose content expose content to the Internet.to the Internet.
This public This public content is content is accessible to accessible to other computers other computers that can perform that can perform a query of MIRC a query of MIRC content.content.
Internet
How do you access How do you access content through content through
MIRC?MIRC?
MIRC QueryMIRC QueryQ
uery
Local MIRC
MIRC QueryThe InternetThe Internet
MIR
C Q
uery
MIRC Q
uery
MIR
C Q
uery
MIR
C Q
uer
y
The TJU The TJU ExperienceExperience
MIRC TF Installation at MIRC TF Installation at TJUTJU
Two MIRC servers currently installed.Two MIRC servers currently installed. One departmental (private) server One departmental (private) server
behind university firewall (2003 Server)behind university firewall (2003 Server) One Neuroradiology (public) server One Neuroradiology (public) server
residing on the public DMZ of the residing on the public DMZ of the firewall (2000 Server).firewall (2000 Server).
UsesUses Primarily Teaching FilesPrimarily Teaching Files Repository for clinical research data.Repository for clinical research data.
Public Neuroradiology Public Neuroradiology ServerServer
Resides on the public internet.Resides on the public internet. Contains interesting Neuroradiology/ENT Contains interesting Neuroradiology/ENT
cases.cases. Is listed with the RSNA portal.Is listed with the RSNA portal. Contains a subset of our proprietary DTF.Contains a subset of our proprietary DTF.
Does not contain the majority of our DTF.Does not contain the majority of our DTF. Uses:Uses:
PR device for the division.PR device for the division. Provides opportunity for former fellows to Provides opportunity for former fellows to
“give back” to the division.“give back” to the division. Consultation cases are reviewed in weekly Consultation cases are reviewed in weekly
case conference.case conference.
Features of the Public TF Features of the Public TF MIRCMIRC
Internet
Public NeuroradiologyMIRC Server
firewall
“Home Grown” Neuroradiology DTF
Linked to PACS
Public User
Selected Neuro/ENT Cases Are Pushed Out to Public
NeuroRadiology MIRC ServerUsing Custom Script
Cases on NeuroRadiology/ENT MIRC Server are Available for
Public Access
Registered Author
Registered Authors (former fellows & staff) Can Contribute to the Public
NeuroRadiology/ENT MIRC Server
How is the Public Site How is the Public Site Used?Used?
Public Teaching File Repository for Public Teaching File Repository for Neuroradiology/ENT Cases.Neuroradiology/ENT Cases.
Repository for Repository for consultconsult cases from cases from prior fellows and colleagues.prior fellows and colleagues.
Marketing tool for the TJUH Marketing tool for the TJUH NeuroRad fellowship.NeuroRad fellowship.
Central image server for multi-Central image server for multi-institutional SCI pharma imaging institutional SCI pharma imaging data.data.
Private Departmental MIRC Private Departmental MIRC ServerServer
Departmental MIRC ServerDepartmental MIRC Server
Serves multiple functions.Serves multiple functions. Heterogeneous case mix (> 12,000 cases)Heterogeneous case mix (> 12,000 cases) Largest proportion MSK (>8300 cases).Largest proportion MSK (>8300 cases). Over four thousand Neuro/ENT cases Over four thousand Neuro/ENT cases
from “home-grown” server are indexed on from “home-grown” server are indexed on server with links back to DTF (index server with links back to DTF (index card).card).
Provides support for four clinical research Provides support for four clinical research databases.databases.
““Feeds” to Departmental MIRC Feeds” to Departmental MIRC ServerServer
Teaching Cases
Exported from PACS
Teaching Cases
Exported from Other DTF using ZIP Service
NeuroDTF Index
NeuroDTF Index
Image Storage for Research
Departmental MIRC Departmental MIRC ServerServer
Departmental MIRC Departmental MIRC ServerServer
HAGL
Users of Departmental Users of Departmental ServerServer
Medical studentsMedical students ResidentsResidents FellowsFellows Rad FacultyRad Faculty Trainees & staff from clinical Trainees & staff from clinical
servicesservices ResearchersResearchers
Uses of Dept MIRC Uses of Dept MIRC Teaching FileTeaching File
Decision SupportDecision Support Source of images for Source of images for
presentations.presentations. Case ConferencesCase Conferences Pre-boards warmupPre-boards warmup
Community vs Personal Community vs Personal LibrariesLibraries
MIRC supports creation of “private” MIRC supports creation of “private” libraries.libraries.
The best way to realize the full The best way to realize the full potential of a shared community potential of a shared community teaching collection is to build a teaching collection is to build a community of users/contributerscommunity of users/contributers..
The value of MIRC software, is that The value of MIRC software, is that you can support both!you can support both!
The Single The Single Biggest Obstacle Biggest Obstacle to Success in the to Success in the
DTF World….DTF World….Compliance with Compliance with
the authoring the authoring process.process.
The Authoring The Authoring ProblemProblem
Lessons LearnedLessons Learned The MIRC software suite is scalable: from The MIRC software suite is scalable: from
a single user/contributor private DTF to a a single user/contributor private DTF to a large multi-user/multi-contributor public large multi-user/multi-contributor public DTF.DTF.
The software The software will not build the collection will not build the collection for you…for you… Only people will!Only people will!
The only way to build a great collection is The only way to build a great collection is to encourage multi-user contribution and to encourage multi-user contribution and to build a community that promotes to build a community that promotes knowledge sharingknowledge sharing..
Even with the best of intentions, it is not as Even with the best of intentions, it is not as easy as you might think!easy as you might think!
ObstaclesObstacles
The “ownership” issue…The “ownership” issue… Community property or personal Community property or personal
property?property? Building a great collection requires Building a great collection requires
cooperation from the community cooperation from the community (the entire department or division).(the entire department or division).
Collecting images and a diagnosis Collecting images and a diagnosis are a good start, but is not enough.are a good start, but is not enough. Need librarians that will create Need librarians that will create
complete documentation of cases.complete documentation of cases.
Lessons LearnedLessons Learned Authoring must occur at the Authoring must occur at the
point-of-care, that is during point-of-care, that is during clinical readout.clinical readout.Avoid retrospective submission.Avoid retrospective submission.
Authoring process must be Authoring process must be fast fast and ridiculously simple!and ridiculously simple!At minimum, key images, At minimum, key images,
diagnosis, and a clinical history.diagnosis, and a clinical history.The rest can be supplemented The rest can be supplemented
later.later.
Lessons LearnedLessons Learned Case material with limited content Case material with limited content
have limited value.have limited value. Most of our cases are Dx and images Most of our cases are Dx and images
alone.alone. Limited content still has value for:Limited content still has value for:
Decision supportDecision support Case conferencesCase conferences Creating presentationsCreating presentations Self-assessment board prep.Self-assessment board prep.
Limited content not effective for Limited content not effective for self-study.self-study.
Lessons LearnedLessons Learned Shame people into cooperating!Shame people into cooperating! Make the process fun!Make the process fun! Incorporate your DTF into a regular case Incorporate your DTF into a regular case
conference.conference. Even “suspicious” people will gradually see Even “suspicious” people will gradually see
the benefit.the benefit. Have a periodic Have a periodic Unknown of the Month, Unknown of the Month,
Day or Week.Day or Week. Encourage trainees to submit answers.Encourage trainees to submit answers. Tie a prize or reward into most correct cases Tie a prize or reward into most correct cases
or most submissions.or most submissions. Ask staff/fellows to select favorite cases Ask staff/fellows to select favorite cases
for residents to review from collection. for residents to review from collection.
Lessons LearnedLessons Learned
Through group cooperation, we have Through group cooperation, we have amassed over 11,000 Neuroradiology amassed over 11,000 Neuroradiology cases (non-MIRC).cases (non-MIRC).
You need at least one person to champion You need at least one person to champion the process!the process!
Encourage staff, residents and fellows to Encourage staff, residents and fellows to contribute.contribute.
Engage leadership to support effort.Engage leadership to support effort. Participation is Participation is rewarded rewarded by access to a by access to a
large, indexed repository of images for large, indexed repository of images for self learning, conferences and lectures.self learning, conferences and lectures.
ConfessionConfession
Everything is not perfect at home…..Everything is not perfect at home….. Even in a Even in a controlledcontrolled environment in environment in
my own division, compliance with my own division, compliance with authoring is far from 100%.authoring is far from 100%. Staff tend to pass the buck to busy Staff tend to pass the buck to busy
trainees who trainees who “forget”“forget” to author at the end to author at the end of the day.of the day.
Variable definition of a Variable definition of a valuable casevaluable case.. Lack of appreciation of “the classics”.Lack of appreciation of “the classics”. A generalized “fear” to save a case A generalized “fear” to save a case
without pathologic proof.without pathologic proof. ““What if I’m wrong????”What if I’m wrong????”
Personal ConfessionPersonal Confession Influence on other divisions in my own Influence on other divisions in my own
department has been less than ideal.department has been less than ideal. 22ndnd largest DTF collection is MSK (>10K largest DTF collection is MSK (>10K
cases) all located on a poorly organized cases) all located on a poorly organized fileserver.fileserver. Pilot project: Converted >8K to MIRC, now Pilot project: Converted >8K to MIRC, now
web enabled and indexed.web enabled and indexed. Division director “prefers” the old method.Division director “prefers” the old method. Departmental PACS to MIRC authoring Departmental PACS to MIRC authoring
tool:tool: Utilization has been poor.Utilization has been poor.
The reason? You need more than one The reason? You need more than one champion in a large, dispersed champion in a large, dispersed department.department.
Final ThoughtsFinal Thoughts People will tend to gravitate to what People will tend to gravitate to what
they already know or do:they already know or do: Email images to themselves.Email images to themselves. Save images to USB/CD.Save images to USB/CD.
Changing behavior is difficult, unless Changing behavior is difficult, unless you can convince users that the you can convince users that the secondary gain is better than the current secondary gain is better than the current solution.solution.
Contributing to the TF must Contributing to the TF must tied to the tied to the academic mission.academic mission.
Make it fun! Make it fun!
The FutureThe Future The one The one keykey technical element to a successful technical element to a successful
departmental teaching file is to simplify the departmental teaching file is to simplify the authoring process so that it is authoring process so that it is inexcusable inexcusable not to be performed during clinical read out.not to be performed during clinical read out.
IHE has come to the rescue with the IHE has come to the rescue with the Teaching File and Clinical Trial Export Teaching File and Clinical Trial Export profile.profile.
Four vendors at RSNA this year are Four vendors at RSNA this year are demonstrating this interactivity.demonstrating this interactivity.
PACS vendors PACS vendors mustmust be pressured into be pressured into supporting this profile.supporting this profile.
SummarySummary MIRC Teaching File Software Suite offers a MIRC Teaching File Software Suite offers a
viable, robust and scalable system for viable, robust and scalable system for creating comprehensive DTF collections.creating comprehensive DTF collections.
The sofware is well supported by the RSNA.The sofware is well supported by the RSNA. Free for use – installation CD’s available!Free for use – installation CD’s available! Project is being driven by the user Project is being driven by the user
community.community. Two user group meetings at RSNA!Two user group meetings at RSNA!
Software itself will not build a great Software itself will not build a great collection:collection: People/Cooperation/Community are key!People/Cooperation/Community are key!
MIRC Information & MIRC Information & SupportSupport
Check out the MIRC section on the Check out the MIRC section on the RSNA.org website!RSNA.org website!
Support tools:Support tools: MIRC Wiki: MIRC Wiki: http://mircwiki.rsna.orghttp://mircwiki.rsna.org MIRC forums: MIRC forums: http://forums.rsna.org/http://forums.rsna.org/