# Image Examination Workflow in Healthcare Clinics

## A. Introduction
In modern healthcare settings, the management of radiology medical images plays an important role in diagnosis and treatment. While large hospitals often employ Picture Archiving and Communication Systems (PACS) servers for storing and sharing images, small clinics face significant challenges in implementing such infrastructure due to space constraints and maintenance demands. This article explores a practical solution to enable clinics, equipped with personal computers, to efficiently manage and share medical images and records through cloud-based technology.

## B. Background
### Challenges in Small Clinics
Unlike larger healthcare facilities with PACS servers, small clinic typically lack the resources and physical space to house extensive image storage servers. Consequently, they encounter difficulties in uploading and sharing critical medical images, hindering collaboration with remote doctors and limiting patient access to their own data.

## C. Method
To address these challenges mentioned in the part B, we propose a solution that empowers healthcare facilities, including small clinics, to upload medical records and images to a secure cloud server accessible via the internet. This approach offers convenience for both healthcare professionals and patients, facilitating remote consultations and allowing patients to view and safeguard their medical images. By having an organized and accessible image repository, at the same time it allow teleradiology services, where remote radiologists can efficiently access and interpret images, leading to quicker diagnoses and reports.

### Key Components of the Medical Imaging System in Clinics:
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1. **Simplified RIS and HIS Integration:** Clinics can streamline their operations by integrating a more straightforward and consolidated Radiology Information System (RIS) and Hospital Information System (HIS).

2. **Order Management:** Orders can be managed in the HL7 v2 format and converted into modality worklists (MWL) through the integration of HIS and RIS with various imaging modalities.

3. **Cloud PACS:** Clinics can use cloud-based PACS as an image manager and archive, reducing the need for on-site image storage servers.

### Workflow for Image Examination:
The image examination process in clinics follows these steps:
1. **Doctor's Order:** The attending physician initiates an examination procedure within the HIS+RIS system.

2. **Modality Worklist:** The order is automatically converted into a modality worklist, allowing for easy retrieval and tracking of order information within the modality.

3. **Image Acquisition:** The designated modality (e.g., X-ray) performs the examination and generates patient images.

4. **Cloud-Based Storage:** The acquired images are securely saved in the cloud-based image archive and content management system.

5. **Access and Display:** Physicians have the flexibility to query, access, and display the stored images as needed.

6. **Examination Reports:** Doctors, as the creators of medical evidence, can readily generate detailed examination reports.

### Image Storage and Transmission:
The process of image storage and transmission in the medical image examination workflow unfolds as follows:

1. **Doctor's Order:** The physician initiates an examination procedure from their personal computer.

2. **Image Acquisition:** Images generated by the modality are transferred to the doctor's personal computer. Notably, modality devices within a clinic can only connect to the Hospital Information System (HIS) system within the local area network (LAN).

3. **Cloud-Based Storage:** The images are then seamlessly transferred from the doctor's personal computer to the cloud-based image storage system.

4. **On-Demand Access:** Medical images can be downloaded from the cloud server whenever necessary, primarily when composing examination reports.

## D. Discussion
### Indonesia SATUSEHAT Radiology Image Architecture and Workflow
**SATUSEHAT DICOM Architecture**

Step 1. Create Order which generate Accession Number
- If hospital **have** MWL, then order store in hospital's MWL Server
- If hospital **doesn't have** MWL, then order will be input manually into the modality

Step 2. Send ServiceRequest to SATUSEHAT FHIR Server

Step 3. Modality retrieved order data
- If hospital **have** MWL, then Modality will retrieved data, including the Accession Number from hospital's MWL Server
- If hospital **doesn't have** MWL, then data will be input manually into the modality by radiology technician.

Step 4. After modality perform the image acquisition/ scan and initiate *C-STORE* request to store images:
- If hospital **have** PACS (Picture Archiving and Communication System), then DICOM image file will be store into PACS DICOM Storage and continue modality C-STORE
- If hospital **doesn't have** PACS, then DICOM image file will be store **temporarily** into the modality and continue modality C-STORE

Step 5. DICOM Router (a source code system provided by DTO) will always perform listening to the C-STORE event, thus DICOM file from modality will be automatically processed by the DICOM Router.

**SATUSEHAT DICOM Router Architecture**

Step 1. DICOM Router received DICOM image file from Modality or PACS through C-STORE init. Next the DICOM file will be stored in the internal directory of DICOM Router application

Step 2. DICOM Router store and extract DICOM file, especially to get the Accession Number, since this is the important step to move to the next step. The data stored in internal database

Step 3. DICOM Router check ServiceRequest in SATUSEHAT by Accession Number which retrieved from the DICOM extract file. (If success, then move to the next step. If fail, then proceed from the starting point again.)

Step 4. Create ImagingStudy
Step 5. Store ImagingStudy to SATUSEHAT FHIR Server. (If success, then move to the next step. If fail, then proceed from the starting point again.)
Step 6. Upload DICOM file into SATUSEHAT DICOM Store. (If success, then move to the next step. If fail, then proceed from the starting point again.)
Step 7. If step1-6 success, then the related data and DICOM file will be deleted from the temporary storage
Step 8. Finish and DICOM Router back to idle stage

**SATUSEHAT DICOM Router Workflow (PACS+MWL)**

**SATUSEHAT DICOM Router Workflow (Without MWL)**

## E. Conclusion:
This streamlined approach to manage medical images in clinics ensures efficient workflow, enhanced accessibility, and improved collaboration among healthcare professionals. Leveraging cloud technology, even small clinics can provide top-notch medical services while reducing the burdens associated with traditional image storage systems. This transformative solution promotes the seamless sharing of medical information, ultimately benefiting both medical practitioners and patients.

## References
* [Indonesia SATUSEHAT Integration DICOM](https://drive.google.com/file/d/19jbsb-A72unCQq3Cnwmh01KD1g1TnGLi/view?usp=sharing)

## See also
:::info
**Enabling Teleradiology service using FHIR Standard**
Scenario: Small clinic may have imaging modalities like X-Ray, USG, etc. But lack on-site radiologists who can interpret the images and generate radiology reports ... [**[continue reading]**](https://hackmd.io/@victoriatjia/fhir-tr4-sc2-en)
:::