2. MILLENSYS Tele-Radiology Solution

3. Introduction Workflow/ Components Communication / Optimization Millensys Teleradiology Features Failure and restore scenario Similar Project (Eastern Cape, South Africa) Q&A Main Topics

4. Teleradiology of radiological patient images, such as x-rays, CTs, and MRIs, from one location to another for the purposes of interpretation and/or consultation What is Tele-Radiology Why is Tele-Radiology Needed Teleradiology improves patient care by allowing Radiologists to provide services without actually having to be at the location of the patient. Radiologists are increasingly a scarce resource, given that imaging procedures are growing by ~15% annually against an increase of only ~2% in the Radiologist population The virtual radiology network (VRN) is a modern service for radiology groups that collects digital imaging studies from multiple, geographically-dispersed locations and delivers them securely, reliably and efficiently to physicians over the Web. Teleradiology improves patient care by allowing Hospitals to outsource subspecialty expertise needed but not found except in big cities. Tele-Radiology, Definition

5. Teleradiology Workflow / Components

6. Hospital 1 Hospital 2 Hospital N Hospital 3 Images sent to main server using priority queuing Image are be sent to service provider PACS Image are available ON Web Statical Info. are sent to management Images to be sent to Millensys MINI PACS at other branches Verified reports to be sent to datacenter server Verified reports are sent to datacenter server Verified reports to be sent BACK to Acquisition server Service Provider N Service Provider 1 Tele-Radiology, Workflow

7. Tele-Radiology, Proposed Solution

8. Tele-Radiology, One Solution Internet And Intranet Internet And Intranet Report with Dictation Report with Dictation Work Online/ Offline Work Online/ Offline Process and Diagnose Process and Diagnose Search Worklist High Availability Archive Web-based Administrator Web-based Administrator Use Multiple Compression Use Multiple Compression One Solution, MILLENSYS Web-based Teleradiology

9. Data Center Data Center Service Provider Service Provider Hospital Tele-Radiology, Solution Components Reporting Workstations Web Viewing Mobile Viewing Radiology Scheduling Data Center Web-PACS Store/forward MiniPACS Billing and MonitoringAdministration Service Provider PACS (Optional)

10. Tele-Radiology, Data Center Billing and MonitoringAdministration

11. Dealing with Emergency Cases: Tele-Radiology, Emergency Cases Study Identification N : Normal Study (No report needed) R : To be Reported E : Emergency etc. Study Identification N : Normal Study (No report needed) R : To be Reported E : Emergency etc. The report is sent back to the Hospital The Technician identifies the case as an Emergency The Case is sent to the PACS Server with High Priority Emergency case is sent to the Data Center before any Normal Case Emergency case is sent to the Service Provider to be reported The case is reported and sent back to the data center

12. Teleradiology Communication / Optimization

13. Tele-Radiology, Communications ADSL SDSL 56 kbps 2Mbps - 14.4 Mbps Stationary 348 kbps Moving 54 Mbps 24 Mbps (1:4) 24 Mbps (1:1)

14. CT Image Transmission CT Image Information CT Image Size0.5MB CT Image Size after Lossless Compression0.25MB Average Study Size (2-Slice CT)100Image Total Average Study Size after compression25MB Link Speed ADSL 4Mbps (1:4)1MB Upload Band Width Utilization50% Idle Time Between studies30seconds Average Time to send 1 image5.00seconds Average Time to send 1 Study8.83Minutes Total Studies sent per hour6.79Study Link Speed SDSL 4Mbps (1:1)4MB Upload Band Width Utilization60% Idle Time Between studies20seconds Average Time to send 1 image1.38seconds Average Time to send 1 Study2.29Minutes Total Studies sent per hour26.18Study CR Image Transmission CR Image Information CT Image Size10MB CT Image Size after Lossless Compression5MB Average Study Size (2-Slice CT)2Image Total Average Study Size after compression10MB Link Speed ADSL 4Mbps (1:4)1MB Upload Band Width Utilization50% Idle Time Between studies30seconds Average Time to send 1 image100.00seconds Average Time to send 1 Study3.83Minutes Total Studies sent per hour15.65Study Link Speed SDSL 4Mbps (1:1)4MB Upload Band Width Utilization60% Idle Time Between studies20seconds Average Time to send 1 image21.17seconds Average Time to send 1 Study0.71Minutes Total Studies sent per hour85.04Study Load balancing Should be an issue for multi-site/multi-modality transmission Tele-Radiology, CT and CR Transmission *The previous examinations depend on the size of each case and the type of connectivity available for each site.

15. Tele-Radiology, Mammography Transmission Mammography Image Transmission CR Image Information Image Size10MB Image Size after Lossless Compression5MB Average Study Size (2-Slice CT)4Image Total Average Study Size after compression20MB Link Speed ADSL 4Mbps (1:4)1MB Upload Band Width Utilization50% Idle Time Between studies30seconds Average Time to send 1 image100.00seconds Average Time to send 1 Study7.17Minutes Total Studies sent per hour8.37Study Link Speed SDSL 4Mbps (1:1)2MB Upload Band Width Utilization50% Idle Time Between studies20seconds Average Time to send 1 image50.33seconds Average Time to send 1 Study3.36Minutes Total Studies sent per hour17.88Study Load balancing Should be an issue for multi-site/multi-modality transmission Using Digital Mammography, the image sizes will be much higher (x6) and we need either to increase the link speed to able to reach the same studies.

16. Tele-Radiology, Optimization and Compression Hardware Compression Software Compression Compression of WAN traffic using WAN Routers with Layer 2 payload compression or Layer 3 TCP/IP header compression using Cisco Internetwork Operating System (Cisco IOS) Compression Methods Lossless JPEG (1:2) Lossless JPEG 2000 (1:4) Lossy JPEG (1:9 ~ 1:70) Streamed Communication Using traffic dispersion to increase the download speed and the utilization of the link bandwidth Using rule-based auto-routing techniques to insure the delivery of studies between servers.

17. Teleradiology Millensys Features

18. Pure Web-Based Technology Same GUI for all users Depending on Active Server Pages “ASP” Model. Streaming with Dispersion over low band width lines. Multiple compression methods for studies Simple-Fast Search Results. Resume downloading of studies when connection failure. No need for special communication ports. Embedded reporting tool with dictation and speech option. Fast client Setup. Automatic client update. Supports of multi-branch hospitals Built for the enterprise Tele-Radiology, Technology

19. Priority queuing for emergency studies Secure over the Internet and HIPAA compliant Auto-routing between acquisition and reporting facilities Multiple compression methods (JPEG, JPEG2000) Handles transmission of studies and reports. Short term archive in hospitals Long Term archive in Data Center Clustered Solution to get 99.9% uptime Monitors the Round-trip time for studies Assure the delivery of studies when link failure Resume transmission automatically when link is up Tele-Radiology, Archive

20. Run on any Web Browser Streaming technology In viewing and download. User defined image compression for rapid download Customized worklist with user profile Visual Hanging Protocols Rapid operations for large studies Display static and dynamic studies Oblique, Bi-Oblique and Curved MPR/MIP Slice Locator / Pilot Image for CT/MRI Printing on DICOM and A4 Printers Multiple Measurements Image Processing and Annotations 3D Reconstruction and Fly-Through Option Tele-Radiology, Web Distribution

21. Web Reporting Template Reporting Compatible with Microsoft Word Voice Dictation and Transcription Speech Recognition (Option) Send Reports back to Hospitals Tele-Radiology, Web Reporting Dictation Transcription

22. Web administration Single administration for PACS/RIS Manage user profiles Manage user rights View Audit logs Manage Multi-Branches Tele-Radiology, Web Administration

23. Tele-Radiology, Administration Report on the type of studies transmitted Report is user selectable Report is generated from the web

24. Tele-Radiology, Administration Monitor the round-trip time for studies from the time the study is acquired till the final report is sent back to the hospital

25. Tele-Radiology, Administration Generate multiple bills on the reported studies.

26. Compression on the web JPEG Lossy/Lossless, JPEG 2000 CR study (Lossless) delivered in less than a minute over a 1Mbps ADSL Upload Priority queuing, Emergency Studies have highest priority in transmission Reports are sent back in Text and dictated voice formats User Selectable compression before download Roaming Profile for radiologists Works with Any PACS solution, MILLENSYS or Third Party View Images and Report on Multi-Monitor Configuration Compression Transmission Facilities Multi-Level Security Tele-Radiology, Major Features

27. HIPAA Compliance Web Based Administration at Data Center Log Files to monitor system operations and users Clustered Solution in Data Center to guarantee 99.9% uptime operation SAN Storage is a non single point of failure device with RAID 5 storage Store and forward for images from Hospitals to Data Center enable continuous operation in case of link failure. Cases resume transmission when link is up automatically. Administration & Management: Tele-Radiology, Security