1. Radiology in the Developing World
Dr. John Knoedler FACR

2. International projects Rotary
Herman Oosterwijk,
John VandenBrink
RandyWear
Rotary Diagnostic Imaging and Medical Informatics Support team

3. GLOBAL HEALTH CONCERN What’s the Problem?
60% of All Medical Diagnoses Requires X-ray Analysis
2/3rds of the world’s population do not have access to basic medical imaging
Common health problems diagnosed with a basic X-ray:
Trauma
Infection, including TB, pneumonia and complications of AIDS
Parasites
Cancer in many variations
Intestinal obstruction and some other abdominal problems

4. Benefits of Diagnostic Imaging
Difference between getting the right or wrong treatment
Life or death
Rapid recovery or permanent disability and loss of earnings resulting in poverty for the whole family.
With access to diagnostic X-ray services
Reduces the spread of contagious diseases to the community at large.
Reduce disability days and missed work due to injury.
Reduces costs of health care due to incorrect treatments.
People can return to home and work more quickly
It is essential to the health of any society that all people have access to diagnostic imaging services.

5. Diagnostic Imaging Needs
World Health Organization (WHO) estimates for all diagnostic imaging needs:
40% are chest problems (including TB and AIDS-related infections)
20% are accidents and injuries
15% are pregnancy-related
10% are musculoskeletal and abdominal problems
15% are other health issues
Special Need: Co-Infection of HIV/AIDS and TB
If a X-ray can be read within 30 minutes, diagnosis can often be made before the patient disappears into the community and is lost to treatment and follow-up.
The sputum technique, requiring microscopy, takes far too long (days or weeks) and the patient very often cannot be tracked down once the diagnosis is made.
Antiretroviral Therapy cannot be started until patient is cured of TB. Any delay in TB treatment can result in significant complications of HIV and AIDS

6. First-Referral Hospitals
In 1992, a WHO Study Group stated: “Every first-referral hospital must have an imaging service providing diagnostic radiography.”
Approximately 80,000 potential x-ray units are needed worldwide to satisfy current population demands.
WHAT IS A FIRST REFERRAL HOSPITAL?
Located in remote areas -- often the next level of care patients visit after seeing a primary physician in a rural/community clinic.

7. World Health Organization
World Health Imaging System for Radiography (WHIS-Rad) is a WHO specification for a general purpose X-ray unit for small hospitals and clinics
- Performs all standard radiography procedures
Superb image quality
Highest possible radiation safety, easy & intuitive to use
Reliable under most difficult conditions
Health care workers can be trained quickly
Operates on batteries, capacitors and solar cells
Simple maintenance
Less expensive to purchase
low operating costs

8. WHIS-Rad
World Health Imaging System for Radiography (WHIS-Rad) is a WHO specification for a general purpose X-ray unit developed with humanity's needs at heart, the best expertise at hand, and with hospital budgets in mind.
Performs all standard radiography procedures
Superb image quality
Highest possible radiation safety, easy & intuitive to use
Reliable under most difficult conditions
Operates on batteries, capacitors and solar cells
Simple maintenance
Less expensive to purchase, low operating costs
Easy to operate (extensive manual)

9. Imaging in diagnostic radiology is based on three technological solutions of diagnostic data acquisition:
Analog systems: cassette with an intensifying screen, x-ray film, negatoscope;
Computed radiography: cassettes with imaging plates, CR reader, control station with monitors for description;
Direct and indirect digital systems (DR and DDR) - plates of amorphous silicon coated with a layer of scintillation material, such as cesium iodide (CSI) used in image intensifiers or TFT matrix (electrically controlled switches, thin-film counterparts of MOSFET-type transistors), control station with monitors for description.

10. At present there are two distinct methods of Digital Radiography.
Phosphor plate radiography;[1] This resembles the old analogue system of a light sensitive film sandwiched between two x-ray sensitive screens, the difference being the analogue film has been replaced by an imaging plate with photostimulable phosphor (PSP), which records the image to be read by an image reading device, which transfers the image usually to a Picture archiving and communication system (PACS)
Direct radiography (confusingly also abbreviated to DR). A direct radiography system has a sealed imaging cassette, this contains an imaging system not entirely unlike the CCD in a digital camera. the image is recorded then transmitted wirelessly direct to the PACS (hence the name Direct Radiography)

11. Benefits of Digital X-Ray
Improved patient care
Images immediately available for diagnoses and treatment
Teleconsultation by radiologists remotely
Brings medical expertise to remote locations on real time basis
Image quality vastly improved
Potential to reduce the operational costs
Digital images can be stored, transmitted, and displayed electronically.
Film, Chemicals and dark room replaced
Work flow efficiencies

12. Digital Images The user can; adjust brightness adjust contrast
apply magnification
apply image processing
apply measurements, do calculations, and obtain statistics
apply annotations
include stamps

13. + Digital Imaging Innovation: No film cost ($1-2/sheet)
No chemicals, supply issues
Send electronically to specialists, local and remote

14. Computed Radiography (CR)
The Pros
CR costs significantly less than DR in every aspect. From equipment, install, and ongoing servicing.
CR units are compatible with many different X-Ray devices; they are quite versatile in that they’re able to convert many analog units.
CR’s can render an image digitally in less than a minute, and once it is done, storage is simple and space efficient.
Least labor intensive of X-Ray conversions.
The Cons
Much slower than DR.
Not able to have instant gratification when it comes to image quality.

15. Digital Radiography (DR)
The Pros 
Digital is replacing analog at an exponentially fast rate, and eventually, it will be harder for those with analog systems to find parts and to find people that are trained to use them.
If you replace your analog with DR, you most likely won’t even need to remodel your X-Ray space.
DR’s can render an image in about 5 seconds.
New systems sometimes come with software that is far more advanced than analog.
The Cons 
Far more expensive than CR.
Labor intensive, meaning that install can take up to four days to complete.

16. KCMC proposed architecture
EMR
Orders (HL7)
Fuji Prima T (2)
archive core
Modality Worklist Provider
Review (EMR)
Wlist
(DICOM)
Database
Images
(DICOM)
2 TB Image store
NAS back-up
2 TB Image store (mirror)
CR QA station
Legend:
Fuji
DICOM Systems
Diagnosis; 3 2MP viewers; CCanvas
EMR vendor

17. Workflow KCMC Place order in EMR
EMR sends order to Worklist provider (HL7)
FUJI pulls worklist from Worklist provider (DICOM)
Image is acquired and scanned in CR reader
QA performed at QA station
Image sent to PACS
Image reviewed by radiologist on view station
Report entered into EMR
Report pulled up in EMR by physician
Image pulled up by physician using clearcanvas
(future) image pulled up in EMR using viewer

18. DIMIST Status: Partnership with ACR International Outreach committee
Build relationships with vendors (RSNA)
Nepal installation successful in Bayapatal Hospital or CR system (Park Ridge, Wilmette, Libertyville Sunrise)
Bokuba, Tanzania, CR and multiple workstations cost $41,000, RI Global Health grant pending (Lake Tahoe)
Killimanjaro, Tanzania, U. of Minnesota sponsored, pending funding. Mid-size system, including extension to cancer center ($100k). Upward to 90 systems
CHAK Kenia: planning phase. Upward to 40 clinics (N. Texas)
Children’s hospital Tanzania. Planning phase.
Uganda: Expand Ultrasound sites