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no.1 03 2011 international www.visus.com image management in healthcare including reports view a perfect marriage alliance medical and jivex generate ideal radiology services the first and only enterprise pacs in bahrain compression without compromises esr paper offers guidance for irreversible data compression achieving the best out of mammograms jivex mammography

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visus view imprint publisher visus technology transfer gmbh universitätsstr 136 44799 bochum germany fon +49 234 936 93 0 fax +49 234 936 93 -199 info@visus.com www.visus.com editorial services european hospital design visus technology transfer gmbh christiane debbelt circulation 11,500 all rights remain with visus reproduction in whole or in part inclusion in online services and other internet platforms as well as copying of material onto data carriers such as cd-rom dvdrom etc without prior permission of visus is prohibited by-lined contributions and enterprise presentations express the author s personal opinion visus does not accept liability for the accuracy and completeness of contributions and quoted sources including spelling errors 2

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editorial jörg holstein and klaus kleber visus founders and managing directors dear readers dear friends of visus how can we efficiently digitalise and manage medical images it was the technical solution to this question which in 2000 triggered the founding of visus in the ten years since then we have learnt so much one crucial insight was and remains the fact that despite the incredible speed of technological progress it is continuity and reliability that lead to success this holds true not only for customer relationships but also for the co-operation with our partners and our staff the ambition to optimize and further develop digital image management continues to be the driving force of our endeavours with this first international issue of visus view we want to explore the impact our work is having on every-day clinical life we will travel from bochum to switzerland the netherlands finland poland and all the way south to bahrain to afford you an inside view of our projects and obviously we would like to present our newest concepts and co-operations and our answers to some of the most pressing issues around medical image management we should be pleased if you enjoyed our selection of topics and hope you will find visus view an inspiring read cordially yours jörg holstein and klaus kleber 3

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visus view 03 2011 4

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contents contents 10 years visus 6 ten years ago jive met radiology visus celebrates its 10th anniversary view reports 8 managing large distances telemedicine in northern finland tel lappi project finland 10 12 14 16 20 a perfect marriage alliance medical and jivex generate ideal radiology services alliance medical poland bespoke pacs solution for the orthopedics department adapted functionality maximum efficiency schulthess klinik switzerland one solution for hospitalwide image management máxima medisch centrum netherlands one for all ­ all for one jivex links radiologists and cardiologists across hospital walls st johannes hospital dortmund germany the first and only enterprise pacs in bahrain bahrain defense force hospital bahrain interview 24 compression without compromises esr position paper offers guidance for irreversible data compression professor dr peter mildenberger radiologist university hospital mainz germany view 18 cooperation between visus and t-systems setting standards for long-term archiving axel fromm senior business consultant t-systems international breast cancer screening in europe exemplary ­ but there is always room for improvement eu guidelines for breast screening lossy data compression industry focuses on virtual quality control dr marc kämmerer jivex product manager and radiologist visus international sales top quality across the board jivex certified partner network 22 25 26 view solutions 19 everything else is out image management and long-term archiving jivex managed services achieving the best out of mammograms jivex mammography communicating with referring physicians via telemedical services jivex telemedicine meeting a healthcare provider s needs jivex enterprise pacs solutions 5 23 28 30

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10 years visus ten years ago jive met radiology visus celebrates its 10th anniversary the year 2000 was not only the beginning of a new millennium it was also ­ at least in the perception of many of us ­ the dawn of a new era internet networks digitalization were innovations that held vast promises and technology seemed to know no boundaries with the burst of the dot.com bubble some of the high-wired dreamers crash-landed painfully but still there are plenty of success stories ­ powerful ideas that withstood the test of reality one of those ideas was born in a somewhat unlikely place far away from any cash-flooded silicon valley bochum germany on 24th may 2000 jörg holstein and klaus kleber founded visus a technology spin-off of the institute for microtherapy at the university of witten/herdecke focusing on applications research that linked internet technologies and dicom the young entrepreneurs had developed a pacs with image distribution capabilities today visus is one of the major providers of innovative complex image management solutions for hospitals and doctors offices in europe the product family jivex offers a broad array of applications ranging from pacs for individual clinical departments to enterprise pacs with teleradiology or complex multi-site solutions managed by a dedicated computer center the visus founders mix of innovative thinking and bold entrepreneurship has since become somewhat of a trademark of their home country the ruhr valley in germany the former heart of the german steel and coal industry that had declined to a dilapidated rust belt is experiencing a renaissance as 2000 founding of visus as technology spin-off from the private university of witten/herdecke by jörg holstein and klaus kleber 2002 innovation award of north rhine westphalia for jivex asp 2001 introduction of jivex for pacs and image management first reference projects in germany 2003 expansion of the jivex product family to a hospital-wide and interdisciplinary image management solution for all clinical departments 2004 introduction of the innovative platform jivex 4.0 and the jivex asp provider solution implementation of a jivex system throughout lapland tel lappi in cooperation with our finnish partner onemed formerly tamro medlab 6

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10 years visus think tank for medical science and technology roughly 130 hospitals four university hospitals several medical technology corporations and about five million people living in the area provide fertile grounds for projects and partnerships that reach far beyond the banks of the river ruhr indeed far beyond germany already in 2004 the young it entrepreneurs ventured across the border a project in finland was the stepping stone followed by contracts in switzerland the netherlands poland and finally north america and the middle east to adapt to these developments the sales force was split and different teams are now responsible for domestic and international customers today visus is present on almost all continents and with more than 750 pacs customers visus technology made in germany has become a global mark of quality no surprise then that in view the international demand the visus staff of originally eight has grown to eighty most of them based in bochum located in the immediate vicinity of the ruhr university bochum the visus team no doubt will continue to develop technologies for the future backed by a solid infrastructure excellently trained staff satisfied customers and experienced partners visus is perfectly positioned for another successful decade 2005 complete implementation of an online communication solution for referring physicians/institutions in the first german healthcare network in cooperation with ispro implementation of the largest german teleradiology network with more than 100 sites for diagnostic network ag introduction of the jivex solution for digital mammography screening 2007 first reference customers in north america and pay-per-study and pay-per-volume reference customers cooperation agreement with sana hospital group to develop an interdisciplinary solution for the exchange of image and diagnostic results first enterprise pacs installation realized by visus middle east for bahrain defense force 2009 strategic market development in eastern europe through visus eastern europe further expansion of the product family to include ecg and radiotherapy for reference customers 2006 first large installation in china in cooperation with medavis processing of more than 1,500 examinations per day visus data security certification issued by the german center for telematics in healthcare introduction of jivex asp as pay-per-use system fda approval for the us market and incorporation of visus usa as a joint venture with net.orange 2008 cooperation agreement with t-systems for storage service ssp relocation to biomedizinzentrum bochum 2010 2011 more than 800 pacs installations in more than 40 countries worldwide introduction of jivex diagnostic 3d with integrated clinical applications by calgary scientific milestones 7

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view report tel lappi project finland managing large distances telemedicine in northern finland the lapland hospital district in the northernmost region of finland caters for between a quarter and a third of the country s territory yet only about 119,000 people live in this vast area some 2.5 of the whole population of finland however lapland ­ or lappi in finnish ­ attracts 1.8 million tourists every year providing specialized or even basic healthcare services to such a disparate population presents major challenges to the local authorities there is one key instrument though that has helped to overcome these hurdles the pacs from visus which today is a crucial support tool for health professionals in the region care in northern finland is provided by 15 municipal health centers and one central hospital in rovaniemi travelling distances to this hospital are 450 km from the town of utsjoki and 425 km from kilpisjärvi how can access to medical imaging services that meet the requirements of today s patients be ensured under these conditions in order to tackle this question the finish health authorities began designing national e-health strategies as early as the mid1990s since then finland has witnessed the development of a nationwide networked healthcare infrastructure with comprehensive digitalization of patient information and semantic as well as technical compatibility of electronic patient records as part of an effort towards achieving access to patient information anytime and anywhere across the country jivex ­ a convincing solution the distribution partner for visus in finland is onemed oy as the largest healthcare product distributor in northern europe onemed can build on strong local knowledge and thorough professional expertise in 2005 onemed set up test installations that quickly proved that in the customer s particular environment the jivex system performs better than competing products even the facts that with only one telecommunication operator in the area providing network services pricing was relatively high and that network connection speed between health centers and the central hospital were only 2-4 mb did not present problems for jivex phase i the project started with the installation of the jivex central server and the raid in the system room of the lappi central hospital followed by the installation of twelve fuji cr readers and local jivex servers at every health center with an x-ray department an installation took place every week accompanied by training for all users the local jivex servers encompass a radiology workstation with dual 2 mp displays fit for diagnostic purposes the functionality of the local jivex servers includes receiving examination data from cr storing this data into the local database in a compressed format and sending it to the central pacs after office hours web distribution is also handled by these local servers local ethernet speed is 100 mbit the tel lappi project in the lappi hospital district a number of projects of varying durations are under way which aim at utilizing modern information and communication technology to facilitate provision of care and to reduce costs the longest and perhaps the most successful one is tel lappi with financial backing from the eu and with pilots dating back to 1997 this project was designed to enable the development of services based on telemedicine the project included teleradiology video teleconsultation and teletraining first aid ophthalmology transfer of ultrasound as well as ecg data an electronic referral-feedback system and in emergencies the transmission of vital data such as blood pressure measurements from ambulances imaging services in particular x-ray play a major role in the project in view of the lack of radiologists on-site at the municipal health centers and the enormous geographic distances the goal was to enable physicians at local health centers to provide radiology reports by transmitting imaging data to radiologists and specialists at the central hospital phase ii and scope after successful installation in the health centers the customer decided to replace the existing pacs at the lappi central hospital with jivex over a ten-months period all data from the kodak system was converted to jivex the resulting homogeneous solution from visus created a network integrating the health centers and the central hospital plus a link to the national finnish pacs the modality landscape of 8

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view report lappi central hospital petri alatolo testing the jivex system this multi-site project includes equipment from agfa aloka ge philips siemens and toshiba in 2007 110,000 examinations were carried out within the system registered users numbered 900 with 60 users working with the solution concurrently conclusion lappi hospital district it specialist petri alatalo said the tel lappi project ­ of which the jivex pacs formed a significant part ­ was the most successful it project ever in our district the official report of tel lappi iii published by the hospital district states that the pacs is easy to use and image transfer and processing are quick and functional the document notes that costs savings were realized and that the availability of images and in the view of some physicians image quality have improved moreover digital imaging reduced the number of repeat examinations the report also states that the utilization of a server for regional radiological images such as surgery-related image consultations has clearly reduced the barriers to the basic and specialized healthcare systems and has assured the functionality of the treatment chain the digital imaging system is already being used in neighbouring sweden for example in the karesuvanto dental clinic according to onemed sales manager eini tiihonen the distributor was awarded this large challenging and innovative project thanks to the flexible functionality of local jivex servers and the central archive good service and short response time also played a key role in this landmark success she said nordicandba lt i c visus nordic and baltic timo j aarnio iltatuulentie 1 02880 veikkola finland fon +358 925 68 159 e-mail sales@visus.com 9

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view report alliance medical poland mobile mr outside mobile mr inside mobile mr scanner a perfect marriage alliance medical and jivex generate ideal radiology services the figures speak for themselves poland has about 3,000 radiologists to perform all services for about 350 public hospitals in this large country the number of examinations is also continuously rising due to the quickly improving infrastructure of hospitals with advanced radiological equipment thus a gap between demand and supply is obvious and providing hospitals with external radiology services is clearly a safe recipe for success ­ assuming that the service meets the high expectations of modern high quality radiology this is the case with alliance medical a company that offers the entire range of imaging diagnostics and therapy from mobile and static units to teleradiology services this firm s key partner european medical distribution emd visus partner for poland and responsible for the project management as well as for the local service and the jivex trainings alliance medical in poland has two main business lines the first is performing mr and ct scans either with mobile units or in static sites second is the reporting of scans performed by the hospital itself in one of our reporting centres explains dr magdalena wozniak medical director at alliance medical poland the project started in 2007 and today four mr trucks cover 35 hospitals across the country as well as one static mr unit in dabrowa gornicza and one ct site in ilawa with the mobile and static units the company is offering a very attractive alternative to outsourcing radiological services the arrangements are oriented towards the real needs of a hospital and are implemented as flexibly as possible for everyday use the static modules are constructed to fit perfectly into the hospital surroundings patients do not need to leave the hospital grounds and the institution can be sure to work always with state-of-the-art technology for medical facilities that want to offer special examinations but do not need to do so every day the fully-equipped mobile trucks are an attractive and cost-saving method in both cases our 10 customers can choose to what extent they want to use our services which varies from providing the equipment to a full service that includes reporting the need for those solutions in poland is huge as the case numbers of our mobile trucks show so far dr wozniak explains underlining the success of the business model obviously the examinations from both the mobile trucks and static sites need to be reported efficiently and alliance medical soon recognised that working with dvds is anything but fast and effective an integrated ris and pacs solution was the key to connect the sites with a company-owned reporting centre where all images could be handled within a tough timeline we voted for the visus jivex as pacs which connects our units with the centres as well as with workstations at the radiologist s home this is necessary because we offer a 24/7 service so the challenge was to have a high quality diagnostic environment that is reliable fast and comfortable and which meets the logistic demands of several reporting stations and also a growing and also a gro-

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view report reporting center lublin dr magdalena woz ´niak medical director alliance medical wing number of pacs clients with visus we found a perfect partner who established the infrastructure and the service necessary to meet and to expand our ambitions the alliance medical director points out indeed since the jivex implementation reporting of images gained a new quality in terms of speed perfectionism and safety and paved the way for the second core business the teleradiology service dr wozniak we soon saw the potential of this new infrastructure offered by visus and thought this was an ideal environment to provide imaging not only for our units but also for other hospitals so in september 2010 we began with three reporting centres in lublin lodz and gdansk about 25 radiologists work in the three reporting centres to read mainly ct and x-ray images from hospitals that own the equipment but do not have the manpower to cope with all the diagnoses all examinations from the hospitals are delivered to the visus pacs and workstations ­ no matter where ­ in the centre or at home mr exams are read within 48 hours ct images within 24 hours and emergencies within two hours images acquired in one of the companies´ units are stored on servers owned by alliance medical the scans from the reading service are stored on a hospital server as well as on a company server we make sure that the data storage complies with the legal requirements at the moment this works fine and we have quick access to the data for future scenarios we have to think about innovative storage solutions that keep us more flexible regarding capacity dr wozniak points out adding this is even more necessary when our plans for growth are realized due to various legal issues regarding mobile diagnostics which arose recently in poland we will concentrate on static sites on the one hand and the teleradiology service on the other our aim is to gain several new hospitals within the next two years and we are lucky to have visus on our side because we know that a reliable pacs solution is the basis for this successful growth about alliance medical with over 15 years of unparalleled operational and service excellence alliance medical is now europe s largest provider of outsourced diagnostic imaging services the offices in the uk ireland italy spain poland germany and the netherlands all lead the way in their respective local healthcare markets delivering first class diagnostic solutions to both the private and public sectors the company s extensive scale of operations delivers advantages in terms of availability service levels and competitive pricing central eastern europe visus central eastern europe c/o emd european medical distribution s.r.o mr balazs terpal svätoplukova 30 83103 bratislava slovakia fon +421 2 49 111 201 e-mail info@emd-company.eu 11

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view report schulthess klinik switzerland bespoke pacs solution for the orthopedics department adapted functionality maximum efficiency schulthess klinik in zurich switzerland is a leading orthopedic clinic for prosthetic surgery of the upper and lower extremities and for spinal and joint surgery the high-quality care provided by the 160-bed facility which is located in the south of zurich is recognized by national and international sports organizations the clinic is swiss olympic medical center fifa medical centre of excellence and f-marc fifa medical assessment and research centre roughly 8,000 patients per year seek treatment at schulthess four conventional x-ray systems and an mri system are available for diagnostic imaging since the clinic does not operate a dedicated radiology department all conventional images are acquired and read directly in the relevant departments mri scans are made by the independent radiologist who has his office on-site as early as 2002 schulthess klinik introduced their first digital image archiving and communication system we had to learn pretty soon though that this early pacs was not particularly reliable system crashes led to substantial down times in view of the high throughput in our house down times that would last for days were entirely inacceptable says dr thomas guggi senior resident in the orthopaedics department although the provider offered to implement major updates to his system the schulthess physicians began to look for alternative solutions many solutions failed our tests because they were too strongly geared towards radiology rather than orthopedics they offered too much functionality that we do not need in our daily work and thus we would not be able to use the system efficiently guggi sums up his experience finally in 2005 the decision was made in favour of jivex a system which convinced the schulthess team with its tailormade functionalities and intuitive operation we were looking for a variable and flexible system which can be configured to the particular needs of an orthopedic clinic visus designed a tight package of individually tailored modules and services guggi says the it expert and current user also places strong emphasis on service and support to ensure uninterrupted operation and last but not least he adds the visus system offered great value for money special pacs for orthopedics guggi who is also a trained computer specialist headed this search in earlier projects i had come to know many systems thus we had soon compiled a short-list of three providers whom we asked to submit an offer based on a detailed requirements specification document the major selection criterion was system stability to ensure uninterrupted operation moreover the users requested the pacs to offer intuitive handling 12

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view report dr thomas guggi senior resident orthopedics department better planning translates into better quality implementation of the system including migration of legacy data went smoothly and without impairment of the daily operations today more than 100 physicians work with jivex the system met with high acceptance from day one primarily due to two factors the functionalities were adapted to the core processes of the orthopedic clinic and operation of the system is really easy and intuitive the benefit for the clinical workflow convinced even the staunchest of sceptics the physician explains in addition to radiology images arthroscopy data are being archived in the pacs thus several images can be used for comparative purposes now a reality saving time and increasing efficiency the online archive which ensures fast and direct access to all relevant patient data at any time and from anywhere further optimized the workflows we have patients whose treatment progress has to be assessed regularly therefore we need fast access if we do not want to waste time in our daily workflows guggi underlines the pacs moreover facilitates physicians team discussions before we would be running from one meeting to the other today we discuss cases on the phone if my colleague in the other department has already called up the images he gives me the patient id i access the same images and off we go that s immensely effective and time-saving all in all jivex has accelerated the workflows at schulthess klinik and made them much smoother one major advantage is the fact that no images are lost in pre-digital times about ten percent of the x-ray images could not be found when we prepared the meeting with the patients in the era of high technology that is entirely inacceptable we aim to provide high quality care ­ that means the images have to be accessible quickly and at any time today old images current images and images showing the therapy progress ­ they are all a mouse click away and can be easily presented to the patients visus prepared the project very thoroughly and consequently implementation went without a hitch the pacs has been up and running for five years now ­ and everybody is happy guggi smiles better safety and security with digital planning in 2009 schulthess made the next step towards full digitalisation an orthopedic planning software which is accessible from each workstation was integrated into jivex this new tool facilitates surgery planning and allows the surgeons to prepare the intervention in much more detail guggi explains the images are simply loaded from the pacs into the planning software where electronic templates are used to plan position and shape of the prosthesis ­ that s simple quick and safe the final plan can then be stored in the pacs and called up from any workstation also in the or guggi describes the workflow and obviously we can use these images in conversations with our patients to explain and support findings or therapy progress 13

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view report máxima medisch centrum netherlands máxima medisch centrum mmc eindhoven máxima medisch centrum mmc veldhoven one solution for hospitalwide image management máxima medisch centrum mmc is a modern 836-bed hospital comprising the two sites eindhoven and veldhoven in the framework of an initiative launched in 2007 to improve the efficiency of healthcare delivery both sites sharpened their profile while eindhoven focuses on standard procedures and short stay treatments veldhoven is an acute care hospital where more complex procedures are carried out the areas of medical specialities represented at mmc are among others perinatology including an nicu and pediatrics obstetrics emergency care and cardiology both locations have out-patient departments getting the most out of the technology environment since the quality initiative at máxima medisch centrum defined excellent primary healthcare and operational excellence as major objectives the hospital s ict environment has to support these aims by helping to streamline processes and optimize workflows any technological solution implemented in the departments has to be able to develop in line with present and future healthcare needs it therefore must comply to open standards be based on transparent sources and be able to integrate with existing solutions image data play a crucial role in any hospital and the specific needs and requirements with regard to handling and management of such data pose a major challenge case in point digital medical images generated by different modalities have to be stored and made available for multi-disciplinary diagnosis and for external referring physicians jivex by visus provides a hospitalwide image management solution that uses a standard method for image storage and distribution integration of jivex with other hospital applications in 2003 máxima medisch centrum was the first hospital in the netherlands to implement the jivex enterprise solution integration of non-dicom data into the existing applications was essential for jivex to be able to support the clinical workflows and the different departments prior to implementation the workflows had been thoroughly analyzed a major issue was the communication between the image management solution and the ehr electronic health record and the hospital information system his jivex offered a sophisticated approach the system generates a patient worklist per department based on the his the medical images acquired during an examination or an intervention must immediately be made available in the reporting application of the his jivex uses an url link to the his which means that the physician can select the patient in the his and then simply click on the url link to review the relevant images for documentation and reporting purposes some departments need specific post-processing tools to gather additional information from the medical procedure that has been performed for example cardiologists have to process ultrasound images and ecgs other departments need reconstruction or measurement functionality these technological innovations lead to an enormous increase in 14

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view report martijn schasfoort beng business manager medical and information technology máxima medisch centrum eindhoven/veldhoven the netherlands data volumes ­ despite clear instructions to cap data volume growth jivex can be integrated with other processing software such as tomtec voxar and mortara jivex is used in many departments at both mmc locations except in the radiology department hospital management is currently considering integration of the radiology images in the jivex pacs which would make all medical images available for all physicians with one look-and-feel it is possible to connect jivex to other pacs a scenario that will be further developed in 2010 when the unique patient number is available in the different applications jivex ­ a team effort at máxima medisch centrum medical technology and ict tasks and responsibilities are anchored in a single department for medical and information technology which has 72 employees one of the strong points is that visus provides all necessary technical trainings so that all the information for maintaining the system is available and can be handled by the hospital engineers on their own the implementation of jivex at máxima medisch centrum is performed by hospital technicians with support from visus engineers jivex meets specific needs of physicians every physician in a hospital has very specific information needs for diagnosis and treatment and thus collects and analyzes different types of information be it raw data generated within the own department information generated in other departments or reports and documentation by colleagues or referring physicians the requirements with regard to data management however are to a large extent identical across departments ­ easy storing and retrieval of digital images or hospitalwide access to all relevant information from any data source creating links with a region s major healthcare providers in the eindhoven region in the southern part of the netherlands all major healthcare providers are connected to a fibre optic network and use a pacs based on dicom standard which enables them to exchange image data the problem however is the fact that every hospital uses its own patient identification number in 2009 a unique identification number for every citizen the so-called bsn citizen service number was introduced in the netherlands it gives registered healthcare providers access to the health data of a particular patient and is expected to help reduce medical errors a hospital can retain its own patient identification system but the citizen service number will provide additional verification 15

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