Examine PACS: Conversation with ... Rex Jakobovits

The technology behind sharing teaching files

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Rex Jakobovits (Vivalog Technologies)

With MyPACS.net, radiologists can view, upload and share teaching files in a customizable Web interface. (Vivalog Technologies)

With MyPACS.net, radiologists can view, upload and share teaching files in a customizable Web interface. (Vivalog Technologies)

RT Image: What are the technology applications your company offers and how do they help radiologists?

Rex Jakobovits: There are two separate applications to talk about: one is MyPACS Enterprise, which is a software product we sell to hospitals, and the other is MyPACS.net, which is a free Web application that lets anybody share their cases and view other peoples' cases.

Back in 2000, we launched MyPACS.net at [The Radiological Society of North America's Annual Meeting]. Lots of radiologists were keeping teaching files for use as reference cases. When trying to make a challenging diagnosis on a case that comes across the PACS workstation, it's nice to be able to look at example images of diagnoses under consideration, so you can compare the images side by side. Radiologists often keep collections of teaching files for that purpose, as well as for training residents or sharing with colleagues.

The teaching file contains the key images showing the findings, and potentially some text describing the findings and a general discussion of the disease being identified.
Everybody had drawers full of teaching files in their office file cabinets. It was very hard to share them. Some savvy radiologists started creating HTML pages out of their teaching files so that people could access them on the Web. But still, that was a very tedious process.

So we came up with the idea to build a Web site where you would upload images and have a form where you selected from some structured attributes to identify the anatomy, pathology and modality used and enter in some structured text for the history, findings, diagnosis and the discussion. And the author can choose whether to keep the case private, which means only their account has access to it on the Web, or they can make it public, which means anybody on the Web can access it.

So that was MyPACS version 1 way back in 2000. And it quickly gained popularity because it turned out that there were many hundreds or thousands of radiologists out there who wanted to be able to share their cases with the world and didn't want to have to deal with having to build their own repository. So they're just uploading images and filling out the forms and boom, now everyone can access the case.

RT: What was some of the user feedback you received and how did you improve your product to meet these requests?

Jakobovits: We listened to our users. Some of them were saying, "We really want to be able to add folders so that we can organize cases our way." So we created this sharable Web folder hierarchy feature. And then they were saying, "We want to be able to view them as unknowns for training, instead of just seeing the diagnosis and captions and all the text all at once." So we built the training mode, which starts with the history of the patient and allows the user to look at the images and think about what the diagnosis might be, and then reveal text about the findings and diagnosis in a stepwise fashion.

RT: MyPACS has been around since 2000. What are some of the new features of the latest version, MyPACS V5?

Jakobovits: The new version of MyPACS that's coming out uses this technique called AJAX to give the user a richer user interface that feels more like a PACS. So you have your thumbnails on the left and your images on the right; and you click on one of the thumbnails and the image displays on the right and it automatically sizes itself to fit the exact viewing space that you have. If you want to see it in full screen, you click on the button and it takes over the whole screen and you can just see the image by itself, which is what it would do in a PACS when you're trying to make a diagnosis.

And it's very important for the radiologist to be able to have that control over the image because their goal is to see these findings that are sometimes hard to see and maybe it's a sliver of gray in the middle of a field of lighter gray. So they really need to be able to see the full resolution image in diagnostic quality and perhaps they might want to zoom in.

So just like you can do now in the new generation of Web mapping software, you can zoom in and pan around on the image. And when you go past a threshold, it brings in a higher resolution image so that you can see more detail. And all this is done in a pure Web application that doesn't require users to download any software at all. And how does it do this? It uses this new technique called AJAX.

RT: What does AJAX stand for?

Jakobovits: "Asychronous JavaScript and XML" is a technique to manipulate the browser and communicate with the server asynchronously. AJAX-based solutions offer no compromise in security and ubiquity – they can be run on any hardware/browser combination, without requiring changes to the default browser.

RT: How do physicians in third-world countries benefit from MyPACS?

Jakobovits: Third world countries are lacking radiology expertise, and they need all the help they can get when they're trying to make a diagnosis. They might have X-rays of a patient and they might have some limited amount of training on how to read X-rays. They go to MyPACS.net to find example cases. Let's say they think they're looking at pneumonia, but they're not sure. They can see 55 or 100 pneumonia cases on MyPACS.net and compare them to their patient's X-rays. If they want feedback from radiologists, they can post their patient's images as a teaching file case and add it to the "Help Wanted" folder.

Radiologists from the U.S. and other countries can respond to the physician's questions with their own opinions. We will soon be adding a feature that allows volunteer radiologists to receive an e-mail whenever users are soliciting opinions on their cases that match the radiologist's expertise. This will really increase MyPACS's usefulness as a tool for international outreach.

RT: What about Vivalog's collaboration with the American College of Radiology? Can you tell us a bit about that?

Jakobovits: The American College of Radiology (ACR) is going to be launching their learning files in an online form hosted by MyPACS. They have, over the years, created a series of 14 CD-ROMs. Each CD-ROM has hundreds of teaching files on it and they're really popular with residents because they're the exact cases that you need when you're studying for the board exam.

ACR purchased a license for MyPACS enterprise to host their content and we've imported all of their 14 CD-ROMs into a Web application that they're going to now charge subscription fees for people to access. Now, users will have unified access to all of the learning file cases, without having to swap CD-ROM volumes.

—Jane Kollmer