Image Processing Strategies in Picture Archiving

and Communication Systems

Hartwig Blume

An image processing strategy is presented that

as- sures very similar soft-copy presentation on Journal o f Digital Imaging, Vol 12, N o 1 (Februa ry), 2020: pp 43-47
diagnos- tic workstations of a picture archiving and
communica- tion system (PACS) over the lifetime of
an image file and simultaneously provides efficient
work-flow. The strategy is based on rigid partitioning
of image process- ing into application- and display-
device-specific pro- cessing. Application-specific
processing is optimized for a reference display
system. A description of this system is attached to
the file header of the application- specifically
processed image which is stored in the PACS.
Every diagnostic display system automatically
reproduces the image quality for which the
application- specific processing was optimized by
adjusting its properties by display-system-specific
processing so that the system becomes
effectively equal to the reference display system.
Copyright a 2020 by W.B. Saunders Company

KEY WORDS: image processing, picture archiving

and communication systems (PACS), display-specific
im- age processing.

I MAGE PRESENTATION in film-based digital

radiology, illustrated in Fig 1, appears to have
two distinct advantages over filmless radiology
within an open picture archiving and communica-
tion system (PACS): (1 ) Typically, an image acqui-
sition modality is connected in point-to-point fash-
ion to a laser image printer. Application-specific
processing and printer-internal processing are
matched to yield expected image quality in the
printed image; (2) The printed film image has
archival properties so that the image quality that
was used for finding the primary diagnosis is saved
for the life of the image.
In today's filmless PAC systems, soft-copy dis-
play devices with different image quality are used
for the primary diagnosis. Modality and application-
specific image processing are typically not tuned to
a given display device and presentation arrange-
ment. Apart from the gray-scale response of the
display system which may follow the digital imag-
ing and communications in medicine (DICOM)
Display Function Standard, image quality in the
displayed image is not predictable. The display
system may contain monochrome or color CRT
monitors. The systems may be able to display
1280 1024 or 2560 x 2048 pixels. The displays
may vary in the maximally producible luminance
and luminance range and, especially, in the
modula-
tion transfer function (MTF). Depending on the
quality of the display, the radiologist may have to
make extensive use of image processing tools such
as contrast and brightness adjustments and edge
enhancement as well as roaming and zooming to
arrive at a diagnosis. These operations may require
an appreciable length of time and affect the effi-
ciency of the radiologist.
If the image is recalled from the archive in the
future, the display system used in the past for the
primary diagnosis may no longer exist. Display
technology may have changed. The radiologist may
not remember the display processes that he used for
finding the primary diagnosis. In what follows, a
processing strategy is outlined that overcomes
these shortcomings. I

IMAGE PROCESSING STAGES IN A PACS

AND THE REFERENCE DISPLAY SYSTEM
In PAC systems, image processing should be
systematically partitioned into four stages (Fig 2).
Digital projection radiography such as stimulable
phosphor computed radiography (CR) or flat-plate
detector direct digital radiography will be used to
illustrate these stages.

Sensor-Specific Processing
All sensor-related correction operations take
place in the first stage. They may consist of
correction for gain variations among different ele-
ments of the detector, correction for defective
pixels, subtraction of systematic noise components,
and elimination of distortion. The correction opera-
tions may also include MTF restorations to
compen- sate degradations in resolution induced by
the read mechanism. The resultant digital “raw”
data typi- cally cover the entire detector acquisition
range which is wider than the clinically interesting
data span. The clinically interesting data span
depends on exposure level and technique factors as
well as

From Philips Medical S›'steins, Shelton, CT.

Address reprint requests to Harnri g Blume, Philips Medical
Systems, 710 Bridgeport Avenue, Shelton, CT 06484.
Copyright0 2020 by W.B. Saunders
Compan\ 0897-1889/99/1201-0001$I0.00/0

43
 HARTWIG BLUME

Fig 1. Image processing for

digital radiography with film out-
put.

on the imaged body part and reason for the except for gray-scale mapping and a tool set of
examination. general-purpose processing functions. By not reduc-
ing ltte digitization resolution at the end of the
Application -Specific Proces.sing modality and application-specific image processing
Application-specific processing may begin with and by attaching the desired gray-scale rendering
an auto-ranging operation by which the clinically function to the image file, greatest flexibility for
interesting data span is selected from the raw data the image user is maintained to adjust gray-scale
range. (This is almost standard practice in stimu- presentation. Moreover, the modality and applica-
lable-phosphor and other CR systems.) Next, the tion-specific image processing may be chosen such
image is spatially filtered to adjust the contrast of that, after some gray-scale transformation, the
small and mid-size details and suppress random processinp• state is also suitable for hard-copy
noise depending on the application requirements printing. To implement this transformation, it is
for presentation on a specific display system called desirable that the image is still presented with high
the reference display system (see next Section). digitization resolution.
The filtered image is still represented by the full
digitization resolution (eg, 10 or 15 bits). The file Reference Displa ’ S5’stem
header of the image contains a table defining the The modality and application-specific process-
difference between the desired gray-scale rendition ing should yield image quality such that, for finding
and the DICOM Display Function that all display the primary diagnosis, a minimum of user interac-
systems are required to reproduce. tions, if any at all, are required on the reference
Our processing strategy assumes that PACS display system. A goal for the reference display
workstations, even diagnostic workstations, do not system may be that all clinically interesting anatomi-
have the capability to perform the myriad of cal and pathological details can be rendered in a
different modality and application-specific process- single presentation setting as on a hard-copy film
ing operations (for CR, CT, MRI, US, and so on) when hung in front of a light-box.

Fig 2. Image processing for

the primary image interpreta-
tion on workstations of a PACS.
PACS IMAGE PROCESSING STRATEGIES
45

The reference display system is characterized print. Typically, the maximum luminance is lower
by the following nine parameter sets: (1) Type of by a factor of five to ten. The luminance range may
display (eg, monochrome CRT with P45 phosphor be smaller. The MTF is anisotropic and may have,
or color liquid-crystal display (LCD)); (2) Nominal at the Nyquist frequency, a value of 0.5 in vertical
pixel size and pixel matrix (eg, 170 mp, direction and of 0.2 in horizontal direction. A
1726 x 2304); (3) Display controller output look- typical laser image printer has a uniform modula-
up table (eg, 8-bit in/10-bit out); (4) Display tion transfer factor of 0.8 at the Nyquist frequency
system follows DICOM Display Function Standard; of the printed image. Finally, the soft-copy display
(5) Maximum luminance and luminance range; (6) system may have higher noise.
MTF (typically 8 representative data pairs); (7) As has been shown,2 it is entirely possible to
Multi-format arrangement (eg, 12 on 1); (8) Ex- compensate such differences in display system
pected pixel mapping (eg, one-on-one or one-on- performance by image processing. When using the
two-by-two); and (9) Interpolation technique (eg, image state of digital chest radiographs that the
high-resolution cubic spline). The reference display modality processor (of a dedicated thorax imaging
system parameters are made part of the image file system with a selenium detector) prepared for a
header. They describe the display system for laser image recorder, the soft-copy-specific
which the modality and application-specific process- ing included standard tone-scale
processing parameters were optimized. Together reproduction, com- pensation of psycho-physical
with modal- ity- or application-specific gray-scale effects owing to lower luminance, luminance
transforma- tions and user-initiated processing range, and image size, and anisotropic MTF
operations, which are executed at the time of restoration. For a single display setting and
viewing the radiograph, they define the image without user interaction, the resultant soft-copy
presentation state that the radiologist used for the image on a 4-million-pixel CRT display system was
primary interpretation. found to be clinically and visually equivalent to the
hard-copy film hung in front of a light-box.
Displa y-S ystem-Specific Image Processing
The properties of the display system (the display Modalit) - or Application -Initiated and
controller and, for example, a monochrome CRT User-Interactive Presentation Processing
monitor) must be known and monitored. By com- The last stage of the image processing chain
paring the measured maximum luminance, lumi- may consist of two sets of operations: First, the
nance range, image size, MTF, and noise with the modal- ity- or application-specific gray-scale
reference display system characteristics, image rendition, which is presented as a table in the
processing operations may be derived that make the image file header, is implemented. This operation
displayed image quality equivalent to that expected is best combined with the standard tone-scale
from the reference display system. For the execu- reproduc- tion of the display-system-specific
tion of these processing operations, the modality processing and is preferably executed with high
image data should have high digitization resolu- digitization resolu- tion. Second, the user may
tion. interactively change the gray-scale rendition, for
Obviously, the reference display system proper- example, by adjusting window-width and window
ties cannot differ too strongly from the actual level of the image that emerges from the first
properties of the display systems in the diagnostic operation, and sharpen the image. Additionally,
workstations at hand. Otherwise, it may be impos- the user may employ zooming and roaming in the
sible to implement the reference display. The course of the primary interpreta- tion of the image.
reference display system properties and the modal- The first operation really is part of the
ity and application-specific image processing state application- specific processing. It is implemented
should be appropriately chosen for the display at this late stage to permit the user to choose an
technology and image processing power of the entirely different gray-scale rendition. However,
diagnostic workstations. instead of applying gray-scale operations in
Today's high-resolution display systems (with 4 succession, the application-specific gray-scale
or 5 million addressable pixels) do not provide rendition may be discarded and the user-preferred
image quality that, without user interaction with rendition may be applied in its place. This
the display system, is clinically equivalent to a technique is especially
film
46 HARTWIG BLUME

preferable when, for whatever reason, the digitiza- of image processing between modality or applica-
tion resolution of the image data had been reduced tion-specific processing and display-system-spe-
at a preceding stage. cific processing?
The user-applied functions shall be recorded in Conceivably, most of the display-system-spe-
the image file header so that the image presentation cific processing, especially the time-consuming
that was used for the primary diagnosis is anisotropic spatial filtering for the MTF restoration
automati- cally reproduced as the default state of the display system, could be executed by the
concerning the gray-scale rendition, edge-
modality image processor. The relatively short
enhancement, and zoom- ing when the image is
delay owing to the spatial filtering then does not
recalled and that, for example, by a flashing text
matter. This strategy, however, may have two
overlay—“roam!”—it is indicated to a later user
disadvantages: (I) The image prepared by the
how the image was viewed originally.
modality processor is no longer suitable for print-
ing unless the printer or print server could reverse
DISCUSSION
the MTF restoration; (2) An image is archived that
By defining and effectively realizing a reference is processed too much for the intrinsic properties of
display system, several objectives are accom- a specific display system. Similar to the printer
plished: (1) The soft-copy image quality becomes situation, future display systems would have to
essentially independent of the display technology have the capability of reversing some of the
of a given diagnostic workstation; (2) Workstations processing operations implemented earlier. Corre-
automatically fulfill presentation expectations of spondingly, it may be disadvantageous to send an
the user; (3) The image quality is very similar at all image that was specifically processed for a given
diagnostic workstations in which the reference diagnostic workstation technology to a lower-
display conditions have been implemented; (4) If resolution clinical review stations or personal com-
the reference display system provides sufficiently puter on the physician's desk. Thus, the image
high image quality, user interactions may not be prepared by the modality or application processor
required for routine application; (5) Because the should be as universally useful as possible. Every
properties of the reference display system are part presentation device should process the image ac-
of the image header and because the application- cording to the specification of the reference display
specific image processing state provided by the system and its own intrinsic properties.
modality is archived—not the processing state
Patient or examination folders are often down-
produced for a specific display system, the image
loaded to a given workstation at the instance a user
can be displayed with the same image quality at
needs them. Any requested image must be dis-
any diagnostic workstation in the future.
played within a few seconds after issuing the
The concept of our reference display system has
request. Presently, the MTF restoration operation
some similarity with the embedded profiles of the
lasts about one and a half minutes on a relatively
Apple ColorSync principle (Apple Corp, Cuper-
slow computer (SUN SPARC 20 with 75-MHz
tino, CA).
processor and a 256-MB RAM). Two scenarios are
The reference display system does not represent
conceivable to execute the time-consuming
a standard. It may be adapted to specific applica-
display- specific processing in advance: (1) The
tions, display technologies, and available system
patient folders are pre-loaded to the workstations
processing capabilities. It may be changed at any
for display-device-specific image processing; (2)
time. Nevertheless, the definition of the reference
The active file server may automatically create
display system is a non-trivial task. Not only has it
image files with the MTF restoration which are
an impact on PACS architecture and performance,
transferred to specific workstations on demand.
but also, as pointed out earlier, on the efficiency of
This strategy would be based on our experience
the radiologists.
that only small differences in MTF exist between
Two of the most crucial considerations are (1)
monitors of a given model. Hence, the MTF
For a given actual display system, are there algo-
restoration can be performed in advance for all
rithms and implementations available to realize the
diagnostic worksta- tions with the same type of
reference display system without significantly af-
CRT monitor. The disadvantage of this scenario is
fecting the work-flow? (2) What is the best division
that the active file storage system must hold two
versions of every
PACS IMAGE PROCESSING STRATEGIES
47

image: (a) the one prepared by the application that was used for the primary diagnosis, the same
processor and (b) the MTF-restored one. The first image quality may be maintained over the lifetime
image version is to be archived after the primary of the image file.
diagnosis is completed and after the image file has Existing and proposed DICOM standards like
been tagged with the user-initiated processing the supplements for digital radiography and for the
operations. soft-copy presentation state address only limited
CONCLUSION aspects of our strategy. It is proposed that the
DICOM Committee considers providing a standard
An image processing strategy has been protocol for our entire tagging concept.
presented by which radiological images can be
displayed with high image quality so that little, if ACKNOWLEDGMENT
any, user interaction is required. By tagging the
The author is grateful to Dr David Clunie, who pointed out
image file with a description of the reference Apple ColorSync and its web site (http://colorsync.apple.com/).
display system

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