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When patients require procedures that involve medical images, the actual scans are only half of the process. What remains is the reading, or interpretation, of the exam. This is usually handled by a doctor who’s a radiologist. Common types of exam modalities include X-Ray (Radiography), MR or MRI (Magnetic Resonance Imaging), CT or CAT (Computed Tomography) and US (UltraSound), among others.


Initially, exams like X-Rays were read on film by being developed and placed on a lightbox mounted on the wall. This meant the radiologist had to be on location at the facility where the modality was located to interpret the X-Ray. When emergency situations arose after hours, physicians would often end up driving back into the hospital to be able to review the results of a study. Early advances to address this inconvenience were made possible using a modem and a camera-on-a-stick (which was literally as described). This crude method was a slow transmission, but marked the beginnings of remote viewing in medicine.

With the advent of PACS (an acronym for Picture Archive and Communication System), access to receiving, displaying and storing exams from a multitude of modalities on one workstation was a giant leap forward for medical technology. But it was to go one further; sending exams, Telemedicine or Teleradiology.


Teleradiology is the transmission of patient images from one location to another for the purpose of sharing studies with other radiologists and physicians. It offers improved patient care by allowing radiologists to provide their expertise without having to be at the same location as the patient. This is particularly important when a subspecialty is needed (like a pediatric radiologist or neororadiologist). Essentially, Teleradiology makes it possible for trained specialists to be available around-the-clock.

In order to protect private patient data from unauthorized access, the issue of being able to communicate securely is also a requirement. Teleradiology systems must be HIPAA (Health Insurance Portability and Accountability Act) compliant, to ensure that a patient’s privacy is protected. Many times, this requires communication over a VPN (Virtual Private Network), though some advanced PACS systems offer built-in encryption and security (making VPNs unnecessary).


When a new exam is done, it is useful for a radiologist to have access to prior exams in order to compare results. The convenience of storage in a PACS system makes comparison with previous studies possible. Sometimes, awareness and organization of multiple prior studies presents a potential problem. Radiologists don’t want to miss being able to reference a prior exam, but also don’t want to be overwhelmed by what could be irrelevant studies. Patients could have multiple prior exams, but if one is on a different body part than the most current study, it may not prove useful. Or, if exams were acquired at different locations, organization of them by a facility’s MRN (Medical Record Number) may not properly match them, as MRN naming conventions vary by site. This even presents a more dangerous situation, which is pairing unrelated exams due to unintentional MRN duplication. Add to this the potential for data entry typos common with human error, and the need for a reliable, configurable means of searching for prior studies is obvious.

Sophisticated PACS systems overcome these problems using a Master Patient Index (MPI). This functionality ensures a radiologist can access all prior studies regardless of where they originated. This is because the MPI overcomes demographic variances from disparate centers. Flexibility in matching exam search, using not just MRN, but name, date of birth, gender and RIS system, may deliver more accurate search results. This offers invaluable exam pre-fetch capabilities for consolidated sites.


Teleradiologists can provide a Preliminary Read for emergency (or stat) cases, or a Final Read, for the official patient record and for use in billing. Preliminary Reports include pertinent findings. Final Reports include all findings and require access to prior studies and other relevant patient data. Turn-around time is often critical, with a 30-minute window common.

The past 25 years have seen tremendous growth in Teleradiology utilization. From initially using individual radiologists to interpret occasional emergency studies from off-site locations–frequently in the radiologist’s home, using a dial-up modem–it has expanded rapidly as the speed and accessibility of the internet improved and spread. Reading occasional studies per week turned into a handful per night, to working as much as a radiologist desired, with studies available 24 hours a day, seven days a week. Teleradiology saw the advantage of taking time zones into consideration; when it’s the middle of the night in Los Angeles (and few radiologists may be available), it’s early morning on the East Coast. Medical outsourcing grew rapidly, with radiology groups forming Teleradiology on-call services around the country. Some even expanded to taking advantage of international opportunities, using services based in India, Australia and Switzerland, to maximize the time zone difference for hospitals based in the United States. The American College of Radiology (ACR) requires physicians interpreting images in other states to be licensed in both the state where the image was generated, as well as the state where the interpretation takes place, which adds a further complication.


Radiologists have options when it comes to recording their impressions as part of their interpretation. Some capture their thoughts in audio recordings, which are then transcribed by a transcriptionist. Some launch a dedicated voice-recognition system, which transcribes their thoughts in real-time as spoken, and some use common voice-recognition programs interfaced with their PACS system. Many make use of dictation templates, including “normals”, which present an expected result for patients not presenting pathology, and can be easily tailored for selective patients with a few mouse clicks.


When urgent findings are discovered during the interpretation, the radiologist needs to confidently communicate that result to the referring physician. This is often referred to as Critical Results. In addition to communicating the critical finding to the referring physician, the radiologist often follows up with the referring for an update on what actions were taken as a result.


With the ImageQube Cloud, teleradiology is available with all the functionality needed for utmost efficiency. It offers a configurable, remote application delivering real-time, fully-functional, fault-tolerant access to studies, with the capability to display all modalities, including built-in PET Fusion, Digital Mammography (with Tomosynthesis) and ABUS. All core radiology tools are native, including MPR, Anatomic Triangulation, MIP, Slab Imaging and more. The ImageQube Cloud is secure, without requiring VPNs. This means exams can be uploaded from the facility to the Cloud Data Center securely using its DICOM Upload application, and users can access studies securely logging in from anywhere.

Using a sophisticated Master Patient Index, radiologists can rest assured that any related prior exam is made available to them for comparison. This MPI is configurable, with four different confidence settings in presenting archived exams, including matching:

  1. Medical Record Number and Last Name.
  2. Last Name, First Name and Date of Birth.
  3. Last Name, Date of Birth and Gender.
  4. Last Name, First Name.

As the search criteria loosens, more potential patient matches are presented as possible prior exams. Radiologists can choose from these for comparison studies.

ImageQube Cloud can not only auto-distribute exams to specified users by specialty, schedule or a multitude of other configurable variables, but also allows for exams to be downloaded from the Cloud to local computers. This comes in handy since the quality of internet connections may fluctuate for some users; download to local may deliver better interaction performance and speed. Once the exam interpretation is complete and internet connection re-established, the new exam status is automatically synchronized with the ImageQube Cloud in the Data Center.

ImageQube Cloud offers great flexibility in dictation. Users can choose to capture recordings using its built-in transcription module, or auto-launch a third-party dedicated voice-recognition system, where the Medical Record Number is sent across and the patient file opened. Or, the user can take advantage of the ImageQube’s integrated dictation module using their own Dragon software for voice-recognition capabilities. The dictation module allows users to sign preliminary reports, sign final reports, add an addendum to a final report, or take advantage of templates, including custom and “normals” templates. Reports generated on ImageQube Cloud can have custom headers and footers, if desired. There’s a built-in “state machine”, which tracks an exam’s progress. If turnaround time is limited by contract, the ImageQube Cloud offers elapsed time reporting, so affected exams are prioritized. The ImageQube Cloud includes the ability to email out the report when completed.

Paperless workflow is enabled on the ImageQube Cloud, with the ability to scan documents directly into patient portfolios, or drag-n-drop any file. Referring physician portals can be accessed securely in real-time, containing images, reports, key images, print pages and annotated images highlighting pathology. Instant messages can even include images, and be sent securely between users. ImageQube Cloud includes its own, built-in Critical Results application, which not only allows a radiologist to confidently communicate an urgent finding to a referring physician with an acknowledgement of receipt, but can prompt the radiologist for follow up, if desired, while creating a log of all communication activity.

ImageQube Cloud’s API is configurable, and can easily integrate with today’s EHR technologies. It even includes the ability to limit access to only states where a radiologist is licensed to practice. With auto-assignment, and an effortless, rules-based workflow distribution, its convenience is state-of-the-art.

ImageQube Cloud makes PACS available without any of the usual barriers to entry. There’s no hardware to install, no minimum volume or commitment, no up-front costs or capital investment and no VPN required. It includes unlimited licenses, online archive, disaster recovery, maintenance and support and software upgrades in a competitive, per-exam price. The ImageQube is platform and browser independent, so it runs on any desktop operating system. With cumulative pricing discounts, and the ability to scale from individual users to large facilities without sacrificing functionality, the ImageQube Cloud can fulfill the PACS needs of any type of user. You don’t need an IT department; installation is almost DIY. Start your one-month free trial today!

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Medical Imaging Storage

In medical imaging PACS systems, storage is a significant consideration. In fact, the “A” of “PACS” stands for “Archive” (“PACS” is an acronym for “Picture Archive Communication System”). Medical archives are comprised of newly acquired exams, prior studies (for comparison) and some type of disaster recovery. Newly acquired exams and prior studies from the past three to seven years are usually kept in an online archive, which provides retrieval of exams in a matter of seconds . Disaster recovery, in simple terms, ensures that all data has duplicate copies archived, often on a different format and/or in a separate location to eliminate threats from Acts-of-God, viruses, hackers and media failures in impacting the stored studies.

Storage used to largely be on spinning disc servers, stratified in a hierarchical design, which organized and separated studies by age (some PACS providers permit this to be configured per a facility’s preference). Online studies may include current to six months old; nearline exams could be comprised of six months to two years old; farline studies would be made of exams from two years to seven years and beyond. What drove this breakdown was the performance difference dictated by cost of hardware components (online servers were faster and more costly). As hardware costs have become more affordable, while simultaneously improving their performance, these server classifications have tended to disappear into simply, “online” and “long term archive”. Historic media included tape (DAT, AIT, LTO formats), optical discs (DVD), spinning disc (SCSI, SATA, SAS) and, presently, SSD. State-of-the-art systems demand RAID-6 arrays and redundancy of components, with farline studies often still migrating to tape media. Rules of how long particular studies must be maintained in an archive vary by state; the general rule of thumb is seven years, except for mammography and pediatric studies, which are typically longer.


Disaster recovery can consist of simple replication of the images associated with a study, to a much more thorough duplication of all aspects of a system, including images, database, annotation, print pages, key images, user preferences and work environments. In a system with thorough, complete disaster recovery, entire PACS systems can be recreated from the disaster recovery layer should the main system suffer any corruption. Though spinning disc servers provide fast retrieval, they may be vulnerable to attacks on data stored, including viruses, hackers and ransomware. By opting to create a disaster recovery layer on a separate format, like tape, many of these risks are eliminated.

Though most PACS providers strive to deliver .99999 uptime of their imaging system, some emergent care facilities seek to insulate themselves from any potential interruption to workflow. Further protection can be had via high-availability servers, where failover is instantaneous to a parallel server, or clustered servers, where multiple systems also offer load-balancing, increased processing power and scalability, or outright parallel systems, where both PACS applications and medical archives are mirrored in their entirety.


There are various ways of taking advantage of available archive capacity. Some PACS vendors store studies in an uncompressed state, which delivers the fastest performance in retrieval (there’s no time required for decompression before a study can be displayed). However, compression of an exam allows much more data to be stored on a server with fixed capacity, so the trade-off between speed and capacity needs to be considered by a facility in designing its archive. Some vendors have a means of keeping the database quick and agile, no matter how large the archive grows. When exams are online, the images and the database information (patient, exam, series and image information stored in tables for every image) are kept together. When an exam is moved from an online state, vendors with sophisticated archives can archive (remove) the database information, leaving a pointer to where the exam is located on the storage disc, while simultaneously compressing the image data. This allows the database to remain lightweight and agile, rather than slowing down, as hundreds of thousands or millions of exams are added to the system.

The industry standard in medical storage adheres to DICOM (Digital Imaging and Communications in Medicine), which ensures that technology from various vendors will be interoperable if they are DICOM compliant. In the past, PACS providers stored all of their data within their own system. With the advent of VNAs (Vendor Neutral Archives), additional options are available for medical data storage. However, some PACS providers have archives that are VNAs, but also offer sophisticated functionality in addition. In this instance, they deliver integrated servers, where archive software is installed on server hardware. In this way, when the PACS viewer is used in conjunction with the archive software, faster performance and additional functionality are the result. Examples of these types of benefits over mere DICOM storage include:

  • fast, 2-3 second retrieval
  • updating to patient demographics
  • automatic pre-fetch of prior exams when a new exam is scheduled
  • maintaining workflow flags into the archive
  • preserving annotation made on images
  • storing reports with exams
  • storing key image summaries
  • storing print pages
  • maintaining work environments
  • maintaining user preferences
  • system auto-diagnostics.

In addition, some PACS providers permit documents and other data of virtually any format to be stored with exams. This means not only PACS information and reports, but insurance information, prescriptions, audio recordings and many other types of related information is made available to the users of the PACS, via the archive, without having to launch other applications.


PACS systems and their archives used to be limited to having hardware installed on-site at the facility at which they were located. In the recent past, some flexibility has been introduced by allowing storage in the cloud, at data centers. Cloud storage offers advantages, including taking the burden off the facility of maintaining a proper, climate-controlled environment for their storage servers and disaster recovery system. However, it does introduce the need for secure communication of the exams from the facility to the data center. For many vendors, this requires the installation and expense of a VPN (Virtual Private Network) between the facility and the cloud site. Some sophisticated PACS vendors have built-in, encrypted, secure upload capabilities, eliminating the need for the VPN.

If a facility is multi-site, and high-volume, some PACS providers can make exam retrieval even more efficient if they have the capability of using a distributed architecture. This capability allows storage modules to be located on-site, while interacting with the cloud, delivering not only faster retrieval of exams and more efficient network communication, but also relieves the burden on scanners inflicted by potential internet disruption.


When an archive contains many years worth of exams, perhaps collected from disparate medical facilities, matching existing studies with newly acquired exams is wrought with the potential to miss a prior study that could be a useful reference. This is caused by exams from different facilities being identified with varying facility naming conventions (first name/last name versus first initial/last name, for example), or being tagged with unique medical record numbers per facility, or, through simple human error. These differences present a challenge in matching exams, which usually looks at medical record number. Some PACS vendors have the capability to overcome these demographic variances from disparate centers using a Master Patient Index (MPI), which permits searching by a variety of fields, including medical record number, last name, first name, date-of-birth, sex and RIS key.


Archive needs are impacted by two major factors. The first is increase in volume. The second is growth of exam size. Over the years, an average exam size across all modalities hovered about 50MB in size. Some modalities have seen significant growth over a short period of time. For example, for the mammography modality, moving from film (approximately 162MB) to digital marked the first step in size growth for this exam. But, that was dwarfed by the addition of breast tomosynthesis, impacting the size to exams that are regularly 1GB each! The storage needs for mammography are compounded by the fact that studies of this modality must be kept significantly longer that other modalities. This raises the consideration of cost. PACS and archive used to be a purchase of a system, which was a capital expense. As forecasted storage capacity was filled, additional storage would be added, equating to additional budget considerations. Many PACS vendors diversified into business models that were based on volume, known as “Per-Exam”. In these models, rather than budgeting for a significant capital expense, systems were leased at a per-exam (or, in some instances, a per-click) rate. A dollar figure per study was established, and multiplied by the number of studies done on an annual basis. Many PACS providers vary the price of the exam according to the modality size; as the modality size increases, the associated cost goes up. Some PACS vendors are able to keep the cost-per-study consistent, eliminating concerns for the facility, and simplifying the auditing of the business relationship. The per-study business model has been applied to VNAs and cloud storage (even without PACS viewer access).


In the ImageQube Cloud data center, access to PACS storage and disaster recovery are available. The archive is configurable per a facility’s preference, permitting modalities to be kept online for defined periods of time in RAID-6 arrays, while delivering an industry-leading level of disaster recovery, duplicating not only images, but the database, annotation, print pages and much more. By replicating this data on tape via fully-robotic libraries, it is protected against viruses, hackers, ransomware and other threats. Though this storage offers many benefits when used with the ImageQube PACS viewer, it is also a DICOM compliant, Vendor Neutral Archive (VNA), guaranteeing interoperability with any DICOM device. The ImageQube Cloud PACS storage offers ease-of-use, where documents and attachments of virtually any format can be stored with the exams using a simple drag ‘n drop (with the security to make these attachments available only to internal users, or extended to clinical users in addition). Taking advantage of the ImageQube Cloud’s secure DICOM upload functionality, a Virtual Private Network (VPN) isn’t required to upload exams to the archive. This feature offers encryption and security from an application installed on a simple desktop PC at the client facility. The ImageQube Cloud PACS archive has a configurable means of matching prior exams with new studies using its Master Patient Index, permitting comparison of a variety of fields in the patient record, including first name, last name, date of birth, sex and RIS key, overcoming the challenges inherent in exams stemming from different facilities, human error and other variances.

Feel the freedom offered by the ImageQube Cloud’s PACS storage, where there’s no minimum volume, no commitment and no up-front cost. You get a vendor-neutral archive with a disaster recovery layer, providing its own secure, encrypted communication where no VPN is required. All with a consistent, competitive per-exam price regardless of modality.

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Medical Imaging – PACS


PACS is an acronym for Picture Archive and Communication System, which is a medical imaging technology that provides access to viewing, storing, receiving and sending exams from various modalities. PACS eliminates the need for and associated costs of film, including laborious viewing, filing and transporting. PACS makes workflow more efficient for radiologists, technologists, referring physicians and staff. It also greatly improves patient care, delivering quick turnaround of exam interpretation by both on-site and remote diagnosis.

Modalities frequently viewed and stored on PACS include:

  • X-Ray
  • CR – Computer Radiography
  • DR – Digital Radiography
  • US – Ultrasound
  • MRI – Magnetic Resonance Imaging
  • CT – Computed Tomography
  • PET – Positron Emission Tomography
  • MG – Mammography
  • Nuclear Medicine
  • and many others.


PACS providers may offer a viewer, storage and disaster recovery layer. Viewers have functionality which allows users to manipulate images. Some basic functionality includes:

  • hanging protocol layout – generic & custom
  • splitting display windows vertically & horizontally
  • cross reference – active window cross-referenced against all other intersecting images
  • anatomic grouping – links relevant images within active exam
  • window/level values
  • filter sharpen
  • zoom/magnify/pan
  • annotate – symbols/comments/measurements
  • cine

Some PACS providers design additional advanced functionalities as native to their viewer software, while others may launch third-party systems to deliver added functionality, if at all. Advanced viewer functionalities also available include:

  • MPR – Multi-Planar Reconstruction – creates new image from selected slices of original
  • MIP – Maximum Intensity Projection
  • anatomic triangulation – synchronizes all visible series to same anatomic region
  • PET Fusion – PET CT
  • Tomosynthesis
  • Critical Result alerts – Radiologist may note, broadcast and monitor critical findings with referring
  • Peer Review – allows radiologists to score results from studies previously dictated by others
  • ED Discrepancy – Emergency Department Discrepancy


PACS access used to require an on-site workstation at a facility. With the advent of the internet, and secure communication capability, remote access has become both common and expected. Remote access provides a convenience to physicians–who can now, literally, read exams anywhere they have an internet connection–and created a market for teleradiology, allowing radiologists to receive exams day and night, interpreting and responding within a promised, finite time period. Accessing PACS remotely must be secure, which often requires the use of a VPN (Virtual Private Network).


Radiologists using PACS to interpret exams need the means to record their interpretation into a report. This is often done using voice recognition, or dictation into a recorder which is subsequently accessed by a transcriptionist memorializing the results into a typed document. Radiologist reports are made available to the referring physicians through a variety of means. Some basic PACS providers fax or email reports; sophisticated PACS providers allow secure access to referring physicians on their system remotely, delivering not only reports, but access to images, key image summaries, print pages and other useful patient and study documentation.


Many PACS providers install hardware on-site at a facility. Some offer access via the cloud, hosting at a data center. Though both have their advantages, using a data center removes the concerns normally associated with protecting and monitoring an on-site computer room. However, getting exams securely transmitted from a facility to a data center usually requires a VPN.

Medical archives can consist of online and offline status exams. Online are typically on SSD or spinning disc servers, and retrievable within seconds. Offline archives may also be stored on spinning disc, or in fully-automated, robotic jukeboxes. These comparison exams are older and retrieved less frequently, so they can be stored in formats that may not be available instantaneously.


Disaster recovery is an additional layer of protection, where, at a minimum, duplicate copies of exams are stored in a separate location or on a different format, in order to ensure a level of comfort from an act of God destroying archives, a facility or worse. More experienced PACS companies not only preserve images, but offer duplication of all aspects of a work environment, so restoration after a calamity, though rare, can be efficient and thorough.

Installation of PACS is usually a long-term commitment, with the expectation of a forecasted volume of exams on an annual basis, equating to a significant capital expense and multi-year relationship. Also, ongoing maintenance and support, along with software upgrades, are usually additional expenses.


The ImageQube Cloud data center delivers convenient access to PACS with no on-site hardware installation required! All modalities are displayed, including PET Fusion, Digital Mammography and Tomography. ImageQube offers built-in advanced functionality, including MPR, Peer Review, Critical Results, ED Discrepancy, Instant Messaging, Teleradiology and much more.


ImageQube Cloud makes PACS available without any of the usual constraints:

  • No Minimum Volume
  • No Commitment
  • No Up-Front Cost
  • Vendor Neutral Archive
  • Secure Communication – no VPN required
  • Unlimited Licenses
  • Disaster Recovery layer

ImageQube is platform independent, so the PACS viewer runs on any desktop operating system; users can work on a PC, Mac or Linux workstation. Our teleradiology module allows study data to be pushed to specified users for totally secure, diagnostic, on-call capabilities. It’s encrypted and secure, with site-specific, remote imaging available anywhere. Scalable and fault-tolerant, it fits the needs of users and facilities of any size. So, the needs of multi-site hospitals, outpatient imaging centers and even individual teleradiologists can be met without sacrificing functionality or budget. Its paperless workflow includes the ability to drag ‘n drop documents directly into a patient’s portfolio. Referring physicians can be granted encrypted secure access to reports, images, key image summaries, print pages and critical result alerts, without requiring a VPN.

ImageQube Cloud also includes software upgrades and maintenance and support at no additional cost. Support is available 24/7, while auto-diagnostics deliver hands-free monitoring with pre-alerts of any potential problems. Archives are DICOM and vendor neutral. Our disaster recovery provides a duplicate layer of protection, archiving images, the database and user preferences, eliminating threats from viruses, hackers, ransomware and media failures. Using our secure DICOM upload application, exams are transmitted to the data center without requiring a VPN.

With “how to” videos accessible online and no on-site hardware installation required, ImageQube Cloud is almost DIY; no IT department is needed. Check out ImageQube Cloud with a no-obligation, free trial!