PACS and a network DICOM viewer for cardiology (under Windows)

Objective: deploy an office-based PACS server for a colleague; must be Windows-based; make it as simple as possible, but also powerful enough for clinical use; (optionally), enable integration with Filemaker-based EMR programs*

*shameless plug: if you’re a cardiologist using Filemaker, try our eAtreio solution!

Ingredients: CONQUEST PACS server, ClearCanvas viewer, Onis viewer, Synedra viewer

Recipe: First, we should obtain all necessary components from their source.

  • CONQUEST – is a public-domain DICOM server written by  Marcel van Herk and Lambert Zijp at the Netherlands Cancer Institute. It is multi-platform and, as far as I can tell, well-supported. Compared to the other free options (KPACS et al), I think it’s the better one.
  • ClearCanvas – this is commercial software from an established Canadian firm, but a community edition is available for personal use without limitations; I must say that their policy of providing a (comprehensive) network viewer for free (and FOSS too!) is commendable! We’ll be using it mainly to send CDs to the PACS server but also for basic viewing and JPEG/AVI export
  • Onis – again a limited version of a commercial DICOM client with a lot of features; can upload to Conquest, as well as view angiograms; in fact, it may represent the optimal first station for the patient CDs (view them, store them locally, and then send them to Conquest at the end of the day)
  • Synedra – another commercial DICOM viewer, this time from Austria. This viewer is, in my humble opinion, the absolute best Windows-based viewer for a cardiology practice; it’s also free in its basic configuration
Other notable software

There is quite a number of options that we could consider at this stage, instead of the ones listed above. Here’s some:

  • KPACS – a venerable free server; however, it does NOT allow Q/R, and this is a serious limitation as it only allows local viewing
  • ClearCanvas Image Server – a free fork of a commercial RIS; it is probably the most powerful of the lot, but requires installation on a Windows Server workstation
  • Onis viewer – is an excellent viewer/client/mini-server, that can substitute for the ClearCanvas+Synedra combination on its own
  • Medavis DICOM importer – for quickie imports; however, I could not manage to get it to work with Conquest (probably some Little/Big Endian issues)
Installation steps

Next, install the appropriate (x86 or 64-bit) version using the default options on the clinician’s desktop PC. At this point, it is necessary to formulate a plan for a basic (DICOM) network even for the local computer; for the sake of simplicity, let’s create two network nodes – one for the physician and one for a secretary nearby. Remember that accessing the local host (i.e. one’s own PC) can be achieved by pointing to the IP address of [127.0.0.1].

DICOM network parameters [AE title, port] should be unique and thought out in advance. For the sake of clarity, the information we’ll have to enter manually is enclosed in brackets (don’t include those); most options, except some more meaningful names, are the default ones.

Physician desktop computer, running Windows 7, (network IP: 192.168.1.31)

– Conquest PACS, with an AET of [CONQ] listens on port [5678]; Synedra viewer, with an AET of [SYN] communicates on port [11112]; ClearCanvas has an AET of [CLEARCANVAS] and listens on port [106].

Secretary’s PC (network IP: 192.168.1.32)

– ClearCanvas is all that’s necessary, and has an AET of [RECEPTION], on port [2762]

Configuration

Below are some screenshots of the configuration screens for the individual applications, with some important hints where necessary. Note, at this point, that there is a significant “voodoo” factor that comes into play when configuring DICOM appliances. For example, a particular AET name or a port may prevent access, and one can spend all night trying to troubleshoot the situation. I suggest that you enter the information as listed here, and then try changing them, if necessary. Same applies to the Windows firewall – turn it off first, and then try to configure it!

Conquest

– important options are highlighted below

ConquestMain

– the server’s AET is “CONQ” and it listens to the port 5678

– the option “Keep Server Alive” is selected

Conquestassoc

– the section about “Known DICOM providers” is, obviously, very important; here’s the text dump of my setup (tabs appear as spaces):

CONQUESTSRV1 127.0.0.1 5678 un
CLEARCANVAS 127.0.0.1 106 un
SYN 127.0.0.1 11112 un
KPACS 127.0.0.1 5680 un
MEDAVIS 127.0.0.1 104 un
ONIS24 127.0.0.1 107 un

– I’ve had good success with the options listed above; note that spaces were removed and replaced with a single <tab> character by hand!

ClearCanvas

– click on “My Servers” and enter the PACS server information:

CCServer

(note that “Image streaming” is NOT checked)

– now enter the local info about ClearCanvas, under Options:

CCOptions

Synedra

– enter the PACS server information as appropriate, under “Options”; must also check the box “Deactivate extended negotiation”, as shown below:

SynOptions

– you might also check some cardiology-specific options, e.g. “open in Movie mode always”, so that angiograms begin playing immediately

Onis

– a very powerful client, with a built-in database; one can load the office patients’ CDs, view them in real-time and send them over to the Conquest PACS at the end of the day

– the Conquest server is specified as a “client”:

onisclients

onisdicom

– change the [ONIS24] port to [107]; Conquest will connect to that

Medaviz

– is included here for the sake of completeness; however, I could not manage to connect (probably because of Little/Big Endian protocol issues with Conquest)

MEDAVIS1

Windows-specific setup

– at this point, we must add a firewall exception for each of the above programs, by using the Control Panel

Firewall2

– for this project, and to prevent network-related headaches, the firewall was OFF:

Firewall

We’re done. The workflow under this setup is as follows:

  • put a DICOM CD on any local PC and load in ClearCanvas (click on “My Computer”, then right-click on the DVD drive and select “Import”), OR Onis (probably better)
  • send the study to the Conquest server
  • open Synedra and log to the Conquest server
  • perform a search on the Q/R tab
  • double-click the study to review the angiogram

In order to create a CD (or a DICOM USB file), Onis is probably the best. If we need AVI export, ClearCanvas allows that.

copy-d2a_5365-28-35-f4-b.gif

ADDENDUM

– a quick note on configuring KPACS to send all stored studies to Conquest (in case you started with KPACS first):

KPACS status

KPACS assoc

– OsiriX configuration to work with Synedra as a viewer:

osirix2

osirix

REFERENCES

– Synedra user manual: manual_en

– the Conquest users forum

– an orthopedic surgeon offers some useful tips (from the ClearCanvas forums)

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