vamg6792@UXA.CSO.UIUC.EDU (Vincent A Mazzarella) (03/24/91)
Sender: Hospital Computer Network Discussion Group and Data Base <HSPNET-L@albnydh2.bitnet> REPORT FROM ACR WORKSHOP ON COMPUTER NETWORKS IN RADIOLOGY RESEARCH MARCH 14 - 15, 1991 Bethesda, Maryland This workshop was sponsored by the American College of Radiology and supported by the National Science Foundation, the National Library of Medicine and the National Cancer Institute. It was held in the beautiful conference facilities at the Lister Hill Centre on the campus of the NIH in Bethesda, Maryland. About 50-60 people from around the country attended. It became evident that almost all of them were already familiar with the extensive computer networks provided in the country and were present to learn more about the further developments of high speed networks. The meeting was opened by Dr. Dan Masys, the Director of the Lister Hill Centre for Biomedical Communication and by Dr. Ron Evens, who Chairs the ACR Commission on Technology Assessment and Efficacy Studies. The first session was chaired by Dr. Ron Arenson, Professor of Radiology at the University of Pennsylvania. The first speaker was Dan VanBelleghem, Associate Program Director, NSFNET. He described the historical development of the present NSFNET starting with the early beginnings of BITNET and ARPANET, through the present NSFNET to the projected NREN which stands for National Research and Educational Network. The 1992 budget for this facility is 638 million dollars of which 30% is provided by ARPA and another 30% by the NSF. The remaining monies are provided by other bodies. The primary purpose of the NSFNET is to provide super computer services and by the summer of 1991, the major network for this purpose will be running at 45 megabits/second. Mr. VanBelleghem contrasted the various computers ranging from CRAY Y-MP/8 running at 2,000 Mflops down to the VAX 780 at 0.15 and the IBM PC-AT running at 0.033 Mflops. There are CRAYS based at Cornell, the NCSA at the University of Illinois, at Pittsburgh and in San Diego. In 1984 the network used to use the super computer based at Boeing and accessed this with a 9600 baud line. The speed of communication has risen incredibly and the speeds in the 89/90 time frame are 1.5 Mbits/second rising to 45 Mbits/second in 91/92 and to 1 Gbit/second in 95/96. In contrast, the number of packets transmitted in 89/90 was half a billion, and in 91/92 is expected to exceed 5.5 billion packets. The connection to Europe runs at 128 Kbits/second. The actual physical connections are maintained by commercial interests in the form of MCI, Sprint, etc. The use made of NSFNET is 19% interactive sessions, 21% file transfers, 16% name servers, 26% mail/bbs/conference and 18% for other activities. The proposed uses of NREN are to access remote systems for visualization and for large file transfers. A number of researchers are also placing sensing devices in remote locations and using networks to transmit the data back to a central base. Software distribution is expected to be a large user of NREN and other uses are for database and library activities, scholarly collaboration and education. A number of policy issues were discussed by Mr. VanBelleghem. These included security, fair use and access, connection to commercial networks, the transition of the government supported NSFNET to the commercial sphere, methods of charging users, standards for network interchange and international connections. The next speaker was Dr. Dan Masys who is the Director of the Lister Hill Centre for Biomedical Communications at the National Library of Medicine. He discussed the biomedical networks and once again, provided the historical background for this discussion. In 1964 Index Medicus was computerized and in 1971, MEDLINE was established. In 1989, this was succeeded by MEDLARS and there are now 39 databases which are accessed for over 5 millions searches per year. Such searches are also available from the commercial networks as well as a number of sites around the world. This facility is to be augmented by Loansome Doc for ordering documents for direct delivery or by FAX and Loansome Doc will become part of GRATEFUL MED as of January, 1992. Dr. Masys presented an interesting nomogram which related the amount of data to be transmitted against the time which one would feel appropriate for transmission in order to determine the data rate necessary. This emphasized the fact that if one wishes to display a medical image at fairly high resolution in a screen print time of the order of one second, extremely high data rates are required. On the other hand, if one is satisfied with the transmission of fairly small files of ASCII data, and the time for transmission is relatively immaterial, then data rates of the order of 1200 board are perfectly acceptable. Although the use of the network for e-mail and file transfer is high, much of the super computing and database access activities are associated with molecular genetics and the structure of DNA. Dr. Masys suggested that the major challenge to date is bringing the various databases into some form of standard format such that search routines for one database were applicable in other databases. In many senses, this is the database analogue of the problem faced by medical imagers with the variety of formats in which images are found in medical imaging devices. Dr. Masys suggested that the current problems are a lack of many local connections and the absence of organizational commitment. Here he cited the case that when a large number of NCI grantees were canvassed, they supported the concept of electronic networks but emphasized that it should be done without any reduction in the amount of money available for research grants. Another problem which he cited was the fact that the biomedical sociology tends to be based very much on the Flexner Report which stipulates that medicine should be learned at the feet of the greats and as a consequence of this, networks tend to be psychologically shunned by the people involved in medical teaching. Speaking to the future, Dr. Masys suggested that MEDLINE would be further expanded to include genetic information for gene matching under the human genome project and that providing the standards could be established, it would be possible to start consideration of transmission of biomedical images. The National Library of Medicine is in the process of transferring the many billions of pages of text to computer data base due to the fact that the paper with an acid base is rapidly crumbling to dust. Such transfer to computer data base would facilitate the automated interlibrary loan system. 57,000 prints and photos of medicine have been placed on video disk and the National Library of Medicine is in the process of coding another 17,000 x-ray images onto optical disks. The visible human project includes volumetric images of the complete human which it is hoped would provide for library searches based on object classification within such images. This, in a sense, would lead to the concept of a virtual library. Dr. Masys concluded his presentation with the quotation of a Chinese proverb, "tell me and I will forget, show me and I may remember, involve me and I shall remember". Dr. Elliot Fishman from the Department of Radiology, Johns Hopkins Hospital, was the next speaker and he provided an overview of the use of computers in radiology. Perhaps without intending to be so, Dr. Fishman was very controversial in his suggestions that radiologists should be reading studies from workstations and that they should therefore be able to manipulate images in order to achieve the best reading conditions. He was also very emphatic that users should be able to access software in order to make desirable changes. It seemed to me that to suggest that radiologists would perform all of their film reading sessions at workstations ignored the method of payment and would have a significant reduction on radiologists salaries. Further, I personally questioned whether the distribution of software to users would be in the best interests of the users since I am sure the FDA would have particular concern regarding the liability issue of software errors. Following the morning coffee break Dr. Robert Esterhay reviewed the development of interactive workstations. He indicated that most activity is text base with clinical trials, literature searches, data collection and data uploads being the major activities. Most physicians use computers for administrative activities but do not use them for access to data such as that available at the National Library of Medicine. The NCI is working towards remote data collection and access facilities in order to promote clinical trials into a wider community. This project is planned in three phases with the third phase being that of decision management tools associated with the data collected. A request for proposals has gone out and the product is in the development stage with a projection for the fall of 1992. Also concerned with interactive workstations was a discussion by Dr. Michael Merickel from the University of Virginia in Charlottesville, who discussed the specific application of workstations for pattern recognition of atherosclerosis and cancer. The next two speakers addressed the problems associated with standards. Dr. Thompson from the University of North Carolina in Chapel Hill, suggested that the approach to standards needs to be more holistic and that the ACR/NEMA standards should be extended into the area of hospital information systems (HIS) to include voice as well as both image and textual data. He suggested that radiology is only one component of the complete information available regarding patients. He had a vision of creating communication links that would even avoid direct physician/patient contact. There is a standard body concerned with HIS and this includes delegates from Europe and Japan as well as those from North America. Dr. Steve Horii from Georgetown University, Washington, described the history and mandates of the various working groups within ACR/NEMA. Much of the information regarding ACR/NEMA is familiar to the readers here so that I will not reiterate it. The last speaker before lunch was the Senior Vice President of Vortech Data, Mr. Lee Bryan, who observed that medicine in fact is a very small marketplace and we should keep a constant eye on other markets such as CAD/CAM and publishing. He envisaged networks moving towards file servers and in the future, computer servers in the form of large high capacity computing facilities. He mentioned a new system that would be available from HP that would be running at something like 72.2 megaflops. Thursday afternoon commenced with a further description of the NSFNET management by Susan Calcari of the Merit Corporation which manages NSFNET. She described what NSFNET is and how Merit fits in to the whole management of the network. She described the various other networks such as MILNET and NASA which fit into INTERNET and described how the network goes from the campus to the regional, then national and finally to the world level. To give some indication of the speeds of T1 and T3 networks, she suggested that T1 network was capable of transmitting five pages of typed data per second whereas a T3 network could transmit as many as fourteen pages of such data per second. There are 2,417 networks associated with NSFNET of which 717 are international networks. Merit adds about two networks per week to the overall and once again, the usage figures were very similar to those cited previously. The usage by packets was 23% mail, 23% for file transfer, 19% for interactive activities and 8% for name lookup. In the area of actual data, in terms of bytes, she demonstrated that 27% is mail, 44% is for file transfer, only 7% for interactive work and 4% for name transfer. These figures are growing at the rate of about 20% per month. Ms. Calcari claimed very high reliability of the system with a quoted figure of 99.89% up time. This is remarkable and does not coincide with the experience of most people. However, as Ms. Calcari pointed out, the figure she was quoting was for NSFNET, not for the many nodes within smaller networks that are connected to the INTERNET. In response to a question regarding the connection of INTERNET into Eastern block countries, Ms. Calcari pointed out that INTERNET is dependant upon TCP/IP and this is a technology which cannot be exported to East block countries. Only BITNET connections are allowed to the Eastern block. The next part of the afternoon session was occupied by some demonstrations. Dr. Carl Jaffe from Yale University demonstrated file transfer by logging into Yale and roaming his various accounts there. He transferred some MRI images down to the Mac II at which he was located. Dr. Jaffe is on sabbatical at the National Library of Medicine and he described how he had been able to work with the graphic artists at Yale to produce educational teaching files by transferring the images back and forth and using the program IMAGE for viewing on the Mac. Dr. Lawrance from the National Centre for Super-computer Applications described access to the CRAY and other high performance computers in order to provide exceptional computer power to various distributed users. His handout also gave instructions for obtaining NCSA freeware using anonymous FTP. The anonymous FTP address is FTP.NCSA.UIUC.EDU (128.174.20.50). Following the coffee break Dr. Hahn from SURANET described the midlevel network. He made one quotation which was a very telling one and that is that hardware networks create social networks. That is certainly true in many cases. Mr. David Ely of the Corporation for National Research Initiatives addressed the issues of digital library systems. He described the growth of telecomputing in relation to the growth of other infrastructures within society. He mentioned the development of railroads followed by highways and then electricity distribution followed by the telephone system and suggested that telecomputing would be a further development of this form of infrastructure. The Corporation for National Research Initiatives is extending MEDLARS for the National Library of Medicine and there is a GRATEFUL MED interface via INTERNET from Unix Systems. He suggested that there would be future possible support for nontextual information. He provided a demonstration of the use of GRATEFUL MED over INTERNET. Mr. Ely also introduced the concept of KNOWBOTS which are in essence, knowledge robots. One can build a KNOWBOT locally and then send this to a larger machine, have the program run on that larger machine, returning processed data to the local system. GRATEFUL MED is a good example of this concept in which a search routine is built at the local PC and is then sent to a large database for a search. The final speaker of the afternoon was Ms. Karen Roubicek of BBN Systems and Technologies Corporation which is the information resource for NSFNET. Ms. Roubicek and a colleague, John Curran, demonstrated a product called SLATE which provides the facility for multiple users to access multimedia documents simultaneously and make changes while on line. This demonstration was without doubt the most impressive of the day in which a colleague of theirs was working in Boston on a document that was visible to all in the audience. The users at either end were able to point to various items within the document, both textual images and even sound so that editing could take place at either end. The first speaker on the Friday morning session was Dr. Darleen Fisher who was the Associate Program Director for networking research at the National Science Foundation. She repeated much of the material that had been presented on the previous day by describing the history of ARPA net through to NREN. It should be recognized that Dr. Fisher was not present on the Thursday, so had not been aware of the discussions that had previously taken place. The following session consisted of a panel of speakers who described their own uses of networks in radiology research. This session was Chaired by Dr. Ron Arenson and the first speaker was Dr. Cradduck from the University of Western Ontario who described the use of e-mail and file servers in facilitating the development of INTERFILE for use by the COST-B2 project in Europe. The development of INTERFILE could not have taken place as quickly and expeditiously as it did, had it not been for the wide electronic communication of the members of the working group within the COST- B2 project. The next speaker was Dr. Kuhn from Southern Illinois University who described some collaborative activity in conjunction with the NCSA on the reconstruction of MRI images using various principle components. He presented images to demonstrate this research activity. In response to a question from the audience, Dr. Kuhn admitted that he preferred the high speed network to the CRAY supercomputer over having his own Ardent computer on site. Dr. Shannon who is the Director of the Radiological Services for the Department of Veteran Affairs described the networks that exist within the VA and that this is almost all textual in nature. A new network is being developed for visual data. He felt that fast workstations that would enable to radiologist to emulate film manipulation is very necessary and that high speed communication networks will allow for remote conferencing. Since the term "virtual network" had been used on several occasions Dr. Shannon described a truth table regarding the presence or absence of an object and whether one sees it or not. If the object is there and one sees it, then it can be described as real. If, on the other hand, it is there but one cannot see it, then the object is described as transparent. If, of course, the object is not there and cannot be seen then object is absent yet on the other hand if the object is not there yet can be seen, it is described as being virtual. Dr. Mike D'Alessandro from the University of Iowa described ETNET which is a computer conferencing system operating from the National Library of Medicine. Dr. D'Alessandro has a keen interest in the development of the highway network throughout the United States and he used this as an analogue to describe the development of computer networks going from low speed links to the high speed projected links of the mid 90's. He suggested that the present NSFNET is equivalent to the Lincoln Highway of the 1920's. Dr. D'Alessandro felt it was very important that the group attending the workshop should be held together for future discussions and suggested that ETNET should be used to that end. Dr. Peter Santago of Bowman Gray School of Medicine described the use of a 45 Mbit/second network in North Carolina to provide for teleconsultation. He was followed by Captain Jerry Thomas from the Uniformed Services University of Health Sciences in Washington, DC. Dr. Thomas reported on the networks that had been set up for imaging in association with the Gulf war. He also described the use of local area networks for educational programs and many of the radiology students at the US UHS are taught by this technique. The session was concluded by Dr. Taaffe from Massachusetts General Hospital who described the PACS system under development at Massachusetts General Hospital. The MGH deals with close to 250,000 studies/year including 9,500 from nuclear medicine. This gives a workload of something of the order of 1,200 studies/day for a staff of 79 radiologists and the major problem is one of overload. The PACS system is seen as a solution to this particular problem and he described the system with its several links to outlying centres. Subsequent to the panel discussion there was some more general discussion concerning the next steps to be taken with respect to the development of a radiology network. There did not seem to be any real conclusion to this discussion apart from the fact that Dr. D'Alessandro reiterated the fact that ETNET should be used to continue the discussion but in an electronic medium. Mr. Gil Devey who had acted as the organizer of the workshop indicated that he would be providing an executive summary of the workshop to be published in the June issue of Investigative Radiology. Trevor D. Cradduck, PhD, FCCPM, ABMP March 21, 1991 -- Trevor Cradduck, | Phone: (519) 667-6574 Department of Nuclear Medicine, | FAX: (519) 667-6734 Victoria Hospital, | E-mail: University of Western Ontario, | BITNET: TREVORC@UWOVAX.BITNET LONDON, Ontario, | INTERNET: TREVORC@UWOVAX.UWO.CA Canada, N6A 4G5 | UUCP: TREVORC@RIA.UWO.CA z HSPNET-L albnydh2 3/23/91 'DFP10@albnyvm1 Vincent Mazzarella 3/23/91 Medical Network Conference at