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REVIEW ARTICLE
Year : 2013 | Volume : 36 | Issue : 4 | Page : 187-
192
Establishment of a locally-assembled image viewer system using ultra-books, tablet PC's and
smartphones for research, education, training and medical diagnosis
Sankaran Ananthanarayanan
Ex Radiological Physics and Advisory Division, Bhabha Atomic Research Centre, Mumbai,
Maharashtra, India
Date of Web Publication 8-Oct-2014
Correspondence Address:
Sankaran Ananthanarayanan
Flat No. 604, Indraprastha Complex CHS, Plot 13/14, Sector 29, Vashi, Navi Mumbai - 400 703,
Maharashtra
India
Source of Support: None, Conflict of Interest: None
DOI:10.4103/0972-0464.142385
Abstract
In the field of diagnostic radiological imaging, new challenges, particularly the gigabyte storage,
display and wireless transfer/transmission of images among medical professionals have led to the
use of ultra-books, iPad-like tablets and smartphones, along with the use of innovative medical
imaging software, in view of their several advantages. The article reviews the special features of
these devices and their ubiquitous applications, along with their practical selection for medical
imaging. A prototype home-assembled low-cost image-viewer system using the latest Windows
8.1 based Acer ultra-book computer/monitor system connected to Apple iPad Mini/iPod
Touch/iPod classic devices as well as to an high-definition TV viewing unit is described. This
ultra-book is selected for its touch-screen graphics display, optical drive facility (for reading the
CD-ROM containing images) and for easy portability. Both Wi-Fi broadband and cellular
network are provided for transmitting/receiving images. A novel, elegant and versatile FDA-
approved medical imaging (MIM) software, suitable for analysis and display of images from all
modalities, with cloud facility, was used for long-term storage, display and transmission of
Digital Imaging and Communications in Medicine patient images. The system has been tested
with a variety of educational patient, experimental phantom and resolution images as well as the
images supplied by Apple/MIM. Results show that the ultra-book with Windows 8.1 capability,
in association with MIM software, can serve as a mini-workstation for analysis/processing and
for providing wireless and portable access to all medical (including mammography) images. The
optional pocket type iPod Touch and iPad Mini (with light weight and moderate size display)
devices enable easy accessibility of images at any site. The system with their present resolution
will certainly fulfill their role in education, training and research and is well-suited for diagnosis.
Keywords:At-home image-viewer, iPad mini, iPod classic, iPod touch, medical imaging,
medical imaging software, ultra-book
How to cite this article:
Ananthanarayanan S. Establishment of a locally-assembled image viewer system using ultra-
books, tablet PC's and smartphones for research, education, training and medical diagnosis.
Radiat Prot Environ 2013;36:187-92
How to cite this URL:
Ananthanarayanan S. Establishment of a locally-assembled image viewer system using ultra-
books, tablet PC's and smartphones for research, education, training and medical diagnosis.
Radiat Prot Environ [serial online] 2013 [cited2016 May 3];36:187-92. Available
from:http://www.rpe.org.in/text.asp?2013/36/4/187/142385
Introduction
In the field of diagnostic radiological imaging, the transition from analog to digital was closely
followed by the development of the picture archiving and communication system. [1],[2],[3]
Concomitantly, multidimensional imaging techniques (four-dimensional and five-dimensional
for motion [temporal] and functional [fusion image] studies on three-dimensional images,
respectively) have presented new challenges, particularly in handling gigabyte-size images from
computed tomography (CT), magnetic resonance imaging (MRI) and positron emission
tomography (PET) scanners that generate thousands of images. The analysis and storage coupled
with the display and transmission of these images among medical professionals necessitated
expensive image workstations. Recently, the advent of: A bewildering variety of handy portable
imaging devices and systems, such as ultra-books (compact versions of laptop), tablet PC's and
smartphones with features of cloud storage; new high-definition (HD) TV display systems; and
high-speed broadband and cellular networks have revolutionized the field of storage, display and
transmission of medical images. [4],[5],[6] Also, several softwares, such as a medical imaging
(MIM) software [7] for analysis and manipulation of images have been exclusively developed for
these devices and marketed by companies abroad. The purpose of this article is to review these
systems and devices briefly with their salient features along with their innovative applications in
medical imaging. The author has purchased the different components of the system with his
meager resources and assembled in his home a prototype image-viewer unit for research,
education and training and use for medical diagnosis. It is hoped the description and discussion
of these will be useful for medical professionals, physicists, radiation protection experts,
engineers and others using or intend to use these devices.
Portable medical imaging device
Ultra-books
Several models of low-cost compact, light, portable laptops (also called "notebooks" "netbooks"
or "ultra-books") with Full 1080p HD with light-emitting diode/liquid crystal/organic light
emitting diode displays (the latest of them with touch-screen facility) and based on Apple
McIntosh and Microsoft Windows 8.1 operating systems, have been recently introduced to
replace the bulky desktop computers. Ultra-books are ideally defined by Intel as slim,
lightweight (<1.5 kg) "notebook" PCs, using their latest processor, which have long battery life.
For medical imaging and education, 14"-16" size ultra-books of excellent display resolution
(1920 × 1280 pixels or better) having built-in speakers and Blu-Ray DVD players (either built-in
or with an external drive), enable connection of iPod/iPad/Smartphone/Flash drive devices
(described later) as well as to HDTV units. Internet access via broadband/Wi-Fi modems and/or
2G/3G/4G cellular networks (either built-in or available as separate adapters) facilitate quick
browsing and downloading/uploading of a variety of medical images for education and training.
By using cloud storage [8] (a service model in which data is maintained, managed and backed up
remotely and made available to users over a network, typically the internet), the images can be
automatically transferred to other devices among medical professionals. Ultra-books, with either
built-in or alternatively with interface to external high-resolution cameras, can be used for light
photography for a variety of medical diagnostic and radiation protection education applications.
The captured static or video images thus stored in ultra-books can be edited using higher-end
software like Photoshop and later transferred to Flash Drive directly or to other Apple devices
through Apple iTunes software. [9] Dynamic videos stored in ultra-books can be visualized better
by connecting to fast-response (with a refreshing rate of 600 Hz, for reduced motion blurring)
HDTV systems. The author made a search of the various types of ultra-books, based on the latest
Windows 8, marketed by several manufacturers, which are suited for medical imaging use in
developing countries. Since the storage of images from various equipments (ultrasound [US], X-
ray, CT, MRI, single-photon emission computed tomography [SPECT], PET) in medical
institutions in these countries is still finally in the CD-ROM form (the cloud storage concept has
yet to emerge here), ultra-books with the optical drive feature will be of great advantage.
Examples of low-cost ultra-books with this feature are the Acer 14" Aspire M5-481PT, the
Samsung 14/15.6" series 5/3, Lenovo Ideapad U510, etc., Among the many other latest ultra-
books, the Intel-Core processor/Windows 8.1 based Acer Aspire M5, a quad-core
processor/Android based tablet computer Asus Transformer Prime TF201, and the Intel 4 th
generation dual-core i5 CPU Apple MacBook Air deserve mention. The author has worked
intensively with the Acer M5-481PT model, along with the MIM software (described later) for
storage, display and transmission of medical images from several modalities. [6] The 14" panel
touch-screen graphics display of ultra-book handles animation well with excellent resolution
(1366 × 768 pixels) without unduly draining the battery. Available memory (up to 6GB RAM)
and external connections, along with a high processor speed (up to 2.6 GHz with turbo boost),
allow for handling massive amounts of data inherent in medical images. The cloud feature with
Wi-Fi facilitates storage and sharing of images with other Acer books, iOS and Android devices.
Tablet PC's
For many purposes in imaging, we do not need the full computing power of a desktop or laptop.
Recently, several stylish and lightweight tablets, with touch-screen interface and large displays
with good resolution, have been developed for utilities such as quick browsing, shopping for and
reading e-books, processing/sending E-mails, creating and editing documents, taking and storing
several photos/images, etc., using quality applications. Tablets replace the mouse with the
facility of swiping across the screen, enabling rapid scrolling through websites, pages on books,
stored photos, videos, etc., Tablets also enable connectivity to broadband/Wi-Fi, 2G/3G/4G,
Bluetooth + enhanced data rate (EDR) and other networks and also to laptop/desktop. They are
usually provided with built-in back and front high resolution (megapixel) cameras, which
dispense with external cameras. Besides, other features, such as the built-in earphone/speaker
and facility of 1080p video recording/playing, are also provided. However, there are usually no
USB ports to connect an external camera, iPod or Flash Drive (the recent versions, however,
have Flash Drive connectivity). Furthermore, DVDs and CDs cannot be read/played with tablets;
nor are they readily compatible with scanners/printers, etc., (although the iPAD2 tablet can be
remotely connected to Wi-Fi operable printer). Three of the popular tablets, with comparable
features, useful for medical imaging are Apple iPad4, Samsung Galaxy Note 10.1 series and
Lenovo ThinkPad/Ideapad K1 (Note that there are many other models marketed by other
companies). The first of them has been widely used globally now. Apple has recently introduced
its mini versions: iPad Air and iPad mini. Apple uses the same operating system (the iOS6 or its
updated versions) for their iPad, iPhone and iPod Touch devices (described later) whereas the
other two use the Android (Honeycomb) system. The iOS has several features viz., the iCloud,
iMessage, Notification Center, etc., The iCloud software automatically transfers the iPad
contents (documents, photos, etc.) to the Apple remote server (with facility of free storage up to
5GB) where they are accessible by the other enrolled Apple devices (e.g. iPhone). Similarly, the
iMessage enables to send texts to an iPhone. The Notification Center displays the alerts and
reminders. All the three devices have large-size screens (9.7-10.1") of excellent pixel resolution
(iPad4: 2048 × 1536; the other two: 2560 × 1600 and 1280 × 800 respectively) capable of
providing sharp and crisp displays of medical images (still pictures or videos). Their other
features include: Battery life (talk time) of 48 h. 16-64 GB memory storage, micro SD card,
1GHz processors (iPAD4: Apple A6X dual-core; the other two: Exynos quad-core and dual-core
Nvidia Tegra 2 respectively), megapixel front and back cameras, Wi-Fi/cellular and Bluetooth
connectivity, etc., More details are available from their technical literature. The author has
worked intensively with the iPad mini model, along with the MIM software for storage, display
and transmission of medical images from several modalities. [6] The iPad Mini (software update
iOS 7.0.4) has 7.9" display (1024 × 768 pixels), much longer battery life, Wi-Fi/cellular
connectivity and Apple SIRI (a software-based personal assistant which enables simple voice-
based commands). It must be noted that the memory storage capacities available in tablets are
less than those in iPod and laptops (with typical storage capacities up to 160GB and 500GB
respectively). With the built-in accelerometer, three-axis gyroscope, and compass all working
together, one can rotate tablets in a vertical-to-near horizontal plane (features also shared by
smartphones) to display in portrait or landscape mode, or even upside down, and the display fits
to whatever one is watching, reading, or seeing.
Smart phones
These devices are pocket mobile phones with gigabyte storage and displays with moderate
resolution making them superior to iPod for many imaging applications. Apple introduced the
first of these iPhone devices, which has undergone further generation developments (iPhone 5S
is the latest model). Smart phones with similar display/storage/browsing/transmission network
features and built-in megapixel camera(s) have been recently also marketed by other companies.
These, with comparable features for medical imaging, include (operating systems in brackets):
Samsung Galaxy S5 (Android v4.4.2 [KitKat]), Nokia Lumia 830 [Windows 8.1], Google Nexus
7 [Android 4.4], HTC Butterfly [Android 4.1], Motorola Razr HD [Android Ice cream
Sandwich], Sony Ericsson Xperia SP [Android Jelly Bean] and many others. The iPod Touch (4
th generation) may also be included among these devices in spite of its lack of phone facility. The
screen sizes and display (super active-matrix organic light-emitting diode [AMOLED] or retina
types) resolutions range from 4.6" to 5.1" and 800 × 480-1920 × 1080 pixels respectively. The
battery life (talk time) is in the range of 6-14 h. All of them have good storage capacities (8-
64GB/micro SD card). More details are available from the manufacturers' technical literature.
They share many of the features of tablets, such as broadband/Wi-Fi, 2G/3G/4G, GPRS,
Bluetooth, etc., networking, video recording and viewing, ease of display orientation etc., stated
earlier. For instance, the iPhone/iPod Touch shares the iCloud and iMessage features of the
iPad4. With an external wireless router, the iPod Touch can send/receive the message through
Wi-Fi network (the author has successfully used the Belkin Wireless N Router SURF N300, in
conjunction with the Mumbai Mahanagar Telephone Nigam Limited broadband (speedup to 2
Mb/s) for iPod Touch, iPad mini and the Acer ultra-book mentioned earlier). Smart phones
enable radiologists to access patient images (videos, movies or photos) at any point (at-home
with the iPod Touch, where the wireless router/modem may be located), from hospital
professionals through other Apple devices or the internet and share these and/or converse face-
to-face (e.g. through FaceTime) with other medical professionals. Although the size of the screen
is less than that of the tablet, the resolution offered is adequate for analyzing and interpreting
images (using the MIM software) at-home or on-the-go. For better image details, an HD TV
(with fast response for viewing videos as stated earlier) can be connected. The iPhone 5S and
some other smart phones also have the SIRI feature. The iPhone 5S (16GB) is perhaps the most
expensive of all smart phones. Mobile devices have made ubiquitous access to patient data a
reality for many physicians treating patients at the point-of-care or on a consultative basis. They
provide accessibility especially in an emergency situation. One can also use them for
consultation, collaboration, and teaching purposes.
Medical Imaging (MIM) Software AND MIM Cloud
The MIM software (FDA-cleared) is a versatile, elegant and comprehensive software with which
the images from ALL modalities (X-ray, US, CT, MRI, PET, SPECT) can be displayed and
processed on Windows-based ultra-books (in addition to iPad, iPhone and iPod Touch devices)
and incorporates Health Insurance Portability and Accountability Act compliance to protect
patient information. FDA has, however, clarified that iPad/iPhone like devices should not be
used for viewing mammographic images. Furthermore, these devices should not be used as a
replacement for a proper medical workstation, but the picture details they provide are good
enough to be used for when doctors want to analyze images on-the-go or at-home. This
important mobile technology provides physicians with the ability to immediately view images
and make diagnoses without having to be back at the workstation or wait for the film. This
software is also compatible with Mac systems. The full features and applications of this software
can be obtained from their website. [7] The MIM Software is intended only for (their) cloud
storage and display of Digital Imaging and Communications in Medicine (DICOM) images and
not for images in other formats such as Joint Photographic Experts Group (JPEG), etc., In India,
the CD-ROMs of images, given to the patient for his reference and records, are loaded with
either JPEG (or similar) or DICOM data. In the latter case, some form of converted data is built-
in for display of images in any computer (the author earlier downloaded and installed Apple
iTunes software for transferring JPEG images from ultra-book to iPod Touch for viewing). The
limited free cloud storages (5GB) provided by Acer and Apple for the ultra-book and iPad Mini
users respectively are suitable only for JPEG or similar images. The author, therefore,
downloaded a free commercially available DICOM to JPEG converter for storage of DICOM
images in Acer and Apple clouds. The author displayed on the ultra-book and iPad Mini a
variety of DICOM educational test images from several modalities, drawn from the websites
providing experimental patient, phantom and resolution images (e.g. American Association of
Physicists in Medicine [AAPM], Society of Motion Picture and Television Engineers [SMPTE]
test patterns) or from CD's with patient images. A total of 45 TEST images was
selected/uploaded and displayed on iPad Mini/iPod Touch (including 15 sample patient images
given free by Apple/MIM to iPad Mini clients) of which 30 images transferred to the MIM cloud
were displayed on the ultra-book. The website images were first downloaded into the ultra-book
for transfer to the MIM cloud using the upload utility tool, for long term storage. The CD images
can be directly imported to MIM cloud using the MIM viewer. The actual procedure of upload of
images into MIM cloud can be gathered from the MIM website. Once uploaded into their cloud,
the images can be downloaded and reviewed on the ultra-book or iPad Mini/iPod Touch any
number of times for a maximum period of 90 days (after which it can be extended, if required).
For downloading from MIM cloud and subsequent analysis of images on the iPad Mini, the
necessary software (called Mobile MIM) can be downloaded from Apple stores. For
nondiagnostic viewing of medical images by patients, separate Apple/MIM Vue.ME software
can also be downloaded for iPad Mini display by MIM cloud account holders. It may be added
here that the MIM viewer display on ultra-book and the display on iPad Mini have similar image
processing/manipulation features.
The author reviewed all the images stored on the MIM cloud both on the ultra-book as well as on
the iPad Mini. The sample anonymized patient images provided by Apple/MIM were also
reviewed. The author could successfully use the several controls to manipulate these images, e.g.
window/level, zoom/pan, crosshairs-localization, multi-planar reconstruction; built-in tools to
verify lighting; select Measure, Annotate and SUV with variable ROI; display DVH and isodose
curves; cycle between the image series (includes fusion and MIP movies) and the three plane
views (axial, sagittal, coronal) with coordinate display, etc., The Proview of the MIM viewer
(only available on ultra-book) was more comprehensive (it was also necessary for some image
applications) and was selected in preference to the simple viewer. Almost all the images
displayed on the ultra-book, iPad Mini and iPod touch were comparing well with respect to their
crispness and clarity and CT number correlation. All the devices displayed faithfully all the
AAPM test images (chest, knee, and breast) and practically all the resolution patterns. The
SMPTE test pattern was clearly visualized as per the AAPM display criteria. [4] The various gray
levels in the wedge, line-pair patterns (<3 lp/mm), holes and objects of various sizes (>1 mm),
etc., embedded inside test phantoms (e.g. Wellhofer/breast phantom) were all resolved/displayed
by continuously varying the "level" and "window" settings on both ultra-book and iPod Mini
displays. For iPad Mini, calibration (using a screen of 30 grayscale squares, each containing a
circle that is slightly brighter than the square) was adjusted to achieve best image quality in all
cases. It is of interest to note that the MIM software provides a special light verification check
(TG-18-CT test pattern) for proper display viewing on iPad Mini under ambient light conditions;
unless this test is satisfied, it is not possible to go to the next step of observation and analysis of
images. These served as important QA tests from the physicist's point of view. Unlike the other
popular Swiss Pixmeo OSIRIX software, which is tuned toward the Mac, the MIM software is
compatible with both Mac and Windows systems.
For medical image viewing, the most-critical component is a high-resolution support of the
system/device and for detecting very small lesions, microcalcifications, etc., image resolution
should be at its highest. As already stated above, the ultra-book and iPad Mini are able to resolve
all the AAPM 2k × 2k and SMPTE test patterns and the test objects/patterns in other phantoms.
It may be stated that the ultra-book with its present resolution will certainly fulfill its role in
education and training and has good potential for diagnosis where such highest resolution is not
required. Ultra-books and iPad Mini with still better resolution are available for those needing
them but at increased expense (the latest Apple MacBook Pro tablet PC and iPads with retina
display and Samsung Galaxy tablets/phones with AMOLED display may be anticipated to be
better in this regard). Through the Acer and Apple cloud, the images (and other associate files)
can be remotely accessed through wireless in similar ultra-books or iOS/Android devices by
medical professionals; in the same way, the images stored in MIM cloud can be displayed
remotely through wireless at other Apple devices (e.g. iPhone, iPad, iPod Touch). Considering
these and other advantages already mentioned, it may be stated that the ultra-book serves the
purposes of medical imaging in Indian hospitals. The iPad Mini's light weight and its moderate
size display enables easy accessibility and analysis of images at any site. In association with the
MIM software, the ultra-book will serve as a mini-workstation (although, as per FDA, this is not
intended to replace full workstations) for analysis and processing of medical images and for
providing wireless and portable access to medical images.
At-Home Image-Viewer System
The author has assembled at his home a prototype image-viewer system for research, education,
training and medical use. Although meant primarily for medical diagnostic imaging, it can be
also employed for other uses such as biomedical imaging, industrial radiography, light
photography for various applications, etc., [Figure 1] shows the block diagram of this
comprehensive unit, built around a Windows 8 based Ultra-book (Acer M5-481PT) computer
system (features described earlier), comprising a Samsung PC-compatible 32" TV unit (1360 ×
768 pixels) with remote adjustments for contrast, brightness, sharpness, zoom, color, gamma,
edge enhancement, digital noise reduction, etc.; modem with Wi-Fi router; USB interface for
flash drive (Imation Europe BV); iPod classic; iPod Touch; iPad mini; an inexpensive high
resolution/B and W all-in-one printer-scanner-copier (HP Desk-jet printer F4288); [5] and a
pocket high resolution (3264 × 2448 pixels, 10 bit) digital camera (Fuji Finepix J10). [4] The
computer comes with the latest Microsoft Office and its Picture Manager has the facility to edit
pictures using tools such as brightness and contrast, color, crop, rotate and flip, change picture
size and auto-correct facility to automatically correct color and brightness. All these TV and
computer facilities facilitate obtaining pictures/images of optimum quality. The MIM/Apple
softwares and the Apple iTunes software are downloaded and installed in the computer for
manipulation/processing and transfer of images. The 3G/4G network adapter is added for
enhancing the speed of the system for downloading/uploading images. The ultra-book serves as a
laptop computer; therefore, the full capabilities of the MIM software are realized along with the
several new features of the latest Windows 8 (since updated by author to Windows 8.1) such as
the CD-ROM drive, McAfee Total Protection, SkyDrive, Skype, Kindle, Encyclopedia,
Dictionary, Reading list etc.
Figure 1: Schematic block diagram of prototype image-viewer
with Windows 8.1 Acer computer
Click here to view
Conclusions
The viewer system has been very satisfactorily used by the author on a continuous basis since the
past more than 1½ years. The author's conclusions regarding the use of Apple devices for
imaging are shared by many other investigators [10, 11, 12] in this field. The author states, the actual
selection of a particular model will depend on the features required such as storage/RAM size,
display type, size and resolution, browsing, transfer/transmission of medical images,
analysis/manipulation of images and the accuracy of interpretation, sharing the images with other
medical professionals, high speed network availability, price, etc., From this point of view, the
author opines, the models cited in this article will be perhaps most suited for medical imaging,
using the MIM software or other FDA-approved compatible software. At present, a bewildering
variety of models by other companies are also entering the tablet and smartphone arena and
better less expensive ones (possibly non-Apple tablets and phones hopefully based on the
Android and Windows 8 operating systems) are being introduced.
Note
A number of products and allied softwares from different manufacturers are mentioned in this
review article. More technical details, address of the manufacturer, price, etc., can be obtained
from the respective websites.
Acknowledgments
The author expresses his thanks to M/s MIM software, Inc., particularly to Mr Kanak Chatterjee
and Mr. Mark Dreyer for assistance and many stimulating discussions. The literature from
several companies (e.g. Apple) and the images from Apple/MIM and scientific
associations/groups (e.g. AAPM) were exclusively used in this article for educational purposes
only, all of which are hereby deeply acknowledged.
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