Practical Operating Solutions for Resource-Limited Settings: Image Acquisition, Storage, QA, and Editing

Introduction

  • Purpose: Provide practical, low-cost operating solutions for acquiring, storing, reviewing, editing, and archiving ultrasound (US) images in resource-limited settings.
  • Context: Point-of-care ultrasound (POCUS) programs require more than just US devices; they need a workflow for image storage for quality review, education, and credentialing.
  • Market options: Commercial software can simplify capture, storage, and editing (as discussed in Chap. 19), but may be unaffordable or infeasible for new/unfunded programs.
  • Hardware reality: Newer US machines often include image transfer, but still require storage solutions; older machines may lack wireless transfer and need alternative storage methods.
  • Goal of the chapter: Outline low-cost or free hardware/software options to create a workflow for image capture, storage, review, editing, and archiving (see Fig. 22.1).

Necessary Elements of an Optimal Ultrasound Program Workflow

  • Core workflow components:
    • Image Acquisition
    • Image Storage
    • Image Manipulation (editing/processing)
    • Image Archiving
  • The workflow should support:
    • Easy viewing of images
    • Image formatting options
    • Archiving of images and videos
    • Editing capabilities for images/videos
  • Visual reference: Figure 22.1 illustrates the optimal ultrasound workflow components.

Media Acquisition Options

  • ACEP guidance: Hard copy of all ultrasound images should be saved for all POCUS studies; the method of saving is left to the department.
  • Storage options beyond commercial middleware:
    • Thermal paper prints
    • Digital image storage
  • Depending on the method, extra hardware may be needed beyond the US machine.
  • Images/videos can be temporarily stored on the machine’s hard drive or externally via other hardware.

Internal Image Acquisition

  • Definition: Internal acquisition stores images on the US machine’s hard drive.
  • Offloading pathways after initial capture:
    • PC format or DICOM format for transfer to storage
  • Transfer methods vary by machine:
    • Wireless transfer (if supported by the device)
    • Ethernet (wired) connection for download; requires time to download
    • USB transfer to external thumb drive/hard drive; requires careful handling to protect PHI unless de-identified
  • Scheduling: Downloads can take machine out of service; plan during low-volume times
  • Wireless upgrades: Older machines can sometimes be upgraded with wireless dongles or software to enable wireless image transfer; check with manufacturer for compatibility

External Image Acquisition

  • When internal options are unavailable or insufficient, external methods may be used:
    • External video recorder to capture screen images; saves as video files only (not in DICOM format)
    • Thermal printers: original method for cataloging images; black-and-white prints on thermal paper; images degrade over time due to heat exposure; best stored in climate-controlled locations; only supports still images; printed images can be scanned into the medical record later but are hard copies and can be easily lost (Table 22.1 summarizes pros/cons).
  • External hard drive option: small, portable drives connected to the US cart; removable for transfer to a computer; rewritable and easy to reuse; requires careful handling to avoid PHI exposure; supports offline storage when internal storage is not available.
  • Key takeaway: All acquisition methods should ensure future accessibility for viewing, formatting, archiving, and editing.

QA and Archiving

  • After saving, images/videos must be stored for:
    • Quality assurance (QA)
    • Credentialing
    • Billing purposes
  • Storage considerations:
    • Safe location with redundant backups
    • HIPAA-compliant access control (login/password, etc.)
  • Digital storage options:
    • Simple approach: download to a single dedicated computer with login protection; easy and inexpensive
    • Networked storage: expand to multiple workstations via VPN for viewing from multiple locations; more complex and may require IT support
    • Hybrid systems: hub computer + cloud-based backup to enable viewing remotely and off-site backups
  • Cloud backup discussion: Cloud storage discussed later; balance accessibility with security and compliance

Image Format

  • Two primary formats, depending on acquisition hardware:
    • DICOM (Digital Imaging and Communications in Medicine): standard for storing, printing, transmitting medical images across manufacturers; embeds patient-identifying information within the image, reducing risk of mislabeling; larger files requiring more download time and storage space; requires a DICOM viewer to view; enables a PACS workflow (even a small PACS can be set up on a computer with appropriate software)
    • PC modalities (non-DICOM formats): common image formats such as
    • Images:
        • .jpg, .png
    • Videos:
      • .mov, .m4v, .mp4, .flv
    • Pros: easier viewing/editing with standard software; smaller file sizes; faster downloads
    • Cons: inconsistent across machines, potential loss of embedded PHI handling, may require conversion to a common format; fewer universal viewing tools; image quality may be slightly lower than DICOM
  • HIPAA/HITECH considerations:
    • HIPAA requires protected health information (PHI) privacy in handling, storage, and transmission
    • HITECH requires business associate agreements (BAAs) for cloud storage to ensure encryption during transit and at rest
    • If using cloud storage, consider de-identification or encryption and consult the compliance office
    • If using a single server, ensure HIPAA-compliant security measures (passwords, firewall, user access restrictions, etc.)

HIPAA and Compliance

  • Cloud storage considerations:
    • Only certain cloud options are HIPAA-compliant (see Table 22.3 for examples and providers)
    • De-identification may be required before uploading to cloud services, or use of encryption software to protect data
    • Always consult the local compliance office to ensure storage meets HIPAA and hospital standards
  • Local/server storage considerations:
    • Ensure server is HIPAA-compliant
    • Implement strong access controls, audit trails, and data encryption
  • De-identification workflow:
    • If cloud storage is used, de-identify images or apply encryption
    • Maintain a central index with study identifiers to link de-identified data back to patients when needed, under proper authorization

DICOM Viewers and Local/On-Premises PACS (Table 22.2)

  • Major DICOM viewers, with cost, OS, pros, and cons:
    • OsiriX MD (macOS): Free lite / paid; Pros: user-friendly interface; Cons: Some features may require paid version; mac-only limitations on some platforms
    • RadiAnt DICOM Viewer (Windows): Free lite / paid (Pro); Pros: intuitive, fast; Cons: some features require paid upgrade; Windows-only in free version
    • Horos (macOS): Free; Pros: intuitive; Cons: open-source, may lack some professional features
    • Aeskulap (Linux, Windows): Free; Pros: open-source, cross-platform; Cons: interface may be less polished; some features limited
    • MicroDicom (Windows): Free (basic); Pros: lightweight, fast; Cons: limited advanced features
    • 3D Slicer (Windows, Linux, macOS): Free; Pros: powerful, extensible with modules; Cons: steeper learning curve for beginners; some advanced features require expertise
    • Sante DICOM Viewer (Windows): Free (basic); Pros: intuitive, supports a range of DICOM formats; Cons: more features in paid version; limited platform scope
  • General notes:
    • Many viewers support multi-planar reconstruction and 3D visualization; some offer PACS integration and DICOM server support
    • Open-source viewers provide a cost-effective route for small programs but may require more IT support for maintenance

Internet Cloud Storage and HIPAA Compliance (Table 22.3)

  • HIPAA-compliant cloud storage options listed include (examples):
    • Amazon Web Services (AWS)
    • Backblaze
    • Box
    • Egnyte
    • Carbonite
    • Dropbox Business
    • Google Cloud
    • Microsoft Azure
    • Microsoft OneDrive (OneDrive for Business)
    • Sync
    • iDrive
  • Important considerations:
    • Not all cloud options are HIPAA-compliant by default; verify business associate agreements (BAAs) and security controls
    • For non-DICOM images/videos, cloud storage can serve as backup and shareable access across locations; ensure de-identification if required
    • De-identification or encryption may be necessary before upload; maintain local indexing to re-associate studies if needed

Web-Based Cloud Storage Options (Non-DICOM Image/Video Backup)

  • Web-based storage services (e.g., Google Photos, SmugMug, Shutterfly) can provide cheap or free storage and basic editing features; however:
    • They are generally not HIPAA-compliant by default and could expose PHI
    • If used, images should be de-identified or stored in a compliant manner; use dummy study identifiers in a central log for mapping
  • Pure cloud file storage services (Dropbox, Google Drive, Amazon Cloud Drive, etc.):
    • Do not inherently offer editing; primarily backup/sharing
    • Useful as a mini-PACS for cross-location access if compliant controls are in place
    • Many offer low-cost or free storage tiers; HIPAA compliance varies and requires BAAs for many services

Video Editing Software and HIPAA-Compliant Sharing (Table 22.4 and Tools)

  • Core concepts:
    • De-identification of video clips prior to sharing; batch de-identification support available via specific tools
    • Videos can be de-identified and then shared via HIPAA-compliant platforms or secured channels
    • Tools can crop to remove PHI and create M-mode representations from videos when necessary
  • Online and low-cost editing/sharing tools mentioned:
    • Core Ultrasound tools:
    • ClipDeidentifier: batch de-identification of video clips via drag-and-drop; exact PHI cropping
    • M-mode-ify: converts ultrasound clip to an M-mode image for time/distance measurements (useful for cardiac imaging)
    • SonoClipShare: online ultrasound-specific video-sharing site; de-identified videos; easy dissemination
    • General video editing and sharing software (free or low-cost):
    • ClipChamp (web-based)
    • DaVinci Resolve (Windows/Linux/macOS): powerful editing/colour tools; may have a steeper learning curve
    • Canva video editor: simple editing features, suitable for basic needs
    • iMovie (Mac): basic video editing; often included with Macs
    • Adobe Premiere Rush: cross-platform, simpler version of Premiere; may require subscription
    • Final Cut Pro / CyberLink PowerDirector II Deluxe: more advanced, may be cost-prohibitive for some
    • Other free options:
    • ClipDeidentifier (Core Ultrasound): batch de-identification
    • ClipDeidentifier workflow supports de-identification for HIPAA compliance prior to sharing
  • SonoClipShare notes:
    • Provides video-sharing with de-identified ultrasound videos
    • Useful for education and case discussions while maintaining patient privacy
  • General workflow tips:
    • Use software already available on the computer to minimize costs
    • Create folders and categorization for video clips
    • Use cropping/annotation features to remove PHI and highlight relevant findings
    • Maintain de-identified versions for teaching/education

Key Recommendations (Summary of Core Guidance in Table 22.4)

  • Recommendation 1: The supporting structure of any successful program should include an operating solution to store images for quality, education, and credentialing.
  • Recommendation 2: Homegrown practical operating solutions can help create a workflow for programs starting out or with limited resources by keeping costs low.
  • Recommendation 3: Commercial workflow solutions are not strictly necessary; one can utilize other programs to achieve similar outcomes (e.g., free/open-source tools, cloud options, and local hardware).
  • Recommendation 4: Automating processes should be a goal to help with compliance and consistency across end users.
  • Practical takeaway: Be creative with low-cost alternatives, ensure consistency, and aim for automation where possible to support HIPAA compliance and workflow efficiency.

Table 22.1: External Image Acquisition Modalities – Quick Reference (Pros/Cons)

  • Thermal printers
    • Pros: Small images that can be attached to charts; inexpensive and easy to attach to machines of all ages
    • Cons: Images degrade over time with heat; only still images; requires climate-controlled storage; hard copies can be lost; non-DICOM format
  • Screen capture recorders
    • Pros: Can save stills or videos; can capture dynamic content; facilitates non-DICOM capture
    • Cons: Still images only in some setups; video quality depends on recorder; non-standardized formats
  • External hard drive
    • Pros: Digital files; still images and videos; rewritable and easily connected to computers; can be encrypted
    • Cons: Can be bulky; risk of misplacement; non-DICOM format; potential security concerns
  • Overall takeaway: Each modality has trade-offs between image quality, durability, ease of use, and data security; choose based on program resources, needed workflow speed, and compliance requirements.

Table 22.2: DICOM Viewers – Quick Reference (OS, Pros/Cons)

  • OsiriX MD (macOS) – Free lite / paid
    • Pros: User-friendly interface; good visualization tools
    • Cons: Some features require paid version; limited Windows support
  • RadiAnt DICOM Viewer (Windows) – Free lite / Pro
    • Pros: Fast, intuitive; strong viewer capabilities
    • Cons: Some features behind paywall; Windows-only in free version
  • Horos (macOS) – Free
    • Pros: Open-source; intuitive
    • Cons: Community-driven; may lack some pro features
  • Aeskulap (Linux, Windows) – Free
    • Pros: Open-source; cross-platform
    • Cons: Interface and support can be limited
  • MicroDicom (Windows) – Free (basic)
    • Pros: Lightweight; fast
    • Cons: Limited advanced features
  • 3D Slicer (Windows, Linux, macOS) – Free
    • Pros: Powerful, extensible; supports many formats and modalities; 3D visualization
    • Cons: Steep learning curve; some features require expertise; limited beginner-friendly UI
  • Sante DICOM Viewer (Windows) – Free (basic)
    • Pros: Intuitive; supports various DICOM formats
    • Cons: More features in paid version; some users may find UI less polished
  • General note: Each viewer supports various DICOM formats; some offer PACS integration and 3D capabilities; open-source options provide cost-effective routes but may require IT support

Table 22.3: HIPAA-Compliant Cloud Storage Options – Quick Reference

  • Providers listed (examples):
    • Amazon Web Services (AWS)
    • Backblaze
    • Box
    • Egnyte
    • Carbonite
    • Dropbox Business
    • Google Cloud
    • Microsoft Azure
    • Microsoft OneDrive (OneDrive for Business)
    • Sync
    • iDrive
  • Important considerations:
    • Each provider may offer HIPAA-compliant options and BAAs; verify security controls and data handling practices
    • Cloud storage can provide off-site backups and cross-location access, but ensure PHI handling is compliant
    • De-identification or encryption should be considered prior to upload when necessary

Table 22.4: Low-Cost / Free Image Editing Programs – Quick Reference

  • Pluck (SonoClipShare):
    • Description: Free tool for extracting still images from ultrasound video; supports image annotation
  • Video mosaic builder (SonoClipShare):
    • Description: Free tool to create 5x5 image mosaics; useful for lectures
  • SonoGIF (Core Ultrasound):
    • Description: Free tool to convert video clips to GIFs; useful for quick sharing
  • ClipDeidentifier (Core Ultrasound):
    • Description: Free tool to batch-de-identify video clips; drag-and-drop; ensures HIPAA compliance for sharing
  • M.mode.ify (Core Ultrasound):
    • Description: Free tool to convert a video clip to an M-mode image for time-distance measurements
  • SonoClipShare (Online):
    • Description: Video-sharing site with de-identified HIPAA-compliant videos and images; free with potential upgrades
  • Canva video editor: Free (with optional paid upgrades)
    • Description: Web-based editor; drag-and-drop; basic editing capabilities
  • iMovie: Mac users; Free with macOS
  • Adobe Premiere Rush: Free trial / paid plan
  • Clipchamp: Web-based editor; free tier available
  • Davinci Resolve: Free version; powerful editing and color tools
  • Summary notes:
    • Most tools support cropping, trimming, adding text, arrows, and basic effects
    • Many tools offer de-identification features or workflows to ensure HIPAA compliance when sharing
    • Some tools are platform-specific (e.g., iMovie on Mac) while others are cross-platform (e.g., DaVinci Resolve, Clipchamp)
    • Core Ultrasound tools emphasize de-identification and M-mode conversion to support clinical and educational use while preserving privacy

Practical Workflow and Takeaways

  • Build a simple, sustainable workflow first:
    • Start with a single secure computer for archiving on-site, with password protection and backups
    • Consider VPN-enabled access to view images from multiple locations as needs grow
    • Use non-DICOM formats for ease of viewing/editing when on a tight budget, but plan for a DICOM-based path if clinical integration requires PACS or regulatory compliance
  • Prioritize automation where feasible:
    • Automate de-identification where possible before sharing
    • Set up automatic backups to cloud or external storage to reduce manual tasks and risk of data loss
  • Balance cost and compliance:
    • Leverage free/open-source tools for initial setup and education
    • Add cloud backups or cloud viewing as a scalable option, ensuring HIPAA BAAs and encryption where needed
  • Education and credentialing emphasis:
    • Ensure archived images/videos are accessible for QA and credentialing reviews
    • Create standardized naming conventions and study identifiers to maintain organization across formats and storage locations
  • Real-world applicability:
    • The described approaches are designed to be adaptable to varying levels of funding and hardware availability
    • The same concepts can be applied to other resource-limited settings beyond ultrasound imaging
  • Final note:
    • The overall goal is to establish a reliable, low-cost, and compliant workflow that enables ongoing quality improvement, education, and credentialing through accessible image capture, storage, editing, and archiving solutions.

References (as cited in the source)

  • ACEP guidelines for ultrasound image storage and handling
  • DICOM viewers and PACS concepts: OsiriX MD, RadiAnt, Horos, Aeskulap, MicroDicom, 3D Slicer, Sante DICOM Viewer
  • HIPAA and HITECH considerations for cloud storage and PHI protection
  • Core Ultrasound tools for de-identification and M-mode image creation
  • General-purpose editing tools (iMovie, Clipchamp, DaVinci Resolve, Canva, etc.) for cost-effective video/image editing