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A PACS gateway to the cloud

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A PACS Gateway to the Cloud

Lus A. Bastio Silva, Carlos Costa, Augusto Silva and Jos Lus Oliveira
Departamento de Electrnica, Telecomunicaes e Informtica da Universidade de Aveiro
IEETA - Institute of Electronics and Telematics Engineering of Aveiro
<bastiao, carlos.costa, augusto.silva, jlo>

Abstract The amount of medical images has increased does not grant interoperability with DICOM devices. Medical
significantly over the last decade as result of the increase of institutions have a huge amount of standard devices that cannot
number and quality of studies. Following some researchers, this communicate with cloud computing interface directly. This
trend will continue over the next years. Cloud computing is a new paper presents a module of PACS Cloud architecture to grant
concept based on a well-know model named pay-as-you-go. interoperability with DICOM devices. PACS Cloud Gateway is
There is a new concept dubbed PACS Cloud, which the a component focuses mainly on translate DICOM commands
fundamental idea is to do PACS outsourcing taking advantages in non-DICOM requests and vice-versa.
of the clouds elasticity and scalability, avoiding hardware
obsolescence, providing universal access to the information PACS Cloud Gateway makes part of a self-organized
anywhere, anytime and increase the data availability. This paper PACS system in paradigm PACS-as-a-service. Gateway
presents a module of PACS Cloud architecture to grant focuses on full compatibly with Digital Imaging and
interoperability with DICOM devices. PACS Cloud Gateway is a Communications in Medicine (DICOM) standard. It supports
component of PACS Cloud, which focuses mainly on the two very important services: DICOM Storage and DICOM
translation from DICOM commands to non-DICOM and vice- Query/Retrieve, capable to store, query and retrieve studies
versa. While data outsource to the cloud can relieve users from to/from repository. Nevertheless there is a vary complexity of
the burden of local storage and maintenance, it also brings new physicians to move medical data from on-house datacenter to
security concerns. This paper presents a secure PACS Cloud
external providers, claiming lack of privacy and concerning
Gateway to access PACS Cloud archive, which provides a high
security level and without clouds provider dependence. The
due to patient confidentiality information. PACS Cloud
workflows of each process was described carefully, specifying Gateway is aware of this issue, and outlines well defined rules
data flows since that Gateway is contacted by DICOM device, in the PACS Cloud architecture, which provides a high security
until it releases the process. Finally, the platform was level, where the privacy of three main entities is respected:
instantiated in biggest Internet Cloud providers and the hospitals, physicians and patients. The module also offers the
solutions results was analysed. possibility to write in multiple storage cloud providers.

Medical Imaging, PACS; DICOM; Telemedicine; Cloud II. RELATED WORK

Computing The usage of DICOM services within a healthcare
institution is a common activity. The volume of produced data,
for instance, by dynamic cardiac modalities (e.g. XA and US),
The amount of medical images has increased significantly multislice CT, high-field MRI and digital mammography is
over the last decade [1], it is a natural result of the increase of tremendous and there is an increasing trend to the next years
number and quality of studies that are typically stored in [2]. For instance, CT scans (64/128-slices), PET, MRI with
repositories inside the medical institute. Following some high-resolution have typically more than 100MB. Beyond the
researchers [2], this trend will continue over the next years, huge amount of information, there are a lot of concerns with
meaning that PACS (Picture Archive and Communications safety of the data, meaning that losing studies could become a
System) will be dealing with large terabytes or even petabytes nightmare to PACS administrators, physicians, medical stuff,
of information. Considering that information, those systems and obviously for the patient. There is also a new movement to
need to be scale, and their maintenance costs will increase outsource data storage for institutions datacenters outside [3],
gradually. reducing the maintenance costs within medical institutions,
Cloud computing is a new concept based on a well-know which are not theirs core business.
model named pay-as-you-go. There was a new tendency to There is an implementation of medical image file system,
use Cloud computing into enterprises and industry, and [3] which presents a Grid computing model in co-location. The
healthcare market is not an exception. There is a new concept authors claim that the bottleneck occurs typically in PACS
dubbed PACS Cloud, which the key idea is to do PACS server and they propose a distributed file systems in different
outsourcing taking advantages of the clouds elasticity and grids, where the images are split into blocks and the blocks are
scalability, avoiding hardware obsolescence, providing widespread by different locations. Several strategies have been
universal access to the information anywhere, anytime and implemented to avoid flooding on PACS servers. For instance,
increase the data availability. However the concept only itself predictable methods were used to evade overload on the core
servers. The usage of distributes files in different locations and following the providers API (Application Programming
intelligent heuristics has reduced the transfer times. Also, other Interface) and deploy them (e.g. Amazon S3 [9]). Finally, but
approach [3] presents a similar scenario based on Cloud not least, there is Infrastructure-as-a-Service (IaaS) that
Computing. In this case the solution focuses on exchange, supplies resources such as virtualized servers, network devices,
storing and sharing Medical images across different hospitals. and many other resources, e.g. Amazon EC2 [10] is considered
Apache Hadoop is a distributed file system, which is used by a IaaS.
several important companies to distribute theirs contents, e.g.
Yahoo. The solution uses Hadoop and it can be deployed to a
private cloud or, on the other side, installed on a public cloud,
even thought in both situations it has a significant difficulty to
setup. Besides, it is a scalable solution providing replication.
However the paper does not expose any concerns about
security issues.
The medical image archive solution in the cloud [1] is a
PACS-as-a-service solution similar to what PACS Cloud
intends to be. The presents solutions grant interoperability
with DICOM devices and its implementation was created in
Microsoft Windows Azure. However this solution does not
supply any security or privacy method, becoming the proposed
solution an easier target to be attacked. Moreover, they do not
present any results regarding performance or robustness of Figure 1. Cloud computing layer
presented architecture.
A cloud computing service is a distributed system
All the discussed solutions are dependent on technology, technology that consists on the aggregation of resources that
platform or provider. In contrary, this paper proposes a novel are distributed into one single system, aiming to virtualize (e.g.
approach that make possible to store medical images in any decoupling the business service from the infrastructure needed)
cloud player and it breaks the barrier between DICOM and scalability (e.g. the capability of the system to grow when
communications and Web services cloud services, allowing the it is needed) [11]. Besides, one of the greatest advantages of the
connection with the PACS Cloud anytime, anywhere, in a cloud computing is about its resiliency. In theory, the cloud
secure approach. computing services are built in such a way that, if a machine
fails, the system readjusts itself, in order to avoid the user's
III. METHODS AND MATERIALS knowledge of the machine fail. Taking into account this
A. Cloud Computing resiliency, cloud computing seems a useful technology to
ensure some level of stability of the network and computational
There is a new general tendency to outsource compute
system that a single server cannot provide.
power and storage capacity from desktop, portable PCs, and
mobile devices to large datacenters[4]. These fashions do not There has been a strong investment in building cloud
stand for a completely new concept. There are several well- computing infrastructures for health proposals. For instance,
known paradigms that supports outsource as business model, the Harvard Medical School has built an internal computing
such as mainframes, clustering, grid computing, and the most cloud to enable collaborative research along several
recent is cloud computing. departments and partners [12]. Another example, TC3Health
Company is already providing health care payers with an
Computing devices and Internet access are now available
integrated solution supported by Amazon Web Services,
anywhere and anytime, creating new opportunities to share and
namely S3, EC2, and SQS technologies [13].
to use online resources. A tremendous amount of
computational power, such as Google and Amazon, and an B. PACS Cloud
unaccountable number of Internet resources and services, such A PACS Cloud solution must grant access to the archive
as email and storage, are used daily as a normal commodity. server anytime and anywhere. The traditional PACS server has
Also, Internet bandwidth is abundant, which allows storing two major components: DICOM objects repository and
data online. So, the major idea is to use Internet cloud, in a database system. The objects repository typically requests an
self-service model, where the Internet resources are used to infrastructure with huge storage capacity to support all DICOM
rely our services, and these features stand out from the other studies. The database module, typically a database
paradigms, previously referred. management system (DBMS), needs to support the DICOM
Cloud Computing raises to import business models. Firstly, Information Model (DIM) [14] containing metadata
applications can be delivered as services over the Internet. information related to patients, studies, series and images.
From end-users side its a commodity uses these application When an archive receives studies from image modality
like Gmail[5], Dropbox[6], Google Docs[7], and many others. equipment, it needs to store the images in the file system
According to cloud computing [8] this kind of software are repository and update the database with elements extracted
named as Software-as-a-service SaaS (Fig. 1) Secondly, a from the received study. Our approach is based on the
lower level in the architecture is Platform-as-a-service outsourcing of these two PACS archive components to the
(PaaS), where developers might create new applications cloud, namely using the new concepts of blobstore and
database accessible through web services. Blobstore are between DICOM devices and clouds interfaces. It provides two
associative memories, e.g. key-value storage providers, where DICOM services: Storage (e.g. DICOM C-STORE) and
the blob is an unstructured data (value) stored in a container Query/Retrieve (e.g. DICOM C-FIND and C-MOVE). Those
and the lookup is preformed true a text key. They are a key modules are located in institutional intranet and need to be
component of most actual cloud platforms and infrastructures, registered in Master Index to access to PACS Cloud services.
including Google App Engine (GAE) [15], Microsoft Windows
Azure[16], Amazon Web Services (AWS) [17] and Eucalyptus IV. SYSTEM DESIGN AND IMPLEMENTATION
[18]. All those players provide scalable and fault tolerant A. Components
blobstore data management.
The PACS Cloud interfaces were specified in a developed
The proposed PACS Cloud architecture was thought to PACS Cloud Framework. As a consequence the PACS Cloud
separate sensitive data elements manipulation from demanding Gateway interfaces was bounded in the framework, too (Fig.
computational operations. The solution developed is based on 3 3). The Framework outlines the signaling messages, DICOM
components: PACS Cloud Gateway, PACS Cloud Master messages in XML, API to Master Index, and API to Slaves
Index and PACS Cloud Slaves (Fig. 2). This paper focuses on databases and APIs to Cloud providers. All components of
PACS Cloud Gateway, but we are giving a quickly overview of PACS Cloud were implemented in Java, but it can be
each component towards a better understanding of following implemented in another language, since assert the PACS Cloud
chapters. Framework specifications.
Master Index
PACS Cloud Core System

!"#$%#&'()%% !"#$%#&'()%%
>,4./,?% ;,84.+%<3).=%
Hospital A

HTTP Trustable provider or on-house

C-STORE !"#$%#&'()%*+,-./'+0%
Workstations C-CFIND
Gateway Cloud

Figure 3. Internal components


PACS Cloud Gateway broke the barrier of non-operability

Figure 2. Architecture of PACS Cloud between DICOM devices and Cloud Providers. Therefore it has
two different implementations: (1) DICOM server compatible
The Master Index is the PACS Cloud core entity. It and cloud providers interface (web services). The
contains information about other modules, including Gateways implementation of DICOM standard is supported by the
and Cloud Slaves (repository and database). It also provides DCM4CHE library [19], a SDK that is used to extract DICOM
authentication services to institutional gateways. Finally, all data elements from persistent objects, to implement the Storage
DIM identifiable information related with patient and study SCP and Query/Retrieve SCP services (Fig. 4).
levels are stored in a master index database, fundamental to
ensure solutions for confidentiality and privacy.
The Cloud Slaves provide, on one hand, storage of sightless 0!1'23)-4%56#78%4-1239-4:%;(-1/<=-,13-2-%+>)%$,'1+?-@%
data (objects repositories) and, on other hand, a database
containing all no identifiable metadata extracted from DICOM
studies, i.e. the most demanding task concerning computational
power. The database slaves provide query services over no =D$E&-,% F9&'()4% )9GH9C-%
patient identifiable DIM fields. The proposed architecture
makes possible to have one or more Cloud Slave modules
hosted in different Internet Cloud providers, e.g. it is possible,
for instance, to have a database Slave module and two
repository Slaves in three distinct Cloud providers. A+2+%B31,(+&%8+9C3>-%

Cloud Gateway is a very important component in this

architecture (Fig. 2). It provides a interface between DICOM
Figure 4. Gateway - Components
world and Cloud systems. Internet Cloud providers just support
web services as system interface, which is a barrier to PACS PACS Cloud Gateway receives DICOM images and it will
server implementation through cloud computing. In order to forward these images to the blobstore in a specified cloud
solve this problem was introduced a DICOM-Web service provider. The access to the cloud blobstore providers is
gateway, named PACS Cloud Gateway, that aims to translate supported by jclouds [20] that implement several blobstore
DICOM commands in web service request towards a totally cloud providers. Furthermore, the PACS Cloud Gateway sends
connectivity between them, e.g. granting interoperability
metadata information to databases: Master Index and Slaves On the server side, there are a couple of classes focusing to
databases. The communication between the PACS Cloud create DICOM services listener (Fig. 6). Then forwarding the
Gateway and Master Index uses RESTful web services through messages or DICOM objects to the Cloud Slaves blobstores
the RESTlet framework [21]. and respective metadata for Slaves databases. It also needs to
communicate with gatekeeper, i.e., Master Index, to request
B. Architecture other kinds of information like PatientName, study session
The PACS Cloud Gateway architecture contains 4 different keys, etc.
packages, such as described below:
Server DICOM: Contains DICOM Services: server.dicom

Verification, Storage and Query/retrieve. It also DicomNetwork

encompasses the auxiliary classes to provide doStartService()
interaction with Cloud services. getAETitle()
Core: It stores all settings and POJO (Plain Old Java registerServices()
Object) classes. It contains a thread mechanism to
monitor new requests/signaling from Master Index,
but it also holds download manager in order to Storage QueryRetrieve
overcome the download single thread. doStartService()

GUI (Graphical User Interface): PACS Cloud

Gateway runs graphically on the system tray
(platform independent). It contains the system tray Figure 6. Class diagram (DICOM package)
graphic stuff and configurations window; it is able
to add/edit or remove DICOM nodes. Besides Storage and QueryRetrieve classes, there are also
Clients: In this package are implemented all classes other classes such as FindRSP and CMoveRSP, which are
that communicates with Master Index, and Cloud DIMSE responses. These responses were created using the
Slaves. actual state of the PACS Cloud databases. The solution also
implements upload and download in multithread towards a
Weve defined an abstract wrapper to communicate with better performance on the storage/retrieve medical data. It
Master Index dubbed MasterIndex (Fig. 5). It does not supply contains a thread poll to limit the number of threads alive and
any implementation, but it holds the interface to the methods this value might be changed on gateway configurations.
implementation, as know as adapter pattern. Thus, the real
implementations were done using RESTful client web services In order to improve requests handlers to/from slave
through the RESTlet framework, in MasterIndexImpl. database, an abstraction to DIM structure was created (Fig. 7),
Following this principle, the interface can be implemented which are maintained in a separated project (PACS Cloud
using another frameworks or other kind of providers, for Framework).
instance SOAP (Simple Object Access Protocol). Patient
-patient name
- study instance uid

SlaveIndex MasterIndex Series

storeMetadata() storeMetadata() - series instance uid
getStudies() searchByPatientName()
getPatient() hasCMove()
getStudy() sendCMove() Images
getSerie() isCMoveDone() - sop instance uid

Figure 7. Class diagram: DIM model

Figure 5. Class diagram (clients package) The initial settings are load from a class named Startup,
living in core package. In the first stage it will validate gateway
One of the biggest concerns in the architecture was the login, and then requests settings, e.g. PACSs AE Title.
support of multiple providers. In the first stage it looks like a
Finally, the gateway, by itself, encompasses configurations.
technological problem, but it is not. In order to solve this
For instance, the TCP ports where DICOM services listen, the
problem, we have defined a proper classes definition, so that it
username and password, and MasterIndex endpoint. All those
would become easier to implement it, in other cloud players.
configurations can be changed through the GUI or in the
Into client package, the class SlaveIndex (Fig.5) is just an
config.xml that is created automatically in the first time that
adapter to the real implementation, like MasterIndex. We have
application start.
also created a CloudInputStream and CloudOutputStream to
read/write operations in cloud Blobstores providers.
V. WORKFLOWS AND DATAFLOWS Likewise, retrieve process execute the same workflow, but
PACS Cloud Gateway is responsible for communication as it accesses to blobstore to retrieve DICOM objects. In the C-
DICOM service following DICOM conformance statement and MOVE process, when a C-MOVE Request is received by a
send, query or retrieve information from PACS Cloud in a gateway, destination AETitle and query level is extracted from
transparent way to the DICOM client side. On one hand, the the command data. In order to solve moves between multi-
movement of images from modality to PACS Cloud happens institutional sites, a signal is sent to the receiver gateway (step
when acquisition devices send the studies to the PACS Cloud 5 and 6). In the storage process, the download process uses
Gateway (Fig. 8). multithread and multiple objects are downloading at the same
time. On the other side, gateway starts a DICOM C-STORE
process with a negotiation to storage repository. Each object
PACS Cloud
Master Index (5)
successfully transferred from the blobstore is decrypted with
study session key and DICOM C-STORE process sends the
PACS Cloud
PACS Cloud
Gateway object to storage repository. After all objects have been
transferred to the local repository association, the C-Move
C-STORE (3) PACS Cloud
C-FIND/ (4)
Response is sent to the C-Move requester entity.
(1) Slaves (6)
(Cloud (8)
Devices Providers) VI. RESULTS
A new PACS solution, which is able to store medical
studies in the cloud safety, has been developed. The data are in
Figure 8. PASCS Cloud Gateway - generic workflow the cloud, but the provider cannot do anything with it because
they are all ciphered and the keys live in Master Index, where
A. Storage Service cloud provider does not access. PACS Cloud Gateway grants
In the storage process, gateway is waiting for DICOM interoperability with DICOM devices working as a tradition
requests. The DICOM upper layer is maintained by dcm4che2, PACS archive from DICOM clients side perspective.
which deals with association and low-level protocol. Furthermore, from the administrators side, it reduces
Nonetheless, the transfer capability, AEtitles, delays and other drastically the IT infrastructures and brings new management
important DICOM issues in protocol need to be customized. facility in multi-site institutions with shared PACS.
All those settings are loaded from Master Index.
A. Performance measurements
In the storage workflow, modalities produce images and The prototype was tested through several study cases with a
send images operating with DICOM communications with C- huge amount of DICOM images of different modalities, stored
STORE command. Before it happens, modality needs to know in multiple providers: Google Storage and Amazon S3. In all
which SOP classes and PACS support transfer syntaxes. In step the tests the solution proved to be robust, enable to store, query
of this procedure, the gateway receives a DICOM ASSOC and retrieve all expected studies.
REQUEST to verify if server supports the SOPs. Following
the numeration in Fig. 8, in step (1) the acquisition devices To evaluate the software in performance and robustness,
invoke a C-STORE command, and data flows to the PACS PACS Cloud was tested several times using a data set of 6
Cloud Gateway. When the storage process is finished, PACS studies containing 855 DICOM files. There are a couple of
Cloud Gateway will send the metadata to the slaves database modalities on those studies: Cardiac XA, US, MR, CT. We
providers and to the Master Index (steps 2 and 3). Note that all have used the campus Internet connection and the gateways are
images upload to the Cloud are encrypted with AES algorithm. running Pentium4, with a 2,6 GHz processor and 2GB RAM.

B. Query/Retrieve Service We made several trials of storage and retrieve with Amazon
S3 and Google Storage, considering just average times of both
The Query/Retrieve process is subdivided in two DICOM process. It includes upload and download processes under
independents commands: C-FIND and C-MOVE, where the HTTP and DICOM communication from/to gateway to
C-FIND is associated with the queries and the C-MOVE with DICOM devices.
image objects retrieve action.
There are average measurements, result of several trials
On the other hand, the query and retrieve process are with different modalities. We did the tests with two blobstores
executed from workstations. In the query process there is no providers: Google Storage and Amazon S3 (Table I).
communication with blobstore. PACS Cloud gateway just
requests information to the indexes (step 5, 6 and 7). The C- TABLE I. STORAGE MEASUREMENTS
FIND request contains query items that can be a sub-set of
!"#$%&'( )*+,&%-. /"%01-+!2 3""4%-+5.6 789+9:+5.6
DIM fields and can contain a wildcards elements in search
!" # $ %&'( )&*)
like, for instance, in patients name. According with query !" $+ ( *&%% ,&#+
specificity, it can be executed directly in the DIM Cloud Slave !" $# '&( ((&$) %,&-(
Database (step 6). If the patients name is referred in query ". (#' $)&* %)&#$ (,&$,
items or this contains wildcard, there is a query for Master /01 (%) #-&* *,&*- #,&-)
Index. In the end, gateway will collect both data and send C- ". %-% (+) ((#&), $'$&)'
FIND Response with matchs result. The results were analyzed, and seems that there are
different measures between different providers (Fig. 9), which
means that for each provider the solution can be tuned, for healthcare institutions. The characteristics of the presented
improving the performance. PACS Cloud grant a great scalability and reliability of data. It
has a significant impact on healthcare institutions, which
&$!"!!# allows the reduction of datacenters IT infrastructure
outsourcing the data to the Cloud. In spite of spent energy, air
&!!"!!# condition, maintenance and other issues, PACS Cloud will
work in a financial model pay-for-what-you-use having
%$!"!!# positive environment and financial impact.

%!!"!!# 450#06# The integration inside a healthcare instruction is effortless

and inexpensive, given that the solution is compatible with
acquisitions and workstations devices. Furthermore, there is no
provider dependence in this implementation due to its well-
modeling support couple of them, thus being easier to
%# &# '"&# %("$# )*"$# &!(# implement new providers. Due to legal issues, namely data
protection laws, the approach to outsource the medical data to
Figure 9. Results for Storage process public data might not be accepted in some countries because
they force to know the location where the information is stored.
The download process is faster than upload as can be seen Nevertheless, PACS Cloud Gateway allows storing the medical
in the results. (Table. II). data in private cloud. Thus, the presented solution is compliant
with these laws and possible to deploy in the real environment.
!"#$%&'( )*+,-./"0/0&%-1
2"%*+-/!3 4""5%-/617 89:/:;/617 Lus Ribeiro, Frederico Valente (workmates at IEETA) and
!" # $ %&' %&' Adrian Cole (from jclouds)
!" $( ) %&* %&+
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