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Box DICOM Viewer - Overview

by ‎02-29-2016 09:24 AM - edited ‎04-03-2017 11:06 AM (9,050 Views)
 
The Box DICOM Viewer is a new feature and one part of the Box for Healthcare offering. It allows users to store, view and share DICOM files (X-rays, CT scans, Ultrasounds and MRIs) securely in the cloud. This new feature gives users the ability to share imaging studies across a hospital enterprise, with patients or with referring physicians. The Box DICOM Viewer allows users to view DICOM files on any web browser or mobile device. This new functionality helps improve interoperability and care coordination in healthcare by securely housing clinical imaging studies in the cloud so they can be viewed and shared at the point of care. 
 
Medical images have long been siloed inside of enterprise-based clinical software systems that work with the imaging equipment that captures them. The cloud can securely bridge the gap between the equipment that radiologists and technicians use to capture data on site and the people they ultimately need to share that data with. Users of the Box DICOM Viewer will be able to take full advantage of the HIPAA-compliant Box file sharing solution and make use of the DICOM Viewer's diagnostic quality capabilities for measurement and annotations. The Box DICOM Viewer has been cleared by the U.S. Food & Drug Administration (FDA) as a Class II Medical Device and is completely browser-based and zero-footprint. This means it requires no additional products or plugins like Java or Flash and uses HTML5 for viewing. 
 
The Box DICOM Viewer is being offered as part of the Box for Healthcare offering.  For more information, ask your Account Executive about how to access it. 
 

Getting Started

 
Once you have purchased the Box DICOM Viewer, your Box Customer Success Manager will enable the feature for your entire account (for all users). The Box DICOM Viewer is only available to Box customers with an Elite Box account which is part of the Box for Healthcare offering. 
 
Once the feature has been enabled, you and your managed users will be able to import DICOM studies and view them inside of Box. If you are having difficulty launching the Box DICOM Viewer and you have already purchased the feature, contact your Customer Success Manager or dicom-support@box.com.
 

Importing DICOM Studies

 
Before using the Box DICOM Viewer, you will need to import your DICOM studies into Box. There are two ways to import DICOM studies into Box: 
 
The Box DICOM Import Tool: A web-based widget that enables you to upload DICOM studies to Box from your desktop or from a CD to Box
 
The Box DICOM Proxy: An on-premise piece of software that uploads DICOM images to Box directly from your Patient Archiving and Communications System (PACS) or from your on-premise server
 
Note: If you use the normal Box file uploader to add your DICOM files, they may not load in the Box DICOM Viewer correctly. You must use the Box DICOM Import Tool to generate a ".boxdicom" file
 

To import DICOM studies with the Box DICOM Import Tool:

  • Navigate to the folder in Box where you would like to upload your study.
  • Click on the ellipses (...) to open the menu.
  • Under More Actions, click Import with Box DICOM Import to launch the Import widget.

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  • You can import your study in one of two ways: 
    1. Drag and drop individual images or entire folders into the outlined area of the Import screen.
    2. Click Choose Files to select and upload individual files. Click Folders to select and upload entire folders.
  • It may take a few moments for your study to upload. Once the upload is complete, a link to its folder will be displayed.
 
IMPORTANT: The Box DICOM Import Tool will create a file with the extension ".boxdicom" in the folder to which your study is uploaded. Opening this file will open your study in the Box DICOM Viewer. This is a file that the Box DICOM Viewer uses to display all the components of your study. It is recommended that all studies are imported into Box via the Box DICOM Import Widget or the Box DICOM Proxy so that a ".boxdicom" file is always created. 
 

To Import DICOM Studies with the Box DICOM Proxy

Many DICOM devices do not natively support secure encryption. A common solution is to use VPNs (Virtual Private Networks), however these virtual networks often have high costs and can be unreliable. The Box DICOM Proxy allows you to automate the uploading of DICOM studies using the the Internet without a VPN. It uses a secure TLS-encrypted DICOM connection to send DICOM data directly to Box. Please contact your Account Executive or Box Customer Success Manager for information about installing the Box DICOM Proxy.  Box Consulting also offers set up packages for customers who have purchased the Box for Healthcare offering.
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Using the Box DICOM Viewer

 

This is the DICOM workspace:
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Blue - Toolbar | Green - Study Panel | Red - Light Box | Purple - View Menu
 
To launch the Box DICOM Viewer, simply open any .boxdicom file while you are inside a Box folder. By default, the DICOM workspace will open in a new tab in your browser.
 
Each series of images from your imaging study will be visible in the study panel on the right hand side of the Box DICOM Viewer. By default, the light box will display up to the first six series in your study. You can choose which series are displayed in the light box by selecting them in the study panel, or by clicking and dragging them into the light box.
 
In the following sections, we will walk through the various actions you can perform in the Box DICOM Viewer.
 

Toolbar

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The Toolbar displays all the tools you can use to manipulate and annotate your DICOM images. For most healthcare organizations, these tools can be compared to standard PACS viewing tools. You can also generate a shared link to your study at any time by clicking Share (See "Sharing DICOM Studies" below).
 
  • Stack: Moves between frames of an individual series displayed in the light box. 
    • Select Stack from the main toolbar to change your cursor to the Stack tool. Then click on a series in the light box and drag up/down to move the series forward or backward. You can also scroll up and down with your mouse or trackpad to progress through images in the selected series. Scrolling is always tied to the Stack function, regardless of what tool is selected in the Toolbar. 
  • Window Level: Changes the window levels (Window Width and Window Center) of an individual series displayed in the light box.
    • Select Window from the main toolbar to change your cursor to the Window tool. Then click on a series in the light box and drag to change levels. Click and drag left or right to adjust the window center, and up and down to adjust the window width.
    • You can also choose from a list of preset Window Levels in the View Menu, or use the appropriate keyboard shortcut. See "View Menu" below for more information. 
  • Pan: Moves an image within its cell in the light box. This is useful for focusing on a specific area of a zoomed in image.
    • Select Pan from the main toolbar to change your cursor to the Pan tool. Then click and drag on a series to move it.
  • Zoom: Zooms in or out of a particular image displayed in the light box. 
    • Select Zoom from the main toolbar to change your cursor to the Zoom tool. Then click on a series in the light box and drag up/down to zoom in or out.
  • 3D Cursor: Displays a single point across all series in the light box.
    • Select 3D from the main toolbar to change your cursor to the 3D cursor. Then, click on any point in one panel to show the corresponding point in every series. For example, you can use the 3D cursor to locate a single point on a patients body from multiple angles. 
  • Annotate: Marks up individual images in your series with an annotation. (See table below) 
    • Click the icon to open a drop down menu of options. Annotations are tied to individual images in your series. They cannot cannot span multiple cells in the light box, and will not be carried across stacked layers of a series. Annotations are included in key images
    • Once you create an annotation, you can right-click on it to make changes to the color and font size, or delete the annotation altogether. 
    • To move an annotation, simply click and drag to your desired location within the cell you are working in. 
    • To save your annotations, click Save Annotation from the Annotate dropdown menu.
Please see the table below for Annotation descriptions you can select and create:
Arrow
Click and drag to draw an arrow in the desired size.  
Distance
Click and drag between two points to measure the distance. The measured distance reflects the distance between those two points in real life (in millimeters).
Ellipse
Click and drag to draw an ellipse in the desired size. The area and average radio-density of the selected region are calculated automatically.
Angle
Click and drag to draw an angle in the desired size. Adjust the angle by dragging the ends or vertex of the angle.
Cobb Angle
Click and drag to draw a Cobb Angle in the desired size. Adjust your angle by dragging the ends or vertex of the angle. Note: this is generally used to measure the curvature of the spine
Text
Click into a cell to add the text annotation. Once the text annotation pop-up appears, type your annotation and click OK.
Spine
Click on individual vertebrae to number them. By default, the spine tool starts at C1, and moves forward by one vertebrae each time you click. You can select a specific vertebrae number, or change the order that the numbers progress in the Spine Toolbox, which will appear in the bottom right corner of the screen. The Spine toolbox can be moved by clicking and dragging it around. 
Gonstead
Follow the instructions in the Gonstead Toolbox to use this tool. The Gonstead Toolbox will direct you to click on specific points around the pelvis. Once you have selected all 12 points, the Box DICOM Viewer will display Gonstead measurements.

 

  • Grid: Defines the cell formation you would like to work with on your light box.
    • Change this at any time by simply dragging images from your Study Panel to specific cells. 
  • Overlays: Displays a select subset of DICOM headers in light box cells.
    • Toggle overlays by clicking on Overlays in the toolbar. You can also toggle them on and off in the settings menu (More>Settings>Preferences) by checking/unchecking the Show Overlays checkbox. 
    • You can choose which fields are displayed by overlays in the Overlays Tab of the settings menu (More>Settings>Overlays). See "Settings" below for more information.
  • More Options: 
    • Click More in the toolbar to access the following options:
View Mode
Changes the way the Box DICOM Viewer is rendered in your browser. 
MultiMon
Opens another DICOM Viewer window that can be displayed on a separate monitor.
Full Screen
Makes the DICOM Workspace full screen.
Hanging Protocols
Opens the hanging protocols menu. Use hanging protocols to define the way specific studies are displayed in the Box DICOM Viewer. In the Hanging Protocols menu, click Capture in the bottom left to save your current DICOM settings, including the number of browser windows you have open and the grid configuration within those windows, as well as the settings of each individual cell (window levels, metadata, etc). You can name these settings and save them as a new hanging protocol. When opening a study containing identical series description metadata, the Box DICOM Viewer will automatically display your study according to the appropriate saved hanging protocol. 
Settings
Opens the settings menu. See "Settings" below for more info.
 

Study Panel

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The study panel houses every series in your study. From here, you can choose which series are displayed in the light box. 
 
Series Display: 
Click on a series in the Study panel to display it in the first cell of the light box, or drag and drop a series into any cell to display it in that cell.
 
Click on the arrow to the right of your study's name for more options -

 

Show Default View: Resets your light box to its default view settings. Any annotations will be saved.
 
Show Study by Objects: Displays your study as individual objects so that you can select any image from your study. 
 

Light Box

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The light box is the main area of the Box DICOM Viewer workspace. 
 
Progress bar: Indicates your current place in a certain series. The progress bar is located at the bottom of each cell in the light box. It changes color as the DICOM Viewer loads the images in the series. Unloaded sections are black. As images are loaded, the progress bar turns gray. The blue section is your current location in the series. 
 
Localizer lines: Shows where the selected series intersects with all other series. To turn localizer lines on or off, click More in the toolbar, then click Settings to open the settings menu. Toggle localizers on and off by checking/unchecking the Show Localizer Lines checkbox.
 
Orientation markers: Determines how the images from your study are oriented in relation to your patient's body. 
These markers are located at the top, bottom, right, and left sides of each cell in the light box. The Box DICOM Viewer uses standard abbreviations for orientation markers: H = head, F = foot, R = right, L = left, A = anterior, P = posterior.
 
Resizing Cells:
Click and drag on the gray divider lines to resize cells in the light box.
 

View Menu

Hover over a cell in the light box to display the view menu.
 
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Orange: Image Transform | Red: Presets | Green: Key Image | Blue: Cine Mode
 
Image Transform
Click on the Image Transform icon to flip, rotate, or invert the color of images in the selected series.
 
Presets
Click on the Presets icon to change window levels based on predefined presets: 
  • Default - use the default window level settings from DICOM headers (if available).
  • Auto - calculate window level settings using a min/max algorithm - keyboard shortcut: 0
  • CT/MR - Choose window levels from a predefined list of presets. Presets are numbered 1-9, corresponding with their keyboard shortcut. 
  • Add Current - Save current window levels as a new preset. Shift+click on a preset to delete it. Custom presets are not linked to keyboard shortcuts, and must be selected from the View Menu.
Key Image
Click on the Key Image icon to save the selected cell as a .png file in the same folder as your study. Key images include window levels, pan and zoom settings, and all annotations. 
 
Cine Mode
Click the Cine Mode icon to automatically scroll or pause the selected series. This is useful when viewing a series that plays like a movie, e.g. an ultrasound.
 

Sharing DICOM Studies

 
The Box DICOM Viewer enables care coordination and interoperability challenges by making clinical imaging studies easier to share securely in the cloud. This clinical image sharing feature gives users the ability to share imaging studies across a hospital enterprise, with patients and with referring physicians. It can also be used for collaboration around research needs. 
 
With Box, you have two ways to share: 
  1. Either use a shared link
  2. Invite people into a Box folder as a collaborator. 
Shared Link 
To generate a shared link to your study, click the Share button, located on the right side of the toolbar. In the popup window. You can set access levels to control who can see your shared study. For example, if you are sharing a study with someone inside of your organization, and do not want that study to be seen externally, choose "People in your company." If you want to share your study with a patient who does not have a Box account, choose "People with the link." You can also choose "People in this folder" if you only want to share the study with other Box users who are already collaborators in the folder containing your study. 
 
Note: You MUST click the "Share" button from within the Box DICOM Viewer screen itself. (See screenshot below). If you share only the ".boxdicom" link from its folder, your study will not be shared correctly.
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Adding Collaborators 
Alternatively, you can invite users as collaborators into the folder. Ensure that they have "viewer" access or above, or they will be unable to view your shared study. External collaborators do not need to have the Box DICOM Viewer enabled in order to launch the Box DICOM Viewer. 
 
Note: If you are inviting in a collaborator who may not have a Box Account, then they can create a free Box account when they receive the collaboration invite from you in their email. 
 
*For more information about basic folder sharing and collaboration on the core Box product, check out the Training section in the Box community: https://community.box.com/t5/Collaboration-and-Sharing/tkb-p/CollaborationandSharing
 

Settings

 
In the settings menu (More>Settings), you can set more detailed preferences for the Box DICOM Viewer and modify the overlays that are displayed.
 
Preferences Tab:
Number of windows
 
Specify how many windows you'd like the Box DICOM Viewer to open by default. This is useful for multi-monitor set ups. If you are using software which blocks pop ups or advertisements, be sure to set an exception for the Box DICOM Viewer to make use of this feature. 
 
Max Cache Size
 
Set a limit on the amount of data that the Box DICOM Viewer can cache in memory.
 
Show Overlays 
 
Check to display overlays, uncheck to hide
 
Show Localizer Lines
 
Check to display localizer lines, uncheck to hide
 
Enabled synced series
 
Check to sync series that are more than 95% parallel. Synced series will scroll together. This setting is enabled by default.
 
Enable prefetch
 
Check to download all data for the entire study when you open it, rather than loading each image as you advance the progress bar.
 
Overlay Color
 
Change the color of displayed overlays
 
Orientation Color
 
Change the color of displayed orientation markers
 
Localizer Color
 
Change the color of displayed localizer lines
 
Overlays Tab:
Use the overlays tab to manage the data fields included in overlays. You can add or remove fields, or move already displayed fields up or down.
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Keyboard shortcuts:
Arrow Keys
 
Step forwards or backwards through an individual series
 
Shift+Arrow Keys
 
Change the active light box cell
 
Tab
 
Cycle the active light box cell forward
 
Shift+Tab
 
Cycle the active light box cell backward
 
~
 
Sets window levels to default settings
0
 
Automatically sets window levels
 
1-9
 
Window Level Presets (See "Presets" above for more info)
 
Delete/Backspace
 
Delete the most recently created annotation
 
Windows: Control + K
Mac: Command (⌘) + K
 
Take a key image
 
S
 
Stack Tool
 
W
 
Window Levels Tool
 
P
 
Pan Tool
 
Z
Zoom Tool
 
D
 
Distance Tool
E
 
Ellipse Tool
 
A
 
Angle Tool
 
C
 
Cobb Angle Tool
 
T
 
Text Tool
 
Windows: Control + O
Mac: Command (⌘) + O
 
Toggle overlays
 
Windows: Control + L
Mac: Command (⌘) + L
 
Toggle localizers
 
Windows: Control + S
Mac: Command (⌘) + S
 
Toggles synced series
 

Additional Support 

 
For support, please email dicom-support@box.com or contact the Box support line at 1 (877) 729-4269. You can also view commonly asked questions on the Box community site: www.community.box.com.
 
  • Got a Box account? Click here to take a class about the DICOM viewer.
  • Don't have a Box account yet? Click here to take the class.