When you encounter images that would make a good teaching file case, there are two different ways to get them into the teaching file server: 1) use DICOM to send them to the teaching file's DICOM queue, or 2) export the images as files and upload them to a case through your web browser.

If your PACS or modality is configured to send images to the teaching file, the DICOM method is a good choice. It can save you from having to export and upload the images as separate steps, and it can automatically record case information such as exam date, modality, and patient number, without having to enter those fields by hand.

To send a series or exam to the teaching file server's DICOM queue, you will need to access the images in your PACS workstation or modality console, and then execute a DICOM Send operation. The details on how to do this vary from vendor to vendor. Please inquire with your local PACS support staff for specific instructions.

Once the images are in the teaching file's DICOM queue, you can access them from within the DICOM tab of the Enhanced Case Editor, where you will be able to retrieve the study by patient name or accession number, loading it into your web browser. The built-in DICOM viewer lets you cycle through images in the series, adjust windows and levels, and add selected slices to the case with a single click. See the section on Using the DICOM Interface for more details.

The DICOM method is not always available, however. Furthermore, the DICOM method requires the following conditions:

1. The images must originate from a DICOM source. This rules out non-DICOM images such as digital photographs or pathology slides, or images copied from a Powerpoint document.
2. The DICOM source must be preconfigured to push images to the teaching file's DICOM server. Your PACS administrator needs to register the teaching file server as a valid DICOM destination. Some vendors or policies might prevent this.
3. The images don't require cropping or other manipulation. The DICOM method is fine if all you need to do is adjust the windows/levels, but if you plan to crop the images or draw annotations on them, you'll need to use the Upload Method.
4. You are able to run the Enhanced Case Editor. The DICOM interface is only available on the Enhanced version of the editor, which requires a PC running Internet Explorer Version 6 with javascript enabled.

If any of the above conditions are not met, use the Upload Method instead of the DICOM method.

The second method for getting images into a case is to upload image files directly to the case. You will need to know where the images are (in a folder on your hard drive, or perhaps in a remote directory on your file network). The Case Editor will prompt you to specify the location of the files, and they will be automatically read into the teaching file's image repository and inserted into the case. Specific instructions and screen shots are available in the section Uploading Files into a Case.

If the image files are stored as DICOM objects in your PACS but you would rather use the Upload method over the DICOM method, you need to first export the images to your hard drive. Most PACS workstations allow you to save images as files to your hard drive using a built-in menu option. For example, if you are using a GE PACS, you can use the Pathspeed "Save Image" menu to export images at bitmaps, or the Centricity Send Exams menu to email images to yourself. Please inquire with your PACS support staff for specific instructions on how to export images.

Once images are exported, you can use external software such as Photoshop to crop images or mark them up with graphical annotations. For example, you could use arrows and text overlays to indicate findings. If you do so, you may want to save two versions of each image: one with the markup, and one without. When you add the images to a case, you will be able to specify how they are displayed, so that the marked up images only appear when the findings are revealed.

Note: you do not need to worry about the size or file type of the images. Images will automatically be resized and reformatted for optimal viewing through the web browser (although the original images will still be available if you need them). The teaching file server can handle over 80 image types, including DICOM, bitmaps, GIFs, JPEGs, and other common formats.

If your workstation does not give you the option of saving images as local files, you may consider using screen-capture software such as Cropper (free), 20/20 (free) or Snagit (~$50) to capture images exactly they are displayed in the PACS workstation. This method is described in the AJR article "A Simple Method of Capturing PACS and Other Radiographic Images for Digital Teaching Files", AJR 2002 178:817-819. This method also has the added benefit of allowing you to use your PACS workstation's built-in manipulation tools to crop, annotate, and adjust the image before capturing it.