Patent Publication Number: US-2019180864-A1

Title: Method and system for selecting and arranging images with a montage template

Description:
FIELD 
     Embodiments described herein relate to systems and methods for performing image analytics to automatically select, arrange, and process key images as part of a medical image study. 
     SUMMARY 
     When physicians, such as radiologists and cardiologists, review medical images captured as part of a clinical imaging procedure for the purpose of creating a clinical report, they commonly select key images. “Key images,” as this term is used in the medical industry, identify “important” images in a study. Key images may be displayed in a montage, such as a single composite image or as individual images separately displayed, such as in a virtual stack of images. The key images may include images supporting a normal finding, an abnormality, a change from previous image studies, or the like. In some embodiments, to provide a proper diagnosis, a reviewing physician compares one or more of these key images to one or more images included in another image study, sometimes referred to as a “comparison image study.” Accordingly, the reviewing physician must be able to located relevant comparison image studies and properly compare images between multiple studies or risk providing a misdiagnosis. 
     Thus, embodiments described herein improve clinical efficiency and accuracy related to reading and reporting medical images using rules and, in some embodiments, artificial intelligence. In particular, embodiments described herein assist reading physicians in selecting, arranging, processing, and reporting key images from a current image study and comparison image studies using automated, rules-based actions to expedite the reading and reporting of medical images. 
     For example, in one embodiment, the invention provides a system for automatically processing an image included in an image study generated as part of a medical imaging procedure, the system includes at least one display device; at least one memory for storing images from one or more image studies; and an electronic processor configured to: display a set of medical images corresponding to an image study on the at least one display device; determine a key image included in the set of medical images; display the key image within a montage template; automatically, based on the position of the key image within the montage template, annotate the key image; and display the key image, as annotated, within the montage template. 
     Another embodiment provides a method for automatically processing an image included in an image study generated as part of a medical imaging procedure. The method includes determining a key image for an image study; displaying the key image within one of a plurality of sub-containers of a montage template; automatically, based on the one of the plurality of sub-containers of the montage template, processing, with an electronic processor, the key image. Automatically processing the key image includes at least one selected from a group consisting of: selecting another key image for the image study, labeling the key image, marking an anomaly within an image, comparing the key image with another image, generating text for a structured report for the image study, and measuring a structure within an image. Further, the method includes displaying, with the electronic processor via a display device, the montage template and results of processing the key image. 
     Another embodiment is directed to a non-transitory computer medium including instructions that, when executed as a set of instructions by an electronic processor perform a set of operations. The set of operations include displaying a montage template including a plurality of sub-containers, wherein a first one of the plurality of sub-containers is designated as a required sub-container; displaying at least one key image associated with an image study within a second one of the plurality of sub-containers; and preventing a user from submitting a finding for the image study in response to the first one of the plurality of sub-containers not including a key image. 
     Other aspects of the invention will become apparent by consideration of the detailed description and accompanying drawings. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         FIG. 1  illustrates a system for performing image analytics according to one embodiment. 
         FIG. 2  is flowchart of a method performed by the system of  FIG. 1  for automatically selecting a key image for an image study according to one embodiment. 
         FIGS. 3-4 and 6  illustrate graphical user interfaces for selecting and displaying key images for an image study according to various embodiments. 
         FIG. 5  is a flowchart of a method performed by the system of  FIG. 1  for automatically annotating key images for an image study according to one embodiment. 
         FIG. 7  is a block diagram illustrating a montage template including a plurality of sub-containers. 
     
    
    
     DETAILED DESCRIPTION 
     Before any embodiments of the invention are explained in detail, it is to be understood that the invention is not limited in its application to the details of construction and the arrangement of components set forth in the following description or illustrated in the following drawings. The invention is capable of other embodiments and of being practiced or of being carried out in various ways. 
     Also, it is to be understood that the phraseology and terminology used herein is for the purpose of description and should not be regarded as limiting. The use of “including,” “comprising” or “having” and variations thereof herein is meant to encompass the items listed thereafter and equivalents thereof as well as additional items. The terms “mounted,” “connected” and “coupled” are used broadly and encompass both direct and indirect mounting, connecting and coupling. Further, “connected” and “coupled” are not restricted to physical or mechanical connections or couplings, and may include electrical connections or couplings, whether direct or indirect. Also, electronic communications and notifications may be performed using any known means including direct connections, wireless connections, etc. 
     A plurality of hardware and software based devices, as well as a plurality of different structural components may be utilized to implement the invention. In addition, embodiments of the invention may include hardware, software, and electronic components or modules that, for purposes of discussion, may be illustrated and described as if the majority of the components were implemented solely in hardware. However, one of ordinary skill in the art, and based on a reading of this detailed description, would recognize that, in at least one embodiment, the electronic-based aspects of the invention may be implemented in software (e.g., stored on non-transitory computer-readable medium) executable by one or more processors. As such, it should be noted that a plurality of hardware and software based devices, as well as a plurality of different structural components, may be utilized to implement the invention. For example, “mobile device,” “computing device,” and “server” as described in the specification may include one or more electronic processors, one or more memory modules including non-transitory computer-readable medium, one or more input/output interfaces, and various connections (e.g., a system bus) connecting the components. 
       FIG. 1  illustrates a system  100  for automatically selecting, arranging, and processing images. The system  100  includes a server  102  that includes a plurality of electrical and electronic components that provide power, operational control, and protection of the components within the server  102 . For example, as illustrated in  FIG. 1 , the server  102  may include an electronic processor  104  (e.g., a microprocessor, application-specific integrated circuit (ASIC), or another suitable electronic device), a memory  106  (e.g., a non-transitory, computer-readable storage medium), and a communication interface  108 . The electronic processor  104 , the memory  106 , and the communication interface  108  communicate over one or more connections or buses. The server  102  illustrated in  FIG. 1  represents one example of a server and embodiments described herein may include a server with additional, fewer, or different components than the server  102  illustrated in  FIG. 1 . Also, in some embodiments, the server  102  performs functionality in addition to the functionality described herein. Similarly, the functionality performed by the server  102  (i.e., through execution of instructions by the electronic processor  104 ) may be distributed among multiple servers. Accordingly, functionality described herein as being performed by the electronic processor  104  may be performed by one or more electronic processors included in the server  102 , external to the server  102 , or a combination thereof. 
     The memory  106  may include read-only memory (“ROM”), random access memory (“RAM”) (e.g., dynamic RAM (“DRAM”), synchronous DRAM (“SDRAM”), and the like), electrically erasable programmable read-only memory (“EEPROM”), flash memory, a hard disk, a secure digital (“SD”) card, other suitable memory devices, or a combination thereof. The electronic processor  104  executes computer-readable instructions (“software”) stored in the memory  106 . The software may include firmware, one or more applications, program data, filters, rules, one or more program modules, and other executable instructions. For example, as illustrated in  FIG. 1 , in some embodiments, the memory  106  stores an image selection application  110 . As described in more detail below, the image selection application  110  is configured to apply rules to automatically select, arrange, and process key images for an image study. It should be understood that the functionality described herein as being performed by the image selection application  110  may be distributed among multiple modules or applications (executed by the server  102  or multiple servers or devices). Also, in some embodiments, the functionality described herein as being performed by the image selection application  110  (or portions there) are performed by one or more software applications executed by other computing devices, such as the user device  120  described below. The memory  106  may also store rules applied by the image selection application  110  as described herein. However, in other embodiments, the rules may be stored separate from the application  110 . 
     The communication interface  108  allows the server  102  to communicate with devices external to the server  102 . For example, as illustrated in  FIG. 1 , the server  102  may interact or communicate with one or more image repositories  112  through the communication interface  108 . In particular, the communication interface  108  may include a port for receiving a wired connection to an external device (e.g., a universal serial bus (“USB”) cable and the like), a transceiver for establishing a wireless connection to an external device over one or more communication networks  111  (e.g., the Internet, a local area network (“LAN”), a wide area network (“WAN”), and the like), or a combination thereof. 
     In some embodiments, the server  102  acts as a gateway to the one or more image repositories  112 . For example, in some embodiments, the server  102  may be picture archiving and communication system (“PACS”) server that communicates with one or more image repositories  112 . However, in other embodiments, the server  102  may be separate from a PACS server and may communicate with a PACS server to access images stored in one or more image repositories. 
     As illustrated in  FIG. 1 , the server  102  also communicates with a user device  120  (e.g., a personal computing device, such as but not limited to a laptop computer, a desktop computer, a terminal, a tablet computer, smart phone, a smart watch or other wearable, a smart television, and the like). The user device  120  may communicate with the server  102  via the communication network  111 . The user device  120  may communicate with the server  102  to access one or more images stored in the one or more image repositories  112 . For example, a user may use a browser application executed by the user device  120  to access a web page provided by the server  102  for accessing (viewing) one or more images. In other embodiments, the user may use a dedicated application executed by the user device  120  (a viewer application) to retrieve images from the image repositories  112  via the server  102 . 
     As illustrated in  FIG. 1 , the user device  120  includes similar components as the server  102 , such as an electronic processor  124 , a memory  126 , and a communication interface  128  for communicating with external devices, such as via the communication network  111 . The user device  120  also includes at least one output device  132 , such as one more display devices, one or more speakers, and the like configured to provide output to a user, and at least one input device  134 , such as a microphone, a keyboard, a cursor-control, device, a touchscreen, or the like configured to receive input from a user. 
       FIG. 2  is a flowchart illustrating a method  300  performed by the server  102  (i.e., the electronic processor  104  executing instructions, such as the image selection application  110 ) for automatically selecting, arranging, and processing medical images according to some embodiments. As noted above, in some embodiments, the user device  120  may be configured to execute one or more software applications to perform all or a portion of the functionality described herein as being performed via execution of the image selection application  110 . 
     In some embodiments, the image selection application  110  performs the functionality described herein in response to various triggering events. For example, in some embodiments, the image selection application  110  perform the functionality described herein in response to a reviewing or reading physician accessing or viewing a particular image study. For example,  FIG. 3  shows a graphical user interface (“GUI”)  200  provided on a display device of the user device  120 . In  FIG. 3 , the right tab  210  or right panel shows various images  212 ,  214 ,  216 ,  218 ,  220 ,  222 ,  224 ,  226  from an image study available for manual selection by the user. The left tab  230  or left panel provided on the graphical user interface  200  includes a column or vertically oriented row of medical images  232 ,  234 ,  236  from a primary or current image study, along with a column or vertically oriented row of images  242 ,  244 ,  246  from a previous or prior image study that form a collection of images provided in a montage. In some embodiments, the primary or current image study includes the most recent medical imaging procedure conducted on a particular patient or an image study needing a diagnosis. 
     Returning to  FIG. 2 , the electronic processor  104  is configured to determine a first key image (at block  304 ). In one embodiment, the electronic processor  104  is configured to determine the first key image based on input received from a user selecting a particular image as a key image. For example, using the example GUI  200  illustrated in  FIG. 3 , a user may manually select a key image by selecting one of the images  212 ,  214 ,  216 ,  218 ,  220 ,  222 ,  224  and moving the image, or an enlarged portion of the image, to the location of the image  232  in the left tab  230 . Thus, a user manually selects the first key image and positions the first key image within the montage on the left tab  230 . The user may manually select the first key image via a mouse click, an audio command via a microphone, a keyboard shortcut, a touchscreen action, or dragging or swiping an image. In other embodiments, the electronic processor  104  is configured to automatically determine the first key image. For example, the electronic processor  104  may be configured to automatically identify particular anatomy in an image, abnormalities in an image, normal findings in an image, or the like and, thus, may be configured to automatically select an image as a key image. In some embodiments, the electronic processor  104  may be configured to automatically select key images using the image analytics as described in U.S. patent application Ser. Nos. 15/179,506 and 15/179,465, both filed Jun. 10, 2016. The entire content of each of these applications is incorporated by reference herein. Accordingly, it should be understood that, as used in the present application, a “key image” includes an image (or a portion thereof) (i) manually identified as a key image or (ii) automatically determined as a key image using various image analytics techniques and methodologies. 
     As one example, an image included in a current image study may include an index lesion, defined as a key finding that is representative of the patient&#39;s problem or shows a pertinent negative finding. Such an index lesion could be identified because of an action of the reading physician or automatically because the anatomical position matches the location of a previously marked index lesion in the same patient. Under any one of these circumstances, when the image is added to the montage (meaning marked as a key image and/or added to a specific montage of images), the electronic processor  104  is configured to automatically select another key image (e.g., the best matching comparison image that also contains the same index lesion) as described below. 
     In particular, regardless of whether the first key image was determined from input from a user or automatically, the electronic processor  104  is configured to automatically determine a second image based on one or more rules (at block  308 ). The rules may consider characteristics of the first key image, the exam type, the modality type, patient demographics, user findings, or the like. For example, the rules may specify that when the first key image is selected from a magnetic resonance (“MR”) image (“MRI”) study and the initial diagnosis (provided by the user or automatically using image analytics) is “normal,” a predetermined set of images (of particular anatomy, with particular image characteristics or positions, or the like) should be automatically included in the set of key images. The rules may use metadata for an image or image study (e.g., DICOM header data), patient data, clinical data, and the like to automatically select the second key image. 
     It should be understood that the second key image may be included in the same image study as the first key image or a different image study. In particular, in some embodiments, the second key image is included in a prior comparison image study. In this situation, the second key image may include a key image or nonkey image from a comparison image study. However, in other embodiments, the second key image may be an image within the comparison study identified by the electronic processor  104  (regardless of whether the image was identified as a key image in the comparison image study) as being relevant, such as by analyzing and interpreting a diagnosis or finding (as recorded in a structured report for the comparison image study) for the comparison image study or by anatomically matching to a location of a key image in the current study. It should be understood that, in some embodiments, the first key image may be included in the comparison image study and the second key image may also be included in the comparison image study, another comparison image study, or a current image study being reviewed by a user. 
     The rules may be customized for individual users or groups of users, such as by user, user role, a location of the modality generating the image study, the location of the user, a modality, an exam type, a body part associated with the image study or a particular image, patient demographics, a network of the user, a clinic the user is associated with, a referring physician, and the like. Thus, for example, if a particular physician selects a key image, the electronic processor  104  may be configured to automatically select and apply a rule for the modality and finding that is specific to the user as compared to other rules for the same modality and finding. 
     As illustrated in  FIG. 2 , the electronic processor  104  displays the first key image and the second key image to aid a user in studying and reading the first image study (at block  310 ). In some embodiments, the second key image and the first key image are displayed in a montage template, such as a montage displayed on the left tab  230  in  FIG. 3 . For example, as illustrated in  FIG. 3 , the image  232  is a first key image selected by a user, and the image  242  is a previous image determined by the electronic processor  104  to be the second key image. As also illustrated in  FIG. 3 , the image  232  may be displayed adjacent the first key image  232  for comparison purposes. In some embodiments, the rules used to automatically select the second key image may also specify (based on a template provided for the montage, a position of the first key image, or a combination thereof) where to position the second key image within the montage. As noted above, these portions of the rules may be customized based on preferences of a user, a group of users, or the like. 
     In some embodiments, the electronic processor  104  is also configured to automatically generate text or labels for the key images. For example,  FIG. 3  illustrates descriptive text for an image, such as the date of the image study including the key image (e.g., “Jun. 30, 2017”). 
     In some embodiments, the electronic processor  104  is also configured to automatically generate text for a report (a structured report) associated with an image study based on the selection of key images. For example, the electronic processor  104  may be configured to automatically generate text based on what images were compared, what anatomy was reviewed, measurements in images, or the like. This text can be displayed to a user for review, editing (as needed), and approval. In some embodiments, the user may indicate (by selecting a button or other selection mechanism or issuing an audio or verbal command) when all of the key images have been selected (and annotated as needed), which may trigger the electronic processor  104  to generate text for the report. 
     It should be understood that, in some embodiments, the electronic processor  104  is configured to automatically select multiple key images for an image study (e.g., a third key image, fourth key image, and the like). Each automatically-determined key image may be selected from the same image study, different image studies, or a combination thereof. For example, in some situations, the selected key images may be from different types of image studies or different image studies generated at different times (e.g., to show a treatment progression or change). Further, additional key images, such as images  234 ,  236  are selectable by a user in a similar manner as discussed above to select additional key images. All of the key images selected for a particular image study are provided as an initial montage, which a user can review, edit, and approve. In particular, the user may have the option to remove or replace key images by selecting and deleting the images. 
     In some embodiments, the rules described above, are predefined for one or multiple users. The rules may also be manually configurable or changeable by particular users. Alternatively or in addition, the rules may be initially created or modified using machine learning. Machine learning generally refers to the ability of a computer program to learn without being explicitly programmed. In some embodiments, a computer program (e.g., a learning engine) is configured to construct a model (e.g., one or more algorithms) based on example inputs. Supervised learning involves presenting a computer program with example inputs and their desired (e.g., actual) outputs. The computer program is configured to learn a general rule (e.g., a model) that maps the inputs to the outputs. The computer program may be configured to perform deep machine learning using various types of methods and mechanisms. For example, the computer program may perform deep machine learning using decision tree learning, association rule learning, artificial neural networks, inductive logic programming, support vector machines, clustering, Bayesian networks, reinforcement learning, representation learning, similarity and metric learning, sparse dictionary learning, and genetic algorithms. Using all of these approaches, a computer program may ingest, parse, and understand data and progressively refine models for data analytics. 
     Accordingly, a learning engine (executed by the server  102  or a separate computing device) may be configured to receive example inputs and outputs (“training information”) that allows the learning engine to automatically determine the rules described above. In some embodiments, the training information includes information regarding what images were selected as key images for previously-reviewed image study, what images were annotated, a diagnosis for the image study or individual images, or the like. Again, machine learning techniques as described in U.S. patent application Ser. Nos. 15/179,506 and 15/179,465 (incorporated by reference herein) may be used to automatically create or modify the rules described herein for automatically selecting key images. User interaction with selected key images may also be used as feedback to such a learning engine to further refine the rules. For example, when a particular user repeatedly adds a particular image to a montage, deletes an automatically-selected image from a montage, changes the position of an image in the montage, or a combination thereof, the learning engine may be configured to detect a pattern in such manual behavior and modify the rules (such as user-specific rules) accordingly. 
     As noted above, in addition to selecting key images, a user may also position key images within a montage (e.g., at particular positions). For example,  FIG. 4  shows a graphical user interface (“GUI”)  400  provided on a display device. The right tab  410  or right panel shows various  412 ,  414 ,  416 ,  418 ,  420 ,  422 ,  424 ,  426  from an image study, and the left tab or left panel is a montage template  430  includes three rows and three columns of partially filled spaces for medical images, some of which include medical images  432 ,  434 ,  440 ,  442  for a back and lumbar regions of a patient. The images  432 ,  434 ,  440 ,  442  have been selected as key images in the example illustrated in  FIG. 4 . As discussed above, in some embodiments, one or more of the images  432 ,  434 ,  440 ,  442  are manually dragged into the montage template  430 . Alternatively or in addition, one or more of the images  432 ,  434 ,  440 ,  442  are automatically selected and positioned within the montage template  430 . Based on an images position within the montage template, the electronic processor  104  may be configured to automatically generate a label for an image within the template  430 . 
     For example,  FIG. 5  is a flow chart illustrating a method  500  for automatically labeling an image included in a montage. The method  500  is described as being performed by the server  102  (e.g., through execution of instructions, such as the image selection application  110 , by the electronic processor  104 ). However, as noted above, in some embodiments, the user device  120  may be configured to perform all or a subset of the functionality illustrated in  FIG. 5 . 
     The functionality of  FIG. 5  is described, as one example, with respect to  FIGS. 6 and 7 .  FIG. 6  shows the montage template  430  completed with medical images  432 ,  434 ,  436 ,  438 ,  440 ,  442 ,  444 ,  446 ,  448  provided in display sub-containers on a display device for multiple components of the back of the patient. In one embodiment, the right tab  410  is a first tab, and the left tab defining the montage template  430  is a second tab.  FIG. 7  schematically illustrates the configuration of a montage template  470  for a MRI of a knee of a patient. The montage template  470  may be disposed in, for instance, the left tab shown in  FIG. 6  in one embodiment. 
     As illustrated in  FIG. 5 , the electronic processor  104  is configured to display a set of medical images corresponding to an image study on the at least one display device (at block  504  in  FIG. 5 ) as shown by the images in the right tab  410  in  FIG. 6 . The electronic processor  104  is also configured to display a montage template (at block  506  in  FIG. 5 ) as shown by the montage templates  430  and  470  as illustrated in  FIGS. 6 and 7 . In some embodiments, the electronic processor  104  is configured to automatically select the montage template, such as based on a type of the image study (a modality type, procedure type, or the like), patient demographics, an anatomy, key images selected for the image study, user preferences, and the like. 
     The electronic processor  104  is also configured to determine a key image included in the image study (at block  508 ). As described above, key images may be determined manually, automatically, or a combination thereof. As also described above, each key image may be positioned within the montage template and, again, this positioning may be performed manually or automatically by the electronic processor  104 . Based on the position of the key image within the montage template, the electronic processor  104  is configured to automatically annotate the key image (at block  510 ) and display the key image with the annotation within the montage template (at block  512 ). For example, each montage template may include one or more pre-labeled sub-containers that specify required or recommended images. For example, as illustrated in  FIG. 7 , a montage template for a lumbar spine MRI may include a sagittal ACL sub-container  474 , a sagittal PCL sub-container  476 , a sagittal medial meniscus sub-container  478 , a sagittal lateral meniscus sub-container  482 , a coronal sub-container  484 , an axial patella sub-container  486 , a sagittal lateral meniscus sub-container  488 , and a sagittal medial meniscus  492  sub-container. Thus, by positioning the appropriate images from an image study into the appropriate montage position, the electronic processor  104  is configured to automatically label each image (anatomy, positions), which eliminates the need for manual labeling, which can create delay and can introduce human errors. 
     In addition to labeling key images, one or more sub-containers within a montage template may be associated with particular automated functionality. For example, in some embodiments, the electronic processor  104  is also configured to automatically label other images in an image study based on the labels automatically added to key images positioned within a montage template (e.g., based on an image&#39;s position in a series of images with respect to a key image). Similarly, in some embodiments, when a key image is added to a particular sub-container of a montage template, the electronic processor  104  may be configured to automatically select another key image that includes a corresponding image from a comparison image study. The electronic processor  104  may also be configured automatically analyze an image or multiple images to perform various types of analyses. For example, the electronic processor  104  may be configured to compare and describe index lesions, identify anomalies, compare findings or anatomical locations, determine progressions, take measurements, add one or more graphical annotations (“marktations”) to an image, or the like. For example, an image from a brain MM showing an index nodular metastasis in the left occipital lobe may be added to a montage and the electronic processor  104  may be configured to automatically compare and describe index lesions, automatically add a brain MM image from the most recent comparison image study, and analyze and reports the progression or regression of the lesion. 
     The results of such analysis may be provided as text (e.g., for inclusion in a structured report), a table, or the like. For example, the electronic processor  104  may be configured to generate text based on the analysis and display the text to a user for review, editing, and approval. Similarly, the electronic processor  104  may be configured to create a table of findings and analyze the table to determine disease changes, such as by comparing images using one or standard methodologies, such as RECIST 1.1 rules. Such analysis may be reported to the user and, optionally, added to a structured report. 
     Particular sub-containers may also be designated as required or optional, and the electronic processor  104  may be configured to automatically prompt a user for a key image for such sub-containers and may be configured to prevent the user from submitting or saving a report or finding for an image study until all required key images have been added to the montage. 
     Different processing may be associated with different sub-containers of a montage template and may also differ depending on the key image positioned within a particular sub-container (or key images positioned in other sub-containers of the montage template). Also, in some embodiments, a user (via the GUI) may be configured to provide a tool that allows the user to associate particular sub-containers with particular functionality. Also, the processing functionalities may be configured to be customized for particular users or groups of users. Furthermore, in some embodiments, the processing for one or more sub-containers may be based on findings or other input from a user and, thus, may be dynamically updated based on user interaction. 
     Alternatively or in addition, the processing functionality associated with particular montage template may be automatically generated or modified using artificial intelligence as described above for the rules for selecting key images. For example, a learning engine may be configured to automatically learn data patterns associated with labels or actions taken by a user to define processing for a particular sub-container. In some embodiments, a learning engine may also be configured to consider processing performed when a previous exam was read, such as a comparison image study. For example, under the appropriate circumstances, when an image is added to a montage, the electronic processor  104  may attempt to segment and measure the volume of anomalies if this was the processing performed when the comparison exam was read and reported. As an example, when a chest computed tomography (“CT”) slice is moved to the montage template, the electronic processor  104  may be configured to detect aortic abnormalities or other specific abnormalities that were assessed on the prior image study or clinical report. Also, feedback from a user regarding automatically-generated text could be provided as part of a closed feedback loop to help the system  100  learn the proper behaviors for processing key images. The labels associated a montage template may also be used automatically learn anatomy based on user actions. For example, labeled images may be used as training data for a learning engine. 
     In one embodiment, the system analyzes the exam images to understand the anatomical location, such that when a user selects an exam image as a key image, the image is automatically positioned in the proper location in the montage template. Thus, the montage template or key image template can work in two ways in increase efficiency as the template can provide 1) a means for labeling images as to anatomy or other characteristic(s), or 2) a standardized format for key images that specifies an order or location that is automatically filled as key images are selected (as the system can automatically derive these characteristics), or both. The montage template therefore can enhance user consistency and efficiency in multiple ways. In other embodiments, the selection of key images by the user is provided by various automated and semi-automated arrangements. In one embodiment a user clicks on an image. In another embodiment, a user provides an audio command to a conversational audio interface. The system may infer a selection, so that if a user says, “Normal brain”, the system might use configured or machine-learned rules to select one or more key images based on inferred actions. 
     Thus, embodiments described herein provide, among other things, methods and systems for automatically selecting, arranging, and processing key images for a medical image study. As described above, various rules may be applied by the systems and methods to quickly and effectively process image studies that may include hundreds or thousands of images without requiring or minimizing user input or interaction. Machine learning techniques may be used to establish or modify such rules, which further improve the efficiency and effectiveness of the systems and methods. Various features and advantages of the invention are set forth in the following claims.