System Integration: DICOM-TLS Connectivity Guide

Butterfly Cloud can connect to your organization’s DICOM endpoints via secure DICOM-TLS connection or Butterfly Link, available with Butterfly Enterprise memberships. 

Ultrasound studies acquired on any Butterfly probe in your organization can be forwarded into one or more of your hospital’s DICOM storage systems, such as a Picture Archiving and Communication System (PACS) or Vendor Neutral Archive (VNA). Butterfly can also connect to a DICOM Modality Worklist (MWL) to minimize the need for manual entry of patient data. When configured, members of your organization will be able to use the Worklist to populate patient data fields prior to uploading studies from the Butterfly iQ App.

To read the Butterfly Cloud DICOM Connector Conformance Statement, click here.

Butterfly DICOM Connector over DICOM TLS

The Butterfly DICOM Connector creates a secure, encrypted connection between Butterfly Cloud and your facility’s DICOM endpoints. This enables secure transmission of ultrasound studies captured with Butterfly iQ. We utilize DICOM-TLS (Transport Layer Security, v 1.2) to facilitate point-to-point, encrypted communication without the drawbacks and setup challenges associated with a VPN tunnel.

Unlike a traditional, on-premise modality, which resides on your internal network, Butterfly Cloud establishes a secure connection over the Internet to your network perimeter. You will need the public IP address of your network and an available public facing port to receive the data. DICOM-TLS* requires that the DICOM traffic is decrypted on your network. Common approaches to "terminating" the TLS connection at your network are listed below with applicable setup guides.

• Load Balancer (like Citrix Netscaler or F5 Big-IP).
  • Citrix Netscaler DICOM-TLS Termination Guide
  • F5 Big IP DICOM-TLS termination Guide
• Software-based TLS termination (stunnel.org) running on a Virtual Machine server.
  • Stunnel DICOM-TLS Termination Guide
  • Osirix Connectivity using Stunnel on MacOS Big SurMacOS
• PACS or DICOM middleware that supports TLS natively.
  • Osirix TLS Termination

*DICOM-TLS is recommended but optional for veterinary practices.

For additional troubleshooting of your DICOM connections please see our guide here.

DICOM Connectivity Guide from Butterfly Cloud

How to Use These Instructions

These instructions will guide the user in the setup of a basic DICOM connection between Butterfly Cloud and the customer’s PACS.

Introduction

When a medical modality or a DICOM software client connects to a (PACS) server, communication begins between the systems. Unlike traditional on-premise imaging modalities, Butterfly Cloud (hosted in Amazon AWS) is the source of the DICOM communication with your facility’s PACS and all connectivity options are configured directly in your instance of Butterfly Cloud.

Figure 1. Butterfly Network Product Ecosystem

Prerequisites

1. Access to your PACS as well as its DICOM configuration information. The PACS IP address and port must be accessible from the Internet (not just your local office network).
   • If your PACS is hosted by a 3rd party, then you may need to contact their Technical support.
2. Ensure that you have access to Butterfly Cloud (cloud.butterflynetwork.com) as an Admin so that you can configure the PACS connection.

Set Up the DICOM Connection from Butterfly Cloud

1. Log in to Butterfly Cloud using your Browser - ensure that your user role in Butterfly Cloud is that of Administrator.
2. Navigate to the DICOM Configuration menu. Click on your username in the upper right of the window and select Organization Settings.
   

   

3. Select the Connectivity tab and click the ‘+ Add’ option next to Connections to create a new DICOM end-point that will be used with your DICOM integration.
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4. Proceed to enter all of the necessary connection parameters.
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   • Name = Friendly name for the Connection.

     In the Security section - ensure that TLS is set to ‘Inactive’ for Vet only, ‘Active’ for all other connections.

     Host = DNS name or IP of your DICOM end-point.

5. Please note that the IP address must be a public IP that can be accessible from Butterfly Cloud to your network. This will typically be the IP address of your network firewall or router. Non-routable/private IP addresses are not valid.
6. Click Save, then click on the Connectivity Tab to create the DICOM Integration.

Configure the DICOM Integration and Associate it to the DICOM Connection

1. After clicking on the Connectivity tab, click the ‘+ Add’ option next to Integrations and select PACS/VNA.
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2. Give your PACS a friendly Name, and select to associate it with the DICOM Connection created in Set Up the DICOM Connection from Butterfly Cloud.
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3. Proceed to enter all of the necessary DICOM integration parameters.
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   • SCU - Calling AET = The source AE Title of Butterfly Cloud (typically ‘BUTTERFLY’).
   • SCP - AET = the AE Title of your DICOM destination.
   • Enter the Port that your PACS is listening on. Please note that the port that is entered here is the public-facing port that is exposed by your network to the Internet.
   • Set the Compression level of the DICOM Images and Cine Loop as required or preferred. The settings above are typical. Select ‘Save’ to complete the setup.
4. NOTE
   • If your PACS/VNA is not operating in promiscuous mode, then you will need to add the Butterfly Cloud AE title as an approved DICOM source.
   • Please be aware that the PACS will likely see the IP address of Butterfly Cloud as the source of DICOM data.
   • If you want to firewall traffic from Butterfly via DICOM-TLS, please contact Butterfly Support for the current list of IP addresses for your region. Butterfly reserves to update the IP addresses which traffic comes from as necessary. 

Verify the Connection from Butterfly Cloud

1. Switch back to Butterfly Cloud in the Browser.
2. Navigate to the integrations menu. Click your username in the upper right of the window and select Organization Settings.
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3. Select the Connectivity tab and click the ‘...’ next to the newly created DICOM integration. Select the Echo option to perform a DICOM C-ECHO from Butterfly Cloud.
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4. Click Echo, then Click on ‘Echo’ again in the upper right of the pop-up menu. This triggers a new  DICOM C-ECHO; please verify the output is similar to below.
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5. You have set up a connection to your DICOM destination.

(Optional) - Automatic Forwarding to DICOM Storage

1. To automatically send any studies saved to a Butterfly Cloud folder to your DICOM end-point, you can associate it with an Archive.
2. Select the Archive folder that you would like to associate with the DICOM connection.  Select Archive Settings.
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3. Choose the DICOM Storage location to associate with the Archive folder.
   
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4. Now any study saved to this folder (using the Butterfly iQ App) will automatically forward to the chosen DICOM destination.

Not all presets and imaging modes are available everywhere. Check for the availability in your country.