Developing an imaging strategy for your radiology department is more important than ever.
new expectations for ubiquitous access to imaging reports and tools, a
key part of the imaging strategy of the future includes enterprise-wide
deployment of advanced visualization. Yet, it is critical that access to
advanced visualization technology enhance — not hinder— overall
productivity. To this end, the latest iterations in advanced
visualization tools are designed to boost performance, quality,
scalability, access, cost-effectiveness, and flexibility.
Integration into PACS
users have come to expect picture archive and communication systems
(PACS) with advanced visualization (AV) already integrated— but to what
Access to AV tools deployed through client-side image
rendering on stand-alone workstations was expensive and limited to a
single user in a single department. Once the technology evolved into
server-side or thin-client rendering, AV tools were streamlined into
PACS. This allowed radiologists to launch 3-dimensional viewing
solutions right from the PACS, resulting in significant time savings.
This model, however, still required a client installation or plug-in; it
also placed a heavy burden on the workstations’ processing power.
downside of Web-based PACS is that images can’t present in 3-dimensions
because you need all of the processing power at the desktop,” said Brad
Levin, General Manager, North America, Visage Imaging.
we got to the current technologies — server-side rendering and “zero
footprint” models — which may be today’s most efficient methods for
viewing 3-dimensional images across the healthcare enterprise.
key advantage to server-side rendering solutions is that advanced image
processing applications are available to the entire healthcare
enterprise. As a result, they can significantly enhance patient care by
making advanced image data available to every physician.1
a server-side scenario, the images are processed on the servers;
therefore, a case pulled up by a radiologist automatically presents
a3-dimensional view ready for evaluation.
processing approach optimizes the current IT consolidation trend taking
place in the hospital market, where IT management is being centralized
to generate workflow productivity efficiencies and reduce total cost of
ownership,” said Frost & Sullivan Principal Analyst Nadim Daher.
architecture enables access to AV tools through a cloud platform.
Claudio Gatti and Doron Dekel, co-founders and co-CEOs of Claron
Technology Inc., say zero-footprint architecture is an efficient model
for enterprise-wide deployment of AV.
“With zero-footprint thin
clients, there is no need for any installation on the client side, the
browsers deliver data, and the client then runson any browser-capable
device, including tablets and smart phones. This also lowers the
dependence on IT support,” said Gatti.
With the Vue Cloud,
Carestream offers a software-as-a-service (SaaS) approach to imaging
information on a predictable, pay-as-you-go basis. This provides
radiologists with access to clinical data and advanced tools as needed
to aid in diagnosis (Figure 1).
One reason for replacing a legacy
PACS is scalability. If the legacy viewer doesn’t deliver the diagnostic
breadth, scale or performance required, it may be time for a change in
imaging strategy. This is what prompted Rays, a teleradiology group
based in Littleton, CO, to migrate to the Visage 7 solution. “Seeking to
increase efficiency by removing the need to push DICOM files to our
radiologist workstations,Visage was able to meet this requirement with
their streaming technology, while also augmenting the feature set of our
diagnostic viewer,”said Ted Tzeng, vice president of technology at
While zero-footprint models may provide scalability, there
are still some obstacles with zero-footprint technology when supporting
mobile applications, Gatti pointed out. These primarily involve latency
between the client and server, support for both touch and mouse user
interfaces,and the challenge of meeting the requirements for the wide
range of screen resolutions and sizes. To overcome these challenges,
Claron Technology has developed the Nil viewer, a zero-footprint AV
viewer that has largely the same visualization power of earlier
workstations and is accessible from any desktop, tablet, or smartphone.
The company recently debuted both NilRead for diagnostic applications
and NilShare for referring physician and other nondiagnostic users. The
Nil app for the BlackBerry PlayBook provides one-click fast access to
the image viewer running either on Claron’s NilCloud or a medical
facility’s dedicated Nil server.
TeraRecon also provides access to
its AV tools for computed tomography (CT), magnetic resonance imaging
(MRI), and positron emission tomography (PET) through its cloud-based
solution Intuition Cloud. Last year, Kjaya Medical rolled out
iShareScan.com, a cloud-based image sharing solution that supports
on-demand 3-dimensional processing, viewing, and manipulation. The
server leverages Kjaya’s gaming technology-based cloud to manage large
volumes of medical data and stream Web-based advanced visualization
instantaneously without transmitting the raw scan.
images available throughout the healthcare enterprise increases demand
for integration and interoperation between multiple departments inside
and outside of the hospital.
The goal of enterprise imaging is to
“allow clinicians in their clinical workspace to harness the power to
transform care with enterprise imaging and data interoperability; enable
collaborative opportunities in the clinical care continuum across
disciplines; and allow for an extended clinical workflow well beyond
radiology,” explained Rasu Shrestha, MD, MBA, vice president, Medical
Information Technology,medical director, Interoperability & Imaging
Informatics, University of Pittsburgh Medical Center, Pittsburgh, PA, in
a recent Applied Radiology webinar, The Essential Guide to PACS Replacement. (appliedradiology.com/webinars.aspx)
integration of imaging infrastructures across distributed and
heterogeneous healthcare facilities is increasing as a result of
nationwide initiatives, such as the Meaningful Use (MU) program. In
April, the Center for Medicare and Medicaid Services (CMS) and the
Office of theNational Coordinator (ONC) for HIT added medical imaging to
Stage 2 criteria for MU. Imaging is now one of 10 possible objectives
doctors can put on their list of 5 objectives aimed at demonstrating MU.
hospitals integrate PACS with EHR, advanced visualization will become
an enterprise-wide application using server-based processing. Visage
Imaging offers an agnostic viewer that sits on top of PACS, which
supports a best-of-breed model for advanced visualization,voice
recognition, and electronic health records (EHR).
the integration of AV and image management systems, image
postprocessing has become automated to the point that physicians can
immediately interact with 3-dimensional images. This is changing the way
radiologists handle data and view images. While radiologists still rely
on 2-dimensional datasets, they are increasingly viewing studies in
multiplanar and maximum intensity projection (MIP), and using
“We are not just looking at
2-dimensional images anymore. We are using multiplanar imaging on all CT
body work,” said Chris DeAngelo, RT,(R),(CT), director of imaging
technology at Alamance Regional Medical Center, Burlington, NC, which
employs Siemens Healthcare’s syngo.via. “That was a big paradigm
shift for us, as we previously only used the 3-dimensional applications
for studies such as CTangiography. Now the radiologists want to look at
multiplanar imaging on all body CT and neck CT, and the syngo.via made
that simple to integrate and display. The radiologists are interacting
with the fused images, comparing a current to a prior PET/CT.”
Alamance Regional Medical Center relies on syngo.via
as an enterprise-wide solution that integrates imaging modalities and
IT, making it possible to access and share information with clinical
partners. The client-server technology can be accessed directly from a
RIS/PACS,simultaneously launching the patient record in PACS and RIS
with minimal loading time. At Alamance, radiologists commonly read CT
angiography using the vascular package available on syngo.via,
which automatically segments the major blood vessels. Alamance
radiologists also use AV applications for magnetic resonance angiography
where they are reading most studies using MIP and for PET/CT and
SPECT/CT fusion imaging to compare currents and priors.
powered by server-based rendering technology, Synapse 3D, by Fujifilm
Medical Systems, is integrated with Fujifilm’s Synapse
PACS to allow radiologists or technologists to perform renderings and to eliminate the need for third-party software.
Image’s Vitrea Enterprise Suite (VES), version 6.2, can be customized
for specific enterprise needs. The company’s viewer, VitreaView version
6.2, is a universal viewer that enables access to images from disparate
databases, providing one integrated, universal viewer.
Segmentation and analysis
growing trend involves the introduction of more powerful cardiovascular
imaging, virtual colonoscopy, and whole-organ AV applications. The
continued proliferation of imaging for diagnosis and treatments will
lead to more studies that involve dual-source scanners and multispectral
imaging. Consequently, there will be too much data for workflow to
focus on the examination of axial, coronal, and sagittal images.
Instead, workflow will need to become anatomy- and pathology-driven.
anticipate increased automation of segmentation and analysis tasks by
eliminating the need for users to select and trigger execution of
specific applications,” said Dekel. “Once the images are acquired and
sent to the visualization server, the software would open the new study
on its own, review its content, read the requisition and the patient
file, identify the main anatomical regions in the images, and activate
proper preprocessing functions to make it more efficient to review,
measure, and analyze. For example, it could run automated anomaly
detection algorithms and leave marks near locations it suggests the
radiologist look at, reducing the chance that findings will be missed.
Many technological challenges remain, so a long evolution path awaits
In fact, a number of segmentation features are already
automated. Claron Technology’s Within sight Framework (WIF) toolkit
provides technological support for developing applications for
segmentation, especially for CT (Figure 2).
TeraRecon, Inc. also
provides a suite of tools designed to allow physicians to approach
imaging on an organ- or disease-specific basis. The suite includes
lobular decomposition, an analysis and segmentation tool that allows
users to select the volume of interest, the trees related to it,and to
partition the volume into lobes or territories; volumetric histogram,
which supports analysis of a given volume of interest to research into
disease processes; motion analytics, providing a 2-dimensional
representation of a 4-dimensional process.
There is an inherent burden in processing large-volume datasets to
produce 3-dimensional and 4-dimensional images. Another effective
strategy for boosting performance and overcoming latency is using a
CPU-based client. CPU-based computing does the heavy lifting to manage
large data loads at fast speeds and support enterprise-wide and
web-based volumetric rendering with affordable, off-the-shelf computers.
Additionally, CPU-based engines are able to lower costs for end users
because they do not require expensive graphic cards.
AV software that is gaining notoriety is HDVR Connect, a
high-definition volume-rendering solution by Fovia. HDVRConnect is an
agnostic AV solution platform that runs both locally and remotely on
several client-server configurations, such as Windows servers with Mac
and Linux clients, Mac servers with Windows clients, and Linux servers
with iOS clients. It is designed to enable end users to visualize
extremely large datasets without down sampling or sampling a subvolume.
Connect takes full advantage of the trends in imaging and computing —
larger datasets, bigger projection displays, multi-core processors,
multi-threading, multi-CPU environments, and server-side rendering,
without compromising quality or performance,” said Daher.
and surgeons at Teikyo University School of Medicine in Tokyo, Japan,
are deploying Fovia’s HDVR Connect software to stream AV applications on
a mobile, multi-touch platform, allowing them to query and review data
during surgical procedures.
Fovia also offers HDVR Connect SDK,
under which OEM vendors can use their own proprietary user interfaces.
It also supports anOEM’s proprietary algorithms for specialized
BRIT Systems natively integrated
Fovia’s HDVR technology in all of its image viewers and PACS
workstations, including BRIT’s Vision Viewer, PACSView, BRIT Lite, and
WebWorks (a browser-based viewer). The integration provides physician
users with 24-hour remote access to interactive advanced visualization.
also integrated HDVR to boost 3-dimensional performance and speed for
its distributed radiology solutions. “With the increasing amount of data
acquired by modern modalities and the growth of teleradiology, embedded
high-performance volumetric rendering is a must have for all
radiologists reading cross-sectional data — whether from local or remote
workstations,” said Rick Rubin, Chief Engineering Officer at Intelerad.
the increased accessibility of AV for all physicians, 3-dimensional
imaging is becoming more interactive for treatment and analysis.
Imaging’s QI solution uses PhyZiodynamics inVivo supercomputing
technology to enable true fidelity 4-dimensional imaging —3-dimensional
imaging in motion — and serves as a gateway to 5-dimensional imaging,
also known as functional analytics of motion. The system allows users to
navigate interactively with a beating heart, contrast-perfused brain
tumor, and other anatomy.
AV across the enterprise not only lowers the overall cost to the
hospital network but also adds value to the radiology report.
while radiologists and other specialists stand to gain from ubiquitous
access to AV tools, the referring physicians will benefit equally, if
not more, from a robust clinical report.
Gatti said he believes
that, “with few exceptions, advanced visualization technology is as
useful, if not more useful, for the referring physicians than for
He noted, “With the increased accessibility of that
technology to all physicians on practically any computing device with a
decent screen anda network connection, we foresee a growing demand
amongst healthcare providers for radiology reports that can ‘come
alive,’ allowing the referring physicians and the patients to continue
to interact with the images in the familiar life-like 3-dimensional
format. This will give rise to the need for radiologists to remotely
help referring physicians make better sense of what they see through
real-time screen sharing and collaboration tools.”
referring physicians have a choice. They can review patients at
different hospitals on multiple viewers, which results in a disjointed
and inefficient experience. Or they can have one viewer simplify the
“If the referring physicians are confused, they will
take their business elsewhere,” said Levin. “The future is providing
images and tools all in one.”
Whether a system is server-based or
CPU-enhanced, it should be capable of providing images already
processed in 3 dimensions, presegmented, generated within the hanging
protocol, and delivered immediately to the doctor’s fingertips. This
represents a dramatic departure from the way radiology studies have been
managed and may present a vast improvement in the delivery of care,
positioning the patient as the principal beneficiary.
- Siddiqui KM. Advanced visualization: Making the right choice. Applied Radiology. 2008;37(suppl):15–18.
advanced visualization for all. http://www.expresshealth
care.in/inimaging2012apr/inimaging2012april07.html. Updated April 7,
2012. Accessed May 31, 2012.