| |||||||||||||||
|
Home
|
For other articles and previous issues click here. March 7, 2005 Expanding
Image Access — How Server-Based Computing Can Untether Digital
Imaging Growing demand for volumetric imaging capabilities is reshaping the traditional interactions between radiology and clinical physician referrers—putting reconstruction and volume navigation in the hands of ordering doctors. By now, virtually everyone acknowledges that the multiple-dimension, real-time image acquisition capabilities of multidetector CT (MDCT) and MR scanners make standard axial reads on every image impracticable, if not impossible. With thousands of slices generated in a single volumetric scan and scan times cut to minutes (sometimes seconds), radiology finds itself pushed to the wall in terms of staff, time, expense, equipment availability, and patient throughput. The impact on other departments is equally important, as medical and technology advances propel the need for a fresh approach to retrieving, displaying, sharing, storing, manipulating, reporting, and integrating 3-D and 4-D data sets. For many facilities, an answer to these issues increasingly lies in fully exploiting the new power of server-based networking. PACS’s Impact “Historically, in the film-based paradigm, the notion was that radiologists looked for the ‘single best’ image to depict the pathology, and when digital imaging came along, the paradigm didn’t change. Even when PACS emerged, radiologists still looked for the single best axial image—just on a computer monitor,” said Steve Sandy, vice president of marketing for TeraRecon, which makes the AquariusNET server. AquariusNET’s VolumePro engine enables multiple generic PCs to share the processing power needed for concurrent interactive 3-D and multiplanar image review. Now, though, growing demand for volumetric imaging capabilities is reshaping the traditional interactions between radiology and clinical physician referrers. What most experts are calling “a new paradigm” means automating and distributing many functions once performed in radiology by putting reconstruction and volume navigation into the hands of the ordering doctors. “Today’s systems effectively eliminate the need to route images from one postprocessing station to another or from postprocessing workstations to PACS and Web-distribution systems. In the past, the [radiology department completed] reconstructions and they were treated almost as if they were images from a separate diagnostic imaging modality,” said Eric Pearce, manager, Americas Marketing for GE Healthcare, which makes Centricity PACS SE, Centricity Enterprise Web, and Centricity AW Suite software, which builds the capabilities of GE’s Advantage Workstation in to Centricity PACS. While distributing image access and processing power lessens the need for some traditional types of radiology tasks, it increases the pressure to do more scans and deliver detailed results faster. Online Everywhere Todd Johnson, a senior product manager for enterprise applications with Vital Images, explained that because the server does all the heavy image processing, “a conventional Web browser interface enables a user to log in to the application from any PC connected to the hospital network. The client application is automatically downloaded and run from that computer.” Johnson’s company makes Vitrea advanced analysis workstations and VitalConnect integrated software package for Web-enabled image distribution and advanced processing. In addition to basic x-ray and digital radiography, the latest breed of multifunction workstations typically supports intensive processing applications such as simultaneous side-by-side views and powerful 3-D tools such as virtual colonoscopy/endoscopy, volume rendering, multiplanar reconstruction, and maximum intensity projection. End users can pull images from the PACS or other archives for integrating with digitized information from other sources, so one report might incorporate both 2-D and 3-D views from more than one modality. Many systems also handle 4-D visualization for multiphase studies, such as those done for cardiology, neurology, and oncology. And linked via the high-powered server, they enable real-time access to remote analysis tools and interactive conferencing. “These sophisticated types of [image] analysis are becoming more of a daily activity for many physicians rather than just a specialized task,” said Johnson. The PC workstations used in server-based systems mostly run a familiar Windows-based or Windows-like platform to provide both relative ease integration and user friendliness. The processing server streams the 3-D rendering results in real time to any networked PC based on incoming mouse commands. The server sends a real-time screen update to the PC as all the slices are rendered on the server. “Anyone on the network can access studies acquired from the latest MDCT and MRI scanners, even those that generate thousands of slices for multiphase review of CTA [computed tomography angiography] and MRA [magnetic resonance angiography],” Sandy said. Clinicians can manipulate the images on the screen in various ways, without altering or modifying the “burned” originals archived on the central PACS. For instance, a cardiologist or oncologist may want to enlarge or reduce the image, window, and level; highlight selected details in a specific region; adjust brilliance or contrast; include a particular view in a report; and then send that report on to a colleague in another location. The images or slices the cardiologist works with actually reside on the server and are refreshed on demand as the user clicks through a menu via the familiar on-screen cursor and mouse. The Power of 3-D “More and more radiologists on the forefront indicate that [volumetric imaging] is going to be the necessity as [healthcare] moves forward,” said GE Healthcare’s Pearce. “They already realize the need to eliminate the islands of information [that require] sliding a chair between seven different workstations.” Distribution and integration are key. “PACS was designed for radiology,” Pearce added, “but very quickly … you’re going to see better solutions for all the other ‘ologies’—cardiology, oncology, pathology, everything—as the centralized repository for all image data becomes available anywhere, every time, outside radiology.” But, Pearce noted, the real clinical value for many specialists will come only “if they invest the time to become properly trained and learn how to best use [3-D and 4-D technology]… There is a learning curve for clinicians on how to use this voluminous data that’s now available.” For the immediate future, Pearce sees server-based workstations being used to complement the more traditional dedicated workstations. As high-performance multifunction systems are brought online around the institution, expanding automation—and natural attrition—will slowly supplant dedicated radiology-only devices. Building on Success Primo sees the current state of the art being workstations working in conjunction with standard IT-based server platforms, creating “a hybrid bringing in the best of both worlds. Adding high-performance clinical applications on standard PC-based workstations allows not only radiologists but also cardiologists, orthopods, neurologists, and many others in the enterprise to make use of heavy processing power simultaneously. “The good news,” added Primo, “is that although the server needs to be monitored and scaled to make sure user demands don’t outperform its capabilities, this is great technology for providing full performance wherever and whenever required.” Using existing standard LAN bandwidths and a relatively modest-sized server, this architecture supports high-quality imaging for many simultaneous users in different departments. It also simplifies control over who gets full application access by giving the system administrator the power to monitor changing needs and install or upgrade software over the server—even remotely. “The system administrator knows that [most clinicians’ jobs are] very different from a radiologist, whose job is to look at images all day,” said Primo. “So maybe several times a day [a specialist] may want to access volumetric rendering or 3-D manipulation … but a 200-PC network may require only 50 concurrent licenses, [and users can] pay only for concurrent licenses and server expansion as needed.” Redistributing Workflow “Where a PACS is present, it’s much better to integrate clinical applications with the PACS,” he said. “And because the PACS already has a server, implementing server-based computing is hardly an extra investment.” Smedema noted that one major advantage of this architecture is that all workstations can execute multimodality applications with images originating from any vendor. With a single integrated user interface handling both “standard” PACS functions and high-end clinical applications, server-based processing liberates the workstation to behave, to the end user, more like a PC and less like a dedicated PACS-only device. Equally important, the relatively powerful server supports both excellent imaging quality and fast performance for conventional diagnostic imaging functions. That means radiologists can revamp workflow as needed without having to worry about the effects of simultaneous outside users logging on to do other kinds of tasks. So the clinicians, connected to the PACS through a LAN/WAN, are able to execute applications such as VE or 3-D/4-D rendering of MR and CT image stacks at their own locations whenever they need to, noted Smedema. Vital Images’ Johnson illustrated: “Say a surgeon calls the radiologist with some questions. They can review and interactively manipulate the image data sets together, with their PC workstations completely synchronized, and share any new manipulations [like] turning or scrolling in real time, simultaneously. Each one can respond, draw arrows, and take measurements.” Other examples include reducing a large study to a report with some key images to send to colleagues or for consultations, illustrating a diagnosis and treatment plan by showing the images to the patient in the office, or responding to an emergency case by viewing volumetric data from home. Reengineering Relationships Even as the technology modifies traditional relationships, Sandy said it’s providing the tools to solve more problems more efficiently—and more collaboratively. “If the cardiac community starts buying scanners, radiology will have to find new ways to partner with them,” he said. “The new model is already showing radiologists that they have to be about more than finding pathology and writing a report. Radiology’s customers are the physicians who are planning patient intervention and treatment strategies; radiologists need to be able to understand the best interventional approaches and help with the planning, or they [the radiologists] become less valuable.” Sandy sees the movement to put digital medical images, and the ability to manipulate those images as needed, into the hands of many clinical users outside the radiology department as “a fundamental, structural, systemic change” already affecting how everyone in the enterprise does their jobs. “This isn’t just a small trend,” he said, “and it isn’t happening just in research hospitals.” Still, no one interviewed for this article has seen any move to circumvent radiology. “Improved access to the new imaging tools actually creates more interaction between the radiologists and the clinicians,” said Vital Images’ Johnson. “Giving clinicians direct access to what radiologists are traditionally used to dealing with, [clinicians] are coming up with more questions. They want to know how what they can now see for themselves meshes with other parts of the report, or other images.” GE’s Pearce agrees: “Radiologists understand that giving their customers—the referring doctors—the tools they need now [for] accessing and distributing images and information is a critical step.” He believes the new technology allows extending productivity assessments beyond historical benchmarks such as reduced film use, faster patient throughput, and improved report times to also take into account “the less quantifiable measurements”—especially the ability to do more with fewer staff. For instance, “for some institutions, an IT solution is the only way to move forward. Because they can’t get enough technologists or radiologists, these workstations with specialty software have become the only way to continue to do business and grow. Or if you serve a geographically remote area and can’t [attract] a full-time radiologist, this may be the only way exams can get read.” And of course, even outside those immediate concerns, Pearce adds, “If you have a [network] integrated to the [referring] physician’s portal and can send images instantly, you’re going to drive more business.” “This paradigm change will completely change the infrastructure on how to deliver service and health functions to users,” Siemens’ Primo said. “For instance, the radiology system administrator will suddenly discover that instead of having, say, five imaging users—the radiologists—there are now 2,000 [customers] all over the enterprise.” IT and imaging will be forced to learn new ways to work together to serve all those various users, which Primo sees as healthy progress. “For example,” Primo said, “the radiology system administrator often used to be an RT with extensive understanding of anatomy. In most IT departments now, you don’t find many people who have the clinical knowledge to talk with the end users [about specific medical imaging needs]. But with clinician demand driving the adoption of the new technology, that need is emphasized.” Maybe soon, he added, “IT will start hiring and training RTs.” — J. K. Bucsko is a freelance healthcare and technology writer based in Westville, N.J. She is a frequent contributor to Radiology Today. |
 |
|
3801 Schuylkill Rd • Spring City, PA 19475 Publishers of Radiology Today All rights reserved. |