June 16, 2008

Macs in Medicine
By Beth W. Orenstein
Radiology Today
Vol. 9 No. 12 P. 12

OsiriX started the Apple rolling in radiology, but the machines are starting to turn on across healthcare.

These days, approximately 25,000 physicians—about one third of them radiologists—are viewing medical images on Apple’s Macintosh computers. While that’s just a small fraction of the whole, it is significant because the physicians themselves are driving the movement toward Macs when only a few years ago they had no choice but to use expensive, dedicated PC workstations.

Those physicians are in turn being supported by several partner companies such as PACS makers Meta Fusion of Saratoga, Calif., and aycan Medical Systems of Rochester, N.Y., and providers of diagnostic imaging displays such as Quest International of Irvine, Calif.

The growing interest in Macs in radiology mirrors what’s happening with Macs in general. In May, Apple reported strong sales, shipping 2.29 million Macs during the second quarter, an increase of 51% over one year ago. International Data Corp., a global provider of market intelligence, also reported that Apple’s market share is growing at a rate 3.5 times the overall PC market growth.

Apple has never pursued the corporate market, let alone medical imaging. Its focus has been consumers and education. But observers believe that as more people (including physicians) use iPods, iPhones, and Macs at home, their enthusiasm for Apple products is spilling over to the workplace. It also has helped that since 2006, when Apple switched to Intel processors, users have been able to run Microsoft Windows on their Macs.

Tapping Graphic Potential
Macs’ growth in radiology departments has been fostered by the development of OsiriX, an open-source DICOM viewer comparable to the software on high-end imaging, proprietary vendor workstations. In late 2003, Osman Ratib, MD, PhD, then a professor and the vice chair of information systems for the department of radiological sciences at UCLA, and Antoine Rosset, MD, a radiologist from the University of Geneva and Ratib’s former student, sought to develop a sophisticated, easy-to-use computing platform for interactively viewing the large data sets that the latest generations of their MR, CT, and PET/CT scanners were producing.

Ratib had worked on OsiriX, which was also a DICOM-compliant, open-source, cross-platform viewer for images, but was limited to viewing single, simple images. They rewrote OsiriX from scratch, incorporating existing open-source imaging tool kits so it would be comparable to the software that previously had only been found on high-end imaging workstations costing $40,000 to $150,000.

Elizabeth Kerr, PhD, director of the science and medicine markets for Apple, says the movement toward Macs in medicine has been a growing trend for the past couple of years, but it has really taken off in the last six to 12 months, thanks to OsiriX. “OsiriX running on Mac Operating System X (OS X) in clinical settings is one of the solutions leading the charge,” she says.

Rosset believes one reason the OsiriX platform has gained so much interest among his radiology colleagues is that the price is right—it’s free. Also, Mac computers, while sometimes perceived as pricier than PCs, are nowhere near the cost of the proprietary PACS viewing workstations that imaging facilities must buy for their radiologists.

Kerr says some of the early adopters include major medical institutions such as the Hartford Hospital in Connecticut. The hospital found the Mac/OsiriX combination was the perfect solution, even in its stroke center, which generates huge files on each patient, she says.

Stroke Center
Hartford Hospital serves its radiology department with a multimillion-dollar Philips-Sectra PACS, Kerr says. However, the huge files generated at its stroke center overwhelmed the Sectra server. To solve the problem, the center’s consulting team, the Katen Consulting Group of San Francisco, created an Apple-based neuroarchiving solution that met all of its criteria, including superior 3D visualization. “By moving to Macs and OsiriX, the system not only delivered far superior performance, but it also cost less than half the price of one hospital’s PACS workstation,” she says.

Another emerging area where Macs are being used in medicine is for recording surgeries in high definition for treatment planning and training purposes, Kerr says.

That is what is happening at the Veterans Affairs (Palo Alto, Calif.) Health Care System, led by Roy M. Soetikno, MD, chief of the gastrointestinal section and endoscopy unit. Physicians in the endoscopy unit wanted a way to capture the real-time, standard definition images on their endoscope screens so they could be reviewed and shared with other members of a medical team for treatment planning and teaching, Kerr says. They also wanted to improve the diagnosis of early-cancer lesions by capturing and reviewing high-definition endoscopy movies, a capability that their endoscopes did not include. First they employed Mac video technology and off-the-shelf hardware and software such as Final Cut Pro, so its endoscopists are able to create QuickTime Pro movies of endoscopies for instruction and self-learning presentations at conferences (using Keynote on MacBook Pro and 24-inch iMacs) and for dissemination to other professionals as DVDs.

They called on Meta Fusion to provide a state-of-the-art information system that would integrate with Vista, their nationwide hospital information system. “All of the functions and features that Soetikno and colleagues had pieced together with disparate software applications and machines—and more—have been combined with leading endoscopic functionality to create an organized, state-of-the-art, integrated practice management system,” says Cyrus Hazari, president of Meta Fusion.

Part of the endoscopic capture capability is the generation and storage of DICOM images, and OsiriX (among other viewers) can be used to view these, Hazari says. The systems also track images and movies that are research worthy and can be later reviewed to improve the standard of healthcare at the VA and elsewhere, he says.

Consultation Tools
“The multiplatform image and video functionality and considerably more specialty-specific capabilities can be extended to multiple departments in the VA and, thus, Mac-based information including images and movies can flow between departments with ease,” Hazari says.

Yet another example where OsiriX is becoming increasingly useful is in remote consultation. iChat AV, OsiriX, and the Internet are enabling Edward Zaragoza, MD, an associate clinical professor of radiological sciences at UCLA and the clinical director in radiology at the Santa Monica UCLA Medical Center and Orthopaedic Hospital, and his colleagues at the main hospital in Westwood, Calif., who specialize in PET/CT images, to conduct their daily PET rounds from their offices on their respective campuses.

With a simple plug-in, OsiriX becomes fully integrated with iChat AV in Mac OS X, Zaragoza explains. “We can switch from a live, face-to-face video conference to showing medical images inside the iChat window itself. If they had to conduct the consultations in person,” he says, “one of us would have to get in the car and drive up the Wilshire corridor and, at 4 or 5 in the afternoon, that might take 45 minutes one way. So the operational benefit in terms of time savings is huge.”

Rosset estimates that of the 25,000 OsiriX users, about 30% are radiologists, about 30% are clinicians (cardiologists, orthopedists, etc), about 30% are working in clinical and fundamental research, and a few are patients.

While physicians and hospitals are implementing their own solutions to imaging challenges by using Macs and OsiriX, partner companies are working to provide the technical support that they need.

FDA Approved: OsiriXPRO
aycan Medical Solutions, best known for its DICOM paper printer, has developed an FDA-cleared version of OsiriX for the U.S. market and a CE-cleared version for the European market. “We provide service and support, which includes training remotely or on site, a comprehensive user manual, and, of course, an FDA-cleared version of OsiriX,” says Shaun O’Neil, product manager for aycan U.S.

“We started development of OsiriXPRO about two years ago in Europe and introduced it in the U.S. in November at the Radiological Society of North America [RSNA] meeting in 2007,” adds Frank Burkhardt, director of U.S. operations for aycan.

Every year, aycan conducts an OsiriX user meeting at RSNA. “We’ve already done three of them,” Burkhardt says, “and the last two years they were cosponsored by Apple.”

Burkhardt explains how aycan transforms the open source into OsiriXPRO: “The open source is a very, very complex software and a lot of features and functions are added to it frequently. The fast pace of releases can cause instability. We take the open source and through quality management, debugging, reprogramming, and other processes, we not only stabilize and make the software smooth and its operation flawless, but we also offer plug-ins.”

To date, Burkhardt says, aycan has several large university clinics overseas as customers and is close to making major deals with imaging facilities in the United States. “We launched this solution about two years ago in Europe and last year in the U.S. We anticipate continued expansion into other markets as OsiriX has a global community,” he says.

Looking Ahead
Zaragoza believes that one of the biggest happenings in radiology in the last year is that OsiriX now has a corporation that has taken it under its wing and developed an FDA-approved version of the application. Without FDA approval, a viewer such as OsiriX many not be used for primary interpretations. Many Mac-based users have some other approved viewer running on a workstation attached to their Mac network.

The FDA-approved version is basically the same as the open-source version that can be downloaded for free, Zaragoza says, “but it has another wrapper around it. That’s really very exciting for people that want to use it as a primary tool for diagnosis.”

Hazari says that in the last year, Meta Fusion has made several enhancements to its OsiriX offerings. Among them are the development of a full-featured RIS that includes integration with 64-bit OsiriX running on Mac OS X Leopard, structured reporting with speech recognition (using Dragon Naturally Speaking with Medical Dictionary) on Mac OS X, full transcription options with Phillips SpeechMike integration running on Max OS X, and a full-featured RIS for home reading that includes OsiriX integration.

Meta Fusion also has developed architecture for multisite deployment and operation that minimizes points of failure and ensures autonomous site operation. It also enhanced Web-based architecture providing services to referring physicians and patients, Hazari says.

At the Society for Imaging Informatics in Medicine’s annual meeting in Seattle last month, Quest International introduced a true 12-bit grayscale mammographic medical LCD display solution developed using a Mac system and OsiriX. The system uses the Apple Mac Pro 8-Core workstation with two Totoku ME551i2 diagnostic displays, which are 21.3 inches, 5 megapixels, and DICOM compliant.

Mac Display Solutions
Quest initiated the display solution’s development using a Mac at its customers’ urging. “We received requests from customers looking for medical displays that would interface with a Mac,” says Bill Greenblatt, vice president of sales and marketing for Quest. “We found that with our display solution and the flexible nature of OsiriX, it could be done. Because it is an open-source application and [with] the computing capability of the Mac, it is an attractive option to traditional medical workstations.

“There is so much versatility to the Mac,” he adds. “Many facilities are utilizing or are considering migration to Macs, and they are looking for display options.”

Apple developers are hoping to create tools to allow physicians to use their iPod or iPhone to easily send data to one another to view on their Macs. “With the alignment of high-end medical solutions for the Mac and the interest we’re seeing for the iPhone, we expect to see even more compelling medical solutions for Apple products in the future,” Kerr says. “We are seeing incredible interest in the iPhone from end users, the doctors themselves, and from developers who create solutions specifically for the medical community. The ease of use, the superior graphics, and the eye toward how the user will interact with and use each product—these all are important to the medical community.”

Hazari says one of Meta Fusion’s customers uses an iPod Touch to download and view ultrasound images from his Meta Fusion Web server.

Zaragoza says it is not uncommon for him to be questioned about imagery in the hospital corridors. “I can always take out my iPhone and show in glorious black and white or color display a relevant image. The beauty of the interface on these touch screens is there is a graphic metaphor for zooming and panning of the images, so it may display an image of a certain size, but if you need to see a small detail of the image, the functionality is there to that, too. These devices are enabling users to share information on the run and their ability to do so is very robust,” he says.

With the relatively low cost of Apple machines vs. dedicated viewing workstations and the ease with which physicians can navigate their massive amount of images using OsiriX, Zaragoza and others like him are convinced that the movement toward Macs in radiology will continue to gain momentum.

— Beth W. Orenstein is a freelance medical writer and a regular contributor to Radiology Today. She writes from her home in Northampton, Pa.