Advanced Visualization Kicks it Up a Notch

Advanced visualization is here—and here to stay, promising to improve patient care with exquisite visualization of everything from cerebral aneurysms to vascular disease and colon polyps. Advanced visualization has become an integral and essential component of the 21st century radiology department. "If you have high quality [imaging] equipment, it's a waste without the ability to perform 3D reconstructions. It's the equivalent of buying a Ferrari and not putting good tires on the car," states Hal Folander, MD, chairman of the department of radiology at St. Luke's Hospital and Health Network in Bethlehem, Pa. Volumetric imaging cures the slice harassment caused by the proliferation of multislice scanners that generate more than 1,000 images per exam (or more), says Folander.

Yet, the same time, administering the advanced visualization cure brings its own set of woes. The top challenge? Integration. "If you don't have PACS integration, you're just making pretty pictures," argues Donald Peck, PhD, division head for physics at Henry Ford Health System in Detroit, Mich. Workflow rears another issue.

A lack of integration between the advanced visualization solution and PACS can slow the radiologist by forcing him or her to get up and move to a second workstation, says Peck. In other cases, the radiologist must separately launch the 3D application from the PACS workstation and physically pull in hundreds of images, a process that can take up to a minute per study. "It's unacceptable from a workflow point of flow," states Christoph Wald, MD, PhD, director of 3D Lab for Advanced Image Analysis and Virtual Surgical Planning at Lahey Clinic in Burlington, Mass. Integration is not a black and white proposition. Less than seamless integrations translate into additional log-ins and more mouse clicks.

Integration can address the other major advanced visualization issues: cost-effectiveness and efficiency. Integration enables the department to tap into and maximize its investment in PACS workstations and circumvents delays like re-launching or losing data as images are transferred between machines.

Other key issues in the advanced visualization implementation process include communication with and distribution to referring physicians as the real purpose of every advanced visualization solution is to improve the clinician's ability to deliver excellent, efficient patient care. A thorough review of options and assessment of related solutions—especially PACS and workstations—and clinical needs and goals helps ensure that the advanced visualization program is primed for success.

Integration: Before & after

The integrated department is the picture of efficiency and productivity. Take for example Henry Ford Health System. The radiology department relies on a Philips Medical Systems (Stentor) iSite PACS. The PACS is integrated with Barco's Voxar 3D and Vital Images Vitrea workstation. The two advanced visualization and analysis software packages are used for the majority of the day-to-day reconstructions. The department relies on GE Healthcare's Advantage Workstation (AW) and Siemens Medical Solutions Leonardo workstation for additional modality 3D reconstructions.

"With Voxar and Vital Images integrated into Stentor, we can pull images directly from the PACS," explains Peck. Physicians can right-click on an image to continue working with a reconstruction that had been started by a tech or colleague—without losing previous processing. PACS also provides storage for 3D data, eliminating the need for an additional server for storage. PACS integration allows the department to move data without an intermediary server and eliminates pre-fetching.

Lahey Clinic is taking a different tact. The organization plans to deploy TeraRecon's AquariusNET server to facilitate a more integrated advanced visualization environment. The clinic found itself in a difficult spot with its primary 3D software not yet integrated into its PACS. The PACS vendor promised integration in its next upgrade. Wald explains, "Our PACS upgrade wasn't scheduled for a while, and it isn't always wise to rush into the next PACS release. We needed an integrated advanced visualization solution now."

The clinic plans to install AquariusNET server in its data center. Data will be sent from the modality to the server, or physicians can request 3D with data pulled nearly instantly from the PACS. Wald lists the pluses of this approach. "At the client end, hardware requirements are extremely low, [which reduces the investment.] Another advantage to the thin-client model is that we don't need to upgrade multiple pieces of hardware. Upgrades are completed on the server." Another plus of the thin-client solution is that it does not limit the number of users on the server; however, too many users can slow the system.

Integrated & cost-effective

There are a number of successful integration models. Two challenges associated with advanced visualization are the high cost of the workstations and the need for point of care 3D, says Gary Wendt, MD, MBA, enterprise director of medical imaging at University of Wisconsin-Madison. University of Wisconsin-Madison has integrated Vital Images' Vitrea 2 with its McKesson Horizon Medical Imaging PACS at the PACS level, which goes beyond workstation integration, says Wendt. As a result, radiologists can right click on an image and hit 3D image processing to launch Vitrea. Data are sent without a query/retrieve.

St. Luke's Hospital and Health Network has benefited from integration as well. The radiology department relies on GE Healthcare's AW and Centricity PACS. AW Suite is integrated into the PACS, eliminating the back and forth between modality and PACS workstations. "We've realized workflow benefits with the embedded solutions. Our throughput and efficiency have increased," sums Folander.

Communicating 3D

The ability to create high-quality 3D reconstructions promises to improve patient care with more accurate diagnoses; however, radiologists need to share 3D images with clinicians to win the end game. Truly effective 3D facilitates physician interaction with the 3D model, says Wendt. There are a number of successful options.

St. Luke's Hospital and Health Network consists of multiple offices and outpatient centers. Centricity PACS is linked to a web portal, which allows physicians to access 3D images in their offices without a high-end workstation. "A patient at a distant outpatient center receives the same quality and depth of care as a patient at a tertiary care hospital," explains Folander.

The web portal is one option. Another option for sharing 3D images is a link from the patient record. Philips iSite PACS includes an API (application protocol interface). Henry Ford Health System uses the API to allow physicians to immediately launch images from the patient record.

The quest for enterprise 3D

University of Wisconsin-Madison has employed a second solution to solve the cost-effectiveness and efficiency challenges. Only a few radiologists or clinicians need 3D at any given time, but predicting where or when the need will arise is impossible. At the same time, licensing a fleet of more than one hundred workstations is a costly proposition. The university collaborated with Vital Images and McKesson to develop a floating license program that makes Vitrea available on all PACS workstations. The university pays for floating licenses on the entire fleet of workstations. This model provides the flexibility and access to distribute 3D throughout to physicians throughout the enterprise.

The floating license model may not be the optimal solution, cautions Peck of Henry Ford Health System. If the floating license provides only limited processing tools instead of the comprehensive advanced visualization toolset, its may not suffice for radiologists. "It may be adequate for referring physicians," concedes Peck.

The plug-in module concept also addresses the cost-effectiveness issue, claims Murray Miller, MD, a private practitioner affiliated with the Trillium Health Centre in Toronto, Canada. Miller uses Cedara Software's CT Works for 3D reconstructions. "In Canada, healthcare cannot afford a separate 3D box; the solution must launch from within the PACS workstation," he says. CT Works can be launched within the PACS, but offers more 3D options than the basic tools embedded in some PACS.

Single source or multi-vendor shop?

No advanced visualization solution is perfect for everything.  For example, Voxar is the only program that runs well on a laptop, Wald opines. "I can pull from PACS via a VPN and do 3D reconstructions on the road," he explains.

Lahey Clinic and Henry Ford Health System, like many other healthcare enterprises, rely on multiple advanced visualization providers as part of an entire advanced visualization solution. Henry Ford uses Voxar and Vital Images as the departmental workhorses for bread-and-butter 3D studies such as CT angiographies and vascular work. The hospital's Siemens Leonardo and GE AW workstations, on the other hand, are used for vendor-specific tasks and more advanced cardiac reconstructions. For example, cardiac scoring is optimized on Leonardo. The hospital continues to search for best-of-breed solutions and may add Viatronix Inc. V3D-Colon for virtual colonoscopy.

"It's hard to say you don't need vendor software if you want to be cutting edge," notes Peck. At the same time, Peck admits all advanced visualization packages do the basics. A single solution can make sense for smaller practices, he says.

Hershey Medical Center in Hershey, Pa., opted for the single platform approach. The hospital has relied on TeraRecon's Aquarius Workstation and AquariusNet server as its single 3D solution for two years. Radiologists use the thick-client workstation for complicated cases. Its hardware is configured to handle the intense number-crunching for studies like CT angiograms of the head. The thin-client operates as a separate module on IDX Imagecast PACS workstations and is used for easier viewing and processing tasks.

"Every vendor has its pluses and minuses," explains Dan Nguyen, MD, chief of neuroradiology at Hershey Medical Center. The radiology department promotes 3D simplicity. "We want to make advanced visualization as simple as possible. If it's difficult, physicians won't use it, and it is easier to learn one platform than several."

Similarly, Trillium Health Centre found that Cedara Software's CT Works provides the optimal 3D solution. Its PACS could not effectively reconstruct beyond axial slices, and the CT console was not user-friendly. CT Works addressed the user-friendliness and workflow challenges, enabling radiologists to complete angiograms in a few mouse-clicks, says Miller.

Tips for success

Implementing superior advanced visualization is a process that depends on the right combination of technology, human resources and business solutions. Folander believes that human resources tops the list of 3D priorities. "A hospital can have the best equipment in the world. It's worthless without the right people in the right job."  He credits St. Luke's outstanding PACS administrator with the hospital's 3D success. Another key personnel investment is the 3D tech. A good 3D tech dedicated to 3D image processing boosts the odds of a successful program, says Wendt.

Success rests with details in addition to big picture items. Peck stresses the importance of DICOM-calibrated displays across the enterprise. "DICOM-calibration of referring clinicians' PCs means that the image that pops up for the physician is exactly what the radiologist sees. Windowing and leveling are not necessary." Peck offers another bit of advice. "Stay current with software to help manage the exponentially increasing datasets." Henry Ford Health System completes semi-annual software upgrades.

Finally, streamlined workflow can have a significant impact. Henry Ford Health System struggled with worklist workflow in the early days of 3D. "If you aren't working from a worklist, you're stuck with paper or verbal processes, which makes it difficult to do real-time workflow," explains Peck. But 3D reconstructions aren't always a billable worklist charge. The department came up with a 3D reconstruction non-charge that allowed it to use the worklist and bypass inefficient paper processes.

Future directions & dimensions

The radiology paradigm is evolving and transitioning toward volumetric imaging. Volumetric imaging enables radiologists to manage the thousands of images generated by multislice scanners, and it provides referring clinicians with an accurate, optimal diagnosis. As PACS and 3D march down the path toward integration, there are other advances on the horizon. Many of the latest and upcoming tools are designed to enhance communication with clinical colleagues.

"We will bring the power of post-processing to the entire institution," predicts Nguyen. In the next two years, Nguyen says the line that separates a 3D workstation and server will disappear. "Everyone will have the same tools," he says. The writing is on the wall as AquariusNET is edging closer to workstation functionality with vascular measurement tools and fusion software.

Some sites are exploring the possibility of deploying 3D outside of radiology. Henry Ford Health System is studying the pros and cons of providing access to orthopedic and vascular surgeons. The option would allow heavy 3D users to create their own reconstructions. One downside is the overhead associated with additional 3D software and hardware.

Vendors are simplifying image sharing in other ways. For example, some vendors have added conference-call 3D sessions. Essentially the radiologist and clinicians view the same dataset on separate workstations and the radiologist can drive the image on both workstations to better illustrate key findings. Other new options allow radiologists to email clinical colleagues a document with links to images; when the clinician clicks on the images they become live on his or her screen.


Advanced visualization has become an essential component of the practice of radiology. There are multiple paths to 3D success. The best starting place is an understanding of the technology, its potential and challenges. It's important to understand the degree of PACS integration; not all solutions are fully integrated with every PACS on the market. Beyond integration, the hospital must ensure streamlined communication of findings and develop a plan to take 3D into the future.

An Army of Images: Advanced Vis Improves Care in Military Hospital

Landstuhl Army Medical Center in Germany has relied on MedWeb's teleradiology PACS servers for three years. The PACS is evolving from a basic home teleradiology solution for on-call radiologists to an advanced 3D application. On-call military radiologists in Europe use MedWeb to read studies from spoke clinics at three separate hospitals. In fact, radiologists in Kosovo, Yugoslavia, can use the MedWeb server to shift images to take up the slack when Landstuhl is inundated with a heavy caseload. "Images are available in five minutes or less with a DSL connection," explains Lt. Col. Edward Callaway, MD, assistant chief of radiology at Landstuhl. "After reading the case, we can call the physician with our report. Other clinics can view attached reports inside MedWeb."

Last year, Callaway began testing additional 3D components on the MedWeb server, and a number of injured troops have benefited as 3D is evolving into a standard of care. "It's important for us to have MPR [multiplanar reconstruction] and 3D shaded surface display capabilities. I believe it will become a standard of care in certain cases," explains Callaway. "The integrated 3D tools like MPR help radiologists detect fracture dislocations and other major problems faster and with higher confidence."

The PACS incorporates basic PACS image processing tools, MPR and other post-processing tools like shaded surface display. The one-click 3D capabilities provide a quick gestalt of common injuries among soldiers such as rib, spine and bone fractures and shrapnel location, says Callaway. In the end, the enhanced diagnostic capabilities will enable military physicians to deliver improved patient care for soldiers.