Lumbar image captured on TeraRecon’s AquariusNET

Sophisticated and more intuitive advanced visualization software makes intricate imaging capabilities possible and thin-client options are expanding access across the enterprise. Along with improvements in reconstruction tools, 3D functionality is saving time, improving patient care and facilitating overall workflow improvements.

CT angiography studies with 2,000 images that used to take Richard Hallett, MD, section chief of cardiovascular imaging and medical director at Riverview Hospital in Noblesville, Ind., 30 to 45 minutes to view via PACS now take about 15 minutes. Why? Hallett now uses AquariusNET and Aquarius workstations from TeraRecon. The AquariusNET viewer and server combination allows for processing in a thin-client interface. The software package, primarily used for CT angiography, can be installed on any computer.

Hallett says that there was an initial learning curve, but he found the system fairly easy to learn. As for workflow changes, “it adds time. You have to sit down and interact with the data.” Overall though, he has decreased the time spent on cases because he can get through large volumes of data more quickly and effectively. “It’s time well spent. It allows you to go through lots of information and focus on the things that are important.”

Hallett says that the ability to do reconstructions down the center of a vessel allows him to see an area of narrowing in multiple ways to determine whether the narrowing is due to soft or calcified plaque, and vessel morphology. It makes measurement more accurate and reproducible. The time savings and increased accuracy is a win-win. “It’s a great diagnostic tool from an ease of reading standpoint,” he reports. He also appreciates the ability to email images to referring physicians to keep them in the loop and eliminate their need to get on a PACS to review images. He also can send the same images back to PACS so that they are always available to other physicians.

Accessible anywhere

Hallett’s system allows for 4D image review, including viewing of the beating heart and valve motion. More recently, Hallett says his partners are performing virtual colonoscopy, which is easy to look at on the viewer. Thanks to the server, he can use a remote link himself. Hallett is based in Indiana, but he is a part-time faculty member at Stanford University School of Medicine in Palo Alto, Calif. There is a group at Stanford studying stent grafts in the aorta. With this system, he can use the server at Stanford from his home to stay involved in the research.

Hallett has experience with several advanced visualization systems and says that the thin-client/server setup was selected because of the ease of implementation and ease of use of the software. He played a big role in implementing advanced visualization capabilities at Stanford, too. The facility was rolling out a cardiovascular services program in 2004 and they wanted to grow imaging along with that.

Today, coronary CTA studies are sent to the server, along with complicated orthopedic cases, such as hip evaluations or myelograms—“anything that we need a multiplanar evaluation for,” Hallett says. That accounts for about 20 run-off studies a month. The facility does about 100 CTAs for pulmonary embolis, 25 for thoracic and aorta, 20 for renal arteries and 10 to 15 for head and neck. All MR angiograms—about 50 a month—are sent to the server. They can set up a watermark and autodelete function so that when the server fills up, it will start to delete exams that aren’t locked.

Concentrating on cardio

Frank Rybicki, MD, PhD, co-director, cardiovascular imaging section and director of applied imaging sciences laboratory at Brigham and Women’s Hospital in Boston, Mass., has been using Vitrea software from Vital Images for about three years. The portfolio includes automated vessel measurement, CT brain perfusion, CT cardiac, cardiac functional analysis, CT lung, vessel probe and VScore, which were chosen because “they have excellent advanced post-processing tools for cardiovascular imaging.” Specifically, Rybicki uses multiplanar reformatting, orthogonal (curved) planes as well as 3D volume rendering and maximum intensity projection (MIP). The latest and most important feature in cardiovascular imaging is advanced curved planar reformation for flattening of vascular structures.

“The software is excellent,” Rybicki says. “The workability is excellent and it makes our day-to-day workflow significantly better than it would be with software that’s less facile.”

Reliability is important to Rybicki. “We do a lot of studies each day and have a lot of trainees, so we use the equipment heavily.” Plus, they have a high level of throughput, so they need to process studies quickly. There are techs and five fellows who do only cardiovascular imaging, so they are quite skilled in post-processing. A normal study can be turned around in about 10 minutes, with a more complex study averaging about 45 minutes. 

The benefit of advanced visualization comes in its negative predictive value, he says. If a CT is done and the patient is normal, you can avoid cardiac catheterization. The specificity and sensitivity of CT are not that good, Rybicki points out. If you say a patient has 50 percent stenosis, it could really be 60 percent. “The power of CT is to determine that patients are normal—which is good for low-risk patients.”

Scalable for the enterprise

Chris Young, CIO at St. Thomas Hospital, an Ascension Hospital in Nashville, Tenn., has been an Emageon user for almost three years. “In my opinion, they offer the most scalable architecture. That’s a standard we deploy within Ascension Health.”

Young says that when they chose their vendor, they liked that Emageon was agnostic in terms of dealing with various imaging modalities. The health system was focused on a partner with strong applications and archiving. “That’s one of the biggest issues that becomes problematic when you really scale up,” he says. “We’ve seen other hospitals still print film while they have a PACS. That seems ridiculous to me.” He points out that there are a lot of visualization products available, but “at the end of the day what you really care most about, if you care about patient safety, is something that stays up and is working. We’re a 24/7/365 business. We can’t just tell a surgeon that the system is down.”

Ascension went through a very comprehensive buying process, Young says. They hired a consultant to help with neutrality on the different vendors. “When we were looking, Emageon was a relatively new company which seemed like a risk. But when we really looked at their archiving, the technology was phenomenal. We wanted a company that was growing and was focused to really deliver on our needs.”

Mac Jackson, executive director of imaging for Ascension Health, really appreciated the implementation success package Emageon offered. “It had everything laid out—training, marketing—it cracked the code on how to implement perfectly. If I could get that from every company, I would cry tears of joy.” The Ascension hospitals that did not choose Emageon had a more difficult time with their rollout, he says. 

A lot of people are not paying attention to the future of PACS and advanced visualization, which is progressing at geometric rate, Jackson opines. Given continuing modality advances “and the utilization of multiple modalities to look at a particular diagnosis or issue with a patient is going to create a lot of operational challenges, the biggest being spatial consumption.” Anyone with a replicated architecture is storing images twice. “The days of storing 1 or 2 terabytes are gone,” he says. “Now it’s 20 [TB] a year. Fortunately, the price is coming down, but the technology is advancing.”

The Emageon system didn’t require much training, says Don Hill, PACS administrator for St. Vincent's in Jacksonville, Fla. “Our orthopedic surgeons were already well-versed in such software,” he says. The orthopedic surgeons are using surgical planning tools from Orthocrat, which are incorporated into the Emageon system. Orthocrat allows for implant templates for joint replacements, including knee, hip, shoulder and elbow. The facility performs about 2,500 of these procedures a year.

Rudy Apodaca, CRA, director of radiology at Chandler Regional Hospital in Chandler, Ariz., also uses visualization tools from Emageon. He says that his facility is doing a lot of cardiac CT angiography and 64-slice CT scans. The ability to use the toolset for 3D and fly-throughs on the same workstation is a big plus over exporting studies to other workstations. With the enterprise visual system from Emageon, when physicians look at 3D, they can see different projections and reformat right off of their workstation. That enables them to provide a quick diagnosis. Since a lot of work is for emergency cases, quick turn around is very helpful.

Apodaca says that the facility chose Emageon because they felt the system was the most configurable. “We can add hardware and other components to make it more individualized.” He says that ability to customize is a big advantage. “You can buy just any glove, but wouldn’t you rather have one that fits you just right?”

Apodaca is excited about the latest software version, which offers further enhancements for improving workflow. Studies can be grouped into folders, for example. Since his emergency department is divided into pods, a folder can be assigned to a pod to better manage patient care.

What’s next?

Hallett says the industry is anticipating better stenosis management in the future, with more tools for plaque characterization and visualization. He also sees more segmentation becoming available which will allow users to get rid of all bone, for example, on an image with one click.

Aside from specific applications, advanced visualization continues to evolve as users demand integrated, efficient solutions. Vendors are offering more and more options to meet the workflow and clinical needs of 3D end-users, even as the end-user constituency continues to grow. The time savings, improved diagnostic capabilities and reimbursement changes will drive more facilities to implement 3D and more users at those facilities to take advantage of the benefits.