Coming soon to a display near you: Anytime, anywhere advanced visualization DICOM image set reconstructions. The advent of server-side processing technology permits image manipulations to take place on a central server before being transmitted to a monitor—either a diagnostic workstation, a laptop, a smart phone, or an operating theater display. This structure allows virtually latency-free viewing of images at any location, and in the process, is expanding the role of radiology throughout healthcare.
The University of Pittsburgh Medical Center (UPMC) is one of the largest non-profit integrated healthcare systems in the United States and consistently lands near the top of industry rankings as one of the best facilities in the nation. Its strong reputation draws patients from throughout the United States and from more than 30 countries around the world. UPMC employs more than 5,000 physicians, performs more than one million radiographic studies each year, and consists of a 19-hospital network spanning more than 160 miles.
The wide geographic area served by UPMC creates a distributed environment where specialists and referring physicians often perform procedures at three or four different facilities within the network. Patients, too, migrate within the network; receiving healthcare services at different facilities within the larger enterprise.
“One of the main drivers toward enterprise-level advanced visualization has been the emergence of thin-client technology,” says Rasu B. Shresta, MD, medical director of digital imaging informatics and chief of the division of radiology informatics at UPMC.
“There is going to be a paradigm shift in the way 3D imaging is being delivered in healthcare,” Shresta says. “Up to now, radiologists would take a snapshot or two of a pertinent anatomy, for example an aneurysm visualized in 3D, and would then send this back to PACS as a still image—and this was at best what the referring clinicians and the surgeons got from radiologists. But now, they have the ability to not just view the snapshot, but to click and restore this snapshot to the state that the radiologists left it at; with access to all of 3D tool sets—so that he or she can rotate the study, perform further image post-processing and look at relational anatomical structures etc. This is a paradigm shift in the way imaging is being delivered—and the benefits of having access to these 3D images and tools, not just in reading rooms, but in clinicians’ offices, and ORs and other locations will be tremendous.”
Shresta and his colleagues utilize Vital Images’ Vital Enterprise as their enterprise advanced visualization solution, but legacy dedicated 3D technology workstations from a variety of developers still have a place in the clinical continuum at UPMC. “Certainly, these are workhorses of the system, and are still very much part of the workflow,” he says.
There are multiple advantages to deploying an enterprise-level advanced visualization solution at UPMC, Shresta says.
“The first is ease of deployment. Up to now, the technologists at each modality needed to ensure that studies that needed 3D post-processing were directed to the appropriate thick-client workstation or thin-client server. With this new technology from Vital Images, all the modalities push their data to a centralized server, and the server intelligently routes the 3D studies out to the appropriate environment—either thick- or thin-client. All the image manipulations take place on a central server before being transmitted to a workstation and this enables any study to be available on demand anywhere in our system.”
Continuity of clinical workflow is another advantage that Shresta cites to the UPMC enterprise strategy.
“A technologist or radiologist [such as one of our fellows] can perform portions of the post-processing, and then another colleague [like a radiology attending] can complete the rest of the post-processing.”
Because the technology has been in place only a short time, Shresta says that it has been deployed to a small audience beyond the radiology department.
“We’ve moved the application out to our orthopedic surgeons, cardiologists, neurosurgeons, vascular surgeons and our oncologists at present. Their response has been very enthusiastic. We’re bracing ourselves for even more system users as we plan on bringing on even more clinical specialties shortly.”
Advanced visualization capabilities have also helped renew the relationship radiology has with other clinical specialties, Shresta notes.
“I see this as a powerful tool that is allowing us to bring some of the inter-specialty communication back with our professional colleagues. With the deployment of PACS our interaction gradually became reduced to simply our report and a few key images. Advanced visualization image sets is one way that we’re able to re-engage with the surgeons, the orthopedic specialists and the oncologists in the clinical decision making process. It’s allowed us to re-start that conversation all over again.”
3D reconstructions also have had a powerful effect on improving patient adherence to their treatment plan, Shresta says.
“Our clinical colleagues report back to us that the 3D reconstructions are helping them to explain the seriousness of the condition they’re treating to their patients. In return, they tell us that patients are much better about following the treatment regimen that they’ve recommended. It’s been said that a picture is worth a thousand words; I guess a 3D image is probably worth millions of them.”
The technology also has had an effect on day-to-day practice of some of the radiological sub-specialties, Shresta notes.
“All our sub-specialties have really embraced the capabilities of the application. For example, our chest radiologists use advanced visualization tools on a very regular basis; not just for their MIPs [maximum intensity projection] and MPRs [multiplanar reformatting] but also to probe the larynx. It’s given them tools that they never had easy access to in the past and it’s allowed them to do so much more, which has increased our collaboration with our referring physicians even further.”
IT administration of advanced visualization solutions also has eased with the enterprise-level deployment, Shresta says.
“Enterprise deployment has increased the penetration and growth of advanced visualization across the hospitals and departments. The process has certainly been more streamlined and controlled. Software updates affecting all users can be handled centrally—and automatically, because the next time a user logs in from his or her workstation or personal computer, the latest software is what will be there. We are able to not just manage deployment across the different areas of need, but also track usage, fixes, upgrades and enhancements from a centralized control hub.”
Like any user of a cutting-edge technology, Shresta has a wish list of next-generation ideas to improve the toolset at UPMC.
“I’d like to see a tighter level of integration between the thick- and thin-client applications—such that the distinction, as far as the radiologist is concerned, should essentially disappear,” he says. An externalized, unified worklist is one starting point to accomplishing this. I’d also like to see a flourishing of anticipatory algorithms being made part of the reading workflow, specific to individual categories of studies.”
For Shresta and his clinical colleagues at UPMC, advanced visualization capabilities are creating a paradigm shift both inside and outside the radiology department.
“I think advanced visualization is at the stage where it is on the verge of being ‘discovered.’ There is so much more that can be squeezed from this new realm of image post-processing. It was previously being seen as sort of a niche application that was being used for only certain studies in the radiology workflow. Increasingly—in part due to this enterprise distribution model and in part due to the greater variety of software tools available—it’s becoming more and more part of the mainstream reading strategy as a way to deal with the tsunami of data sets that we’re being inundated with.
“The way for us to make use of almost every pixel of data out there isn’t for us to scroll through 5,000 images in a CT study. It’s for us to look at this study in 3D first and then really hone in on the region of interest. Eventually, and inevitably, it’s going to change the way we deal with these larger data sets in our PACS environment so that we look at a 3D study first before analyzing it in 2D.”
Advanced visualization isn’t a technology that is solely the province of the academic medical center or the large, multi-site practice, Shresta says.
“Good technology is good technology. It isn’t whether it’s applicable to a big radiology group as opposed to a small radiology group. I think it’s important and applicable to all radiology. The major difference, for the most part, is in how the technology is deployed [as either a thick- or thin-client]. Advanced visualization is essentially a game-changing technology.”
Myron A. Pozniak, MD, professor of radiology and chief of the abdominal imaging division in the department of radiology at the University of Wisconsin School of Medicine and Public Health in Madison, Wisc., sees clinician demand as one of the primary drivers toward an enterprise-level advanced visualization solution.
“The clinicians want answers to their diagnostic questions; they want to see things better to assist them in evolving their procedures further and they want to go in better prepared when they’re performing a procedure. They want us to provide them a better roadmap and better answers—basically, it’s all about better patient care.”
The advanced visualization environment at the University of Wisconsin is populated with a mix of vendors, as the facility is host to research and development in several areas for the technology. Pozniak, currently using the Ziosoft Ziostation version 1.2.1, says that his clinical colleagues outside radiology see great advantages with the technology.
“It’s a benefit to the clinicians and their patients. Advanced visualization allows us to get a great deal of information out there to individuals whose business is not the generation of images. It allows them to easily see the abnormality and then incorporate that knowledge into what they know about the case and what they plan to do for that patient and then move forward. It allows them to rapidly get a grasp on what they have to deal with.”
The technology has enabled other clinical specialties to make greater use of radiology, Pozniak notes.
“The image data now exist on the system so that the clinician or the surgeon can access them and can manipulate them in anyway that he or she chooses to do so.” Because of these capabilities, Pozniak notes that radiology is able to deliver even better data allowing for even better clinical care.
“We’re looking to provide the capability for our surgeons to be able to interact with the 3D data set right in the operating room. We’re developing what we call a COW, computer on wheels, which is wirelessly connected to the network and can be moved into the operating theater so that surgeons can have access to the advanced visualization toolset during their procedures. The surgeons will sit down with us to review the data set, for example, to determine where a neoplasm is in relationship to the hepatic vasculature prior to a resection. Having this data set available during the procedure will be a huge benefit.”
As expected, cardiology and orthopedics have been the traditional heavy users of advanced visualization at the University of Wisconsin, Pozniak says. He notes that surgery is rapidly embracing the technology, going so far as to work side-by-side with radiology to fine-tune image reconstructions.
“One of our surgeons routinely meets with our 3D lab people every Friday morning and they sit down and review what’s been done and what they can do to make better data sets for surgery. For us, as imagers, we can create images that are beautiful to us. It’s not always the case that these are what a surgeon needs. We’re lucky that we have someone who is willing to dedicate his time to helping us make our work better for all the surgeons.”
The capability of being able to manipulate image data sets from a workstation anywhere in the facility has been a major driver in the adoption of enterprise-level advanced visualization technology at Dartmouth Hitchcock Medical Center in Lebanon, N.H., says Michael Tsapakos, MD, PhD, chief of cross-sectional imaging.
“One of the advantages to an enterprise advanced visualization deployment is that three-dimensional reformatting can be done at one’s desktop. You don’t have to go to radiology to use a workstation there to either work on a data set or view a 3D image. One of the best things, from a workflow standpoint, is that you can now use this toolset whenever you want—which allows surgeons and ER physicians to manipulate and view images at any time of the day or night.”
Tsapakos, whose facility utilizes the Visage CS Thin Client from Visage Imaging, notes that although image manipulation capabilities are available to the other clinical specialties at Dartmouth Hitchcock, his experience is that they still look to radiology to perform reformatting.
“I haven’t seen a lot of specialists wanting to perform their own image reformatting. They still rely on radiology to do it for them.”
At Dartmouth Hitchcock, orthopedic specialists have been enthusiastic adopters of the technology, Tsapakos says.
“Outside radiology, the major adopters have been our orthopedic surgeons. They use it for three-dimensional reformatting for hip and knee joint visualization both pre- and post-procedure. Our vascular surgeons also are showing a great deal of interest in using the technology for their procedures.”
Tsapakos also has found that the deployment of an enterprise advanced visualization strategy is re-energizing relationships among radiology and the other clinical specialties at Dartmouth Hitchcock.
“The more clinicians outside radiology see the 3D reformats, the more likely they are to order them. We’ve found this to be particularly true with our tumor imaging. Being able to show our surgeons 3D tumor volume images has rapidly led to them incorporating this data into their surgical plans.”
One of the greatest benefits with the enterprise strategy is that it allows for a nimble and dynamic workflow in radiology, Tsapakos says. This capability permits it to be able to respond more quickly to requests from other departments, such as surgery or the ER, no matter what time of day that the order comes in.
“Although most of our reconstructions are performed by our 3D lab, if a situation arises where I need to have a 3D reformat done and our lab is busy, or it’s after hours and they’re not available, I can do it wherever I’m located.”