Workflow Strategies Aid Advanced Visualization

Advanced visualization technology in medicine, the utilization of software-based tools for image reconstruction and analysis, is generally accepted as the province of diagnostic radiology. However, other medical disciplines such as radiation oncology, cardiology, and orthopedics are employing these applications to deliver effective treatment, identify and track the progression of disease as well as plan surgical interventions.

As the technology rapidly moves beyond its radiology-centric origins, a wider variety of clinicians are demanding access to processed image reconstructions—and they want the image datasets as quickly as possible.

The embrace of advanced visualization software by the clinical continuum presents workflow challenges to a practice utilizing the technology, according to Paul J. Chang, MD, professor and vice-chairman of radiology informatics as well as medical director of pathology informatics at the University of Chicago School of Medicine, and medical director of enterprise imaging at the University of Chicago Hospitals.

“There are three dominant workflow models for advanced visualization processing,” Chang says. “The radiologist can do it; a super-technologist trained on the software can do it; or you can outsource it.”

In the diagnostic trenches, most practices opt for a hybrid that may incorporate all three models, he says. However, irrespective of what model is being used, a group must have an infrastructure in place that does advanced visualization processing efficiently.

“Your infrastructure and workflow model has to be agile, flexible and scalable enough to be able to support all three dominant models simultaneously,” Chang says. “Most facilities will have the radiologist and super-tech model in place, and there are some that use all three models.”

For example, in his role as a diagnostic radiologist, he finds that there are some reconstructions that require more of his time to perform than is practical given the volume of imaging exams he must interpret. In these cases, it is vastly more efficient and economical for a technologist skilled in utilization of the advanced visualization software to perform the image processing, and then have it sent to him for clinical interpretation.

Elliot Fishman, MD, professor of radiology and oncology at the Johns Hopkins University School of Medicine in Baltimore, and director of diagnostic imaging and director of the division of abdominal imaging and CT at the Johns Hopkins Hospital has been a long-time user of advanced visualization technology. He recommends that practices seeking to add advanced visualization capabilities to their service lines first look at their image acquisition protocols.

“The first thing, of course, is the ability to acquire the data sets,” he says. “So, whatever CT scanner you have, you need to know how to use the scanner well. You need to have it optimized, because when all is said and done unless you have a good data set, nothing else happens.”

Achieving expertise on the advanced visualization application is the next step a practice must take for successful deployment of the technology, Fishman says.

“The interpreting clinician must gain expertise on the advanced visualization software; it’s this post-processing that allows you to make an accurate diagnosis,” he says. “You need to know how to do the post-processing both accurately and in a timely fashion.”

Fishman states that the reasons most often cited for not performing cardiac CT studies are that it’s too hard to get the data and its too time consuming in the post-processing of the image data.

“Advanced visualization applications have changed—they’re much better; the tools are easier, simpler, and more quantitative, but you still have to learn how to use it,” he says. “I strongly recommend that, as the interpreting physician, you know how to do it yourself. It can’t be something a third-party does and then gives you the information—you need to be interactive with the data set or you’re just not going to feel comfortable reading the studies.”

The 3D laboratory

“A dedicated 3D lab can be the crown jewel your practice needs, a cutting-edge tool that will make your company outshine its competitors,” says Anthony Garcia, R.T. (R) (CT), 3D Lab / QC Supervisor for Tucson, Ariz.-based Radiology Ltd. “The capability to deliver multiplanar reformatted [MPR], maximum intensity projection [MIP], and volume-rendered images to your referring physician base can be a powerful market differentiator.”

Radiology Ltd. is a private-practice diagnostic imaging group that operates a number of imaging centers with more than 40 radiologists and more than 400 technical, clerical, and administrative personnel.

“As the practice has grown, nearly all the CT and MRI scanners have been upgraded to meet the competitive standards of the market,” Garcia says. “It soon became very obvious that the way to afford a large number of scanners was to increase the throughput of each machine, and the way to do that was to move image post-processing away from the image-acquisition workstation.”

He notes that the process to create 2D and 3D batched series for any particular study can engage the operator anywhere from five minutes for a MR angiography (MRA) head and neck exam to 45 minutes for a cardiac CT angiography (CCTA) peripheral run-off. Some of the more involved studies can take even longer. These processes tie up valuable time in technical and equipment resources that can be better utilized than if the processing takes place at the scanning station.

The practice boasts a dedicated 3D lab that handles an average of more than 700 studies a month. The lab processes a multitude of exams, ranging from MRA MIPs to coronary artery visualization and virtual colonoscopies.

According to Garcia, the practice uses a thin-client interface so the radiologist doesn’t have to load all the slice information to his or her reading station. And, since the reading workstation doesn’t have to expend processing power, on-call radiologists have the 3D lab’s resources at their home offices.

Staffing the 3D lab requires some forethought on the part of the practice, Garcia says.

“The use of the radiologic technologist is an obvious solution with the caveat that any technologist who is spending time on 3D is not spending time scanning,” he notes. “Consider using technical assistants to do the bulk of the standard 3D imaging required of the average study. Proper training and oversight provides an excellent option for more efficient and economical staffing that provides benefits for all professionals in a practice.”

Garcia’s 3D lab is staffed entirely by technical assistants who he supervises. He is responsible for providing their education and maintaining the standards of the practice. In turn, he is supervised by a radiologist who monitors the lab’s output to ensure quality control.

“Whatever scenario you choose for advanced visualization deployment, a dedicated 3D lab is a good way to give your practice a cutting edge in a highly competitive market,” he states.

Looking beyond radiology

Diagnostic imaging clinicians outside radiology also have adopted the technology, and report that its utilization has resulted in speedier workflow throughput—as well as bolstered practice referrals.

The implementation of advanced visualization at the Minneapolis Heart Institute in Minneapolis was driven by an uptick in CCTA studies.

“Our coronary CT angiography service line really started to take off once we got high-speed multidetector CT systems,” says Robert S. Schwartz, MD, a cardiologist with the practice. “We simply could not handle the huge amount of interpretative data being put out by these systems in an efficient manner. The workload we would have had by not having advanced visualization technology in place would have been simply staggering.”

Prior to the deployment of advanced visualization tools in the practice, the interpretation time for a CCTA procedure was anywhere between 20 and 30 minutes per exam.

“Since we’ve deployed our advanced visualization system, our read time has dropped down to 3 or 4 minutes for the more straightforward exams,” he says. “More complex exams, of course, take a little longer.”

An additional benefit of the technology has been the ability of the cardiologists to consult more efficiently and effectively with their referring clinician base.

“Because of the efficiency of the software, we’re able to be doing something else, put it aside, and pull up a 3D image and review it with a clinical colleague in a very short space of time; we’re quickly able to demonstrate the exact results of an exam,” Schwartz says.

Referrals to the practice also have increased since the addition of advanced visualization tools.

“We’re seeing more referrals since we adopted the technology; we’re able to send the reconstructions over the network or burn a CD that a referrer can take with them,” Schwartz says.

Michael Ridner, MD, a cardiologist at the Heart Center in Huntsville, Ala., and an associate professor of medicine at the University of Alabama School of Medicine in that city, also has found the addition of advanced visualization technology to be a boon to his practice’s workflow and throughput.

“What it has allowed to provide is network-wide visualization of cardiac CT angiograms, at any site, in any location,” he says. “This permits the cardiologists in our practice to work on these exams anywhere, including at home. In addition, we’re able to share our 3D reconstructions in our consultations with our referring physicians, as well as with the patients.”

The technology has paid unexpected dividends in the Heart Center’s affiliation with local hospitals. He notes that the cornerstone of the advanced visualization software is for diagnostic purposes in the practice, but it has expanded its capabilities well beyond that primary utilization.

“In the ER, we’re able to perform a reconstruction in the department and make a decision as to whether a patient should be admitted or released, which vastly expedites the workflow in that department for patients presenting with chest pain,” Ridner says.

Other clinical departments in their hospital client base also have sought access to the technology, with very positive results.

“It’s also shown great benefit for our cardiothoracic surgeons, where we’ve had a large screen display installed in the operating theaters for their use,” he says. “The surgeon can call up the 3D image in real time and use it to determine anatomy in order to better guide their surgical intervention.”

To demonstrate the capabilities of advanced visualization technology, Ridner and his partners at the Heart Center offered their entire referring clinician base the opportunity to have a no-cost CT heart scan conducted. They then performed 3D reconstructions and met with the physicians one-on-one to show them the images and discuss the results.

“We had over 300 doctors take advantage of this opportunity,” he says. “What happened is that when they saw the results, they were sold for life.”  

If you’re interested in learning more about the options available for advanced visualization technology implementation and deployment, please visit our Healthcare TechGuide. You’ll find company listings, specifications, accessories, white papers and services available from a host of major advanced visualization developers.