Managing the Flow in Radiology

Treatment Planning from Anywhere!
RadWhere Enhances Radiology Workflow
Vendor Neutral Image Archive Goes Live in Quebec

Treatment Planning from Anywhere!

“Thin client” architecture for PACS and RIS is becoming more common with imaging informatics vendors today. Now, the same type of thin client system is being applied to radiation oncology treatment planning systems, such as the latest version of Pinnacle3 SmartEnterprise solution from Andover, Mass-based Philips Healthcare.

Just as with PACS, the older “thick client” solutions for radiation treatment planning required an expensive, local workstation that exclusively handled all of the sophisticated image processing. Once created, those treatment plans stayed local to the hospital’s archiving system. Should the patient need to be treated at another facility, the information technology (IT) department would have to transfer the file to the new location. In addition, physicians were anchored to the workstations to create their plans. And should the plan need to change, older plans needed to be reconciled and replaced by the latest version.

With the new Pinnacle3 thin client solution, all of the graphics processing is taken care of by a central server without the need for expensive workstations. Furthermore, thin client architecture allows physicians to create oncology treatment plans from any off-the-shelf computer, whether that computer is in the hospital or at home.

Since November 2008, Philips Pinnacle3 SmartEnterprise has been installed in a total of 16 sites, including five facilities in the United States.

Even better, when plans are being archived in a single, central, and secure location, the latest treatment plan is available to any authorized treatment center, ensuring safety and efficiency for technologists, as well as flexibility for patients and physicians.

Ali Layeghi, RTT, CMD, medical dosimetry manager at the Radiological Associates of Sacramento Medical Group Inc, Sacramento, Calif, has been using the new thin client system since it was installed in late 2008.

He said, “The biggest thing is the whole configuration of our systems has changed. We have seven radiology oncology centers, and they all run on Pinnacle. We used to have individual servers at each center, and in some centers, we actually had multiple servers. With this new hardware that we installed last year, we now have one computer at our IT center, and everyone is connected to this one huge computer.”

As a result of the new configuration, Layeghi no longer has to transfer plans around from one server to another. “Now, as long as the patient’s file is closed on the system, anyone throughout our system can get to it, open it, and work on it. That’s been a great help.”

Layeghi noted that IT personnel are also happier because they can maintain one system as opposed to the 13 servers. Consequently, every time a software upgrade is needed, the IT people no longer have to patch each of the 13 servers. Now they can do one upgrade, and it’s done for every authorized computer in every location.

“That saves our IT and physics departments a lot of time,” said Layeghi. Physicians, he added, also appreciate that they can plan cases from home through a secure connection.

Another advantage is that clinicians no longer need to covet the most modern workstations, since the Pinnacle system works from any computer. “Everyone has the same capability,” said Layeghi. “Before, some systems didn’t have the full capabilities of the other ones, and some computers were faster than the older computers. So I had complaints at times from my staff or physicians who wanted that same capability as the more modern locations. Now, we don’t have that issue. Everyone has the same capability, the same speed, and the speed of calculation is much faster than what we used to have.”

Layeghi admits that he was worried that tying everyone to one computer could result in no one being able to do any work if something went wrong with the new system. As a result, he says he has kept some of the old workstations online, but has not had to use them yet.

“Every month or two, I take one or two offline. I’ve just been cautious, but we’ve not gone down at all,” he said.

?Tor Valenza

RadWhere Enhances Radiology Workflow

RadWhere, from Nuance Healthcare Solutions, is a front-end speech recognition system for academic centers, hospitals, and imaging centers with unique workflow, data-driven reporting, and communication needs. According to Nuance, it also offers industry-leading diagnostic imaging workflow management, where reports are created with a variety of dictation styles as well as data extraction tools necessary for analyzing productivity and outcomes.

Designed to address the needs of health care networks with multiple RIS, PACS, 3D, and teleradiology systems, RadWhere seamlessly integrates these elements into a single worklist for the radiologist. According to a press release issued by the company, it can launch an unlimited number of legacy and Web-based PACS viewers while intelligently returning orders to the appropriate RIS system from a single workstation. Integration partners provide image routing capabilities that utilize the RadWhere worklists to further streamline the radiology workflow.

Alberto Goldszal, PhD, chief information officer for the University Radiology Group in central New Jersey, applauds the capabilities of RadWhere. “The technology has come a long way in 10 years,” he said. “The ability to distribute all images and reports online is a key differentiator as to how far we’ve come. We are now capable of acting as a fully digital radiology operation from order entry to report distribution.”

RadWhere also provides substantial benefits for facilities that do not need the robust capabilities of multisystem workflow management. It drives RIS/PACS workflow in a single environment or can allow a third-party system to handle order lists, routing, editing, and electronic signature workflow.

“RadWhere provides the ability to receive orders from multiple unaffiliated identities/hospitals and dictate in a single platform or application,” said Goldszal. “This type of workflow orchestration is unmatched by any other application. It’s a single cockpit model that allows for a global workplace and is a major advantage because radiologists don’t have to learn various applications. In contrast, most systems are tied to RIS/PACS and can report only within a single organization. If an individual is reading for three hospitals, without a mechanism like RadWhere, they’d have to go to each hospital.”

Multiple Dictation Styles

RadWhere offers four dictation styles plus digital dictation to accommodate physician preferences. Among them is real-time speech recognition with self-editing. Real-time speech recognition allows one to view text as it is dictated. One can edit using keyboard, mouse, and standard word processing tools, or with voice editing. The software immediately recognizes spoken changes and additions anywhere in the report.

Another feature is Real-Time Speech Recognition with Auto-Loading Templates. The templates are mapped to procedure codes and are triggered by modifiers such as age and gender. Users can voice navigate standard text blocks, which are fully voice editable. Third, RadWhere features Real-Time Speech Recognition with Auto-Structured Reporting. The auto-structured reporting eliminates the need for the radiologist to follow a structured format of a macro, while natural language understanding (NLU) automatically structures report content. Once complete, the application presents the interpreting radiologist with a final report for review and edit. This intelligent phrase recognition and automatic organization tool can greatly reduce the time spent using conventional structured macros.

Lastly, RadWhere features Real-Time Speech Recognition with Transcriptionist Editing. This is a combination of front-end speech recognition with transcription edit workflow. Reports may be created using speech recognition and any of these reporting styles or through a built-in digital dictation interface.

As a practical example, Goldszal states that RadWhere interfaces with all of these systems, addresses all orders, and allows for filtering to create a global, uniform work list. He states that instead of having to open three or four PACS/RIS, one has a unique single cockpit that is able to capture all orders. “From a radiologist’s perspective, increased productivity is realized because you have to learn and work with only one set of tools.” Customers and referring physicians enjoy a more efficient turnaround time?from days to just hours.

?James Markland

Vendor Neutral Image Archive Goes Live in Quebec

Currently, it takes a great deal of information technology (IT) effort for a radiologist in Manhattan to instantly retrieve an archived imaging study from another PACS vendor’s archive across town. The problem is above and beyond mandated privacy laws and has as much to do with the different proprietary PACS systems that can communicate with each other only through cumbersome Digital Imaging and Communications in Medicine (DICOM) importing and exporting procedures.

One hospital system in Quebec is trying to make sharing imaging exams between disparate PACS easier through a “vendor neutral” solution developed by DeJarnette Research Systems Inc, Towson, Md, with project management provided by San Francisco-based McKesson Inc.

The vendor neutral image archive is being utilized at the Quebec Hospital Le R?seau Universitaire Int?gr? de Sant? de l’Universit? de Montr?al (RUIS Montreal) and RUIS McGill. Together, these two institutions cover 68% of Quebec’s imaging exams. The combined archive, called the Diagnostic Imaging Repository or “DI-r,” will store more than 6 million studies a year initially, and over 10 million annually within 5 years.

DeJarnette Research Systems Inc teamed up with McKesson Inc on a vendor neutral image archive.

DeJarnette’s xDL?, Cross-Enterprise Document Librarian is the core technology for this DI-r deployment. The xDL software was designed for medical image data sharing without requiring the connected PACS or RIS or other information systems to adhere to the Integrating the Healthcare Enterprise (IHE) XDS integration profile.

The xDL system also offers support for the emerging IHE data sharing standards (XDS, XDS-I, PIX, PDQ, etc). It’s also a scalable solution that can handle both small and large facility vendor neutral data sharing archives.

In July 2009, the installed system was launched with a 1,600 image CT study, which was acquired and stored to RUIS Montreal-McGill’s DI-r. The study was performed and reported using the PACS/RIS at l’H?pital G?n?ral du Lakeshore in Pointe-Claire, Quebec. It was then transferred 22 kilometers over Quebec’s RTSS (R?seau de T?l?communication du secteur Socio-Sanitaire) network to the primary Quebec regional data center located on the Boulevard De Maisonneuve, in Montreal. The same imaging exam was then replicated at a second Quebec regional data center located some 10 kilometers from the primary regional data center.

“This DI-r will be used as a long-term archive and as a tool to share medical images and reports across all the hospitals connected to it,” said Yves Domaine, program manager, McKesson Medical Imaging Group, in a joint DeJarnette and McKesson press release.

This is the first PACS vendor neutral image archive to go live in the three Quebec RUIS projects. Eventually, 12 medical facilities in Quebec will be brought online with the DI-r by year’s end and a total of 94 facilities will be connected to the DI-r by the project’s completion. The vendor neutral project is part of a Canada-wide DI-r initiative funded by Canada Health Infoway.

As America struggles to redefine health care, improve efficiencies, and switch digital archives and electronic health records, vendor neutral solutions such as this Canadian project may provide a practical solution for institutions over the more manual “pre-fetch” or “push” DICOM-based methods. Such protocols are typically IT labor intensive, and they are not automatic.

Alain Gauvin of McGill University, the lead architect for the project, sees several advantages in the vendor neutral system. “The xDL solution is essential in allowing us to address our considerable interoperability challenge, which requires us to connect many different RIS, PACS, and digital dictation systems to our central archive. The XDS-I support makes xDL ideally suited for subsequently integrating the archive under the umbrella of a unique, province-wide, XDS registry to reference all studies produced in our provincial affinity domain,” he said in the press release.

David DiNoia, DeJarnette’s director of program management and RUIS McGill-Montreal project manager, added in the announcement, “This shared medical image archive deployment is one of the largest and most sophisticated ever attempted. It covers two thirds of Quebec province, 94 medical treatment facilities, 2 large data centers, some of the world’s most sophisticated database synchronization technology, a storage GRID architecture, the interface of seven disparate PACS vendors, the interface of six disparate RIS vendors, the interface of seven disparate dictation system vendors, all in various combinations, while providing support for image and report distribution to nearly 10,000 referring physicians.”

For more information on the xDL system, visit DeJarnette at

?Tor Valenza