3D advanced visualization tools go mainstream as health care institutions realize the benefits of anywhere access.

James Cameron?s Avatar recently exposed the masses to the experience of three-dimensional film and revealed that?when done right?audiences appreciate the added value. The movie generated a box office total of more than $746 million in its first 4 months of release. The reception to three-dimensional advanced visualization tools by medical imagers has not been quite as fervid or lucrative as the award-nominated blockbuster, but it has generated its own enthusiasm?more for its functionality than its fun?as well as a healthy return on the investment.

?The most dramatic [transformation] in the evolution of advanced visualization tools is the move from ?recreational use? to ?mainstream use,?? said Henry Krebs, MD, medical director of radiology at St Joseph?s Hospital in Atlanta. Faster computing power, greater bandwidths, better algorithms, friendlier interfaces, and increased storage capacity have made the use of advanced visualization tools more accessible not only to radiologists, but also to all clinicians within a health care community.

Rich Hallett, MD

Henry Krebs, MD

Rasu B. Shrestha, MD, MBA

The increased access has, somewhat naturally, resulted in increased use, with many facilities offering enterprise-wise and/or remote access. When Jon Bradrick, DDS, director of the division of oral and maxillofacial surgery within MetroHealth Medical Center and associate professor at Case Western Reserve University (both in Cleveland), introduces 3D advanced visualization to neophytes, they always ask where and how they can find his technology. They rarely need to ask about the benefits because they seem evident right away.

Anytime, Anywhere

The biggest wow factor is perhaps the ability to access advanced visualization tools from anywhere at anytime by anyone (who has proper credentials, of course) with the advent of Web-enabled access and thin-client technology. ?Almost all vendors now have some variant of an enterprise-wide or distributed solution, whether it?s a workstation with Web access or a thin-client server platform,? said Rich Hallett, MD, chief of cardiovascular imaging for the Northwest Radiology Network in Indianapolis, and adjunct clinical assistant professor at Stanford University, Palo Alto, Calif.

Thin-client software is easily distributed, so that rather than clinicians having to make a physical trip to an enabled workstation to access advanced visualization tools, they need only find a nearby computer?standard workplace issue will do. ?I can access [these images] on my office desktop PC, the workstations in my clinic, in the operating room, in conference rooms, and on a laptop from home or on trips,? Bradrick said.

In general, remote access functionality, including speed and quality, matches that of on-campus systems. Speed may sometimes be an issue, depending on the system?s capabilities and the available bandwidth, but vendors often offer compression capabilities for quicker performance. The subsequent degradation of the image does not impact referring clinicians, but may alter the radiologist?s decision to proceed. Without compression, radiologists typically have no complaints about remote image quality. ?I have used one 3D solution via thin-client on an airplane, and it worked fine. Speed depends on vendor, but I have found myself very comfortable using DSL speeds and up,? Hallett said.

Easy to Use

In general, physicians are comfortable with the usability of these programs. The learning curve has flattened over the past 5 years as systems have become more intuitive and radiologists more computer savvy. ?Most [systems] have a low to moderate learning curve. The user interfaces have become much easier to learn across the board, but it still takes a little bit of time and some dedication to learn them,? Hallett said.

Rasu B. Shrestha, MD, MBA, medical director of digital imaging informatics and chief of the division of radiology informatics at the University of Pittsburgh Medical Center, outlines a three-step training process designed to maximize clinician use. Pretraining occurs early, even before the system goes live; ideally, the vendor involves radiologists, technologists, clinicians, and IT personnel in mapping and documenting workflow. During the training phase, users are presented with take-home materials and attend hands-on sessions addressing their particular needs over a period of days. Post-training features follow up 2 weeks to 2 months later to make sure difficult concepts are understood and offer the opportunity to ask questions.

Typically, the basics are easy to grasp and become second nature for most radiologists; many clinicians find the basics are all they need. ?You can do probably 95% of everything you want to do with 5% knowledge of the package,? Krebs said.

Clinician DIY

The easy accessibility and usability have opened up the world of advanced visualization to clinicians outside the field of radiology. ?[In the early days] there were usually only a few radiologists who were the ?workstation jockeys? and could produce good 3D images and other manipulations. Now, almost anyone can do it,? Krebs said.

Surgeons and oncologists have been particularly avid users, finding the images helpful in addressing specific clinical needs, such as development of surgical plans. ?Oncologists who want to look at fused PET/CT images to see tumor response no longer have to rely on the radiology report or a visit to [the radiology department]. They can directly interact with the data, update their own measurements, and track treatment response more accurately,? said Pedro J. Diaz, PhD, vice chair of imaging and informatics systems in MetroHealth?s department of radiology and an assistant professor at Case Western.

The debate, according to Shrestha, is to what extent clinicians outside of radiology should be given access to advanced visualization tools. ?There are some who say that giving nonradiologists access to the same set of advanced visualization tools [available to radiologists] may dilute the value of the radiologist, but I believe that if done right, there is, in fact, tremendous opportunity to bring the value back to the radiology department,? Shrestha said.

Faster, Smarter, Better

Anywhere access to advanced visualization tools creates efficiencies in the workflow that can have a positive impact on turnaround time and diagnostic accuracy. Greater computing power and improved algorithms have permitted the automation of more image preprocessing applications, such as bone removal or fly-throughs.

This reduces the time spent on initial image manipulation, whether done by the technologist or the radiologist. Different institutions take different approaches to the workflow: sometimes technologists are responsible for preprocessing; other times, the task falls to radiologists who may be better positioned to answer their own questions.

Greater computing power and improved algorithms have permitted the automation of more image preprocessing applications such as bone removal or fly-throughs.

However the work is shared, quicker preprocessing streamlines the entire workflow. Fast acquisition and processing allow technologists to scan more patients and radiologists to handle greater volumes.

?It?s much more rapid. A [whole-vessel] reconstruction that used to take a 3D technologist 15 to 20 minutes to perform can now be done with one?or even no?clicks in 5 or 10 seconds. Instead of reading a runoff study in 30 minutes, it takes me 5 to 10 minutes,? Hallett said.

The shorter turnaround time means physicians are better prepared and patients receive more specific treatment in less time. Bradrick is frequently consulted on emergency cases while in the clinic, and before seeing the patient, he is able to access relevant information, such as the presenting symptoms, patient history, laboratory results, and images.

?I know 90% of what I need to know from a computer screen in front of me before I even get up and go someplace else within the hospital,? said Bradrick, recalling that years ago, radiologists would have to make calls and walk around the hospital to gather the same data.

However, even though information may be fingertip-ready, clinicians often have to navigate computer applications rather than halls, which can still take more time than physicians may have. ?If you have to stop what you?re doing and launch into a separate worklist, not only does it take time, but it also [presents an opportunity for error], such as picking the wrong study or patient,? Krebs said.

Therefore, the integration of these systems with PACS is fairly common; sharing data with the other information systems, such as EMRs, is more complex. ?It?s not as seamless as I would like it to be, but it?s very easy for someone sitting on our PACS application to have the EMR file open, so the thin client has opened up opportunities to achieve a level of integration we couldn?t do before,? Bradrick said.

Like Face-to-Face

The implementation of remote access and enterprise-wide capabilities also permits greater medical community integration because it offers convenient collaboration, communication, and teaching tools for all parties: technologists, residents and fellows, radiologists, referring physicians, and patients.

Technologists and radiologists share a smoother workflow since technologists can save their preprocessed image files for others to access. ?Anyone who comes to look at that study after preprocessing picks up where the technologist left off. So, the data is already digested and presented in a very efficient and optimal form for the attending physician,? Diaz said.

3D images can be manipulated in real time, giving patients a better understanding of the diagnosis.

Similarly, the radiologist can more smoothly collaborate with other clinicians for consultations with specialists and referring physicians, as well as residents and fellows for educational purposes. ?When there are ways to conference from different locations using the same data set, it can really help the patient. For example, finding the narrowing area of an artery might be useful in determining the balloon diameter to use,? Hallett said.

The 3D images can be manipulated in real time, enabling greater understanding of the diagnosis, particularly from the patient standpoint. ?Patients can?t understand what a two-dimensional CT slice looks like, but they can understand three-dimensional imaging. Frequently, I take patients to my [thin-client] workstation and show them their scans and pathology using three-dimensional reconstruction?sometimes I also have a dried skull that I rotate in unison with the images on the screen?and they all come away saying, ?I finally understand what?s wrong and exactly what my surgery is going to be,?? Bradrick said.

The Bottom Line

All of these advantages associated with enterprise-wide and remote accessibility to advanced visualizations tools can bring economic benefits through additional revenues, expanded capabilities, workflow efficiencies, and improved care.

Currently, a few CPT codes exist that are directly applicable to the use of advanced visualization tools; others bundle 3D imaging in with the study?s reimbursement. ?While the amounts paid are not extravagant, this can at least be a break-even possibility. The bigger benefit is time savings and increased productivity,? Hallett said.

Both help to expand capacity and, thereby, generate new revenue. Streamlined workflows can shorten medical procedures (freeing up expensive OR time), reduce patient length of stays (freeing up beds), and increase treatment effectiveness (freeing patient care of surprises).

Faster turnarounds, better clinical information, and improved patient outcomes result in not only happier referring physicians, but also more of them. ?We see more referrals for peripheral CTA once referring physicians learn we can provide a high-quality, robust product,? Hallett said.

Adding further incentive to transition from thick client to thin client, the increased access comes at a cheaper price. The need for expensive workstations has abated at the same time that the cost of high-quality monitors and storage (needed in large amounts for image files) has come down.

Previously, workstations could be purchased in conjunction with a system?s purchase or on an individual basis. Either way, they cost anywhere from $75,000 to $250,000, a prohibitive price. ?So you couldn?t have enough of them in the department to serve the people who wanted to use them,? Krebs said.

Comparatively, St Joseph?s latest advanced visualization package ran a little more than $100,000 for six concurrent-user licenses. ?If we find out more of our clinicians want one, it?s a small incremental upgrade,? Krebs said.

Purchase options vary according to the vendor and range from zero cost??there is a 3D postprocessing software available for Macintosh that is free and very robust,? Hallett says?to $200,000. ?Some vendors have proprietary server and processor software, while others allow the site to pick the hardware and license the software only. There are also hybrid-type solutions,? Hallett said.

Basic and popular advanced applications are typically included in the purchase price, but most vendors have the ability to add and subtract specific capabilities, such as CT angiograms, virtual colonoscopy, or dental imaging. Very advanced programs may require additional expense.

Service and maintenance are reasonable and tend to be less expensive in thin-client systems because they involve one point of contact. ?It?s a one-time purchase, one-time expense, one point of management, and one database,? Diaz said. Management is similar to that for existing IT systems, facilitating network authentication, program deployment, and regulatory compliance.

The benefits?clinical, functional, and financial?mean that advanced visualization tools, including 3D reconstruction, may have an even bigger impact on medicine than Avatar has had on entertainment.

Renee Diiulio is a contributing writer for Axis Imaging News.


As technology has improved and demand has increased, the number of options for facilities that want to take their advanced visualization tools enterprise-wide and off campus has increased?nearly all vendors now offer some solution to address this demand. Axis Imaging News checked out the solutions used by the experts we consulted.

Philips Healthcare, Andover, Mass, offers a number of solutions within its iSite family to address an institution?s range of medical imaging needs. The iSite PACS delivers enterprise-wide medical image and information management. The solution integrates into existing infrastructure and can employ advanced API functionality to image-enable the institution?s EMR. Tools are available for steps throughout the workflow, including exam lists for technologists, worklists for radiologists, department-specific worklists for clinicians, and full-patient views for referring physicians. iSite Enterprise enables immediate anywhere access to images and features a customizable, intuitive interface, integrated advanced visualization tools, and realtime image delivery to multiple locations. Additional tools include iSite Radiology, iVault, and iSite Volume Vision. (www.healthcare.philips.com)

TeraRecon Inc, San Mateo, Calif, has based its Aquarius portfolio of products on the company?s iNtuition platform architecture. iNtuition-enabled Aquarius products provide an advanced, procedural workstation configuration for the 3D technologist, a powerful reading/browsing station for the diagnosing clinician, and a fast, simple 3D review tool for the referring physician. The AquariusAPS automates preprocessing steps, such as bone removal and detection of centerlines; technologists have the option to validate the work. The images and tools are made widely available with the AquariusNET Server, a thin-client application that works with both LAN and WAN. Other offerings include Aquarius Workstation, AquariusBLUE, and Aquarius Gate. (www.terarecon.com)

Visage Imaging Inc, Andover, Mass, developed its latest generation of the Visage product family using thin-client streaming technology. Visage 7, running native on both Windows and Apple operating platforms, is a diagnostic image solution that is a universal viewer, incorporating 2D workflow tools with advanced clinical 3D applications, ideal for remote access to advanced functionality. The worklist unites multiple locations without routing or replicating images between servers and workstations. The Visage product is a scalable plug-and-play solution designed for rapid 2D/3D-based image interpretation, post-processing, and image distribution. Data from virtually all modalities can be viewed and processed, including Mammo, CR, CT, MR, PET, and PET/CT; clinical packages have been designed for cardiac, oncology, and neuro use and are now included for all users. Visage 7 may be used as a primary system or integrated with an existing PACS to improve clinical functionality. Additional products include Visage PACs and Visage RIS. (www.visageimaging.com)

Vital Images Inc, Minnetonka, Minn, offers the Vitrea Enterprise Suite, a portfolio of advanced visualization tools, clinical applications, and data management systems. Vitrea Core is a scalable, thin-client solution featuring Web-based accessibility to images and tools, as well as integration with PACS and EMR systems. Vitrea Advanced permits customization, with specific applications designed for cardiac, neuro, vascular, oncologic, virtual colon, and orthopedic. The company?s Vital Image Management System (VIMS) stores all data in one centralized server and enables access from advanced visualization workstations and PACS workstations, through Web browsers, or via integration into the EMR. Vital Services are also included. (www.vitalimages.com)

?Renee Diiulio