The Centricity RIS/PACS (center) from GE Medical Systems has integrated 3D reconstruction through technology.

In June, the Society for Computer Applications in Radiology (SCAR) held its annual symposium in Boston. It was SCAR’s biggest meet ever. All the news, it was easy to see, was about the action-packed, high-powered bells and whistles newly available for picture archiving and communications systems (PACS). Intuitive interfaces, ultra-high-speed transmission, multi-tasking, and big functionality from small companies are the trends.

Screen shots are from the Aquarius 3D reconstruction workstation from TeraRecon.

New technologies and savvier customers are clearly driving PACS development. One of the prominent market movements is toward Web servers, and for good reason. It’s one of those things that every facility with digital imaging will consider at some point, and likely acquire.

“A Web server is a key and necessary component of any kind of PAC system,” says David Parker, president of SmartPACS (Irvington, N.J.). “Its primary purpose is distribution of images throughout the enterprise and for wide-area network. One advantage is it allows the client workstations to be much less powerful and costly. Even more important, it allows them to be a much simpler device for management purposes. A facility that uses Web clients as opposed to primary-read client server workstations can reduce the cost of their enterprise clients — places like the OR, the ER, ICU, the floors, referring physicians’ offices, teleradiology, and all these enterprise-wide distribution destinations.” Parker’s is one of a number of companies now marketing Web servers; the SmartPACS solution is called StarPACS.

“We don’t feel at this point that Web is conducive to primary reading for radiologists and maybe orthopedic surgeons,” says Parker. “They usually need a more powerful tool that Web clients can’t deliver. We use a mixture of both ourselves. It’s not a quality issue. The images you see on almost anybody’s Web server are full-fidelity, full-resolution images. The only limiting factor in any of those is what the end-user is displaying images on.

“Five years ago a typical configuration of ours would’ve been 45 primary-read workstations in a facility that’s doing 200,000 exams. Now we would have it down to maybe eight, and all the enterprise viewers will be Web clients.”

Web-based PACS development has been responsible for changing digital image management and availability in other ways, too. For instance, there really is no longer a difference, as far as technology requirements go, between a referring or remote physician and a teleradiologist. Because the line is quickly blurring between a teleradiology system and a PAC system, many vendors agree that eventually there will be no distinction between the two. In the future, all such systems will likely resemble solutions like SmartPACS and Synapse 3.0 PACS from Fujifilm Medical Systems USA (Fuji of Stamford, Conn.). The latter has a feature called MultiView, which allows radiologists to review images from disparate databases at different sites together on one workstation.

“I believe that teleradiology is only another node on the network of wide-area network distribution of images,” says Parker. “It’s the same as images going to referral offices. It doesn’t matter whether it’s going to the town next door or to Australia. The term teleradiology should actually go away. It’s almost all teleradiology nowadays.”

Collections of simplified workstations that can replace expensive, bandwidth-hogging dedicated workstations is another concept whose time has definitely come.

“It is impractical and not cost-effective to put individual dedicated workstations that are quite expensive and complex to use at each point of remote review. That’s just not a good option,” says Steve Sandy, V.P. of marketing at TeraRecon, Inc. (San Mateo, Calif.). The company designed AquariusNET, its server for thin-client distribution. “The elegant solution will be the central shared resource that streams the result to those remote review stations by the use of the thin client, without clogging up the infrastructure or the bandwidth.”

Multi-slice exams, which are becoming more commonplace every day, present a management challenge all their own. Sandy says, “The most inefficient way to transmit them would be to send all the slices down a very limited amount of bandwidth which is used by lots of other people for lots of other purposes. Much better that all the studies remain on the central server, and that any remote PC anywhere can interact with those studies without the slices being sent to that individual local PC, or without that PC having any need or requirement for hardware, software, license fees, video card, memory, or a big CPU. It’s a very effective way that everybody can have 3D post-processing from any point in any review station, whether it be integrated into the PACS or a PC at home.”

What makes thin client distribution more effective? “The horsepower for advanced processing is in the server, not at the client,” says Sandy, “so a dozen or more PC clients can share a server at the same time, allowing each to function as though it has the power and speed of a high-end 3D multiplanar advanced workstation.

“We think the dedicated post-processing workstation is changing in its role, [that it’s] more for the power user or possibly 3D technologists for complicated work-ups — injection fraction measurements for cardiac function, or CT perfusion analysis,” says Sandy. “We think of the server client ideas as that which can be done very quickly, efficiently and within the workflow in a few minutes. Radiologists have but a few minutes [per read] in their everyday work. So the goal of the client is to do simple structural volumetric navigation with a tool anyone can use.”

Many PACS companies are starting to offer thin-client solutions, often based on commonly available hardware. For instance, the LightBeam diagnostic workstation from Amicas, Inc. (Boston) streams images to a Web-based viewer with a wait time of less than two seconds. The viewer also has integrated 3D capability that is operable using the same tools as for 2D exams.

Off-the-shelf hardware is another trend to watch closely, and one that seems inextricably linked with thin-client distribution and Web-based PACS. UltraVisual Medical Systems (Madison, Wis.) recently partnered with Emageon (Birmingham, Ala.) to market open-platform PACS with advanced vision capabilities at competitive prices. Even bigger players, such as Fuji with its Web-based Synapse PACS, are deliberately designing systems around open architecture concepts so that new programs may easily be incorporated as they become available. Algotec, Inc. (Duluth, Ga.) offers MediSurf software, which transforms any Web-enabled PC into a primary diagnostic reading station with a customizable user interface. It allows radiologists to access studies via a single DICOM worklist and thereby share workload, regardless of their locations.

In the PACS environment of the near future, proprietary equipment may very well be a thing of the past.

Integration and more integration
When people talk PACS, they talk integration. Vendors showing off their wares at SCAR were no exception.

SmartPACS’s Parker says, “For most of our customers, which are hospitals that do between 20,000 and 100,000 exams a year, the real key is integration with RIS and HIS, getting good workflow and increasing communication.”

TeraRecon’s Sandy says the magic word is “tools,” as in “integration of all the necessary tools within the PACS workflow — PACS, RIS, HIS, Web distribution and 3D — all within the same toolkit.”

TeraRecon makes the Aquarius workstation for 3D reconstruction. It strives to simplify what Sandy calls the main issue confronting radiology: slice overload from multi-detector scanners. “The huge amount of slices is going to spark a paradigm shift in the way people read images. No longer is it feasible for people to start with a 2D, static axial image with the amount of slices that they have to read.

“In a nutshell, the paradigm shift is this: viewing the entire CT or MR volume of images as a volume, navigating through that data set and, once the pathology is identified, possibly reconfirming back on the original 2D slice. Doctors want to be able to do this within the PACS workflow, and the way to do that easily is to integrate the central server approach so the client can be launched from any PACS review station.”

GE Medical Systems Information Technologies (GEMS-IT of Milwaukee, Wis.) recently integrated TeraRecon’s Aquarius 3D reconstruction processor into its Centricity system, the RIS/PACS version of which was launched late last year. Peter McClennen, general manager of global marketing for GEMS, explains, “All the 3D is now available on every PACS workstation, so you don’t have to go to a dedicated third-party workstation to pull out specific studies to do intense clinical applications — subtraction, image fusion, cardiology things and all the visualization.” GEMS is currently fine-tuning its futuristic visual technologies and testing integration possibilities at the Baltimore V.A. Medical Center in Maryland.

HIS/RIS/PACS, et al
Combined hospital systems may be the most important integration movement of the decade. All the major vendors now offer some type of information systems combo, with smaller vendors coming up with their own innovative versions for institutions of all sizes and budgets.

At the enterprise level, GEMS’s Centricity RIS/PACS includes brokerless integration, with a single desktop each for the radiologist and the technologist. “It really improves the workflow in the clinical trenches,” says McClennan. “They share one image database, and then you have an order management database for RIS-type functionality and a single reporting module.”

The new 2.0 version of Centricity, launched at SCAR, is both a radiology and cardiology system. “You can have custom workflow within the radiology and cardiology departments, but have a common database and Web distribution,” says McClennan. “You can distribute both radiology and cardiology images with a single patient jacket. Brigham and Women’s Hospital [Boston] is implementing the system now. They have 170 ECG carts, and we’ve integrated them all into Centricity so that on the same Web browser, you can see images, reports, and ECGs. We reduce the total applied time the clinician has to spend to collate the diagnostic data for a cardiology patient. And just creating a single Web application for radiology and cardiology was not a small task. It’s more than just an order management system. All the ECGs, image data, gas levels, and procedural information that happen during a cath procedure are combined to create a complete structured report within minutes, and users don’t have to search disparate devices to find this information.”

What customers want … now
The rapid evolution of PACS, vendors will tell you, has a lot to do with customer feedback. Manufacturers are listening, and the results are impressive.

“Radiologists are very focused on large data set management,” says McClennen. “They want very specific hanging protocols. If you have a thousand slices from a CT scanner, you must have a very precise hanging protocol to display the data the way you want them. No two users read the same way. Radiologists want a very customizable workstation; they’re going to spend their entire day in front of a workstation. If it’s not customized, it’s going to impede the radiologist’s workflow.”

Vendors are now going all out to meet that requirement. “We can automatically hang an image,” says McClennen, “with all the window and level parameters set with the specific sequences hung how the radiologist likes them, based on upcounts and the physics of that image.” GEMS has also designed a prototype for a fully customizable, ergonomic radiology work pod that includes an adjustable comfy chair and lighting along with preference pre-sets for multi-user workstations.

“One feature people are requesting is real-time based information,” says Hamid Tabatabaie, president and CEO of Amicas. That’s why the company started delivering a system with a real-time worklist in May. “Any time anyone changes the status of an imaging procedure, everyone else gets to know. As soon as the technologist starts to do the exam, radiologists can see that on their screens. The ER can see that the patient they ordered a CT for just got finished and is about to be rolled back into the ER. Effectively, it’s like a FedEx tracking system: Every step of the way, you know where your patient is and what was done.” The worklist is customizable, too. “Without touching the screen or keyboard, it automatically gets updated.”

Another thing customers want is to get into the digital revolution at a good price. Vendors of all sizes have obliged with products suitable for imaging centers and community hospitals. Agfa HealthCare (Ridgefield Park, N.J.), for instance, now offers Impax Basix, an entry-level version of its PACS. It is purpose-designed for small- to medium-sized facilities. TeraRecon’s budget-sensitive entry is AquariusBlue, a real-time 2D review/3D post-processing diagnostic workstation. It packs a lot of features in a product that’s especially attractive to economy-minded end users. While RealTimeImage (RTI of San Bruno, Calif.) has partnered with Kodak Health Imaging (Rochester, N.Y.) and Inphact (Brentwood, Tenn.) on big systems, many smaller facilities that can’t afford a full-blown PACS are using RTI’s economy solution, iPACS. The company recently shipped its 250th unit.

iPACS is popular because it utilizes an advanced streaming technology that enables diagnostic-quality images to be distributed quickly over the Internet. This is extremely attractive to facilities lacking a private network or high-bandwidth availability, especially those working with remote physicians.

Voxar 3D color volume rendering with bony landmarks dimmed showing multiple aneurysms in the Circle of Willis.

“iPACS enables connectivity of multiple modalities as well as online storage and archiving of those images,” says Zohar Elhanani, V.P. of medical imaging for RTI. The typical installation “just wants a place to archive images and have dedicated workstations along with our Web viewer. Our viewer has most of the functions that a workstation would have, and it runs on Internet Explorer. It doesn’t have 3D presentation or editing capability yet [it will by year-end], but it has full manipulation capability. You can always tie into a third-party workstation, like a Voxar [of Framingham, Mass.] or a TeraRecon station. There’s full query/retrieve capability from our database.”

Fewer systems, more functionality
Since a PACS is a computer, and computers can be used to automate functions such as patient/doctor access to records, it only makes sense that the two should be combined. Programs already available typically allow physicians to remotely access patient images, or they allow patients to access their own data records. Few do both, and fewer still allow patients to access images.

Diagnostikzentrum Graz (DZG), an imaging center in Graz, Austria, is nudging the edges of that envelope a bit. DZG developed a product called Patient Account that it’s beta testing on its iPACS Web server from RTI. It’s an online service that allows both patients and doctors to access DZG patient files. It also allows patients to authorize file access to additional doctors or facilities as the need arises. Some 200 referring physicians and several hospitals currently use Patient Account.

Peter Kullnig, M.D., owner of DZG, says Patient Account was developed to answer a problem common among all imaging providers. “When a patient was sent to us from a referring physician and later went to a hospital, the hospital didn’t have access to the images [because of Austrian privacy laws similar to HIPAA]. We solved that. Now every DZG patient receives his or her own account. The patient can then access images and reports wherever he or she is, and can grant access to them to whomever he or she wants.” If a patient changes physicians, the patient can authorize file access to the new physician. “So wherever the patient goes,” says Kullnig, “to a hospital or different physician or specialist, the patient can give doctors access to his or her images. They can use any PC with Internet Explorer 5.0 or higher, and they can use Internet connections from the lowest to broadband. The images are full-fidelity DICOM,” delivered by RTI’s streaming technology over the Internet.

Meaningful attachments
One of the niftiest (and arguably long-overdue) PACS capabilities has finally arrived: images embedded in dictation and data reports. RTI, for example, has added a module to iPACS that allows the attachment of PDF, Word, MP3 or Wave files to a specific patient file. “Once that’s uploaded with a simple click of a button,” says Elhanani, “anyone accessing a study would be able to click on that study and view the report, and the PDF, Word or sound file will open up on the viewer or be heard.”

Somewhat surprisingly, a study conducted by Algotec revealed that most doctors don’t want to get clinical results by e-mail. The main reason, they said, is that such reports typically didn’t include all the information they need. “More than 99 percent of them have PCs in their offices,” says Kobi Margolin, V.P. of marketing for Algotec, “but only 10 percent use them to connect to the Internet, to read e-mail, or for clinical applications.”

That could all change with Algotec’s new application, E-Report. “It’s a Web-based report that includes not only the textual data, but also some key images identified by the radiologist that highlight the dictated findings,” says Margolin. “It provides an automated tool that takes the radiology report, once the radiologist signs off on it, and automatically puts some key images onto the same page. It’s an MHTML page, which allows you to include JPEG images.” Any E-Report page can be distributed to referring physicians via e-mail, on a CD, as a PACS download, or printed to hard copy, all by using standard Web tools.

Potential becomes success
Much of the excitement at SCAR involved the promise of combining functions to provide more economies for PACS users. PACS is, after all, a computerized system capable of doing the myriad things computers are designed to do. It can — and should — involve far more than just warehousing and shipping pictures. In many cases, it already does.

“Hospitals accept that they have to speed up their processes,” says Kurt Reiff, international sales director of RIS/PACS for Siemens Medical Solutions (Malvern, Pa.). “PACS has been around now for about a decade, but it’s still very much an experimental thing, in many ways. It’s not only looking at images; it’s also about options to be more productive. Siemens has about 1,000 RIS/PACS installations worldwide, half of which are tied into a HIS. And with the shortage of radiologists in the U.S., you have partners in Israel, Pakistan, and India who read images from night shifts using Web PACS technologies. In the same way that car manufacturers have used business improvement tools to boost productivity,” says Reiff, “hospitals are doing that now, too.”