Douglas Page

The phenomenal popularity of Internet sites like Facebook, Twitter, and YouTube has forced developers at those giants to find new ways of handling massive workloads using virtualization, dynamic scaling, and cloud computing.

Healthcare IT and radiology image management are watching these developments, albeit at a safe distance. As healthcare begins to embrace the electronic medical record, hospital IT infrastructures must find ways to manage enormous patient data files. EMRs are not complete without digital imaging; yet digital image files have grown in size exponentially with the rise of high-field MR, multidetector CT, and digital mammography.

Decentralized radiology departments and demands for remote reading also require faster delivery of digital images through the enterprise, across town, and around the world.

“There is a growing need for information systems that have no boundaries,” said Jim Morgan, executive director for Network Systems at Fujifilm Medical Systems.

If radiologists can access imaging studies from just about anywhere, patients are beginning to wonder why their medical records can't likewise be accessed from any clinician's office or any emergency department, no matter where they're located. Demands for EMR integration with regional health information organizations (RHIOs) and continuity of care records (CCRs) are beginning to surface.

“The only way for radiology to meet these growing expectations is to move to cloud computing, and to use web technologies for the support of next-generation radiology tools,” said Shelly Fisher, president of Brit Systems.

Brit and other industry vendors are watching social networking sites like Facebook closely, where open application programming interface (OpenAPI) has become a popular solution to interconnect websites in a seamless, user-friendly manner. This tactic opens a new generation of possibilities for radiology image management.

Brit is implementing browser-based technologies in Roentgen Works, its next-generation PACS, and has developed a suite of radiology workflow solutions that require no installation of a client and no downloads, not even Flash.

“Our next-generation applications also provide CCRs and will communicate to personal health repositories, such as Google Health,” Fisher said.

Agfa HealthCare plans to exhibit a new version of its Impax Data Center at RSNA 2009 with features that, among other things, support sharing of enterprise medical data and images for integrated delivery networks and/or large regional health information exchanges.

Additionally, Agfa is planning to introduce new enterprise-class viewers in 2010, providing faster, simpler, and more flexible viewing for broad types of medical data.

Demand for wide area radiology has inspired Sectra to focus on making decentralized providers more productive. In June, the company launched Sectra PACS release 12.1 with RapidConnect technology, which enables workload sharing across multiple sites.

“We see the need to improve productivity and resource utilization more than ever,” said Martin Håkansson, Sectra's marketing vice president.

Håkansson said providers need ways to enable collaboration and resource sharing across geographic and subspecialty boundaries, demands that have been catalyzed by current economic conditions and proposed healthcare reform measures.

Vendors are also seeing a need for desktop virtualization and consolidation of applications and storage systems on a single set of servers. In virtualized environments, applications are hosted on a central server rather than on individual desktop devices. Among other benefits, maintenance and support is streamlined because malware worries vanish, along with antimalware license fees. IT support costs can be drastically reduced.

Fujifilm, for instance, has deployed imaging solutions that exploit storage and server virtualization in an attempt to lower total costs of ownership and facilitate better image distribution across the enterprise.

GE's Centricity Enterprise Archive expands beyond traditional radiology and cardiology departments to provide a centralized, scalable archive for DICOM objects from multiple departments and multivendor applications. The platform is poised to manage images from endoscopy, ophthalmology, dermatology, and oncology.

“The end result is an application-neutral, multidepartmental image repository that enables an enterprise to create a single longitudinal patient jacket for users across a region that includes multiple hospitals and imaging centers,” said Don Woodlock, a GE vice president and the global general manager for healthcare IT.

While IT systems are consolidating, radiology groups are dispersing. The trend in some radiology groups is toward less geographic consolidation. While procedures such as angiography and fluoroscopy require onsite radiologists, onsite reading of conventional studies is not necessary. Vendor-neutral solutions are making it increasingly possible to manage and distribute images across the enterprise and beyond.

“Time is money and technology is eliminating the time it takes to make money,” said Tyler Harris, NovaRad's director of implementation.

NovaRad's NovaPro facilitates the receipt of DICOM images from unlimited unaffiliated imaging practices and ensures images and information remain separate.

Harris said image retrieval is provided without the need to store or maintain the image file. Images are scrubbed from the archive when a predetermined storage limit is reached, although if archiving is required, the system can be configured as a complete PACS.

The Health Information Technology for Economic and Clinical Health Act of 2009 is the driver behind system interoperability, and interoperability is driving IT consolidation. In radiology, this is expressed as rapid, more efficient communication among different PACS platforms to facilitate workflow across multisite institutions.

With economic and quality-of-care pressures, facilities need fast access to all kinds of health data from anywhere in the enterprise and beyond. Vendors are positioning their solutions to meet these demands.

“The top trend we're following is interoperability, or enterprise reading, which has reading groups purchasing their own image management and reporting systems to read from, as opposed to logging on to various hospital or imaging center systems,” said Seth Koeppel, senior vice president of sales for eRAD.

Many teleradiology service providers already do this, but now community-based reading groups are seeing the advantages.

Koeppel said eRAD is positioned well for this development with its uniRAD solution, which is capable of receiving and making accessible images from a single worklist, managing multiple HL7 interfaces, and communicating with an unlimited number of DICOM archives. Also, a separate RIS is unnecessary since the company's uniRAD has dictation/speech recognition functionality built into it.

Carestream Health is responding to the interoperability trend with its SuperPACS, an architecture that streamlines radiology workflow by allowing radiologists in any location, onsite or remote, to read from a global worklist that serves all sites in a healthcare system. This enables cross-site collaborative workflow, allows optimized use of radiologists, and provides efficient subspecialty reading.

In the near term, Carestream Health intends to launch a vendor-neutral archiving solution that allows centralized clinical information control and archiving, including viewing of imaging exams and other types of patient documents from multiple locations and disparate systems.

Clinicians will be able to view laboratory and pathology reports, DICOM imaging studies, video files, and other patient data from a single unified desktop, regardless of where the data are located, Padan said.

Compressus operates on the theory there is no such thing as a standard radiology practice, that workflow, process, and care delivery vary from practice to practice. Rapid and robust workflow customization for each environment is therefore necessary.

“There is no one off-the-shelf solution,” said Janine Broda, Compressus' chief marketing officer.

Broda said Compressus' MEDxConn-ect remains the first and only software solution that indexes, integrates, and routes all relevant patient data in real-time, improving physician efficiency, reducing enterprise costs, and increasing patient safety.

Physician efficiency is also a focus at RamSoft, which plans to unveil PowerServer 4.7 at RSNA. This package enables referring physician online ordering and reporting of critical findings.

“Radiologists can now report a critical finding with the click of a button,” said Marilyn Solano, of RamSoft's marketing and business development department.

In September, Merge announced a new zero-client web platform designed to image-enable EMRs and other health systems. This technology is available for healthcare providers via Merge's new FusionWebT product line.

“Also, with our recent acquisitions of Confirma and etrials, we now have the capability to bring better interoperability to Confirma's CADstream solutions and to imaging in clinical trials,” said Julie Pekarek, Merge's chief marketing officer.

Other new productivity solutions are appearing.

Siemens is developing a system that complements and integrates its advanced imaging offering with PACS. This solution combines 2D, 3D, and 4D reading, which enables fast reading in any dimension, in one place. The system features case-specific reading.

“Based on clinical images, the system automatically knows when to call up 2D, 3D, or 4D applications, it remembers user preferences, and sorts images accordingly. Thus, reading tools and layouts can be adapted to the user's daily requirements,” said Henri “Rik” Primo, strategic relations manager, image and knowledge management for Siemens Healthcare.

Siemens has also made enhancements to its existing syngo Imaging system, including the ability to park patient information in the event workflow is interrupted, and to display image data of different patients side by side.

As a scalable solution, this syngo version can handle up to 750,000 procedures per year, Primo said.

ThinAir Data sees a present need for groups to read more efficiently as well, but it places an emphasis on more intelligent business and contract management solutions so groups can make the best use of their most valuable resource, the radiologist.

“Helping radiology be more efficient and profitable is more than simply hooking systems together,” said Tony Gevo, director of sales and marketing for ThinAir Data. Gevo said the company plans to unveil a new version of its TeleRIS at RSNA 2009 featuring a new set of tools and a new pricing structure that makes this demand for efficient, profitable reading more possible.

McKesson also believes that now more than ever it is important for providers to focus on their core capabilities, on how to improve their IT infrastructure, and how to reengineer their workflow.

Articles

Advanced computing architectures are necessary to support the demands of wide area radiology.

Imaging forecast: warmer, chance of cloud computing

When economic hard times hit, the instinct of most companies is to take shelter, reduce spending, and wait for good times to return. In order to preserve dwindling capital assets they grow timid, cease acquisition activity, and slash advertising budgets.

Firms do this in spite of numerous studies showing companies that continue expansion activity while maintaining-or even increasing-advertising levels during recessions do significantly better financially than those that react to economic storms by downsizing and reducing spending.

The same principle applies to imaging centers and IT. Those facilities that continue to enhance their IT components and upgrade their digital infrastructure during economic downturns tend to increase market share through added efficiencies. Because the economy has lost momentum does not necessarily mean that sound business drivers have lost validity.

During the current recession, some imaging centers continue to sculpt their business models around efficiency gains. Information technology is the tool of choice; excellent customer service is the target. Satisfied customers, whether patients or their clinicians, translate directly to increased market share.

Battlefield Imaging's use of high-end digital technology and advanced IT in pursuit of superior customer satisfaction is an example.

The solutions in place at the Ringgold, GA, center include NextGen software for practice management and Siemens' syngo Suite for RIS/PACS and report distribution. Battlefield believes an unconditional commitment to IT growth improves customer excellence.

Battlefield's director of imaging, Barbara Marshall, said the center's goal is to provide comprehensive imaging services in a timely manner to every customer.

"If we don't stay current, we face the real possibility of losing that referral," Marshall said.

Battlefield performs about 45,000 imaging studies a year.

Battlefield installed syngo Suite just over two years ago. Marshall said the system has allowed the center to enhance customer service in several areas, including expedited scheduling, more efficient registration processes, and quicker exam throughput.

Patients are not the only ones to benefit. Patient demographic data collected during scheduling automatically flows to the RIS, and also populates modality worklists.

"Technologists no longer have to take the time to complete the patient demographics because it is automatically populated," Marshall said.

Technologists are now also able to transmit images to PACS and referring physicians with the click of a button.

"All in all, these IT improvements have increased our efficiency, improved employee morale, enhanced patient satisfaction, and streamlined communication with our referring physicians," Marshall said.

Dr. James Busch, one of 10 radiologists with Diagnostic Radiology Consultants (DRC), the radiology group that supports Battlefield, said ease of scheduling is one of the issues they found their referring clinicians care most about.

"Clinicians are interested in how fast they can schedule an exam so they can get back to practicing medicine," he said.

Busch said clinicians also care about how quickly they can get the radiology report. Recent IT improvements at Battlefield have improved report turnaround times dramatically. Reports for routine imaging exams are sometimes available before the patient gets dressed.

Busch said most of the time, clinicians who send patients downstairs for an imaging study have the report in hand within 12 to 15 minutes, usually before the patient gets back upstairs to the clinician's office. This is a significant improvement over the 24 hours or more it once took to get reports back to clinicians.

Before Battlefield's IT improvements, when patients were referred out for imaging studies, they normally would not go right back to the clinician. Even if the studies were performed in the same building, because the radiology reports were not available, treatment could not be rendered the same day. Patients would have to call the next day for results and return at a later date for treatment.

Now, patients are often able to get a diagnosis and treatment the same day, advancing customer excellence even further.

"The patients are happy. And if the patients are happy, then the referring physicians are happy," Busch said.

Patients and their clinicians are not the only ones to enjoy the benefits of IT improvements. There are advantages for radiologists, too, particularly for those in groups that read for several sites.

Busch is also CEO of Specialty Networks, the architect of DRC's IT infrastructure. According to him, DRC was the world's first practice to feature a fully integrated radiology image interpretation suite in which RIS, PACS, speech recognition, and practice management were fully integrated, not just interfaced.

Having integrated software implemented across the entire system makes it easier for DRC radiologists at remote imaging centers to read images captured anywhere in the system.

"Common software systems are nice because there is no learning curve when you show up at a different site each day," Busch said.

Using a common IT infrastructure also allows DRC radiologists to read any study from any site, further increasing the quality of care.

"This lets us provide subspecialty interpretation across our entire practice," Busch said. "An exam performed at Battlefield might be read across town because the specialist happens to be across town that day."

A desire to stay ahead of the competition also drives other imaging centers toward advanced IT solutions. Zwanger-Pesiri Radiology, a group of 40 radiologists operating in eight locations on Long Island, NY, is one of them. Chief financial officer John Fragnoli described the Zwanger-Pesiri strategy in the simplest of terms.

"We want to be cutting edge in everything we do, whether with IT or with imaging equipment," he said.

Fragnoli said the company's IT goal is to be at least one step ahead of the competition at all times. This requires constant upgrading of computers and software to stay on the leading edge and find just that much more efficiency.

Efficiency is important because cost cuts and stagnant reimbursement levels have hit Long Island the same as everywhere else. Zwanger-Pesiri currently sees 1500 patients a day across its system.

"We have to increase efficiency to maintain and grow market share and IT allows us to do that, to streamline our operation," Fragnoli said.

When imaging centers embrace IT to achieve customer excellence, the process of system upgrades, enhancements, and implementations never seems to end.

Chief technology officer Robert Day said Zwanger-Pesiri is currently integrating billing into its RIS/PACS configuration. When complete, the system will not only manage all imaging functions, the integrated billing solution will handle all claims and payment processing, manage copayments, conduct online eligibility verifications, and create management reports.

"We already have a referring physician web portal so clinicians can access reports, view images, and see imaging schedules," Day said.

The patient portal will allow patients to read and print reports, forward reports to other physicians, and download and forward images electronically.

Day said one of the advantages of having an advanced central IT infrastructure in a multifacility setting is that there's less infrastructure to build as the company grows through acquisition or expansion. Zwanger-Pesiri's growth is based on a plug-and-play philosophy that eliminates redundant staff and duplicate infrastructure assets.

Departments such as records, billing, and the phone system are centralized, and the staff that supports administrative functions is housed in an office separate from all imaging centers. The existing, scalable IT infrastructure makes it easy to add on.

"Every time we open a new facility we don't need to hire separate administrative staff to support the new centers," Fragnoli said. "Everything is already in place."

A centralized administration, phone center, and IT infrastructure also means imaging centers can be totally dedicated to exams and patient care. When a patient enters an imaging center, everything in the building is patient-oriented, Day said. There are no nonmedical administrative or billing staff or offices onsite.

"This allows us to maximize space to get as much imaging equipment in there as possible and also to make it totally conducive to patient care," he said.

One of the IT features that tends to promote customer care and increase organizational efficiency is the integration of RIS and telephonics. This system allows patient files to be pulled up automatically based on caller ID. Convenience creates satisfaction.

"Satisfied customers create success," said Dr. Steven Mendelsohn, medical director of Zwanger-Pesiri.

Carmichael Imaging, a small radiology group in Montgomery, AL, implemented an integrated Siemens RIS/PACS solution in July. The implementation positions Carmichael right where it wants to be in the chase toward more efficient healthcare, said center director Tommy Patterson.

"We opened in 2002 with the goal of providing patients in a tricounty area of central Alabama with an outpatient environment that would include state-of-the-art technology, convenient local services, and world-class diagnostic care," he said.

When economic hard times hit, the instinct of most companies is to take shelter, reduce spending, and wait for good times to return.

IT provides vital contribution to imaging center customer service

Old imaging equipment never dies, it just falls into the hands of refurbishers. The practice of refurbishing imaging equipment is not new. A U.S. market study conducted in 2006 by IMV showed that 30% of all hospitals and 39% of nonhospital imaging facilities had at least one refurbished modality. Those percentages are likely to rise as the demand for refurbished units grows while the national economy shrinks.

Every healthcare facility now faces the same dilemma: how to deliver more efficient healthcare with less money. But hospitals keen on investing in new high-end imaging equipment find that budgetary constraints compounded by a staggering national economy are obstructing new purchases. Traditional sources of financing have dried up with the collapse of the bond market, and buying behavior has therefore changed. Sites are looking at what they can afford, not just what they need.

A growing number of facilities desperate to upgrade are finding refurbished medical imaging equipment to be a good alternative. Customers who before the crisis may have wanted a 64-slice CT now see that a refurbished 16-slice system is a better financial fit.

Stand-alone imaging centers and outpatient clinics, along with hospitals of 300 beds or less, provide the target market for refurbished equipment companies. In the U.S., GE, Philips, and Siemens run some of the largest refurbishing operations.

Bread-and-butter imaging centers not engaged in demanding research activities often find that it makes more sense to go with refurbished equipment, rather than the more expensive new modalities favored by large tertiary hospitals and academic medical centers. Even those elite institutions often obtain one or two refurbished scanners to serve as backup during maintenance on production units or to augment front-line modalities during periods of peak patient flow. As a result, refurbished equipment vendors see the market expanding even in the largest hospitals.

Blue Star Imaging of Flower Mound, TX, the official imager of the Dallas Cowboys, recently acquired a refurbished Siemens MR (RS Magnetom Espree) and a Siemens CT (RS Sensation 16) to augment six other imaging modalities spread over two sites. Rae McGarrity, Blue Mound's director of operations, called the decision to go with refurbished equipment price-driven.

“The equipment was only a couple of years old and completely refurbished,” McGarrity said. “To us, it was almost like buying a brand new piece of equipment.”

Any stigma attached to refurbished imaging equipment is largely unwarranted. Buying pieces sold as-is may be risky, but refurbished equipment comes with the same warranties and supports the same clinical applications as new units. Refurbished equipment customers get the same clinical functionality, throughput, performance, and service uptime as new equipment customers receive.

Encompass Medical Group/Premier Imaging in Kansas City, MO, bought three refurbished scanners when the facility opened for business in 2004. The group considered reliability as much a factor in its decision as lower cost.

Price was what ultimately drove the decision to purchase refurbished equipment, but the group also understood that this equipment performs the same high-quality imaging as newer modalities, according to Susan Stidham, director of radiology.

Refurbished equipment provides a cost-effective option for imaging facilities that need to adhere to a strict budget to maintain profitability without sacrificing quality of care, Stidham said. She characterized the savings possible with refurbished equipment to be greater than 25%. Encompass-Premier also carries service contracts on all its equipment.

“The service contracts ensure that we can continue to maintain the equipment properly and also provides options for computer software and hardware upgrades,” she said.

A variety of purchase or lease financing options were available to the Encompass-Premier group, which used a combination (see accompanying article). For the refurbished Siemens Sensation 64-slice CT, the group chose a lease option instead of purchase because CT technology changes so rapidly, Stidham said. Leasing gives the group more flexibility in terms of equipment upgrade. The 1.5T GE MR, on the other hand, was a capital purchase. The group also owns two refurbished ultrasound scanners, one from Siemens and one from Philips.

Used imaging equipment sales and auctions can be found even in cyberspace. Plenty of bargains exist on the as-is market, but as-is equipment comes just as it says. As-is usually means no warranty and no vendor to stand behind the product. Let the buyer beware.

The first week of each month, however, government surplus medical imaging equipment goes up for auction at GovLiquidation.com. The auctions are typically well stocked with radiographic and ultrasound equipment. While the equipment is not refurbished and is sold on an as-is basis, some extraordinary bargains can be found.

“The bidder sets the price,” said Tom Burton, president of Government Liquidation. “It's not unusual for items to sell for the $150 minimum bid.” In March, a $32,000 Siemens Mobilett Plus HP radiographic unit sold for $4755.

The refurbished imaging equipment market operates differently. Not every used modality is a candidate for refurbishing. Refurbished equipment vendors are typically highly selective in the units they choose to revamp. Vendors will look at the service history and performance of the unit, then determine if it can be upgraded.

Most units selected for refurbishing are about halfway through their useful life. Manufacturers of new imaging equipment are required to provide service and support for a minimum of 10 years. The sweet spot for most refurbishers is used equipment they can refurbish and still guarantee at least five years of service to the customer.

Deinstallation at the present site comes after selection. This consists of inspection and packaging. Packaging is usually done in the original shipping material so nothing is damaged in transit. Deinstallation and packaging are usually done by the same vendor technicians who installed the modality when it was new. Once repacked, the old unit is transported to a refurbishing facility. Siemens has two, one in Germany and one outside Chicago.

Refurbishing at these facilities begins with a thorough cleaning and disinfecting process. Refurbishers like Siemens replace up to 70 worn parts with original spares on a CT scanner. The unit is then painted. Next, the software is upgraded to the most recent versions.

Customization based on special requests, if any, is next. If the customer is acquiring a CT scanner and plans to offer lung care, this option is installed on the system. The unit is put through the same complete system check and quality assurance review as new equipment. It is then ready to deliver. Lead times for refurbished systems vary by modality, but refurbishing generally takes less than a week.

After packaging and shipment to the customer, the unit is installed and certified by the same technicians who install new units. Use of trained technicians is one of the advantages of dealing with major brand name refurbished equipment vendors.

Brand identification sometimes plays just as important a role in an imaging center's decision to choose refurbished equipment as economic considerations.

“You have to trust the vendor,” said Dr. Mark Lopiano, medical director at Medical Imaging Center of Fairfax in Virginia.

Lopiano's facility of six radiologists acquired a refurbished Siemens RS Sensation 16-slice CT scanner in 2007. Since then, the center has used the machine to perform six or eight studies a day without incident.

CT and MR scanners are the most popular items in the refurbished market. This is perhaps predictable, since turnaround is faster for these units. Most CTs or MRs are replaced every six or seven years, if not sooner due to lease options. Cardiology, on the other hand, might keep its angiography equipment for eight to 10 years.

If customers contemplating the purchase or lease of refurbished imaging equipment stay with any of the big vendors, they'll be fine, Lopiano said. Buying used equipment can present uncertainties, but what attracted Lopiano to the refurbished deal with Siemens was the company's seal of approval that the equipment could be trusted. It came with a one-year warranty. In addition to the warranty, spare parts availability is guaranteed for a minimum of five years.

“Siemens took the unit back to the factory and completely refurbished it, so what you get, essentially, is a brand new machine for something like half the price,” Lopiano said.

In Lopiano's case, he got more than that. His acquisition of the refurbished scanner resulted in more feature flexibility than he might have expected acquiring a new unit.

“I didn't want the tube that comes standard on a 16-slice CT scanner,” he said. “I wanted an upgrade to the Straton tube that comes standard in a 64-slice machine, so we could be in a position to do cardiac imaging.”

The Straton tube yields finer cardiac and vascular detail. Siemens agreed to the swap. That's not all. Lopiano was able to negotiate other features.

“I got more bells and whistles in the form of software, plus I got a workstation with it,” he said.

Even though refurbished equipment is previously owned, vendors are showing growing interest in increasing customer satisfaction. The major equipment refurbishers are collaborating on a set of industry standards, specifying, for example, just what refurbishing means. Right now, refurbishers such as Siemens adhere to international manufacturing quality standards as specified in Medical Device Requirements ISO 9001, ISO 13485, and ISO 14001.

Refurbishing vendors want standards to help ensure continued market growth. Industry experts see a previously untapped refurbished market of thousands of private physician practices and veterinary establishments. Vendors believe this market segment is a perfect fit for refurbished equipment, since costs have reached a price point making it affordable for independent cardiologists, orthopedists, podiatrists, and veterinarians to obtain imaging equipment for their own offices.

One interesting trend to have surfaced in the past two years is the green aspect of refurbished systems. By choosing refurbished equipment, buyers extend the life of a product and thereby save resources. Vendors have noticed that the greening of healthcare can be a selling point. Customers like the idea they may have saved a modality from ending up in landfill.

One refurbisher estimates that the sale of refurbished systems prevents the release of an average of 10,400 tons of CO2 annually, an energy savings that corresponds to the energy needs of about 3000 three-person households per year.

Old imaging equipment never dies, it just falls into the hands of refurbishers. The practice of refurbishing imaging equipment is not new.

Refurbished equipment marketgets fatter in a lean economy

Like devout joggers, thin-client technology keeps getting thinner and thinner. Some clients are now so thin they are virtually transparent.

First came thin clients, in which the bulk of data processing is removed from client workstations and placed on central servers, leaving just the operating system and communication routines on the client.

Ultrathin clients evolved next. These take thin-client computing a step further by moving the operating system and other software to the server side without imposing any software requirements on the client.

The latest iteration of thin-client architecture is called a zero-client, or zero-download. Zero-clients are not much more than dumb monitors. By definition, they have no operating system, no drivers, no memory, and no central processing unit. In August 2007, Pano Logic unveiled a zero-client half the size of a Rubik's Cube: a box less than 3.5 inches square that connects keyboard, mouse, monitor, audio, and universal serial bus peripherals over an existing 100- Mb/sec local area network to a copy of Windows running elsewhere on a virtualized server. (Virtualization is a method of running multiple independent virtual operating systems on a single server.)

The appeal of all thin-client technologies to radiology is that they exploit server processing power while minimizing processing requirements on client workstations. Data-intensive applications are then run on the server rather than on the client. A true thin client means neither the vendor nor the customer needs to install any software on client devices; data are dynamically downloaded as needed.

With servers using multicore processors and blade technology providing all the horsepower, workstations can now be standard desktop PCs-or even PDAs, BlackBerrys, or Smartphones-rather than dedicated high-end monitors.

Thin-client technologies are key to providing instant access to PACS images and reports to a broad  range of clinical users without worrying about physician location or incongruous hardware or software.

“Users can access diagnostic images and perform image processing, such as windowing and 3D, from any location where fast Internet connectivity is present, from any department in the hospital, or from any offsite practice office,” said Henri “Rik” Primo, director of marketing and strategic relationships for Siemens Medical Solutions.

Contemporary radiology applications challenge IT networks with massive file transfer demands. Thin-client technologies handle this traffic better than conventional PCs because thin clients are not moving the actual files; only the pixels required to paint the monitor are being transmitted.

Vendors in the advanced visualization market are beginning to leverage technologies such as XML messaging, user interfaces based on Adobe Flash, and Microsoft's .NET and Silverlight frameworks to provide ultrathin and zero-download software applications to the clinical end-user. For complex 3D processing, for example, software packages are pushed from server to client PC. No local install of software by field engineers is needed.

“It's the best of both worlds: rich-client performance and thin-client convenience,” Primo said.

Siemens already uses thin and richthin technology in solutions for remote image processing applications. Its syngo WebSpace offers 3D and 4D tools in the syngo InSpace4D user interface, which is available to any syngo WebSpace client.

Thin and ultrathin client technologies are not exactly new. They have been emerging for several years. The lower cost of ownership, simplified setup, enhanced customer support, and ease of overall system management from the facility level hold appeal for healthcare and radiology.

“Thin-client computing makes for more flexibility and independence in the choice of client workstations and allows the system to be managed from the server end in the IT department,” said Nadim Daher, a senior healthcare industry analyst at market research firm Frost & Sullivan.

The principal advantage of ultrathin clients is that the extremely low processing power needs on the client side allow mobile and embedded devices of any kind access to advanced applications.

“Referring physicians can be provided access to clinical images and information without any cumbersome downloads or supporting software,” said Kang Wang, Ph.D., senior vice president of research and development and chief technology officer at Amicas.

Amicas embraced thin-client architecture with its PACS some time ago. Its newer ultrathin Amicas Reach solution provides a zero-installation platform for clinicians.

Ultrathin-client computing provides key advantages to both radiologists and referring physicians.

Clinicians can now get radiology results in the office, at home, on the road, or in their pocket. GE Healthcare, for one, is actively developing a number of initiatives in this space and has several products that may run in very thin client environments. One solution sends images from GE's Centricity PACS to an iPhone for remote consultation.

Ultrathin technologies also allow radiologists to more fully utilize reading resources. Exam reading can be performed by radiologists and specialists at any location with most of the same toolsets and functionality they have in the office reading room.

Patients also benefit. Ultrathin computing helps reduce the need for radiologists to travel, greatly accelerating report turnaround. It can take days for patients to receive a final diagnosis from an exam performed at a small rural clinic where radiologists are onsite only two days a week.

“With the scarcity of radiologists worldwide, thin-client technologies enable rapid, universal access to radiologists and specialists for patients at all healthcare facilities, regardless of location or availability of onsite resources,” said Hadas Padan, director of healthcare information solutions at Carestream Health.

Padan said Carestream's PACS and SuperPACS architecture expedites radiology workflows by delivering an identical user interface and toolset for radiologists and remote clinicians.

“This architecture was designed to work synergistically with webenabled technology to deliver the speed and functionality of a diagnostic workstation from any remote PC,” Padan said. Thin-client computing also offers productivity opportunities for radiologists staffing remote clinics. When the workload from local cases is light, they can contribute to the home practice's overall workflow by accessing cases remotely over thinclient networks.

“Workload balancing such as this can create a premium virtual radiologist network,” Wang said.

Claes Lundström, Sectra's director of upstream marketing and research, believes ultrathin clients are most useful when you have a large distributed user group and the only part of the IT environment that can be counted on is the web browser.

“Groups that need ultrathin applications are specialists with unusually poor IT environments or referring physicians with unusually high image review demands,” Lundström said. Sectra has ultrathin solutions for result distribution, including basic image display, Lundström said. Sectra is looking closely into ultrathin architectures within image review and advanced visualization for the future.

“We're also making sure that our efforts are driven by customer value and not technology hype,” he said.

Hyperbole surrounding ultrathin client computing for radiology tends sometimes to distort realities. The technology has its limits.

Advanced ultrathin-client applications are confined in their presentation capabilities by bandwidth and client memory capacity. The price of flexibility gained by thinclient technology is that applications must run in a highly constrained, secure box with limited resources.

“You can't write to disk or access system resources like CD burners or microphones, so the question becomes whether useful applications can be defined so they can run in the box,” said Stuart Long, senior director of Philips Healthcare's global product management and marketing.

In radiology, the best candidates for ultrathin-client applications are the ones with lower data transfer requirements.

“Applications that access electronic medical records and 3D reconstruction applications that stream results as movies would be good candidates for ultrathin models,” said Khal Rai, general manager of GE Healthcare IT.

Conversely, applications that require a high degree of user interactivity or higher storage demands for keeping large imaging studies on the client are less suitable for ultrathin- client computing, since interactive postprocessing and random access navigation of large studies are difficult to achieve under this model. With ultrathin models, lower client hardware requirements and increased client mobility are swapped for limitations in interactivity and the amount of data that can be accessed immediately.

“Ultrathin technology is more movie-watching, with an occasional flashback to a particular scene, than movie-making,” Rai said.

The best approach may be to provide ultrathin-client access where appropriate and the higher performance and functionality of thicker clients when needed and appropriate.

The notion of having a thin application is great, but there is often the need to deploy, manage, and support a relatively thick infrastructure to enable the thin application.

The impact of ultrathin architecture on radiologist efficiency, image analysis capability, and image quality is another concern with thin-client computing.

Clinical multimedia such as 3D ultrasound and diagnostic images need to be accessed, managed, manipulated, stored, and distributed to specialists and clinicians across the enterprise and beyond with speed and efficiency.

Whether ultrathin architectures are up to these demands is not yet known. Although ultrathin-client applications significantly ease concerns about the hardware component of advanced visualization solutions, these implementations place increased importance on enterprise network performance, as well as networks that access the solution remotely. “Initial ultrathin applications may not be able to accomplish these goals,” said Fujifilm Medical System's Jim Morgan, director of marketing for network systems.

While a connection speed of 2 Mb/sec may provide acceptable speed and display performance for static 2D images, dynamic real-time display performance of cine clips such as angiography exams and Doppler ultrasound may suffer from less than optimal bandwidth, resulting in a less than smooth display experience.

“In these cases, a rich-thin client instead of a thin client may provide better performance by shifting some processing functions back to the client workstation or PC,” Primo said.

Latency is another consideration in an ultrathin-client environment. If bandwidth is the road's speed limit, latency is how often you are stopped at a traffic signal trying to get from point A to point B.

Douglas Page

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