Innovators team with vendors to broaden access to new tools

Advanced visualization is worming its way into PACS. Once-dedicated workstations are being democratized to support network access, thin-client servers gel with PACS, and native code embeds sophisticated postprocessing. The technology is no longer exclusively 2D.

This computing evolution was reflected at the Society for Imaging Informatics in Medicine exhibition in Seattle in May. Carestream displayed native 3D and productivity capabilities; Fovia touted an OEM strategy to bring its 3D horsepower to multiple brands of PACS; and Visage, TeraRecon, Agfa, and Siemens each presented varying degrees of thin-client and PACS-based 3D computing.

Inclusion of these products as an integral part of the PACS environment has become critically important to the routine practice of radiology, as clinical applications demand the evaluation of larger and more complex data sets. In a broad paradox, increasingly sophisticated technologies are harnessed to simplify the diagnostic process, just as productivity gains are coming from software that complements human intelligence.

One smart algorithm from GE Healthcare checks radiology reports to help ensure accuracy. This "thought checker," scheduled to begin routine shipment by the end of the year as an upgrade to the Centricity RIS-IC Reporting module, uses the context of reports to identify possible errors. The program might question, for example, whether the radiologist meant "left occipital lobe" rather than "right" by highlighting the directional term in blue. Or it might insert a red bar at a point where certain information needs to be added.

"It understands the concept of left and right and the need for certain measurements," said Michael Mast, GE senior manager of commercial marketing in the imaging integrated IT business unit. "It serves as an extra check in that it gives the radiologist a chance to clarify some points in a report."

Much of the power being added to PACS is coming from innovative fringes of the industry. GE's thought checker came from a partnership with M*Modal, whose AnyModal Conversational Documentation Services combines speech recognition and natural language to interpret the meaning of dictated reports and then identify possible errors.

McKesson's MyPACS.net, a web-based technology designed for radiology decision support and information exchange showcased at the SIIM meeting, came from Vivalog Technologies. This company, which began seven years ago with grant money awarded by the National Institutes of Health, partnered with McKesson before the IT giant purchased the company this spring.

Amirsys' STATdx Diagnostic Decision Support System provides reference tools useful in the diagnostic process. The point-of-care diagnostic support product was designed to reduce the time needed to research and complete difficult analyses.

SofTek's Illuminate product, currently in beta testing, provides a Google-like search function that can be used to find specific types of cases in a PACS. Using one or more search terms, Illuminate might gather hundreds of radiology reports and associated images about a topic, such as Parkinson's disease, drawn from an institution's PACS.

Many of the innovators who remain independent companies are making their products broadly available. Illuminate and STATdx were among a dozen or so products and services at SIIM 2008 inhabiting a technological "ecosystem" built around Philips' iSite PACS.

"We have quite a gamut of niche players enhancing our PACS," said Glenn Petracci, director of cardiology and radiology field marketing for Philips. "With them, we can provide many options to our customers at a very low cost, while conserving our own resources."

As Philips reaps the benefits of hosting myriad ancillary functions, the company continues to evolve its core applications. It highlighted clinical applications, including 3D visualization tools such as iSite Volume Vision, Pulmonary Embolism Assessment, and the work-in-progress CT Colonography.

In this vein of core development, Siemens expanded the reach of its TrueD oncology application from a stand-alone workstation to a network-based release, allowing end users to merge and compare multiple data sets from the same patients without leaving their PACS station. TrueD pulls together data sets obtained from any of several exams conducted, for example, using PET, SPECT, CT, or MR. Analyses are accelerated through the use of an autoregistration function, whereby studies are automatically registered with each other and within themselves, in the case of a hybrid study or studies acquired on different scanners such as PET and CT.

"When you triangulate one particular image, TrueD automatically triangulates the corresponding study from the different time point within less than a second," said Eric Selvin Smith, senior manager for customer relationship management in Siemens CAD and knowledge solutions group.

Carestream previewed as part of its PACS an automatic registration technique that links two data sets, a capability that luminaries will begin testing this fall. The Carestream development reflects a trend toward the integration of advanced functions into PACS. Fovia and Visage courted major OEMs with advanced visualization capabilities that could be absorbed into branded PACS. Fovia, founded in 2003, provides "deep native integrations," software packages tightly woven into existing PACS so that their 3D functions are part of the PACS architecture and user interface.

"We share memory with the PACS," said Steve Sandy, vice president of business development. "So long as there is enough central processing unit power, we can use the existing PACS server rather than having to add on another server."

Visage is taking a different tack toward the same goal. The company, a subsidiary of Mercury Computer Systems, has developed advanced visualization tools that "turbocharge" existing PACS, according to Colin T. Murphy, vice president of sales and marketing. But rather than selling only to OEMs, Visage is also selling its turbocharger directly to end users.

"We want to prove to the PACS companies that we can integrate with them and that we have something that the market needs," Murphy said. "It opens up broader opportunities."

The key to opening up advanced visualization is providing enterprise access, a process made challenging by the need to project images to faraway places that may have limited bandwidth. TeraRecon framed its AquariusWEB viewer as a potential solution. The browser-based viewer uses JavaScript to deliver images to referring physicians through a simple URL. Images can be viewed on desktops, laptops, or personal digital assistants.

"You can click on a link and have access to the 3D image," said Robert Taylor, Ph.D., TeraRecon president and COO. "There is no installation; you don't have to call an IT guy; you don't have to be trained."

Agfa took a higher tech approach, posing novel enabling technologies as the means to reach the periphery of the enterprise. Bill Wallace, an Agfa software developer, described in a SIIM session the firm's early experience with an AJAX (asynchronous JavaScript and XML)-enabled web browser to send images. The AJAX viewer is being developed to act as an Integrating the Healthcare Enterprise evidence creator, image display, and report display, even though it needs no custom installation, he said.

Agfa's goals of creating a mobile web viewer, however, may be reached in the nearer term through technology not exhibited at the SIIM meeting. Medical Insight, a firm based in Copenhagen, is negotiating with the Belgian company to supply software that provides instant access to full DICOM-quality images on any kind of PC, PDA, or even Apple iPhone.

"The key is to provide instant access to data without having to send the data outside the server," said Medical Insight CEO Frits Thomsen.

The company uses a technique called adaptive streaming, which employs specialized applications and rules to manage the pixels in images so they can be efficiently transsmitted over the narrow bandwidths typically used by remote devices. The technology, tentatively dubbed Mobility Enterprise, is now installed at a large hospital system with several thousand users, according to Thomsen. It is scheduled for installation at four others.

Mr. Freiherr is business editor of Diagnostic Imaging.