Internet technologies push wide-area image distribution into uncharted territory

Internet technologies push wide-area image distribution into uncharted territory

Battle already beginning to brew over Java vs. XML

Advances in Internet technologies are making wide-area image distribution increasingly practical and affordable for hospitals and imaging centers of all sizes. The concept is not new; teleradiology has been around for years, and its merits widely acknowledged. But the ability to use off-the-shelf personal computers, Web-based browsers, and standard phone lines—instead of the high-resolution monitors, specialized software, and high-bandwidth connections common to most teleradiology installations—is helping to make digital diagnostic images an accepted, and even expected, component of patient records and physician workflow outside of the radiology department.

The trend toward enterprise image distribution has prompted every major imaging and PACS vendor to port at least the client side of their systems to Windows NT and to add standard browsers and other Web-based capabilities to the latest versions of these products. It has also created a new market for software companies, and several have emerged in the last few years to offer Internet-based medical imaging packages that are challenging the more established players and products.

This new breed of medical imaging vendor includes Amicas (PNN 10/98), eMed (PNN 9/99), Image Medical (PNN 3/00), Riptide (HNN 8/9/00), Stentor (PNN 11/99), and RealTimeImage (PNN 12/99). Their products have been built using standard Internet tools such as Java and XML (extensible markup language) and communication protocols such as TCP/IP that only a few years ago were foreign to most medical device and systems manufacturers. But the open architecture of these Internet-based systems offers a number of advantages over legacy systems that now sport Web-enabled front ends, and the competition among vendors is heating up.

"Our software is Web-based, not Web-enabled, which means the code is optimized to run on the Web and the system can more easily scale," said Gene Thomas, CEO of New Orleans-based Riptide Technologies, which debuted its Internet-based Advanced Radiology Image and Information System (ARIIS) product last year. "Some players take traditional client-server applications and put a Web-based front end on them. That makes it possible to take data from the existing system and make it look pretty over the Web, but it doesn't work that well. It is not flexible, and it doesn't scale well."

Amicas was one of the first software developers to recognize the advantages of Java and other Web-based development tools for enterprise image distribution product development. The company was founded in 1995 to commercialize technology developed by Dr. James Thrall and Adrian Gropper (now chairman and chief technology officer of Amicas) at Massachusetts General Hospital. MGH eventually negotiated an equity position in the company, giving Amicas access to all MGH intellectual property in exchange.

Much of Amicas's early business was in on-call teleradiology; today the Watertown, MA-based company's 59 enterprise image management customers include MGH, Boston University Medical Center, Columbia Presbyterian in New York, the Loma Linda VA in California, and Kaiser Permanente in Oakland, CA. The company also claims to manage more than two million radiology studies annually.

"The only thing available to replace film back in 1996 was hardware-based proprietary ‘islands of information,'" said Barry Gutwillig, vice president of development for Amicas. "PACS vendors today still consider radiology their core business, but they have now put Web server architecture on top. We took the opposite approach: Start with the enterprise, then move downstream to the radiology department."

The Windows NT-based Amicas Web/Intranet Image Server is a Java-based software product that uses standard Web browsers (Netscape Communicator and Internet Explorer) to access and view images at flexible resolution levels. The Amicas software is designed to "sense" a receiving monitor's size, resolution, and whether multiple monitors are being used and then adjust the file to the appropriate resolution. The Amicas software can also accommodate HL7, SQL, or HTTP requests to bring reports to the viewer, and a Java bean or active X control allows the viewer to be launched from inside a RIS, HIS, or other application.

"Unlike traditional PACS vendors that bolt on a Web server to their database and archive, the Amicas architecture is built around and on top of a Web server," Gutwillig said. "So instead of multiple boxes with multiple databases, Amicas uses a single database that controls everything from the DICOM importer to the data manager and Web server."

Earlier this year the company added an ASP component to its offerings through a relationship with IBM. IBM is building and hosting amicas.net, a Web portal designed to bring e-commerce and related applications to diagnostic image management. Initially, amicas.net will handle only billing, system monitoring, and management applications; by next year, however, the company expects the system to be able to track who accesses images and when.

"Amicas will provide Web-based interfaces to allow the local IS manager to set up appropriate security, which will lead to the ability for patient-controlled medical records and patient-secured access privileges," Gutwillig said. "What we are doing today is pricing based on per study, but we still maintain and keep the storage local and resident to the site."

Eventually, however, some of the image data handled via amicas.net will be moved off-site for disaster recovery and backup. Beyond that, Amicas is working to integrate images into the electronic patient record.

"PACS by definition doesn't do that," Gutwillig said. "That's why the Internet is so powerful."

XML vs. Java

One of the newest entrants to the enterprise image distribution market, Riptide Technologies believes its XML-based technology offers several advantages over the Java-based products developed by Amicas and other competitors. Riptide was founded in 1997 by Dr. Richard Ferrans and Perry Schwalb, who had already developed a prototype cardiac ultrasound image capture and Internet delivery system. Ferrans and Schwalb used many of the concepts they discovered while building this protoype to develop ARIIS, Riptide's first commercial product.

ARIIS is a Web-based system that combines RIS, PACS, report generation, and charge-capture capabilities in an open-architecture design to enable real-time access, storage, and distribution of clinical information across an enterprise. The ARIIS PACS was built on Windows NT and SQL7 using XML. The user interface and clinical workstations are based on Riptide's Active DICOM system, which allows images to be displayed and manipulated inside Internet Explorer. In addition, unlike other Web-based systems, ARIIS displays DICOM standard images rather than those compressed with proprietary wavelets outside of DICOM.

"Part of our approach in being Web-based and using off-the-shelf technologies such as Intel-based Dell servers running Windows NT is trying to reduce costs across the board," said Gene Thomas, Riptide CEO. "We are not asking customers to become IT managers or to further burden their IT departments. We can do system upgrades over the Web."

Riptide was one of the first companies to recognize the implications of XML as a development environment for medical imaging and enterprise distribution applications. For example, the XML framework allows ARIIS to cache images on the user's hard drive or the local network so that when a patient is first scheduled, any existing studies can be automatically prefetched and stored in the background, even before the patient comes in.

"A lot of traditional engineering companies have continued to go with Unix as an OS, using Windows only for the workstations, not the servers," Ferrans said. "Java was meant to work in both Unix and Windows, and a lot of Web viewers are Java-based, but Java doesn't allow you to cache images on a client."

In addition to being written in XML, ARIIS uses standard Web protocols such as TCP/IP and HTTP to transmit information more efficiently over the Internet. It was also built from a physician workflow perspective to improve productivity, reduce operating costs, and enhance patient information integrity.

"A lot of vendors continue to use the DICOM communications protocol for communication between different workstations, which is a very cumbersome method once you get outside of the LAN," Ferrans said. "With TCP/IP and HTTP, you can make the whole world look like the local network."

While Riptide can claim only two customers to date (both beta sites), ARIIS just became commercially available on Aug. 1. The company is also anticipating a boost in exposure from a new agreement with Intel Internet Authentication Services (IAS). Through this relationship, Riptide will offer advanced Internet security to hospital radiology departments and imaging centers. Riptide and Intel IAS will work together to integrate Intel's real-time physician identity authentication services, which utilize Internet IDs issued to physicians by the American Medical Association (HNN 5/31/00), into ARIIS.

"We are moving beyond the LAN approach (to image distribution), and what better way to do this than through the authentication mechanism that utilizes the physician IDs authorized by the AMA?" Thomas said. "Intel technology is really meant to enable secure transmission of medical data."

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