PACS vendors face rising tide of imaging volumes

Solutions include ways to store and distribute data while offering seamless integration with workflow tools

The rising tide in radiology image volume is pushing a wave of innovation through the PACS market, challenging imaging and informatics vendors to provide appropriate infrastructures to store and distribute this growing inundation of data.

IT departments are also insisting that imaging vendors maintain image data in standards-based formats so data are agile, accessible, and portable from one generation of storage platforms to the next. Several new solutions will be revealed at the 2006 RSNA meeting.

The Swedish company Sectra will release a new family of workstations optimized to handle high image volumes independent of network capabilities. Sectra does this using a just-in-time mechanism that transfers only the data specifically needed in a given instance.

"This helps radiologists gain fast access to images and start working with the images quickly, regardless of the size of the data set," said Anders Brodin, Sectra's global product marketing manager.

Image acquisition and distribution are not the only paradigms shifting under the load of increased image volume. Multislice CT has turned 3D imaging into an essential technique to review large data sets. Many medical facilities are looking at ways to bring 3D imaging to every desktop by implementing thin-client systems. This approach unties users from a single 3D workstation, which can be hopelessly inadequate for multiple users.

"One 3D workstation is guaranteed to be a workflow bottleneck," said Robert Taylor, executive vice president and chief operating officer of TeraRecon.

The company's workstation solution is AquariusNET, a client-server system that allows radiologists to access 3D reconstructions on their PACS workstations. While the system is available today as a patch to PACS, TeraRecon is working with vendors to embed Aquarius technology deeper into the PACS, radiology information system, and informatics infrastructure. The hope is that the PACS of tomorrow will offer these reading tools already integrated.

Kodak and GE Healthcare argue that this day has already arrived for their customers. Kodak's latest PACS version, which will be unveiled at the RSNA meeting, offers accelerated visualization and 3D tools designed to assist in the reading of extremely large studies over networks with varying speeds. GE will show an upgraded Centricity AW (Advantage Workstation) with multimodality 3D tools for computers networked into its Centricity PACS. This version, called AW Suite 2, will offer optional plug-ins such as CardIQ for cardiology, advanced lung analysis for oncology, advanced vessel analysis for cardiovascular applications, AutoBone, and CT colonography software.

Aycan is following two trends in this area: 3D/4D postprocessing of medical images and the expansion of open-source software into medical imaging. Aycan has released a CE-certified version of its open-source Osirix, an image processing software dedicated to DICOM images for navigation and visualization of multidimensional images. Aycan also plans to demonstrate a new Osirix workstation at the RSNA meeting.

The future of medical displays is not all black and white. Color technologies continue to evolve, although most color displays are not bright enough for diagnostic gray-scale imaging. But Barco recently introduced a high-luminance system that brings black-and-white diagnostic precision to its Coronis Color 3MP Diagnostic Luminance monitor.

One trend seen by display manufacturers is better end-user understanding of monitors in the medical imaging community and a corresponding demand for quality assurance measurements on liquid crystal display devices.

The QA approach typically refers to taking limited measurements of an LCD's current operating parameters, such as backlight luminance and runtime. Double Black Imaging employs a different approach, according to Joe Lloyd, director of sales and marketing: Automated DICOM gray-level and luminance calibration are used to measure, correct, and ensure conformance to the DICOM gray-scale display at all times.

Eizo Nanao Technologies has also addressed uneven brightness on LCDs. According to Hideyuki Honda, North American product manager, Eizo has solved this problem with a patented digital uniformity equalizer, which will become standard in all new models.

NO PACS IS AN ISLAND

The integration of IT systems continues to be a market driver. PACS must be able to communicate with the RIS and HIS.

"PACS are no longer islands," said Penny Reiman, product manager for Misys Healthcare Systems.

Most major PACS vendors are building bridges to systems integration. GE engineers at the RSNA meeting will close the gap between the company's homegrown Centricity PACS and the RIS technology marketed by IDX before the company was acquired 10 months ago by GE. The combined product, called Centricity Radiology, entered pilot testing earlier this year. GE plans to release a commercial version with streamlined PACS and RIS workflow in the run-up to the RSNA meeting.

"We went back to the drawing board and analyzed from a design perspective where we were heading so we could put down an infrastructure that we could build on," said Vijay Tanjore, marketing manager for GE Healthcare Integrated IT Solutions. "This is just the first step for us to move into bigger and better solutions to offer radiology departments."

Embedded in this configuration is GE's latest Centricity PACS 3.0 with Integrating the Healthcare Enterprise profiles that automate exam acquisition, reporting, and communication with referring physicians. Among the highlights are new voice-driven commands and highly configurable work lists.

Agfa's Lenny Reznik, director of enterprise imaging and information, said RIS, PACS, and reporting systems are providing improved radiologist productivity, which is beginning to result in overall departmental productivity. Communication is improved throughout the department, increasing speed and efficiency while reducing errors, Reznik said.

Representatives at Philips Medical Systems also see a trend toward integrating more advanced viewing and clinical analysis applications on diagnostic PACS workstations. Philips is integrating its ViewForum workstation and clinical applications within the iSite Radiology workstation and making its iSite PACS product available in various markets worldwide.

Siemens has reacted to systems integration with its syngo software platform, which includes RIS, PACS, postprocessing, and distribution support that are role-based and tailored to the specific tasks of radiologists, technicians, and referring physicians. The goal is to help providers work more efficiently by providing a system that connects HIS, lab, RIS, and PACS, which are now accessible anytime from any workstation, according to the company.

With this level of integration, radiologists have access to all relevant patient information, such as previous reports, lab values, allergies, and scanned documents, in one application window. Without systems integration, it is not unusual for a single radiologist on an average day to use several PACS, RIS, 3D visualization, and transcription applications continuously. Users are now able to view this information without accessing several different systems.

DR Systems will exhibit its new Unity RIS/PACS platform at the RSNA meeting. Unity offers features that go beyond traditional RIS/PACS capabilities, according to Douglas Dill, director of marketing. For instance, Unity has been designed to provide an advanced medical imaging and information management system infrastructure for regional health information organizations. The company's PACS forms the radiology backbone of the Data Exchange in Santa Barbara, CA, which claims to be the nation's first RHIO.

Representatives at Intelerad say that many of their customers are asking that more focus be placed on workflow and modules more closely aligned with RIS than PACS. At the RSNA meeting, Intelerad's PACS platform will include workflow improvements, including a reporting work list, visualization component, radiology resident workflow, dictation, and report approval process, said Chris Henri, executive vice president.

The desire for greater efficiency is also driving the creation of software systems to assist decision making. Sage Software, formerly Emdeon Practice Services, calls its approach "front-end validation." The system will allow a provider to increase reimbursement rates through greater accuracy, said Paul Stinson, senior vice president for product management and marketing. Additionally, with front-end diagnosis validation, providers may be able to avoid procedures that are not covered by insurers and offer patients alternative studies that are covered.

No single software application can handle the workflow demands of the modern radiology department, according to Michael Mardini, CEO of Commissure. At the RSNA meeting, the company will showcase its RadWhere Workflow Orchestrator, a solution that provides the radiologist with a common reporting system and work list into all other information systems.

Regardless of how many RIS, PACS, or advanced visualization systems are available to the radiologist, RadWhere provides an integration platform for all of them, Mardini said.

LINKING WITH THE EMR

Integration goes well beyond RIS and PACS, however. Now the trend is for clinicians to receive multimedia reports with access to images and 3D reconstructions.

"Clinicians want the ability to access medical images through the electronic medical record, providing a more holistic view of the patient's condition," Reiman said.

Misys is concentrating on enterprise-wide integration of the patient record, including RIS and PACS. By providing a nonproprietary solution independent of any PACS, images can be distributed throughout the enterprise.

BRIT Systems also sees PACS becoming a major component of the EMR. Michelle Fisher, vice president of sales, said PACS will expand into a general storage server for all types of imaging information, including PET, digital mammography, CT angiography, and cardiac scoring for cardiology.

Cyrus Samari, vice president of sales and marketing for Sorna, cautions customers not to overlook CD/DVD recording systems.

"Facilities agonize for months over the selection of PACS and related components, but for their own financial welfare, they should be much more discriminating in choosing CD/DVD recording solutions that best meet their needs," he said.

Another emerging trend is the sharing of modalities between radiology and cardiology.

Agfa, which acquired Heartlab in 2005, can now offer a solution that allows a single view of a patient's radiology and cardiology images. The acquisition also puts Agfa in a position to pursue its goal of an international rollout of a hospital-wide comprehensive information management system. Such systems support patient-centric management in an environment where diagnosis and procedures have to be recorded, findings and therapy results documented, instructions issued, and work assigned.

At the RSNA meeting, Agfa will introduce new advanced visualization applications as extensions to the radiologist's desktop.

"While we will support integration with third-party solutions in this area, we will begin to introduce a suite of internally developed application based on Agfa's image processing libraries. This will help radiologists interpret data from today's modalities with more confidence," Resnik said.

FINANCIAL BARRIERS

Cost is always a barrier to broader adoption of digital systems, particularly now with payment cuts scheduled under the Deficit Reduction Act.

"In the past, a center had to be efficient to be a top performer, but budget cuts are going to make efficiency a prerequisite for survival," said Jill Howell, director of marketing and communications at Source Medical Solutions. "This is especially true for small chains that don't have the volumes to survive in a lower-margin world."

That creates an increasing need for PACS, RIS, and imaging informatics in sites where bankrolls are slim.

"Small practices, imaging centers, mobile imaging companies, and even chiropractic offices need the efficiency that these products provide," said Amber Trotman of Radical Radiology.

Kobi Margolin, vice president of marketing and business development at Neurostar, says the expansion of PACS into smaller hospitals, imaging centers, and private practices is the next frontier.

"The PACS industry has identified this potential growth area over the last few years but for the most part has failed to address it adequately," he said.

Neurostar is offering the Virtual Radiology Network, a large-scale PACS that connects multiple imaging enterprises and allows these organizations to outsource their image management needs.

"Our experience shows that this approach is more attractive and more beneficial to these customers than the traditional PACS model," he said.

RADinfo Systems embraces an enterprise-wide approach. The company will soon introduce an enterprise-scoped and scalable distributed DICOM PACS suitable for radiology, cardiology, orthopedic, ophthalmology, and chiropractic clinics of any size, according to president Chen Tai Ma.

"We are also working on a cross-enterprise image and document sharing system," he said.

Some see cross-enterprise platforms eventually expanding across the country and beyond. Infinitt's diagnostic expansion strategy transcends radiology. The company plans to integrate its medical imaging and informatics platform for cardiology, orthopedics, mammography, dentistry, dermatology, and plastic surgery into one single 2D/3D platform, according to Charles Kim, vice president of marketing.

"This single solution will provide an infrastructure for IHE Radiology and IHE IT to connect every hospital in the nation and throughout the world," Kim said.

Computing on that scale will necessitate technologies such as grid computing. The evolution of PACS throughout the enterprise and beyond has driven imaging from analog to digital and is already pushing it toward grid methodology. As provider enterprises become more distributed and complex, the need for grid computing environments increases to help IT departments manage growth, according to Jeff Timbrook, executive vice president for sales at Acuo Technologies.

Once organizations become filmless, disaster recovery becomes a consideration. DeJarnette sees a growing demand for inexpensive, robust, and reliable offsite storage for PACS data.

"A number of vendors currently offer solutions, but we don't believe anyone has met all three requirements," said Jennings Tracy, national sales manager for DeJarnette. "Robust and reliable are antithetical to inexpensive."

The company is working with several storage vendors to address the issue.

Around-the-clock availability is necessary to support teleradiology coverage. Some vendors are finding more and more traditional customers, such as large academic hospitals or multimodality clinics, need to provide coverage to remote regions, accommodate interpretation outside their facility, or subsidize their primary reads with outside consultants. Intelerad Medical Systems sees a continuing need to develop tools that optimize teleradiology and streamline point-to-point transmission of images.

DIGITIZATION'S FINAL PHASE

Vendors will also be gauging the impact of what some are calling the final phase of digitization-implementation of full-field digital mammography. With the approval of the Fuji FCRm, the only FDA-approved computed radiography-based FFDM system, the industry could see an uptick in adoption of FFDM.

For those who have already implemented both PACS and RIS, the digitization of mammography creates a new set of challenges in soft-copy interpretation. Existing systems will need to be extended and integrated with FFDM, dedicated mammography reporting systems, and mammography information systems.

Kodak's latest version of CareStream RIS, set to debut at the RSNA meeting, addresses these issues. Among generally applicable enhancements, including advanced speech recognition, the upgraded CareStream RIS contains features that streamline the workflow of mammography images, as well as automate Mammography Quality Standards Act reporting and patient follow-up. The company's PACS also contains specialized mammography features that integrate breast MRI and ultrasound CAD software.

These developments should come as no surprise, as the adoption of FFDM places new demands on PACS, according to Courtney Kraemer of Fuji. Integrated high-efficiency screening and multimodality diagnostic tools are now mandatory components of successful PACS installations.

The next major release of Synapse (V3.2) will include full support for women's healthcare imaging, including FFDM and multimodality breast imaging, Kraemer said.