FEATURE Peter Weston MPH, has 12 years experience in web based imaging and infrastructure software and is an independent medical software and IT consultant and non-executive director of Executive Data Systems Pty Ltd. pweston@execdata.com.au
Diversifying the digital radiology technology suite Are radiology services providing their own radiologists and their external referring doctors with appropriate medical imaging where, when and how they want them? The short answer is: ”No, not typically”. Radiology groups, whether large or small, generally have one method for Internet delivery of medical images to their referrers, and usually only a single diagnostic platform (usually a Picture Archiving and Communication System (PACS)) for internal reporting. In both cases, multiple solutions are required to deliver all the benefits of modern digital radiology to the widest possible user group. For the radiologist, a PACS for general reporting and image management is needed, as are advanced visualisation (AV) solutions for reporting on CT and MRI volumes as opposed to individual slices or simple “stack scrolling” of axial images. Advanced visualisation technology is now so automated and fast that it dramatically aids in clinical diagnosis and surgery planning, where it is becoming the default interface for such studies. This technology is also needed to realise the potential provided by the high volume of slices being produced by today’s modern scanners. Advanced visualisation technology is now available through web-based solutions, which means the data is accessed via a web browser, usually with the help of a browser plug-in. A 3D image view is displayed on the clinicians browser, but the complex graphical interpretation occurs on the server. Of course, advanced visualisation solutions also provide 2D views of the three planes (sagittal, coronal and axial) as many PACS do, however the 2D and 3D are “as one” allowing you to walk or measure a vessel in 2D and it will be traced in 3D, for example. PACS typically use “streaming” of compressed individual images for delivery over low bandwidth connections. Some PACS pre‑cache the raw data for the radiologist to allow it to be locally accessed at a later stage. Most PACS now have web servers for remote and referrer access, though few are fully web-based. One radiologist recently mentioned to the author that he has used a workstation-based advanced visualisation solution for the last five years and consequently uses far better clinical tools for multi‑slice studies than the standard PACS provides. Now of course he can benefit from web-based access to advanced visualisation technology (integrated with his radiology information system and/or PACS), meaning he doesn’t have to leave his “integrated desktop”, push a radiographer off their chair, or monopolise that freestanding legacy advanced visualisation workstation in the back room. And now, if desired, he can share access to this system with his specialist referrers. When it comes to referrer delivery, Internet-based filmless
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delivery is still missing the mark. Referrers are not a homogenous group and naturally each subgroup has different requirements. While GPs provide the bulk of imaging requests, their image viewing needs are not as demanding as many specialist referrers. GPs want seamless integration of image delivery with their clinical software, irrespective of their preferred web browser and operating system. And they don’t want additional software installed on their desktop due to increased IT support overheads. Of course, both GPs and specialist referrers also need the report accompanying the images! So, the challenge for radiology groups and their software suppliers in the context of the GP market is platform independence coupled with GP desktop integration — no single provider to the author’s knowledge has achieved all of this yet, though some are getting close. Specialist referrers on the other hand have the same basic requirements, but a far greater need for image access complemented by appropriate clinical and diagnostic tools. There are some specialists that don’t require diagnostic quality images, however cardiologists, vascular and thoracic surgeons reviewing CT studies of the heart for example, love advanced visualisation from which they can automatically review or quickly create a stent plan. Oncologists could utilise web-based clinical tools for prior and current study review of, for example, lung lesion pathology characteristic interpretation and comparative volumetric measurement. And the list goes on. None of this will be a revelation to radiology groups, so why have they not provided what the market desires? While technology change has been rapid, there are other limitations, cost being amongst them. Telecommunication costs, whilst significant, are now at least affordable, obviating this limitation. Integration with other systems can be technically challenging and time consuming, and often underestimated by radiology groups who generally don’t provide enough resources to project manage such implementations. However in the author’s view, the simple answer is there isn’t enough awareness of the reality that several solutions are needed to meet the heterogeneous nature of referring clients. Mobile medical “tablet” computing technologies — or perhaps Apple’s iPad, given how Specialists seem to like that brand — will further increase the number of platforms referrers will inevitably utilise in their clinical practice. Bring it on! So, vendors you are on notice: deliver solutions that cover the myriad of viewing requirements from a single, web-based offering that includes the report. Oh, and make sure it can be accessed by any specialists that may later be involved in the patient’s care, including those specialists working in a public hospital!