Advanced Visualization Goes Enterprisewide, Sort of...

Server-side processing permits 3D image manipulation to take place on a central server before being transmitted to a thin client. This is one innovation that will help facilities meet meaningful use criteria regarding the integration of advanced visualization imaging into the EMR. But there are still some technical challenges ahead.

The Centers for Medicare and Medicaid Services (CMS) has mandated that facilities integrate advanced visualization imaging from CT, MRI and nuclear medicine into their EHRs/EMRs by 2015.

Rasu B. Shrestha, MD, medical director of interoperability and imaging informatics at the University of Pittsburgh Medical Center, sees this as an opportunity to change a healthcare culture that has historically separated EMRs and imaging. “It’s not only about retrieving images directly from the EMR, but also about addressing some of the fundamental flaws of delivering siloed medicine,” says Shrestha.

Such interoperability on some levels is already possible, but whether or not it’s meaningful is the question. In Northern California, clinicians have full access to 3D reconstructed radiology images—MIPs, MPRs and coronal reformats—through embedded URLs in the EMR that launch PACS viewers. However, this does not include 3D volume-rendered images, says Daniel Navarro, MD, the regional chief of imaging informatics for The Permanente Medical Group of Northern California and chief of imaging informatics for Oakland Radiology.

Navarro’s radiologist colleagues have not fully embraced 3D volumetric imaging because of the need for dedicated workstations. This means radiologists must leave their desktop, go to a 3D workstation and call up the case. Radiologists instead rely on dedicated 3D labs to postprocess the few subspecialty cases that warrant volumetric imaging.

Some surgical and oncological specialists have access to volumetric imaging, but it’s through dedicated tools that are not integrated into the EMR, Navarro says. “The thin-client model is an interesting possibility, but it will have to be part of the PACS, then it can be truly integrated into EMRs, so referring physicians actually have access to the images.”

Finding balance

There have been some dramatic changes in advanced visualization in the last few years, including the exponential increase in imaging data; server-side rendering, which allows access to advanced visualization from thin clients, rather than dedicated workstations; and the increasing need of other clinicians to access imaging data. But not every physician wants to view images, and even fewer want to access 3D and/or volume-rendered images.

“The challenge is to find the right balance between having enough tools or too many tools available,” says Shrestha. There is preliminary work being done in terms of having the right set of tools for the right physicians who access the studies. Shrestha calls it a “user-defined set of tools where a customized user-centric viewer is used at the front end.”

Work in this area is in its early stages, but this is where the industry needs to go, he says. “That level of customization will quickly become the theme of how you access data across the board, not just the tools available, but even the types of data that get presented to you.”

The push for meaningful use is mainly about having all patient information available to any clinician in the continuum of care. The problem is that this information cannot be taken out of context. “There are scenarios where standard imaging and clinical data from the EMR work together for clinicians to make better and faster treatment decisions and for radiologists to provide better reporting,” says Khan Siddiqui, MD, principal program manager for the Health Solutions Group at Microsoft and chair of the IT and Informatics Committee for the American College of Radiology. “It’s the same with advanced imaging: The clinician only wants the information if it will be meaningful.”

Some institutions such as Johns Hopkins have built applications that provide clinical context such as lab values, notes and prior reports along with the study being interpreted by radiologists. “Conversely, if specialists don’t have the ability to use advanced visualization tools, to manipulate 3D and volumetric images, then they are not looking at the images in the proper clinical context,” Siddiqui says.

When Siddiqui was at the Baltimore VA Medical Center, he and his colleagues implemented advanced visualization capabilities for the enterprise in 2002. Their strategy was to train all new residents to utilize PACS and advanced visualization tools, and they sent a few dedicated teachers to every department for one-on-one tutorials. By the fourth year of implementation, the majority of clinicians were using advanced imaging tools.

At one point, Khan and colleagues evaluated how radiologists interact with reading stations. They found that the worst input devices were the mouse and keyboard—yet vendors make applications very specific to the mouse-keyboard combination. “Yes, there are interface challenges for advanced visualization tools, but that’s not the only problem. What is the best way on the other end for specialists to interact with the data? Would surgeons prefer voice- or retina-activated navigation? These are the things to think about as we move toward ubiquitous image access,” Siddiqui says.

In another study, Siddiqui and colleagues discovered that clinicians prefer to learn how to use new technology by “playing” with it rather than by any didactic method. He points this out to emphasize the need for technology to be intuitive and user-friendly, particularly as advanced visualization courses through the enterprise. The question is, are vendors thinking about it from that level.

Intelligent interfaces

A majority of hospitals currently launch routine images through a web viewer of their PACS through the EMR. “There is no question this has value, because the clinician can consume the images in the clinical context using the tools of the EMR she is most used to using,” says Paul J. Chang, MD, professor and vice-chairman of radiology informatics at the University of Chicago School of Medicine.

Chang says the state of advanced visualization image access and retrieval is where conventional image access and retrieval was five to eight years ago. But because those hurdles were overcome and it is now routine for clinicians to access images via the EMR, integrating advanced visualization into the EMR should be a “trivial matter.”

The problem is that server-side advanced visualization is in the early adopter phase. Most vendors that offer advanced visualization offer a thin-client option, but not all thin-client programs have the same rich functionality of thick clients, or workstations. “We’re getting there and I predict in a few years there will be no more thick clients,” Chang says.

Advanced visualization still needs to be better integrated into PACS, he says. The thousands of images from a single CT study must be sent from the PACS to the server, admittedly a better solution than when those slices had to be sent to each workstation, but still a disruption in seamless flow that results in “impedance mismatch.” The extra step of sending images from the PACS to the server (rather than accessing the images directly from the PACS) can result in potential bottlenecks when you consider the hundreds of advanced imaging cases done per day, Chang says.  

Finally, echoing Shrestha, Chang says that the advanced visualization data available to subspecialists must be delivered more intelligently. “We don’t need to dumb down the interfaces, rather, we need to optimize the experience, the data available, so clinicians can navigate the territory without needing to know anything about advanced visualization mechanics.”

He uses the analogy of a manual versus an automatic transmission. The automatic car is not a dumbed-down version of the manual car. It merely optimizes the driver’s experience without the need to know anything about transmission mechanics. It gives the driver a meaningful experience, according to Chang.

At the University of Chicago, Chang can launch advanced visualization tools from the EMR. “I’m compliant to the letter of the law. Do I think my surgeons will use this technology? No, because it’s too hard to use, the interface is not as intelligent as it needs to be.”

Chang is confident the bugs will be worked out within a few years and the meaningful use of advanced visualization images through the EMR will become as routine as the accessibility of static images is today.

The most important step for facilities to take to meet meaningful use for interoperability, says Siddiqui, is to have a very detailed RFP for your EMR vendor. “You need to define everything clearly and early on,” Siddiqui says.