Michael Gray

IT Matters – Which of today’s universal clinical viewers have the potential to be tomorrow’s radiology diagnostic viewers?

April 03, 2015
Over the past four years, there has been an uptick in EMR deployments, as hospitals, clinics, and physicians prepare themselves to meet the Meaningful Use requirements mandated by the government. Not long after the physicians get comfortable using the EMR to access the wide range of unstructured data (procedure reports, lab results, care summaries, etc.) associated with a patient’s episode of care, the inevitable question arises, “where are the actual images?”Accessing the usual diagnostic images through separate interfaces to the organization’s individual department PACS viewers has produced less than satisfying results.

Multiple PACS viewers means separate viewing sessions for the physicians, one to review the radiology images and another session to review the cardiology images. The performance of the typical clinical PACS viewer is compromised by high latency broadband connections, and the PACS viewers usually require Windows platforms, thereby excluding most tablets and smart phones tucked into physicians’ pockets. An even larger drawback is the PACS viewer’s restriction to DICOM images.

Today’s clinical viewer is expected to support the fullest range of user platforms including mobile devices, perform incredibly well over broadband, and access and display the complete range of clinical images from radiology to dermatology, the burn center, and surgery. That means displaying DICOM as well as JPEG and MPEG. Yesterday’s clinical PACS viewer has given way to today’s UniViewer.

The UniViewer as I refer to it, is the ideal display application for image-enabling the EMR. This new generation of clinical viewer features a zero or near zero client that communicates with the server-side rendering application that actually executes the image manipulations and then streams the resultant image to the user display platform. This technology is already a major improvement over any of the thin-client clinical viewers featured by most Radiology PACS. Expanding access beyond radiology images is yet another major improvement, as this potentially gives the radiologist access to the patient’s complete medical image record including those clinically relevant images previously trapped in specialty workstations, on thumb drives and in mobile devices.

The first wave of UniViewer introduced back in 2010 has evolved from the simple objective of being a more efficient and performant clinical viewer for a radiology PACS, to a multi-object viewer capable of accessing, managing and displaying any DICOM and non-DICOM image that has clinical relevance to the latest radiology study being interpreted. The further the UniViewer can reach outside of radiology, the more appropriate it is to serve as the universal viewer for the EMR.

Another important feature of many UniViewer solutions is the range of options it has for querying and retrieving medical image data. Most department PACS solutions only support a DICOM interface with external devices, requiring the UniViewer to pre-stage months of image studies on a working cache to meet performance expectations.

The cost of a few terabytes of storage is not the issue. The existence of two separate databases of image data, the original images on the PACS and the copy of the images on the UniViewer cache, creates a synchronization problem. Having to guarantee that the UniViewer is always delivering the most recent version of the image study to the physicians is an undesirable complication.

Most Vendor Neutral Archive (VNA) solutions support the much faster web services interfaces like Web Access of DICOM Objects – using Restful Services (WADO-RS) and Medical Imaging Network Transport (MINT).

A UniViewer and a VNA connected by a web services interface allows the UniViewer to draw image data directly from the VNA. This precludes the need for that pre-staging cache, improves performance, and eliminates the need to synchronize disparate databases. The pairing of UniViewer and VNA using a web services interface has the potential to be much more than a clinical viewer for the EMR physicians.

What if the UniViewer offered a richer set of display features and functions, well beyond what is considered ”clinical” functionality and included hanging protocols? In fact, such an advanced UniViewer paired with a a next generation PACS solution. The only piece missing is the workflow application.

Hold that thought for a moment longer. As expected with any display application, the range of features and functions undergoes constant change. The basic flavor of the earliest UniViewer often did not satisfy the needs of the true image users in the physician community. Ideally, the clinical viewer should provide display tools nearly identical to those available to the radiologists and cardiologists interpreting the studies. Naturally there is now considerable interest in how far UniViewer vendors will expand their feature/functionality suite. The line extending from “clinical” display applications to “diagnostic” display applications is something of a continuum representing the ever-increasing demands of users for more and better tools.

There are, of course, technology requirements associated with the more advanced tools required for diagnostic interpretation, but the hope is that zero or near-zero clients paired with server-side rendering technology can support all of the tools currently included in the most advanced diagnostic workstations used in the organization’s imaging departments, and provide a substantial boost in performance, finally supporting at home diagnostic interpretation. Therefore, it is my contention that UniViewers should be evaluated based on where they sit along this continuum, how far along the continuum toward “diagnostic” a vendor plans to take its product, and how soon.

A UniViewer with a full suite of diagnostic radiology features and functions, paired through web services with a VNA to serve as the image manager, and a Workflow application to build the reading lists, would together make a powerful replacement PACS. If that same UniViewer application suite accommodated both DICOM and non-DICOM data objects, then the UniViewer is both the diagnostic radiology display application and the multi-faceted EMR viewer…tomorrow’s singular solution to the majority of image display needs across the enterprise.

About the author: Michael J. Gray is a consultant specializing in the digital management and distribution of medical image data, and the founder of Gray Consulting. Gray’s areas of expertise are market analysis, technology analysis, strategic planning, equipment utilization, needs assessment, workflow analysis, and vendor analysis/selection.