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Advanced visualization:

Making the right choice

Making image data available anytime, anywhere is the key to the adoption
of advanced visualization techniques. True thin-client workstations with
server-side rendering and enterprise-wide distribution are the current trend.

Khan M. Siddiqui, MD

n the early 1970s, computed tomog- to which images are delivered for image Another form of client-side rendering
raphy (CT) studies generated just a rendering and display. There is, however, involves the radiologist directly perform-
few images that radiologists could a growing trend toward use of a “thin-” or ing image processing. In this case,
spend time examining in detail. Today, a “smart-client” configuration, in which images acquired on the CT scanner are
typical trauma CT study at the Univer- image rendering takes place on the server sent to the PACS. Either the radiologist
sity of Maryland Shock Trauma Center or “back end” at the data center. Images reads the images on a 3D workstation sit-
consists of 2000 slices. A typical cardiac are streamed to the workstation for dis- uated adjacent to the PACS, or the
CT study may generate ≥6000 images. play. Another option is to display all images are pulled from the PACS to a
The difficulty of evaluating so many images on the picture archiving and com- separate 3D workstation for processing.
images has spurred the movement toward munications system (PACS). Client-side rendering forces clinicians
volumetric or 3-dimensional (3D) inter- and radiologists to physically go and find
pretation of imaging data. More and more Image visualization the workstation, which could be any-
radiologists are taking advantage of a There are two basic forms of image where in the hospital and is sometimes
multitude of tools that enable advanced visualization solutions: 1) client-side difficult to find. This creates a hindrance
visualization, advanced functional analy- rendering, and 2) server-side rendering. to the use of advanced image processing.
sis, and quantification of pathology. When the PACS and 3D workstation
Vendors have developed a variety of Client-side rendering are not tightly integrated, workflow can
workstations to support 3D imaging. The How image rendering takes place can suffer. Typically the radiologist views
traditional workstation is a “thick client” have an important impact on workflow. 2-dimensional (2D) images on the PACS.
Client-side rendering creates a big dis- However, in order to do multiplanar pro-
When this article was written, advantage of limiting one user at a time cessing or 3D visualization, measure
Dr. S i ddi qui was Chief of Imaging to use a costly workstation. There are stenoses, or use other advanced tools,
Informatics and Cardiac CT/MRI at the multiple workflows for client-side ren- the radiologist must go to the 3D work-
Veterans Affairs Mary land Health Care dering depending on who actually inter- station, which may or may not be
Sy stem, and Co-Director of the Imag-
acts with the workstation. In one version located nearby.
ing Informatics and MRI Fellowships
at the Univ ersity of Mary land School of client-side rendering, a technologist A semi-integrated PACS and 3D
of Medicine, Baltimore, MD. He is does all the processing. The scan is per- workstation is more convenient because
now Principal Program Manager, formed on the CT scanner, and data are it makes possible simultaneous exami-
Health Solutions Group, Microsoft sent to the advanced workstation and to nation of the data sets on both the PACS
Corp. , Redmond, WA. He currently the PACS. Processed images are then and advanced workstation without hav-
chairs the IT and Informatics Commit-
created by the technologist and pushed ing to physically move from one place to
tee for the American College of Radiol-
ogy and also chairs the Adv anced to the PACS again, where the radiologist another. However, the workstation must
PACS-based Imaging Informatics and interprets them. In this workflow, the be very robust for client-side rendering.
Therapeutic Applications Conference radiologist is at the mercy of the technol- In addition, unless there is integration of
of SPIE Medical Imaging 2009. ogist, who decides the format and orien- contextual data between the systems, it
tation of images the radiologist will see. will be necessary to duplicate the input


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identified and annotated at the PACS

workstation that information may not
be available to the radiologist working
at the 3D workstation. Lastly, a robust
network is required, given the amount
of data that must be transferred to the
3D workstation for processing.

Server-side rendering
The biggest advantage of server-side
rendering is that data are available wher-
ever they are needed, anytime they are
needed. In addition, everyone who is
accessing the data is interacting with the
same data from the same server. Infor-
mation can be saved on that server—a
FIGURE 1. Chest CT in a patient with prior studies. A survey of radiologists indicated that they defining pathology or measurements of
want to see current and prior images simultaneously on the same monitor. They also want to ejection fraction or perfusion, for exam-
see multiplanar reconstructions along with maximum-intensity projection images on the other ple—and all users have access to it.
monitor, and a volume-rendering on the color monitor.
Server-side rendering is less network-
dependent because only a small amount
of data is transmitted at a time, and the
streaming technologies that most ven-
dors use don’t require a robust network.
In addition, workstations do not need
robust computing power, as most of the
processing work is done at the server.
The biggest advantage for server-side
rendering solutions is that advance
image processing applications are avail-
able to the entire healthcare enterprise
and can significantly enhance patient
care by making advance image data
available to every physician. Image pro-
cessing can even be done from home
while securely connected to the server
FIGURE 2. This extremity CT in a patient without prior studies is displayed in accordance with at the host institution.
survey results on radiologistsʼ viewing preferences.
One disadvantage of server-side pro-
of patient and study information from multiple workstations for multipurpose cessing is the limited number of appli-
the PACS into the 3D application. or multidepartmental use. Still, worksta- cations currently available. This is
There are certain advantages to using tion locations are often limited and may rapidly changing, however, and at the
client-side rendering. First, most 3D be inconvenient. Typically, an institution time of the publication of this article, all
workstations available today are de- buys just one or two 3D workstations, applications available on stand-alone
signed for this use. Technologists and and all users must share them. workstations may be available on server-
3D lab personnel can preprocess image To handle all of the image data, side rendering clients. Many vendors
data before the radiologist looks at them. a powerful computer with multi- are putting advanced cardiac analysis
Once the data have loaded, all function- gigabytes of random access memory applications and virtual colonoscopy ap-
ality is performed locally on the 3D and, usually, multiple processors is plications on server-side rendering
workstation. And many 3D worksta- needed. The distributed architecture can clients, for example. Another disadvan-
tions are sold at a discount when pur- create problems, as not everyone may tage is that there may be a reduction in
chased at the same time as a scanner. be reading from the same dataset. For performance when more than the optimal
There are also disadvantages to client- example, if data are sent to a 3D work- number of users are accessing the same
side rendering on a traditional 3D work- station for rendering, and the patient is data and on the server configured for a
station. First, it is necessary to buy later re-imaged or an abnormality is lower number of concurrent users. In


a high-volume practice, such delays

may reduce radiologist productivity.

Survey: Integration
To better understand the need for
tighter integration between 2D and 3D
interpretation, we deployed a survey on
the Internet in 2006 jointly with the
Departments of Radiology at VA Mary-
land Healthcare System, Baltimore,
MD, and Stanford University School of
Medicine, Stanford, CA.1 We wanted to
know whether radiologists and cardiol-
ogists perceived a need for a seamlessly
integrated 2D/3D application or a 3D
advanced visualization application from FIGURE 3. This abdominal CT in a patient with prior studies is displayed according to radiolo-
a single PACS vendor. gistsʼ preferences.
We received 503 responses to the sur- the use of 3 color monitors. As a result, best orientation for evaluating compres-
vey, approximately two thirds from there is some discrepancy between our sion fractures of the spine. When evalu-
radiologists and one third from cardiol- study data and what we would expect to ating for lung nodules, they requested
ogists. We were surprised to find that find today.2 lung and soft tissue windows.
96.2% of radiologists and 92.3% of car- The study involved 8 radiologists from Finally, they requested that 3D series
diologists reported reviewing CT or 3 different medical institutions using also be tailored for specific tasks—for
magnetic resonance (MR) images using 6 different PACS systems and 4 different example, axial maximum intensity pro-
3D and multiplanar reformatting. We 3D systems. The selection of a breadth of jections (MIPs) to evaluate for lung
also asked who usually creates multi- users with multiple systems provided us nodules and coronal MIPs for vascular
planar, 3D, or volume-rendered images with better information on workflow. interpretation.
for interpretation. Both radiologists and As expected, in a survey of 8 radiolo- We then brought all 8 radiologists
cardiologists reported doing image pro- gists and 18 protocols, there was a large together and asked them to agree on a
cessing themselves during the interpre- amount of variance in the initial “blank consistent layout. Some of protocols
tation in the majority of cases, rather slate” evaluation, primarily in the layout they decided on are shown in Figures 1
than relying on technologists (79.2% and positioning of particular image through 3. Figure 1 illustrates the pre-
and 69.2%, respectively). We found no series. However, there were similarities sentation of a chest CT with prior stud-
significant difference between acade- in windowing/leveling, orientation, and ies. The radiologists said they would
mic radiologists and private-practice 3D presentation states. want to see current and prior images
radiologists in the likelihood of process- When the initial results were compiled simultaneously on the same monitor.
ing images during interpretation (78.1% and the participants were presented with a They would also want to see a multipla-
and 81.0%, respectively). consensus layout, there was a high level nar interpretation along with a MIP on
These responses suggest that both of agreement. We were surprised to find the other monitor, and a volume-rendered
radiologists and clinicians want inte- that all 8 radiologists wanted the images image on the color monitor. Figure 2
grated 2D/3D workflow that makes use to be laid out in a 4-on-1 display on both shows an extremity CT without any
of the same application. In addition, monochrome monitors, with volume- prior studies, while Figure 3 shows an
they want to be able to interact with rendered image on the color monitor. abdominal CT with prior studies.
those images rather than use precanned Second, all radiologists wanted Study participants also indicated that
screen captures from a workstation. images presented in axial, coronal, and all 3 monitors should have color dis-
In 2006, we conducted a study that sagittal planes for every case. Third, all plays, so that advanced visualizations
asked the question: If a PACS with a users requested multiple preset windows could be put on any portal available, not
seamlessly integrated 2D/3D capability and levels. However, not all window/ just a single monitor.
were available, what would the ideal dis- level settings were requested for every These studies clearly identify a need
play layout look like? In designing the orientation; instead study participants for a 2D/3D integrated solution and radi-
study, we made the assumption that radi- wanted them to be tailored to the task ologists’ preferred layouts and types of
ologists would use 2 monochrome high- at hand. For example, they requested displays. The next step was to determine
resolution displays and 1 color display. bone window/level settings on sagittal whether radiologists actually worked in
In hindsight, we should have assumed images of a CT of the chest, as this is the this way. To answer that question, we


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looked at the interpretation process in To determine whether these results Current and future trends
real time at our institution. were unique to our department, we It has become obvious to vendors and
In the past, workflow studies involved looked at audit logs from 3 different insti- the academic community that making
human observers with stopwatches. That tutions. At site A (our institution), 90% of image data available anytime, anywhere
approach not only takes a great deal of all studies were being looked at by clini- is key. True thin-client workstations with
time and personnel, it interferes with cians or radiologists in nonaxial mode. At server-side rendering and enterprise-
daily workflow and is full of errors and site B, an academic institution, nearly wide distribution are the current trend.
bias. In fact, this approach creates a “fish 25% studies were being looked at in As time goes on, and more and more
bowl” phenomenon in which radiologists advanced visualization mode. At site C, a studies involve dual-source scanners and
actually change the way they interpret community hospital, only 6% of studies multispectral imaging, there will be too
studies in response to being observed. were being looked at in advanced visual- much data for workflow to focus on the
To avoid this problem, we created a ization mode. When utilization of 3D examination of axial, coronal, and sagittal
new method that uses automated data visualizations was tracked over time, we images. Instead, workflow will need to
extraction and data mining from the saw increasing utilization of advanced become anatomy-driven and pathology-
PACS and the 3D application to assess visualization at site A, whereas utilization driven.
the interpretation process in real time. It at the other two sites was nearly flat. To do that, it will be necessary to auto-
documents the actual interpretation In the middle of the study period, site matically identify where the desired
process and assesses the variability of B integrated its clinical applications anatomy is. Some vendors are develop-
interpretation throughout the day, with- with the PACS and changed its proce- ing tools that preidentify anatomy before
out the need for personnel observing a dures so that all studies done on the radiologists open the study, so that work-
radiologist. In addition, radiologists are scanners were automatically sent to the flow can be based on anatomy. It will
not aware of being observed by anyone, server-side rendering application. It also also be important to prespecify how radi-
even though they know they are being added a 3D button on the PACS that the ologists want to see certain anatomy or
tracked by the application. radiologists could use to launch cases on pathology, rather than simply viewing
We identified lists of desired auditing the 3D applications. After site B imple- traditional planes.
functions, including use of workstation mented the new policy and made it eas- Another trend spurred by increasingly
tools, navigation strategies, time-stamped ier for radiologists to do 3D inter- robust Internet technology is truly
functions, and percentage of time spent pretation, we found that the utilization browser-based advanced visualization
looking at advanced visualizations versus trend became similar to that of site A, with “zero footprint,” without the need
multiple imaging planes. We used the where all studies automatically went to for a client installation or even a “plug-
audit logs from the PACS and 3D sys- the thin-client application. in” for image viewing. This truly en-
tems that were originally developed for At site C, the advanced visualization ables enterprise-wide and Web-based
“debugging” purposes. In their raw form server was in an on-demand mode. All deployment of imaging solutions, and
they are essentially unreadable, but we studies were reconstructed on the scan- even opens the possibility of sharing
converted them to a much more useful ner; therefore, many MIPs, multiplanar images with patients.
format from which we can extract infor- reconstructions, and other nonaxial
mation to understand how the radiolo- images were sent to the PACS directly REFERENCES
1. Lau D, Siddiqui KM, Herfkens R, et al. Survey of
gists interact with images based on slice rather than to the thin-client application. 3-D visualization usage. Presented at the 92nd Sci-
information, navigation time, etc. When radiologists needed to view stud- entific Assembly and Annual Meeting of the Radio-
The initial phase of the study was ies on the thin-client applications, they logical Society of North Ameria. Chicago, IL;
November 26, 2006 .
conducted in 2003, 1 year after imple- would ask the technologist to push them 2. Boonn WW, Siddiqui KM, Vandermeer P, et al.
mentation of server-side rendering and from the PACS. At site C, 3D utilization Defining and evaluating custom 2D, 3D, and
thin-client enterprise advanced visual- remained low throughout the study. advanced imaging digital display protocols. Pre-
sented at the SPIE Medical Imaging 2006: PACS
ization application. We found that 36% These results showed that if an institu- and Imaging Informatics conference. San Diego,
of all CTs done in the department were tion enables technology, makes it avail- CA; February 14, 2006.
being examined in a nonaxial mode by able, and incorporates it into the work- 3. Musk A, Siegel E, Siddiqui KM, et al. The use of
workstation auditing tools to determine how
radiologists, as were 1% of studies flow, radiologists will use it. Studies by 3D/multiplanar workstations are used in the routine
reviewed by nonradiologists. Dr. Siegel3 have shown that use of an interpretation of CT of the thorax. Presented at the
We repeated the study in 2005 and advanced multiplanar interpretation 90th Scientific Assembly and Annual Meeting of the
Radiological Society of North Ameria. Chicago, IL.
found that 90% of all CT studies done in process actually saves time, for example, November 28, 2004
the department were being examined in cutting the time spent reading a chest CT
a nonaxial mode by radiologists. Among from an average of 7 minutes to an aver- For a roundtable discussion of this article,
nonradiologists, 21% of all CTs were age of 5 minutes after implementation of informatics.
being examined in a nonaxial mode. a thin-client solution.