What you need to know now about server-side rendering

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 - Joseph-Marion
Joseph Marion

Streaming technology is the future made present to those who want to watch movies anywhere at any time. It’s becoming the same thing to radiologists, clinicians and patients who want mobile access to medical images.

“How many people bother with renting or purchasing DVDs in an age of Amazon Fire TV or Roku?” wrote Joseph Marion, a healthcare technology consultant whose firm is Wisconsin-based Healthcare Integration Strategies. “The same may likely be the case for digital image access and interpretation through streaming technology.”

For provider organizations that implement vendor-neutral archives, he continued, adding a server-side rendering (SSR) solution— which allows a user’s browser to fetch data from a program or application running on a server rather than one running on the user’s computer—“can augment the need to acquire a complete PACS solution.”

Intrigued by that assessment, this reporter reached out to Marion with questions on the background, basics and finer points of SSR technology.

What technical and economic developments facilitated the rise of SSR in medical imaging?

Joseph Marion: From a clinical perspective, the key driver probably was in the advanced visualization area. People were looking for more cost-effective solutions. If all you needed was a single advanced-visualization workstation, then you probably didn’t need server-side rendering. But server-side rendering can offer some significant advantages to some of the larger provider organizations and integrated delivery networks.

From a technology point of view, healthcare has always capitalized on commercial or consumer developments. And as graphics processing units became more powerful and sophisticated, those advancements became more applicable to applications in medical imaging.

In terms of what’s attractive about SSR, it’s the speed and the potential to lower costs. And from a data security point of view, the fact that no information is being transmitted to the clients is another major advantage.

The only remaining question is on latency of operation (the time it takes to send a message from the client to the server and then back again). So bandwidth is going to be a significant factor in the context of whether it’s an appropriate technology or not.

In what scenarios is SSR clearly superior to client-side, where it’s the local computer or workstation that runs the application? In what scenarios is SSR marginally superior or not the best choice at all?

When you have multiple users in varied locations, there is a clear advantage to SSR technology, because it does offer “any image, anywhere, anytime” kind of access. This is appealing to some of these larger multi-site integrated delivery networks.

If all I have to do is keep a server up to date and any web browser can access it, then I am simplifying how I maintain and update the capability as well. Which again is appealing to some of these larger provider organizations.

What constitutes good performance in server-side rendering?

The gold standard basis was any image, anywhere at any time—and within two seconds. I think that’s probably the benchmark. If you can put the images up there in two seconds for a diagnostician, that’s acceptable performance from a clinical perspective.

And then for clinicians, clearly, they maybe don’t need quite the same level of performance as the diagnostician does. And the patient definitely doesn’t need the same level of performance. So you can accept or tolerate more latency in those situations then you could for the diagnosticians.

Are there any particular technical challenges IT departments should anticipate when moving to SSR?

I think one of the clear questions is going to be, if I am going to locate this thing centrally, do I have any redundancy in the system? Because then I am dependent on two factors. One being if I only have one data center where the servers are located, I have no redundancy. If it goes down everybody is down. And then secondarily, dependent on the network in the context that if the network goes down, likewise, I have no accessibility.

So I think those are probably factors that facilities would need to look at. Do they have the infrastructure in place to be able to support redundancy?

We hear a lot these days about zero footprint viewers. To what extent are these a part of SSR and to what extent are they a category of their own?

There are two pieces to a server-side rendering implementation. There is the rendering engine, if you will; the central server. But then I have to be able to enable viewers to view that. And that’s where the zero footprint viewer comes in. The most effective approach to this, and the most secure approach, is that I never transfer information to the client. So if it is truly a web-based HTML 5 application, say, where I don’t have to have any plug-ins on the local device, that would be the ideal situation. Because now I don’t have to download anything to the client, and there is no information left on the client once the user logs out.

What does the buzz around zero footprint viewers mean for the future of PACS?

I think it is the future of PACS. The whole notion of streaming technology is going to be the future just because of the consolidation that is occurring in healthcare systems. If they want to capitalize on what they have done organizationally, the server-side rendering and zero-footprint viewer are ideal technologies in the context of enabling them to do that from a purely clinical or diagnostic perspective.

From the other clinical perspective and from the patient’s perspective, I think it offers a huge potential because of the proliferation of devices. A lot of people are walking around with smartphones that have enough technology to display clinical images.

In a blog post, you wrote that Fujifilm is “perhaps the most interesting” vendor in this space, “as it has long been a mainstream PACS vendor employing unique technology as part of their Synapse product line to enhance the performance of image access.” It’s been nearly a year. Have you made any observations since then to confirm or change that assessment?

I think Fujifilm is very insightful in terms of moving in this direction. If you look at the whole Synapse product from its inception, one of the advantages that Fujifilm always offered was the performance and advantage of quick access to images. I see this as sort of an extension of that. By capitalizing on that technology, they can sort of bring together a lot of technologies they already have.

The basic Synapse application, the 3D advanced visualization capability and potentially the portal to the clinician and the patient are opportunities—I think it’s an ideal fit for a Fujifilm as opposed to some of the other companies that may be more vested in their dedicated technologies.