Enterprise Visualization: The CIO Story

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When contemplating implementation of an enterprise-wide advanced visualization solution, expect to hear many concerns voiced by various stakeholders—and look for the CIO’s voice to be front and center among them. Topping the CIO’s list of concerns will most probably be whether (and to what extent) the proposed advanced visualization solution is scalable. Duleep L. Wikramanayake is CIO for Advanced Radiology Consultants, Trumbull, Connecticut. He says, “If scalability is limited or missing, I wouldn’t even consider adopting that particular solution. The lack of scalability will leave you flat-footed. You’ll discover that your physicians love advanced visualization and will use it more and more often; soon, you’ll be fielding requests for more users and requests to save the studies longer. Only if you have scalability can you accommodate all this.” Another CIO concern is proprietary versus open-source technology. “The best advanced visualization solutions in an enterprise environment are those that are as nonproprietary as possible,” Wikramanayake says. “Here’s why: Say you have an advanced visualization solution that is based on proprietary technology. It might be ideal for your needs, but then the brains behind that proprietary product decide to leave the company. With them go the company’s potential for making future enhancements to that product. Now you’re stuck with a solution that becomes increasingly less viable over time. You avoid all that by buying a solution built from off-the-shelf components.” Access-point Problems Advanced Radiology Consultants first needed an advanced visualization solution in 2005, having recently acquired a multislice CT scanner; that need was satisfied by procuring a lone thick-client workstation. “I’m sorry, but a thick client, from my perspective, is ugly,” Wikramanayake says. “It’s just very hard to support if, as we are, you’re a distributed organization that acquires images anywhere and then reads them anywhere.” The problem with Advanced Radiology Consultants’ thick-client workstation was accessibility—the lack of it, to be precise. Because there was only one workstation, not every radiologist and technologist who wanted to use advanced visualization could freely do so. If the workstation was busy, users had to wait their turns. “That’s how it goes with a thick-client model: Access points are usually very limited, and they are limited because workstations are so very expensive,” Wikramanayake says. “We have 20 radiologists and about 75 technologists in our group. Clearly, one workstation was going to be inadequate.” Advanced Radiology Consultants—one of the nation’s oldest imaging groups, and among Connecticut’s largest—owns modalities capable of generating advanced visualization studies at each of its eight imaging centers and at Bridgeport Hospital (where the group is contracted to provide full-time coverage). The multislice images are distributed and archived via PACS. Earlier this year, Advanced Radiology Consultants replaced that lone advanced visualization workstation with a Visage CS thin-client solution from Visage Imaging, Andover, Massachusetts. One of its selling points was that Advanced Radiology Consultants could implement this product without the need to make changes to its IT infrastructure. “The product was basically plug ‘n’ play,” Wikramanayake says. “Visage is Web based, so if you have browser capability, you can easily bring it aboard—all you need is an Internet connection and an IP address. It’s a remarkably clean application, and very well supported. Visage’s thin client also works on any workstation, desktop computer, or laptop. As long as what you’re using connects to the Internet, you can access and use advanced visualization.” It helped that Advanced Radiology Consultants’ IT infrastructure is about as robust as it comes. “Our group recognized, some years ago, that modern imaging is as much dependent on cutting-edge IT as it is on innovative radiologic equipment, and so we invested accordingly,” Wikramanayake says. That investment resulted in a gigabit network across the Advanced Radiology Consultants enterprise—270 miles of dark fiber connecting all sites by means of a synchronous optical networking ring configuration. “Any advanced visualization solution needs bandwidth of at least 20 megabits to function properly. Otherwise, as you attempt to deliver the slices to the user, bottlenecks will form,” Wikramanayake says. “That’s true of both thin-client and thick-client solutions.” A Clamor for Integration Currently, the Visage CS resides on a single server at Advanced Radiology Consultants’ primary data center and on a separate render server for rendering images. “The more users you have, the more servers you need,” Wikramanayake says. “A single server is adequate to handle the advanced visualization demands of six concurrent radiologists. We could introduce more servers in our data center for purposes of load balancing and redundancy, but there’s no need, since Visage has the server capacity and redundancy built in. We would only need it to scale up." Wikramanayake recalls that the thick-client workstation that Advanced Radiology Consultants previously used could not save any meaningful number of thin slices for 3D reconstructions. “We don’t generate enough reconstructions to warrant saving those thin slices on PACS,” he notes. “In our enterprise, PACS is used to manage about 600 studies daily from all modalities; of those 600, about 10 to 12 each day are advanced visualizations. We store the thin slices on our Visage CS and can do so for long periods (up to a year) before they become subject to overwriting. If we want to save them beyond that time, all it takes is the easy addition of more plug-in storage. Meanwhile, the important parts of the 3D images are saved permanently on PACS, spinning media, or tape.” The Advanced Radiology Consultants radiologists who now routinely use advanced visualization are delighted enough by the thin-client solution that they have begun clamoring for PACS integration. “Their hope is to be able, with one click, to pull up any 3D image that might be available for the patient whose 2D images they are viewing at that instant. They want to be able to do this without first having to click the Visage icon on the desktop to launch the application,” Wikramanayake says. “This would be consistent with the integration we’ve already developed for other elements of our informatics environment. For example, clicking the desktop icon for dictation automatically also opens the PACS, all the script documents, the technologist’s notes, and the prior studies. Once Visage CS is integrated, the radiologists will have all this and 3D.” Impact on Practice Patterns While the deployment of advanced visualization did not require a reengineering of image-interpretation workflow, it has had subtle and significant impacts on radiologists’ practice patterns. “Thin-client enterprise advanced visualization doesn’t change workflow itself, to any significant extent, because it doesn’t really eliminate the steps involved in performing the work,” Wikramanayake explains. “Instead, what happens is it enables the radiologists to perform that work in a more timely fashion by providing facile access to the applications they need. The radiologists now no longer must go to wherever the thick-client workstation is in order to perform that work. If you have a thick-client model and the radiologists aren’t scheduled, any time soon, to be at the site where the workstation is, obviously, they are not going to be able to engage immediately in the 3D activity they are eager to do. With our thin-client model, the radiologists also can start their work at one site and then, when they rotate over to the next site, pick up wherever they left off earlier.” Concerns about workflow are not confined, however, to possible effects on radiologists. For Wikramanayake, there was also the impact on his own department to consider. “I have a very small staff—just five people—and we manage the entire enterprise 24/7, 365 days a year, so none of us has much time available for chores such as system maintenance and upgrades,” he says. “As a result, it’s our policy to oppose the purchase of equipment that lacks the means of phoning home to let us know it’s OK, and of automatically receiving upgrades or undergoing system self-maintenance. The Visage CS was almost alone among the competition with regard to being able to offer us these capabilities.” Little more than two months after this enterprise visualization capability was made available, approximately half of the Advanced Radiology Consultants radiologists are using it, and many of the rest are requesting permission to start, Wikramanayake reports. He looks forward to accommodating them. “Our overarching goal is to make life better for our radiologists and for our referring physicians,” he says. “Enterprise advanced visualization is key to achieving that goal, and the thin-client model is key to advanced visualization.” Rich Smith is a contributing writer for ImagingBiz.com.