3D Rendering: Options Galore

After more than five years on the market, 3D options continue to evolve to better meet the diverse needs of radiologists, cardiologists and a variety of specialists. With a wide array of options available, hospitals can devise a 3D rendering program to meet their unique needs. For some, the 3D lab approach offers the best first-line model. Other sites aim to put 3D tools in the hands of heavy users like orthopedic and trauma surgeons via a thin-client system. Outsourcing is another option that suits sites that lack the volume to justify a full-time solution or require overflow coverage. In many cases, a hybrid approach that blends various models offers the ideal solution. This month, Health Imaging & IT visits a few sites to learn more about the ins and outs of a variety of 3D rendering models.

The 3D lab approach

The 3D lab is a commonly employed 3D rendering option. Many facilities and groups centralize 3D post-processing in a lab, using super-techs to complete the lion’s share of 3D post-processing and reconstructions. Take for example Spectrum Health in Grand Rapids, Mich. The health system uses a full-fledged 3D lab with six facilities porting CT and MRI studies to the central lab for 3D post-processing. The lab is staffed by two full-time 3D imaging specialists with an additional six techs trained to handle 3D reconstructions, which ensures 24/7 coverage. The 3D solutions include TeraRecon Aquarius and GE Healthcare AW workstations and TeraRecon AquariusNET thin-client system for enterprise wide access to 3D applications and GE Remote Access software for remote access to GE 3D workstation functionality. The clinical caseload is varied, but predictable, with vascular studies like emergency carotids dominating the 3D workload, says 3D Imaging Specialist Shannon Culver. The lab completes between 600 and 650 billable 3D cases monthly; about 400 cases are CT reconstructions, and the remainder are MR studies.

With nearly four years under its belt, Spectrum Health’s 3D lab has fine-tuned its workflow. Routine outpatient 3D studies are auto-routed to the 3D lab, post-processed according to protocols and sent to PACS for storage with the original study. “The workflow was challenging when we opened the lab. It took some time to determine if it would be best to pull studies or auto-route them and if patient information should be phoned, texted, emailed or faxed,” recalls Culver. Currently, paperwork for routine cases is faxed to the lab. The health system uses text paging to facilitate rapid turn-around for emergency cases. In addition, AquariusNET is integrated with PACS, so physicians can access 3D applications enterprise-wide.

The 3D lab model optimizes patient care, says Culver. “It takes consistency and continuity to provide the best patient care. Spectrum Health has dedicated many man hours to developing and tailoring 3D protocols. As a result, our physicians receive consistent, replicable 3D reconstructions.” 

Similarly, University of Minnesota Medical Center Fairview in Minneapolis, Minn., has employed an Advanced Imaging/Post-Processing Lab for five years. The lab is equipped with three post-processing workstations that run Vital Images Vitrea, Tera-Recon Aquarius and Barco Voxar 3D software and handles about 200 3D cases monthly.

The clinical caseload at the medical center consists primarily of pre-operative organ donor studies like mapping vascular systems or liver volume. The workflow is fairly straightforward. Original images are transmitted from the acquisition workstation to the 3D lab, where 3D Advanced Imaging Technologist Steven Horowitz completes the reconstructions and sends them back to the referring physician. After the physician dictates the case, reconstructions are stored in PACS with the original images. Although the current model provides medical center staff access to the raw data, reconstructed images and reports via PACS, the medical center plans to deploy Vital Images ViTALConnect web-based software later this year.

The new software should improve the current workflow, which requires physicians to visit or call the 3D lab to request additional views. “When we add ViTALConnect, physicians can complete reconstructions on their own. It will provide better and faster access to images, which should improve patient care,” explains Horowitz. For example, if a surgeon requires a different view during surgery, he can view images on the PACS workstation and create the required view during the procedure. In addition, the web-based tool allows physicians to use commonly used advanced visualization tools like MPR from home.

Enterprise-infused 3D

While sites like University of Minnesota Medical Center plan for thin-client 3D, others have jumped in with both feet. Atlanta Medical Center in Georgia is a level two trauma center that’s tapped into Vital Images ViTALConnect web-based software to deliver universal access to 3D. “Advanced visualization should be quick, simple and everywhere,” opines Ron Gilbert, PACS administrator.

Atlanta Medical Center installed ViTALConnect in October 2007 and plans to roll out 3D access across the enterprise. The web-based system improves on the center’s initial 3D approach. Prior to ViTALConnect, Atlanta Medical Center relied on nine Vitrea workstations for 3D reconstructions. The approach, however, stymied workflow for both surgeons and CT technologists. That’s because the medical center placed eight workstations in the radiology department. When a surgeon needed a reconstruction, he walked to the department, interrupted CT scanning and waited until a tech completed the reconstructions. “Now, surgeons won’t stop techs in CT production. They can complete the reconstructions themselves or ask other techs to complete the reconstructions on a PACS workstation,” explains Gilbert.

The heart of the model is the multi-purpose workstation. Gilbert purchased PACS workstations to accommodate 3D specifications and run ViTALConnect. The upshot? Heavy clinical users of 3D like trauma surgeons, orthopedic surgeons and vascular surgeons can access 3D functionality at any PACS workstations. “A surgeon can’t walk 100 feet in this medical center without bumping into a workstation with 3D access,” states Gilbert, “It speeds up their workflow because they don’t need to come to radiology to view 3D reconstructions.”

The ticket to successful universal 3D access is appropriate infrastructure. ViTALConnect uses the same infrastructure as the center’s PACS: a dedicated CISCO 4900 Catalyst network with a dual redundant, self-healing engine, a virtual private network and four render servers. “Don’t skimp on the infrastructure,” cautions Gilbert, who budgeted 10 to 15 percent of the 3D purchase for supporting infrastructure. Gilbert specified the center’s hardware for growth and planned the infrastructure to handle 200 percent of the current volume. 

The approach works. “Physicians are thrilled,” says Gilbert, “because everyone has what they need: convenient access to the 3D tools necessary for optimal decision-making and patient treatment.”

The time share model

3D rendering is an essential tool of 21st century radiology. Unfortunately, 3D rendering solutions carry a hefty price tag. Initial and ongoing costs include workstations and training of both technologists and radiologists. Although the advent of thin-client solutions delivers an easier to swallow price tag than stand-alone workstations, 3D still remains a significant investment for most hospitals and imaging practices. Take for example Borgess Medical Center, a Kalamazoo, Mich-based trauma center. Last year, it became apparent that its fat-client 3D rendering program had grown obsolete. The center’s CT workload had boomed, and techs could not keep up with CT volume and post-processing. At times, 3D rendering was delayed because techs needed to staff the scanner rather than the workstation. It was clear the site needed a new solution, but it lacked the resources to purchase a thin-client solution.

Enter a new model. 3DR of Louisville, Ky., has pioneered the time share model. Robert Falk, MD, chief medical officer, explains, “3DR began three years ago as we watched area hospitals pour resources into 3D workstations at different sites and invest in training multiple users. It wasn’t an efficient approach.”

In response to the changing 3D climate, Falk and his partners created 3DR; the service provides advanced image processing to hospitals and imaging centers across the country. 3DR is outfitted with the Visage Imaging Visage CS thin-client 3D post-processing system and markets 3D post-processing services to clients across the country. “3DR can be a full- or part-time solution depending on the customer’s needs. We provide capacity. Some customers need night or weekend coverage, others require overflow post-processing services and some need full time post-processing,” says Falk.

How does it work? A client purchases a set number of cases for post-processing monthly. Some hospitals send raw data to 3DR, which is equipped with a 50 megabit internet connection. Other clients use a thin-client server configuration, with 3DR techs accessing data via the server. 3DR techs complete the reconstructions according to pre-defined protocols for the type of study. For example, 3DR’s bread-and-butter study, CT angiography, typically includes cine lopes and certain angles. After completing the requisite reconstruction, techs send the images to the client’s PACS. If a radiologist requires another reconstruction, he can page a tech to reach into the workflow and complete the additional post-processing. Turn-around is a respectable four hours for most cases, and STAT studies like stroke perfusion can be completed within 30 minutes.

Since early this year, Borgess Medical Center has used 3DR as its 3D rendering solution for about 100 studies monthly. “We’ve operationalized the cost of 3D, avoiding the initial capital outlay as well as the staffing cost of additional techs,” explains Director of Radiology Tom Mushett. Radiologists and techs are satisfied with the new arrangement; turn-around time sits at two hours, and physicians can access the 3DR server from any radiologist workstation if they need additional reconstructions.

The thin-client model facilitates the time-share approach. That’s because slices need not be moved around with the thin-client solution. Instead, multiple users can access slices and reconstructions concurrently. In addition, the radiologist can take over and answer specific questions after a tech completes the initial post-processing. For example, if a 3DR tech completes a standard 3D reconstruction and the radiologist detects a problem with the proximal LAD (left anterior descending) artery during review, he can access the data via the thin-client to segment a particular section of the LAD to answer the question. “It makes radiologists more efficient and keeps control in their hands,” sums Falk.

According to Falk, the arrangement is a win-win proposition. “3DR can function as a hospital’s 3D lab. It’s a completely scalable solution that can eliminate a hospital’s need for 3D techs and equipment.”   

3D solutions: The right questions to ask

3D solutions represent a significant investment, so it’s important that imaging facilities and departments ask the right questions prior to purchase.

• Consider the organization’s clinical and business needs and goals. A trauma center requires a different solution or model than a community hospital because it needs rapid response. Don’t forget to justify the investment in terms of volume. It’s not necessary to outfit a high dollar, multi-vendor lab for a low volume facility.
• Remember the reconstructed images are the end product. Ask every vendor to load a typical dataset onto its system to make sure the end results suffice. Look for speed and ease of use as these factors determine the ultimate success of a system.
• The 3D program is only as strong as the network it runs on, says Culver. Although some systems can operate on a lightweight network like a DSL connection, a robust network (think gigabit speed) ensures rapid transmission.
• Train, train, train. Invest in vendor courses and university programs like the 3D mini lab at Stanford University in Palo Alto, Calif., for 3D techs. Use internal resources, too. Physicians can review anatomy and physiology with techs, and an open lab door nurtures informal and ongoing learning. Offer classes and departmental training sessions to heavy clinical 3D users like orthopedic surgeons.

3D highlights

3D rendering is an essential clinical tool. Hospitals can devise an individualized and cost-effective model by surveying their needs and goals as they develop or adjust their 3D program. Sites can select from a wide array of options—ranging from the 3D lab to outsourcing to thin-client, ‘universal 3D’ to hybrid investments to optimize their 3D program. The right model will deliver the results every hospital needs: accelerated and improved workflow and informed, timely clinical decision-making made possible by the availability of essential clinical data.