By Erik L. Ridley, AuntMinnie staff writer

July 19, 2012 -- Mobile devices open up a whole new opportunity to utilize medical images, but institutions have choices to make on how to implement this exciting new technology. Options such as native apps or Web-based viewers based on HTML5 each come with their pros and cons.

Dedicated native apps that run on Apple's iOS, for example, theoretically are able to take full advantage of a particular device's capabilities in a way that's not possible with an agnostic Web-based approach. However, a Web-based viewer, and particularly one based on HTML5, can provide applike capabilities but in a browser or platform-independent manner.

In a session moderated by Dr. David Hirschorn of Staten Island University Hospital at last month's Society for Imaging Informatics in Medicine (SIIM) meeting, a sampling of vendor representatives shared their approaches to mobile image viewing and their vision for the technology's future.

Thick client

MIM Software was the first vendor to receive U.S. Food and Drug Administration (FDA) 510(k) clearance; in February 2011, the firm received clearance for a mobile application for diagnostic purposes, its Mobile MIM application for use with CT, MRI, PET, and SPECT image viewing in the absence of a workstation. A second 510(k) clearance was given in December 2011 for use with x-ray, ultrasound, and radiation treatment plans, said Chief Technology Officer Mark Cain.

The vendor chose the iOS platform and to make a dedicated app for a number of reasons. First, development began in 2008, when there weren't many other options. With a stable platform and a stable set of hardware, that decision worked out well, Cain said.

"The same app that we had built in 2008 was virtually the same when we finally got clearance," he said.

Mobile MIM is a thick-client app, performing tasks such as multiplanar reconstructions and image fusion on the device itself. MIM Software did encounter some hurdles in its attempt to get FDA clearance, including software versus hardware issues. As a software company, MIM Software does not manufacture the hardware.

"When we first started with the FDA, we were thinking in terms of software, and showed it to the FDA; they were thinking of hardware and it all went downhill from there," he said. "So we had to adequately approach the problem of hardware. As a 510(k), which is a demonstration of safety and effectiveness as compared to a predicate device, we had to handle the technical differences that existed, and in the case of the iPad and iPhones, the technical differences were in fact that hardware wasn't being manufactured for diagnostic use, and the fact that you could use the device in various environments."

The company addressed this problem by using software calibration for visual collaboration of the display. To address environmental variations in use (i.e., indoors or outdoors), the firm placed a dark square on the screen that is tapped by users if they can see it, ensuring that they have appropriate screen brightness levels, Cain said.

Agnostic approach

Another vendor, Carestream Health, has taken an agnostic strategy to mobile applications with its HTML5-based Vue Motion image viewer, which can run on multiple platforms.

There are a number of considerations in terms of what features should go into a mobile application, said Diana Nole, president of Carestream's Digital Medical Solutions (DMS) business.

For example, radiologists reviewing imaging results on a mobile device may want to have a dedicated app or be able to launch it from some other application, she said. Referring physicians, however, most likely don't need a dedicated app.

"They're going to go into that information through the [electronic medical record (EMR)]," she said. "[Most of the] EMR companies are making dedicated applications, so we would just kind of come through that as the imaging-enabled piece."

In terms of overall design considerations, the mobile system needs to be flexible and able to support ad hoc use.

"It's not necessarily as much of a structured workflow as you find in a PACS workstation, so the way we design it needs to be a little bit more [flexible] with doing a little bit of things more ad hoc," she said.

Because these applications are going to be deployed to a wide variety of users, they need to be simple to deploy and adapt, without any training requirements, Nole said. Other issues to consider include physical conditions, device durability, ambient lighting, and security. Fortunately, a lot of technology is being developed by the general industry to tackle these issues, she noted.

Nole shared a recent mobile use case in which Carestream participated with Spire Healthcare, the second-largest private hospital provider in the U.K. with 37 hospitals. Formed via the acquisition of many different facilities, Spire elected to deploy a universal viewer that spans both disparate and multiple-vendor PACS, Nole said.

"These mobile devices ... actually helped to satisfy the use of case collaboration, which was the problem they were trying to solve," she said.

More than just tablets and smartphones

Mobility doesn't necessarily mean just using tablets and smartphones; laptops can also reasonably be considered mobile devices, said Bobby Roe, director of solutions architecture and customer experience at Visage Imaging.

As a result, Visage has taken the approach of utilizing native apps in both Windows and Macintosh environments in addition to iOS, he said.

Visage Client features built-in clinical tools and subspecialty tools for cardiology, neurology, and oncology. It makes use of sophisticated protocols that drive system functions such as selection and immediate display of relevant priors, multistep layouts, and a built-in advanced visualization capability, he said.

Server-side rendering is employed to reduce load on the network and workstations. In addition to the native Visage clients for Windows and Mac, Visage has developed a native iOS app called Visage Ease. Visage's protocol handler for integration with other clinical apps works across all the platforms and responds in the same way, Roe said.

"So you have, for example, a Web app portal to referring physicians and you have got a button in there that they would normally on their desktop machine click on to open up the image viewer. That will work exactly the same way ... on all three environments that we support because of the way we have integrated that protocol handler," he said. "It will take you immediately straight into that specific study, or even in the iOS environment straight into the specific series that you wanted to deliver them to."

Visage Ease iOS is designed to provide a fast, quick reference for clinicians who are on the go, Roe said. Access is provided to the full study in a series-by-series fashion, and key images can also be provided as identified by diagnostic users of the Visage Client on Windows or Mac.

Roe noted that Visage Ease is not intended for diagnostic purposes. The company is working on getting FDA clearance, he said.

Web and native app

Robert Taylor, TeraRecon's president and CEO, said that the advanced visualization company's interest in mobile devices and distribution, in general, is for distributing findings in context to referring physicians or to the next consumer of the image after the diagnostic step has been completed.

"We're definitely not focused on the diagnostic side, we are focused on the consumption side of it," Taylor said. "That's why, when mobile devices came along to the point where you could put this kind of functionality onto them, we were extremely interested because they are totally designed for consumption."

TeraRecon's mobile app has been downloaded more than 4,000 times and is available for the iPhone, iPad, and Android.

The company has focused on a Web client with its initial image distribution efforts, and introduced its zero-footprint Web viewer in 2006. Mobile support was added in subsequent years. The thin-client app supports image manipulation.

"It's not just about making the 3D rendering, it's really about displaying the consumable product, the output of the interpretation," Taylor said.

In 2008, the viewer could detect if it was being run on a mobile browser. The company discovered, however, that the iPhone with Safari Web browser didn't at the time support enough rendering power to get the images on the screen quickly enough.

"Actually, the Android worked pretty well but the iPhone didn't," he said.

As a result, TeraRecon elected to develop a dedicated iPhone app to make better use of the iPhone's power. While the Web version on the next generation of the iPhone worked pretty well, the app has retained its popularity among users, Taylor said.

Despite the utility of the Web version, TeraRecon is also experiencing demand for a dedicated Android app.

"The trouble with Android is that there are so many browsers and so many different versions you really need an app to get it all under control," Taylor said. "So actually there's quite a lot of demand for the app form factor because it creates that controlled environment."

As for the Web, it's true that HTML5 allows for a lot to be done within a browser and makes it feel more like an application, he said. But in the real world, many of the browsers in use today don't support HTML5.

"If you want to go into a modern production imaging environment, you need to support browsers all the way back to IE7 at least, and you need to work across various other platforms such as Safari, Chrome, and so on," Taylor said. "HTML5 is definitely the future, but we also need to have something to work in the context of those earlier generations of browsers. The ability to get on an app if it makes sense for you, but to have the Web work as well as possible, is pretty much the strategy we've taken."

TeraRecon's iNtuition Enterprise Medical Viewer (EMV) is a zero-footprint platform that supports a wide range of browsers and is also optimized for mobile browsers, he said.

"As a company, we probably are moving toward browser-based rendering or browser-based delivery of functionality as a standard," he said. "But there's definitely a strong demand and big role for a contained application definitely on Apple, but also within the Android environment."

Other aspects

Image sharing and cloud storage are also areas impacted by mobile devices, Hirschorn said in concluding the SIIM session.

"There are other completely different companies in that space that are dealing with this," he said. "But you see that it's part of this as well. It's not just about radiologist access, it's not just about referring physician access, it's also about patient access."

Copyright © 2012

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