Change is coming down the health imaging and IT pipeline at breakneck
speed. This change spurs a number of questions for healthcare leaders:
How do new trends and technologies fit together in the 21st century healthcare facility?
How can a hospital or imaging center effectively deploy solutions
to create a better healthcare environment, with improved efficiencies
and a stronger bottom line?
What unknowns do we need to watch out for?
As you probably already know, top trends tend to gravitate. And as you
read through the Top 10 Trends that Health Imaging & IT has
identified, interwoven themes abound.
One cannot consider any facet of radiology or cardiology without
touching on the ongoing staff shortage among radiologists, especially
specialists, interventionalists, cardiologists, RTs and nurses. And so,
as healthcare facilities look at solutions, they must think about its
impact on workflow and people.
Then there is new technology itself; each new advance opens multiple
doors and possibilities - and brings many challenges. For example, 3D
is facilitating image-guided radiation therapy (IGRT) and joining
multislice CT images into image volumes. Lung CAD is tied to multislice
CT, too, as well as RIS-PACS. PACS vendors are rushing to establish
ties with 3D software makers and integrate both products to ease
workflow. Wireless networks, tablet PCs and integrated RIS-PACS are
changing the very practice of radiology, rapidly disseminating
real-time images and information beyond radiology and throughout the
healthcare enterprise. That leaves teleradiology - or remote reading -
as some now call the means for reading images on-call, for nighthawk
coverage or for expert reads, which today is rarely done without the
help of PACS. And then there's molecular imaging, where again,
multislice CT plays a vital role in combination with PET (positron
emission tomography).
For change to be truly effective, decision-makers and thought-leaders
need to understand the implications, benefits and challenges of
individual trends. Then they need to examine how a specific solution
works in their enterprise and begin to plan or modify their plan for
the future.
1. Integrated RIS-PACS
Most large PACS providers are in the RIS game as well, and if they're
not, they're partnering to create an integrated RIS-PACS. Why? Because
radiology departments - and healthcare enterprises - need to gain back
the integrity of the radiology workflow process to increase efficiency.
To effectively manage images in a digital environment, you need the
combined resources of the RIS - radiology order entry and management,
scheduling, auto-fax or email of radiology results, billing and charge
capture, film tracking, inventory control, report generation and
quality control and transcription and/or speech recognition - and the
benefits of the PACS - image acquisition from the modality and image
viewing, archiving and distribution.
Until recently, RIS and PACS served as distinct solutions. RIS doesn't
understand DICOM, so RIS can't handle PACS imaging data without an
interface or broker. And the PACS doesn't understand HL7. But the wave
of future is a single database, brokerless, software-based, fully
integrated RIS-PAC system. About eight integrated RIS-PACS offerings
are on the market today, with varying degrees of functionality.
Overall, the systems' objective in having a single database across the
RIS, imaging suite and PACS is to provide a single instance of patient
and image data throughout a multi-facility, often multi-site,
healthcare enterprise. Integrated RIS-PACS synchronizes and provides
more consistent data with greater integrity and fewer overall errors.
An integrated solution is a data miner's dream; it is a repository for
complex data that can be analyzed for advanced business planning and
management. Thus, RIS-PACS facilitates productivity on many levels as a
single location for all image and business data.
Still, the integrated RIS-PACS nirvana is far from reality for most
hospitals. While vendors are pushing forward on the RIS-PACS front, the
current best-of-breed world with separate RIS and PACS tools suits most
hospitals just fine. Migrating to an integrated RIS-PACS is not as easy
as purchasing individual components. Hospitals often have to contend
with two legacy systems, and in most cases, it isn't feasible to
upgrade both systems to current technology at the same time.
Future directions: Look for more integrated RIS-PACS offerings -
as vendors look to create the multimedia electronic medical record,
supported largely by radiology and cardiology. Amongst some of the
questions the buyer seeking a truly integrated RIS-PACS should ask are:
Is the system integrated or merged? Single or dual database? What
information can be stored - images, reports, measurements (such as OB),
observations? What is the interface level (integrated, broker, merged)?
Where are the images stored? Who keeps track of the image and
information management? Where are the reports stored? Also key are
Integrating the Healthcare Enterprise (IHE) integration profiles.
2. Multislice CT
It's a brand new, faster, higher slice CT world. Consider:
Johns Hopkins in late February installed Toshiba America Medical Systems first Aquilion 32-slice CT scanner.
Philips Medical Systems launched the Brilliance 40-slice scanner
in December 2003, and installed the first scanner at Indiana University
Hospital in March.
Siemens Medical Solutions Sensation 64 will be available this fall.
GE Healthcare received 510(k) clearance for the first volume
computed tomography system (VCT), which will enable 64 slices with 40
mm coverage. The new scanner will be available later this year.
What - in addition to the 1,500 to 3,000 images (on the 32-slice
scanner) - do these new high-powered scanners deliver? While scanning
time continues to drop, image volume and memory demands are growing
exponentially. For example, each study on the Aquilion 32 can yield one
gigabyte or more of images. Volume CT enables high-resolution whole
body imaging in less than 10 seconds. A 40-slice scanner can cut
cardiac CT scan time in half over a 16-slice scanner, translating into
fewer motion artifacts. The 32-slice Aquilion halves the time of a CT
angiogram to a mere 10 to 15 seconds, from 20 to 30 seconds, minimizing
breathhold artifacts. Thinner slices also improve resolution markedly
for CT angiography visualization that seeks targets such as calcified
or vulnerable plaque (in the works). Early data are showing that CTA
vs. x-ray angiography provides 85 percent of the specificity and
sensitivity, without entering the body and better visualization of
stents is also possible.
Cardiologists and radiologists at Johns Hopkins are evaluating other
cardiovascular applications such as using the 32-slice scanner to
monitor arteriosclerosis and myocardial ischemia.
Virtual angiography is also dawning. Faster multislice exams also are
helping out with pre-surgical planning, better assessing the impact of
stroke and in brain perfusion imaging.
Dedicated workstations and PACS viewing stations are absolutely
essential to viewing the high volumes of high-quality examinations. The
abilities to scroll through images and complete multi-planar
reconstructions and volume rendering also are critical. Vendor
solutions to the data crunch include Philips Brilliance Workspace,
which enables real-time inspection of large datasets with no
pre-processing; GEMS Xtream workflow productivity engine and Siemens'
WorkStream4D for workflow optimization and data handling.
Joao A.C. Lima, director of cardiovascular imaging and cardiology at
Johns Hopkins University School of Medicine, says another challenge is
storing images in a format accessible to cardiologists and referring
physicians. For now, Lima and his colleagues are comparing a homegrown
CT storage solution and PACS.
Other challenges with the mega-scanners come on the patient safety end.
Radiation dose could be a concern, particularly if a patient requires a
therapeutic procedure immediately after the CT scan. But overall,
multislice is proving to be a win-win situation for the facility that
has a good image management plan.
Future directions: Look for multislice CT and CAD to converge in
the future. There need to be more answers to logically and practically
reviewing studies with thousands of slices. One of the first hints is
Siemens' syngo LungCare. The new technology is designed to aid
diagnosis of pulmonary nodules via nodule-enhanced viewing, including
automatic segmentation, close-up inspection and automatic calculations.
The next wave after 32- and 40-slice will be 64-slice scanners, which
may be key in chest pain management. And what's further off on the
horizon? About 2008, with huge boosts in computing power, 256-slice
scanners will screech onto the market.
3. 3D Imaging
Handling image review of those hefty multislice CT volumes - as well as
MRI and ultrasound images - is a challenge made easier by 3D
post-processing, which is certainly exerting muscle and demonstrating
clinical utility. Market research firm Frost and Sullivan predicts that
the market for 3D will reach $1 billion over the next five years, more
than doubling from the $400 million posted in 2002. About 60 to 65
percent of that growth is attributed to 3D imaging hardware and
software for CT and MRI, with the balance coming from ultrasound.
The premise behind 3D is simple - it brings a sense of order and
organization to the very large datasets acquired through multislice CT,
MR and ultrasound, and it allows that information to be distilled down
to a few key images - which is becoming more preferred by surgeons,
referring physicians and oncologists. The more sophisticated techniques
of MIP (maximum intensity projection), MPR (multi-planar reformat) and
surface shading expand 3D's clinical utility.
Although the primary clinical applications of 3D are cardiovascular CT
and MR and surgical planning, the scene is rapidly evolving. 3D also is
being increasingly deployed in more targeted radiation therapy and CT
colonography, and could become primary viewing mode for this exam.
Dynamic CT arteriography is dawning, too.
As hospitals and physicians continue to adopt and rely on 3D, they need
to determine the most effective way to deliver the technology to
radiologists, specialists and referring physicians for review. Geoffrey
Rubin, MD, chief of cardiovascular imaging at Stanford University
School of Medicine, predicts that sites will migrate to the central
server approach, which allows users to interact with 3D via a
conventional PC workstation. The alternative approach requires
specialized, expensive workstations ($80,000 to $100,000) and graphics
cards, which may be overkill for many physicians who use 3D
sporadically throughout the day. And with 3D applications on the rise
throughout the hospital, vendors are striving to find ways to deliver
3D to clinicians outside of radiology with PACS companies pairing up
with 3D software vendors to deliver a one-two punch.
Future directions: Applications of computer vision, such as CAD
and one-button, automatic bone removal (to reveal organs hidden
beneath) will play increasingly important roles in 3D volume imaging.
4. Lung CAD
Expectations are high for lung CAD for CT to hit the clinical realm
when R2 Technology's ImageChecker CT hits the market. In February, an
FDA panel recommended approval (with conditions) of the system for the
detection of lung nodules during review of multidetector CT chest
exams. Pablo Delgado, MD, associate professor of radiology at
University of Missouri-Kansas City and a beta user of the system,
admits that lung CAD's clinical impact has not yet been determined. But
its potential for assisting in the detection of potentially malignant
lung lesions that might otherwise go unnoticed, however, is quite
promising.
According to the American Lung Association, lung cancer remains the
leading cancer killer in the U.S., with nearly 170, 000 new cases
diagnosed in 2002. The American Cancer Society estimates that more than
150,000 Americans die of lung cancer annually. In 1995, the five-year
survival rate for all stages of lung cancer was 14 percent. If lung
cancer is found and treated while it is localized, however, five-year
survival rates increase to 42 percent. Only about 15 percent of lung
cancers are found in the early stages. These statistics make a fairly
compelling argument for lung CAD, and the incidence of misread studies
solidifies the case for the technology. Clinical studies demonstrate
that radiologists miss potentially malignant lesions on lung CTs in 20
to 30 percent of cases. Furthermore, radiologists at Brigham and
Women's Hospital reported that CAD detected clinically significant
lesions in approximately 20 percent of cases where the original
interpretation was normal.
Equally promising is lung CAD's potential to detect other lung disease
- such as pulmonary emboli, pneumonia and emphysema. And this market
could be quite large. Every year, close to 342,000 Americans die of
lung disease. Lung disease is America's No. 3 killer, responsible for
one in seven deaths, according to the American Lung Association. And
most lung disease is chronic - with more than 35 million Americans now
living with chronic lung disease who must be monitored.
The growth of multislice CT, increasing image volumes and the continued
radiologist shortage point to the utility of computer-aided detection.
PACS also is driving the CAD concept. Radiology is migrating to
soft-copy reading, which lends itself more easily to CAD.
Lung CAD is analogous to mammo CAD. That is, lung CAD will be used as
an adjunctive tool for a "spellchecker" or second review. After making
the initial interpretation, the radiologist can pull up the CAD image
and see if provides additional information, all in a matter of seconds.
The R2 system will join Deus Technologies RapidScreen RS-2000
x-ray-based lung CAD system. Delgado believes that two CAD options can
co-exist because chest x-ray remains the front-line screening
mechanism, while CT is the primary method for delineating lung
abnormalities.
Future directions: We'll see more widespread use of lung CAD
over the next few years, as convenience of use across all CAD platforms
increases to minimize the time spent by the radiologist viewing
CAD-fortified images (while the number of markings per image
decreases). iCAD aims to make a splash in the market with Second Look
CT Lung. The work-in-progress system incorporates CAD and workflow
enhancement tools. Lung CAD also will need to see greater integration
with IT for easier image management - while figuring out an image
management strategy for CAD images. Finally, reimbursement for lung CAD
could be on the horizon. While the Centers for Medicare and Medicaid
Services have not yet approved a specific CPT code for reimbursement
for x-ray or CT lung CAD; providers, vendors and patient groups are
lobbying for a change. And if lung CAD follows the pattern set by mammo
CAD, reimbursement will come, spurring more widespread adoption.
5. Image-Guided Radiation Therapy (IGRT)
The days of delivering radiation therapy based on simply shaped fields
with large margins around a tumor are over. The combination of
sophisticated treatment planning software and finer imaging has made it
possible to exactly focus each beam on the tumor, sparing healthy
tissue.
While IGRT is a great leap forward, it does present some challenges,
says James Cox, MD, head of the Division of Radiation Oncology at MD
Anderson Cancer Center. IGRT depends on locating both anatomic and
functional abnormalities, so improving treatment depends on advances in
imaging - particularly functional imaging. And as more precise doses
are confined and conformed to the tumor, radiation oncologists can no
longer base treatment on anatomical landmarks. Respiration and cardiac
motion can change the position and shape of the tumor. "The big
challenge now in the chest, upper abdomen and pelvis is to find a way
of imaging that accounts for variability in location and shape of
tumors. That is very much a work-in-progress," comments Cox. The latest
IGRT tools include:
Elekta Inc.'s Synergy treatment system, which provides 'real-time' 3D tumor localization during treatment.
Varian Medical System's On-Board Imager, a Linac-mounted
accessory to obtain high-resolution x-ray images to pinpoint tumor
location and track anatomic motion.
Nomos Corp.'s BAT system uses ultrasound to confirm the location of target organs or tumors.
Future directions: As imaging - particularly functional imaging
- advances, IGRT will reap the benefits of more precise disease
definition. New tools to manage tumor motion and variability will also
aid IGRT. The ultimate solution may be tracking the tumor and changing
the shape and focus of the beam as therapy is delivered, but that
technology is at least several years away.
6. Staffing
Where are the radiologists? During the 1990s, relatively low salaries
and lengthy partnership tracks drove medical students out of the
profession. At the same time, new imaging technology and the aging
population led to an explosion in imaging volume. Daniel Corbett, a
vice president with Davis Smith physician recruitment firm, reports,
"Imaging volume is growing 6 to 15 percent annually and up to 25
percent annually in some areas." Falling Medicare reimbursement and the
resulting flat income for radiologists further exacerbates the
situation.
The result is a full-fledged crisis. Fifty percent of practicing
radiologists are over 50, and 25 percent are over 58. Short-term aid
came in the form of the falling stock market, which caused some aging
radiologists to postpone retirement plans. Nonetheless, it will be 10
to 15 years before the shortage rights itself, says Corbett. Starting
salaries have doubled to $300,000 since the '90s and partnership tracks
have decreased to no more than a year.
Still, Corbett asserts that the real key to solving the shortage is by
implementing advanced practice models. The new model is democratic and
run like a business instead of a medical practice with base hourly pay
based on effort or shifts worked and net profit divided equally among
all radiologists. Similarly, hospitals and radiology groups need to
cease and desist. With the professional reimbursement component
falling, radiology groups are eager to claim a technical component via
an outpatient imaging center. Hospitals tend to fight these ventures
tooth and nail as radiology is often 25 percent of their net bottom
line. Corbett notes, "When hospitals and radiology groups fight with
each other, they are both going to fail." A better tact is to establish
a joint venture, which can be a win-win situation for both the hospital
and radiology practice.
And for sure, radiologists are not the radiology department's sole
staffing concern. Radiologic technologists and nurses are in very short
supply, too. Currently the American Hospial Association estimates the
RT vacancy rate at 18 percent. By 2010, the American Society of
Radiologic Technologists (ASRT) says the imaging profession will fall
30 percent below staffing needs. The nation will require an additional
55,000 radiologic technologists, 4,000 radiation therapists and 4,000
nuclear medicine technologists by 2008, reports the U.S. Bureau of
Labor Statistics. And currently, qualified radiation therapists are in
the shortest supply, with the American Society of Radiology and
Oncology (ASTRO) reporting an 18.3 percent shortage of radiation
therapists. The nursing situation is equally dire. The Journal of the
American Medical Association estimates that by 2020, there will be at
least 400,000 fewer nurses available to provide care than will be
needed.
Workflow-enhancing technology also can help to ease the pain. Eliot
Siegel at the Baltimore VA has reported seeing a 40 percent boost in
overall radiological technologist productivity after making the
conversion to filmless imaging. Also, according to data from AHRA, once
a facility has implemented filmless imaging, there is evidence of a 25
percent decrease in actual FTEs relative to expected FTEs.
Future Directions: The radiologist, RT and nursing shortage will
continue for at least 10 to 15 years, forcing hospitals and radiology
practices to implement strategies to attract and retain radiology
professionals. This includes:
Competitive salaries and benefits
Career ladders and educational opportunities for all employees
Retention bonuses
Higher utilization of teleradiology/remote reading
Cross-training of employees to ease the burden
Hiring a chief retention officer to analyze and improve the situation
7. Teleradiology/Remote Reading
Teleradiology is making its mark - and evolving out of its "tele"
bounds and into the remote reading zone. Remote reading can be one of
those wonderful win-win scenarios. Hospitals can tailor-make a solution
to meet their unique needs. For example, they can:
Secure after-hours coverage through a nighthawk service
Outsource some or all imaging services
Find an expert source to read specialty exams
On the flip side, remote reading can be a profitable endeavor for providers, whether they are hospitals or nighthawk services.
Jeff Bauer, PhD, senior vice president with Superior Consultant
Company, estimates that nearly half of hospitals have accepted and
implemented remote reading, making it a billion dollar industry. Remote
reading is fully reimbursed, clinically proven and relatively
inexpensive to implement and operate, and with the technical pieces of
the remote reading puzzle - PACS, speedier WANs, T1 lines, higher
bandwidth and broadband connections - firmly in place, Bauer expects
the remote reading-uninitiated to continue to fuel growth.
The growth of the radiology remote reading market has led to an
abundance of new purchasing options, including shared services, leasing
and outsourcing. Hospitals need to evaluate all of the options on the
market - not just ROI associated with equipment purchase. In addition,
analyzing the myriad financial options, hospitals on both sides need to
ensure that their equipment is up to snuff - PACS, RIS and dictation
software should be smoothly integrated. Finally, legal and liability
issues pose somewhat significant challenges. Teleradiology providers
must secure licenses and credentials in transmitting and receiving
states and liability coverage with teleradiology entrepreneurs
contending that insurers charge a hefty teleradiology premium.
Remote reading will continue to grow both through new customers and
pioneers, who will drive growth as new technology facilitates new
applications. Case in point? One of the hottest trends is sharing
images with referring physicians and even patients. The next step,
integrating remote images and radiologists' reports, can already be
glimpsed on the horizon.
Future Directions: Teleradiology and PACS will continue to be
integrated with IS components, particularly RIS and scheduling. In
another two to three years, the remote reading IT backbone - PACS -
could be replaced by what Bauer refers to as DACS (digital archiving
and communication systems). The new technology could provide a solution
not only for digital images, but also for digital photos and other
digital data acquired outside of the radiology department - but easily
accessible to all caregivers.
8. Wireless Networks
Wireless networks have made a big splash in healthcare thanks to their
ability to streamline workflow and provide health care professionals
with wireless access to patient information anytime, anywhere. Two
factors are driving the wireless revolution, says Keith Mattes, senior
technology consultant with Summit Technologies. Productivity gains are
the Holy Grail in today's short-staffed healthcare environment. HIPAA,
and the need to provide physicians with timely patient information, is
also fueling the fire. Moreover, wireless can be quite cost-effective
compared to cable and hard-wired networks.
Wi-Fi turns traditional, inefficient hospital process on its head.
Nurses no longer spend hours inputting patient data. Instead it's done
in real-time on a handheld, tablet PC or laptop. Similarly, physicians
have cut the cord - gaining immediate, real-time access to patient data
via wireless devices, enabling them to make timely and informed
decisions about patient care. Wireless can cut patient errors as well
through computerized prescription writing programs or RFID tags to
verify patient information before administering medication. Early
wireless success stories report revenue increases up to 30 percent and
patient load increases in the 10 percent range.
Still, wireless is not a snap. Ventures need to be well-planned with
all of the relevant players, including IT and the HIPAA officer and
medical staff, in the loop. Hospitals need to assure quality wireless
access everywhere and consider the pros and cons - including security,
bandwidth (wireless bandwidth is "shared" with mobile devices using the
same access point sharing the connection) and cost of various flavors
of wireless - 802.11a , b and g. A number of hospitals are moving
toward enterprise-wide implementations that include multiple options.
After the network issues are clear, proposed applications should meet a
simple needs test. For example:
Is there a need for mobile decision-makers?
Can the application improve productivity, patient care or revenues?
What problems can wireless solve?
As vendors and users devise ever more creative wireless applications,
IT and hospital leaders need to proactively address its primary
downside - security. Wireless networks are inherently insecure.
Developing a security plan before purchasing the first piece of
hardware allows the hospital to buy the right components to improve
security. The security plan might include:
A virtual private network (VPN), even within the hospital firewall
WEP security with 128-bit encryption as minimal (but not sufficient) measure
Newer, robust security offerings such as TKIP, AES and EAP
Static IP addresses for wireless clients and MAC address access only
A regular effort, once the network is installed, to be sure it remains secure
Future directions: Frost and Sullivan projects that wireless
revenues will nearly double from $330 million in 2003 to $637.3 million
in 2007. Mattes also forecasts continued growth as hospitals recognize
that they can leverage the initial investment in wireless with
second-generation applications such as IP phones, handhelds and nurse
call systems. Other future applications will continue to focus on
mobility and productivity. Security will improve with WPA (wi-fi
protected access). 802.11i may be available by mid-year, enabling even
more robust security. As wireless technology moves forward and
bandwidth increases, the ability to view images on wireless devices
will improve.
9. Molecular Imaging
The hottest current trend in molecular imaging is the shift to PET-CT.
In fact, some experts predict that within two years all PET scanners
sold in the U.S. will be combined devices. That's because PET-CT
provides increased diagnostic accuracy over CT and PET alone. Take the
case of a lung lesion. The accuracy of a diagnostic CT scan is in the
60 to 70 percent range; a PET scan is about 90 percent accurate and the
accuracy of PET-CT reaches 95 to 98 percent. That increased accuracy
often facilitates treatment changes with one-third of patients seeing
alterations in their treatment plans based on the results of a PET-CT
scan. PET-CT's functional capabilities also mean that it could be
deployed during chemotherapy to track a patient's response to therapy,
allowing oncologists to change the therapy if it is not working.
While current applications primarily occur in the oncology realm,
PET-CT is making inroads in other clinical arenas. Scans are and will
be increasingly utilized to screen for heart disease, and the recent
approval of rubidium and ammonia tracers should facilitate this trend.
In another year or two, PET-CT could enable a combined cardiac
viability study and CT angiography. Finally, PET-CT is showing promise
in Alzheimer's cases. CMS is conducting a study to demonstrate the role
of PET in Alzheimer's disease, which could lead to its reimbursement.
The broader definition of molecular imaging extends beyond PET, PET-CT
and nuclear medicine. Molecular imaging will see a combination of
engineering, imaging, informatics and biochemistry, enabling physicians
to predict disease, view disease earlier and treat it more
specifically. GE Healthcare is banking on the broader definition
evidenced by its pending acquisition of Amersham, which is scheduled to
close in the second quarter.
Molecular imaging facilitates the personalized medicine approach, which
customizes and targets therapy. For example, physicians could identify
breast cancer patients with the HER2 gene disposition and treat them
with Herceptin. Women without the disposition, who would not benefit
from Herceptin, could be offered other, more suitable treatment options.
Molecular imaging also will drive new treatment modes such as the
guided missile approach. Consider Prostacint, an approved marker to
detect recurrent prostate cancer. Researchers are tagging the
Prostacint with Bexxar and Yttrium 90 to target and kill metastatic
cells. This may be the tip of the iceberg. AnnexinV, currently in
clinical trials, localizes in dying cells to illuminate portions of the
heart affected by a myocardial infarction. AnnexinV also could be
tagged with a therapeutic agent and guide the agent to damaged site to
grow new blood vessels.
David Rollo, MD, chief medical officer for Philips Medical Systems,
notes that access to technology will play a role in molecular imaging.
Currently, there are 13,000 SPECT cameras in the country, significantly
more than the instal
Change is coming down the health imaging and IT pipeline at breakneck
speed. This change spurs a number of questions for healthcare leaders: