Peering Into Radiology 2012

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Radiology is evolving at breakneck pace with clinical needs, demographic realities and IT development converging to create change. Looking into radiology’s crystal ball is never an exact science. “We are in a period of time when healthcare is being rewritten and re-defined,” states John Desch, vice president for sales and marketing at Philips Medical Systems. Vendors and healthcare providers alike are in a state of flux as the feds try to slow overutilization of imaging technologies through legislation and reimbursement cuts.

Insiders, however, do have some clear indications about radiology’s needs and what they mean for the radiology department of the future. Perhaps after touring the halls of McCormick Place at RSNA last month, and before making clear plans about the next steps for the department, consider the experts’ take on Radiology 2012.

RIS/PACS: The challenges ahead

RIS/PACS is the driver of digital radiology. Over the next five years, the current trend toward integration will solidify. The best new systems will be universal, enterprise-capable and integrated. Paul Chang, MD, vice chairman radiology informatics at University of Chicago, points to five trends driving RIS/PACS development.

Enterprise digital image management will continue to gain traction. That is, facilities will leverage their investment in PACS and seek an integrated infrastructure to handle all digital imaging including all the ‘ologies’ and visible light images. Hospitals will need a DICOM wrapper or DICOM translation box for non-DICOM data like visible light images.

The twin challenges presented by systems integration and interoperability will persist. Service Oriented Architecture (SOA) and web services go beyond Integrating the Healthcare Enterprise (IHE) and support complex radiology workflow and provide necessary interoperability, says Chang.

Challenge number three stems from hefty datasets. Conventional wisdom might peg storage as the primary problem, but the price of mass storage will continue to plummet, says Chang. “The problem is transmission of data from the server or archive to the web client or workstation,” he says. The solution is server side manipulation, which eliminates the need to transmit large datasets. Datasets can be stored on a hard drive augmented with a dedicated graphics processing unit; results are streamed to the end user, minimizing the transmission burden.

Vijay Tanjore, senior marketing manager, Americas, Imaging Solutions Business for GE Healthcare, foresees storage challenges as RIS/PACS migrates through the enterprise. “There will be a storage crunch because of the size of pathology and endoscopy datasets, and people will run out of storage.” A single pathology image, for example, can range up to 60 to 80 megabytes compared to 0.5 megabytes for a CT or MR image. Sites will be forced to invest in additional storage or transition to an ASP model that minimizes concerns about  obsolescence and capital investments, says Tanjore.

Chang foresees a blurring of the distinction between PACS and the EMR. “We’ll see fewer standalone PACS,” predicts Chang, “PACS will become the multi-media component of the EMR.” The EMR will be customized for the workflow of various end-users. “Every PACS will need to play well with EMRs,” adds Tanjore.

The final issue in the RIS/PACS market of 2012 centers on radiologists. Will PACS make radiologists obsolete, asks Chang? Because clinicians can view images instantly, radiologists need to demonstrate their value to their customers—referring physicians and specialists across the street, across town and across the world. PACS can help radiologists demonstrate their value by enhancing virtual collaboration and communication with end-users.

“The radiologist will be the central diagnostic imaging consultant in the future,” counters Philips’ Desch. New IT solutions will take radiologists beyond image viewing and enable them to see and consolidate health data and use it to predict disease and consult with referring physicians in the primary-care office, surgical suite and across the world.

Jay Moskovitz, radiology informatics manager at Cincinnati Children’s Hospital, recommends sites investing in PACS go beyond the basic questions about DICOM, IHE and HL7 as they invest in the next generation of systems and ask potential vendors:

  • Does the PACS facilitate paperless radiology?
  • Does the system improve documentation and communication among radiologists and with clinicians?
  • How does the PACS improve workflow? Does it address specifically identified site needs?

Other expert advice includes:

  • Look for inclusive systems that handle enterprise images and mesh with the EMR.
  • Don’t drop the interoperability issue; demand sophisticated interoperability from the PACS vendor.
  • Consider datasets from all angles, and get specifics about transmission requirements.

Ubiquitous ultrasound

“Ultrasound could become ubiquitous in the next five years,” predicts Bob Honigberg, MD, chief medical officer for GE Healthcare. Smaller, less expensive ultrasound systems could become an essential primary-care tool by providing a window into the body with physicians using pocket-sized systems to screen for diseases and potentially detect conditions such as functional cardiac problems, abdominal aortic aneurysms and gallbladder pathology earlier in the disease process. In addition, handheld systems could play a role in routine interventions such as placement of central venous or PIC lines. Talk of ultrasound becoming the new stethoscope just might come true soon.

One of the first sub-two pound systems is Siemens Medical Solutions Acuson P10 handheld ultrasound system that rolled out this fall. The new system could reinvent ultrasound imaging. It easily fits in a coat pocket, yet image quality is comparable to a large-scale echocardiography system, says Eyal Herzog, MD, director of the cardiac care unit at St. Luke’s-Roosevelt Hospital Center in New York City. Because the system is compact and does not need to be rolled between rooms, physicians can acquire information in as little as 20 seconds vs. two minutes with a full-size machine.

The P10 is designed to provide a quick look at the patient and not necessarily answer all the questions that ultrasound can answer, says P10 Product Manager Mark Elser. The intent is to use the scanner to answer questions that impact the direction of patient care and determine if the patient needs a follow-up ultrasound or should proceed to the cath lab, CT or surgery.<./

Siemens envisions initial applications in three areas: ED, cardiology and OB/GYN. In emergency cases, the scanner can detect internal bleeding in a matter of seconds. Similarly, it offers a quick overview of basic cardiac anatomy and motion. “It could become the first tool we use to evaluate patients,” says Herzog, “particularly in emergent situations where time is muscle.” Finally, obstetricians could carry the P10 into labor and delivery to determine fetal head position and assess heart rates. Other applications are expected, says P10 Product Manager Kristin Woitovich. “Physicians will invent uses we haven’t thought about.”

No doubt, the system and others like it will move imaging into the hands of clinicians and other non-traditional users like nurses. With training, however, users can quickly become competent in the use of ultrasound to answer specific questions (once American College of Radiology guidelines are eased). A nurse, for example, can use the P10 to detect fluid in the abdomen and refer the patient to the next clinical step. Training and accreditation is critical, says Desch, as there is a potential for problems as non-radiologists use the system to identify or rule out disease. For example, a user might miss disease.

CT on the move

Ultrasound won’t be the only modality extending its reach throughout the enterprise in the next five years, says Peter Kingma, vice president of Siemens Medical Solutions CT business. “CT needs to adapt to clinical needs in the environment. It can no longer be tucked away in a corner of the radiology department.

In the next few years, state-of-the-art CT scanners could sit in more ER’s, providing a front gate to patient care, enabling clinicians to make fast, clinically relevant decisions. Similarly, it could play a starring role in the cath lab where its use as a filter could help patients avoid diagnostic catheterizations. The recently announced Coronary Evaluation on 64 study (CorE 64) results showed that 64-slice CT is as accurate as cardiac catheterization in the primary diagnosis of cardiovascular disease and disorders in all populations; 64-slice also is a good predictor of who will need angioplasty or coronary bypass surgery. Although cardiac CT accounts for a mere 2 to 3 percent of CT exams, it will continue to see phenomenal growth in the next few years, predicts Brian Duchinsky, general manager, CT Advanced Technologies for GE Healthcare

Another potential future application is interventional radiology. “CT has not yet been incorporated into mainstream interventional workflow primarily because interventional procedures require fast 3D processes,” notes Kingma.

Indeed, the need for speed will drive CT development. “CT scanning is not just about more slices. Healthcare needs adaptable scanners that provide high-quality data,” continues Kingma. Desch sums, “We need systems that scan a volume like the heart or liver in the shortest amount of time with the lowest possible radiation dose in the most flexible manner.” This translates into faster scanners with better temporal and spatial resolution and improved contrast. New systems will fit into smaller spaces and provide the structure and x-ray power to accommodate larger patients.

Likewise, GE is focused on improving CT image clarity to improve visualization and diagnostic capabilities. Improvements in image clarity such as low contrast discrimination and improved spatial and temporal resolution are not necessarily accomplished by increasing slice count, says Duchinsky. Other developments could merge CT and functional viewing, taking CT beyond static black-and-white imaging. CT perfusion might be used to evaluate stroke, or the combination of faster scanners with wide coverage might provide a means to deploy contrast-enhanced CT to illuminate the vasculature tree of entire organs. Duchinsky points to another “functional” application. “Radiologists could use dual-energy CT to decompose CT images and enhance specific material like calcium or iodine.” The final focus for GE, Philips and other CT vendors is radiation dose efficiency. “More people will be getting more CT scans over the next 20 years; we need to decrease radiation dose as much as possible,” Duchinsky says.

CT extends beyond scanning solutions. Auxiliary solutions like thin-client 3D tools will offer additional flexibility, not only transmitting data to physicians anywhere and everywhere, but also providing the speed and processing power to enable 3D diagnostic manipulations. Another enabler of enterprise 3D is the accessible, affordable workstation. Look for falling price tags and more options on upcoming workstation releases.

Molecular medicine comes of age

Healthcare desperately needs a helping hand in terms of economics. Currently, healthcare spending accounts for 15 percent of the Gross Domestic Product, but the number is expected to climb as the population ages and requires more healthcare services. Molecular imaging can play a key role fighting and containing costs of the big three: heart disease, cancer and neurodegenerative diseases, says Markus Lusser, global vice president of sales and marketing, molecular imaging division, Siemens Medical Solutions. Molecular imaging can detect disease earlier, which translates into lower costs and increased survival. That’s because smaller tumors can be removed surgically without multi-phase chemotherapy. “The vision,” says GE’s Honigberg, “is to use molecular imaging to move from diagnosing symptomatic patients to detecting disease in a presymptomatic population and to shift from disease diagnosis to prediction and prevention.”

The enabling piece is ultra-sensitive technology that lets physicians visualize disease at the cellular and molecular levels. “Radiologists will combine molecular imaging modalities such as SPECT, MRI and PET with novel biomarkers that target specific diseases, organs and stages,” explains Lusser. What’s more, the radiologist’s role will transcend imaging and encompass treatment—with radiologists delivering individualized treatment.

Lusser envisions a three-pronged approach that comprises in vitro and in vivo diagnostics and knowledge-driven IT. “Molecular imaging will include imaging hardware and intelligent IT systems that mine data,” predicts Lusser. The toolkit will include databases and CAD systems that proactively determine a patient’s likelihood of responding to a specific treatment, and radiologists will be able to monitor disease progression and regression at the cellular and molecular levels.

While vendors are focusing on the array of tools needed to usher in the molecular imaging era, other stakeholders also play crucial roles, says Honigberg. Key stakeholders include the Food and Drug Administration (FDA), National Institutes of Health (NIH), industry and academia. The FDA, for example, needs to provide guidance to help industry move tracers from the research to clinical setting. Take for example the compound that marks beta amyloid plaque and points to early brain dementia. “When do we use the marker,” asks Honigberg, “it’s expensive, and there aren’t adequate therapeutics [for affected patients].”  Consequently, it’s difficult to determine appropriate use for the compound at this time. As technology advances and agencies provide guidance, however, questions like these will be answered and the molecular imaging is expected to demonstrate its utility by improving detection and treatment and lowering costs.

The X-ray market: Digital domination

“All x-ray systems will be digital in five years,” predicts John Allen, assistant director, Canon Medical Systems. Anthony Salupo, clinical manager diagnostic imaging at Cleveland Clinic in Ohio, agrees. “Everyone would like to be completely digital: paperless, filmless and wireless. It saves time, and it facilitates faster results and treatment, which is better for patients.”

Multiple factors drive digital adoption. The economics of digital radiography are well-understood, and the price of digital systems continues to drop. What’s more, the Deficit Reduction Act (DRA) is compelling leanness among imaging providers, so they need to implement systems that help reduce costs and expenses. Digital x-ray fits the bill.

The elimination of film and increases in productivity enabled by digital are important, but healthcare is just beginning to realize the real gain of digital radiography, says Dave Widmann, general manager of Global Radiography and RF Business for GE Healthcare. That is, physicians can manipulate data to provide better diagnostic information, which can translate into better initial diagnoses. “Healthcare can reduce waste by using digital x-ray to better utilize CT and advanced imaging technology,” says Widmann. In fact, recent studies pointed to a reduction in CT studies without findings after an initial digital x-ray exam. Other upcoming developments that will improve visualization include dual-energy subtraction and tomosynthesis.

Imaging’s brave new world

The radiology department of 2012 will look like today’s department, but there will be noticeable improvements. More sites will realize the promise of digital and operate filmless, paperless and wireless systems. Another major change will be the diffusion of imaging throughout the enterprise. RIS/PACS will be an enterprise system that handles all types of images; integration with the EMR and other systems could become standard. Ultrasound and CT will move beyond the borders of radiology. Look for handheld ultrasound systems in clinician’s pockets, and more ER and cardiology departments that house CT scanners. In five years, molecular imaging could transition from potential to reality as various stakeholders move forward with research and development, applications and regulatory guidance. The common denominator for each development? Improved patient care; think earlier detection and treatment with the added benefit of reduced costs. Get ready, the future begins now.