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.
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