Touring the Radiology Department of the Future

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The gap between the diagnostic and therapeutic aspects of radiology will narrow as imaging is used to guide prognosis, treatment and timing of treatment and define patient-specific drug cocktails, says Bradford J. Wood, MD, senior clinical investigator, diagnostic radiology department at the National Institutes of Health Clinical Center in Bethesda, Md.

IT advances are equally crucial as slices, images and data explode. Workstations will need more horsepower to process images, and integration among various components of the department will need to be bumped up several notches. And the mere human radiologists and clinicians faced with this data avalanche will need IT assistance in the form of advanced visualization, CAD and knowledge delivery tools to provide customized, consistent care.

Coming soon to prime time: Molecular imaging

SCAR Experts Peek at the Future

Insiders with the Society for Computer Applications in Radiology (SCAR) shared their insights into the radiology department of the future during a June educational session.In 10 years, CT will become the dominant modality with MR following closely behind, predicts Eliot Siegel, MD, director of radiology, at VA Maryland Healthcare System (Baltimore). General radiography will fall to just about half of department volume from its current 65 to 70 percent. And molecular imaging will become a real player by 2015.  Peering further into the horizon, Siegel foresees the advent of portable bedside, ultra low dose CT and injectable nanobots (molecular-sized cameras) in 25 years. Study size will explode from 0.5 gigabyte in 2008 to 10 gigabytes in 2015 to multiple terabytes in 2030 as personalized medicine, DNA profiles and screening studies become reality. While the hefty size sounds overwhelming, Paul Chang, MD, director of the division of radiology informatics at the University of Pittsburgh Medical Center (Pittsburgh), claims the size of the study won't matter as radiology continues to ride the IT improvement wave with storage becoming faster and more reliable and PACS workstations continuing to add horsepower and other improvements. Also participating was Richard Morin, PhD, of the Mayo Clinic, Jacksonville.

One aspect of the future that is perfectly clear is that imaging tools will become more prevalent throughout the enterprise with various stakeholders competing with and depending on radiologists. The upshot? The practice of radiology must evolve with radiologists serving as informaticians adding value to diagnostic decision-making process, opines Chang.

"One of the big shifts in the landscape is that radiology is no longer limited to imaging anatomy. Now, we can image function and anatomy including the workings of organs, cells and molecules," states Sanjiv Sam Gambhir, MD, PhD, director, molecular imaging program at Stanford University in Stanford, Calif.

In five to 10 years, radiology departments will begin to morph from traditional equipment-heavy zones into wet-lab type environments with a strong focus on chemistry and molecular biology. Here's how it will work: Radio- and optical-labeled imaging agents will transmit a signal to a gamma camera, PET or SPECT camera to produce an image from organs or cells to provide critical information such as the presence of genes leading to breast cancer or metastasis. "This will enable earlier, more accurate detection of disease," says Gambhir. Oncologists and surgeons will be able to non-invasively localize tumors prior to radiation or resection.

"Modalities will not only emerge but converge," predicts Juri Gelovani, MD, PhD, director, center for advanced biomedical imaging research and chairman of department of experimental diagnostic imaging at MD Anderson Cancer Center in Houston. The PET-CT revolution will continue with new detectors. PET-MRI cameras will hit the streets in the next decade, providing better soft-tissue resolution than their PET-CT peers.

But the cameras are only part of the PET equation. "We need more imaging agents than FDG," Gelovani says. "FDG doesn't tell you what drug to use [to treat cancer]. I envision a spectrum of imaging agents that can be applied in a rationale algorithmic manner to obtain a profile of a tumor and select an appropriate drug." Imaging will quantify molecular processes and determine the activity of drugs in the tumor to facilitate individualized therapy. Functional imaging technologies will allow clinicians to monitor the efficacy of various treatments early in the treatment process - instead of two to three months after treatment begins.

Optical imaging to image light coming out of the body is in the works. Optical cameras will be mounted on the ceiling in OR suites, predicts Gambhir. Optical biopsies will become possible with fiber optical confocal microscopes that obtain images at the cellular level via ultra-thin fiber bundles. "We'll be able to evaluate histopathology without removing tissue, and we'll see relationships to other tissues and vasculature," explains Gelovani. Finally, new fluorescently-labeled imaging agents will tell physicians where to place needles and other devices.

CT: Beyond the promise

"We will see a burgeoning of applications for 64-slice CT—especially in the cardiac arena," predicts Lincoln Berland, MD, president of the Society for Computed Body Tomography and MR. Currently, 64-slice facilitates CT angiography and coronary imaging and enhances peripheral vascular studies.

"In five years, CT will be more commonly used in screening," claims Norman Lepor, MD, cardiologist with West Side Cardiology in Beverly Hills, Calif. Lepor likens CT screening to colonoscopy, noting that coronary artery disease is much more prevalent than colon cancer and equally malignant. Sixty-four slice CT offers the sensitivity and specificity to answer the questions of whether or not an individual has coronary artery disease with an absolute rather than relying on relative probability assessments, says Lepor.

The CT revolution is both a hardware and software story. "We'll see more practical 3D applications and use it for almost every kind of exam. This will enable customized surgical planning and drive customized treatment," continues Berland. Similarly, computer-aided analysis will thrive. Software tools will facilitate volumetric studies of organs over time and also help providers determine the most appropriate scanning technique for each specific patient. A tech will simply key-in specific patient factors and the desired outcome, with the computer deciding quantity of contrast, scan rate and slice thickness to achieve the appropriate result.

Exquisite resolution and computer analysis does have a downside. As physicians find more internal blemishes and oddities, they need to determine appropriate clinical management paths. The recognition of pseudo-disease or benign-behaving malignancies will increase with advanced technology, says Berland. For example, radiologists frequently find incidental renal tumors less than three centimeters, but many grow so slowly they don't present a problem for the patient. This brings up a question radiologists will confront more frequently in the future—should the lesion be followed or removed. Radiologists will need to develop and adhere to appropriate clinical management scenarios, a need that could be partially filled with decision support (or knowledge delivery) tools.

MR: A modality evolves

"MR and most imaging technologies are heading toward physiological, metabolic and molecular imaging vs. straightforward anatomic imaging. The MR scanner of the future will not only see anatomy but also image how molecules are behaving," says Suresh Mukherji, MD, chief of neuroradiology at University of Michigan. This will lead to a paradigm shift, predicts Mukherji.Standard cross-sectional imaging to locate tumors will evolve into physiological imaging. MR will be deployed during radiation or chemotherapy to determine if a tumor is being successfully treated. Similarly, a post-stroke MR may help physicians determine if tissue can be saved. Brain tumor resection may be improved with fMRI as higher field magnets more precisely determine the connection between certain areas of the brain and necessary functions. "Molecular imaging and fMRI are much easier with higher-field [3T] magnets," opines Mukherji.

3T does lend itself to better enhancement of tumors, improved spatial resolution and shorter scan times, but it may not be necessary for bread and butter MR imaging, says Mukherji. As researchers continue to explore the benefits of 3T, the technology promises to improve. One of the current impediments is the lack of coils for areas outside of the brain and skull. New coils for other areas of the body should be developed within the next few years, which could drive applications and acceptance.

Advanced visualization becomes universal

The major advanced visualization news does not concern new applications or techniques. The increasing clinical utility and integration of advanced visualization tools is the real story. "I no longer consider it advanced visualization because it's what we do all the time," states Chip Truwit, MD, chairman of radiology, Hennepin County Medical Center. For example, as multislice CT datasets have reached the 1,000-image size, 3D tools are necessary to allow radiologists to look at images in a multi-planar reformat instead of image by image. CT and MR angiographies are another common 'advanced' application.

No matter how it's termed, advanced visualization will continue to pick up speed in the radiology department of the future. For starters, 3D vendors are forming partnerships with PACS vendors to merge applications onto regular PACS workstations. This third party plug-in model brings significant benefits; efficiency will skyrocket as radiologists no longer trudge from one workstation to the next to load and complete advanced applications. Truwit estimates that the current daily workstation to workstation grind can amount to one hour per day per radiologist.

The need for improved efficiency and workflow will drive some advances in the advanced visualization field. Anticipatory automation will become more common. Right now, some tools complete automatic measurements when a radiologist clicks on a coronary vessel. This technique can be applied to a number of standard 3D post-processing steps. CT angiography, cardiac applications, brain or organ perfusion studies, triple rule-out studies and lung exams are ripe for anticipatory automation, which would fuel efficiency and allow radiologists to effectively harness the clinical power of higher-slice CT scanners.

Advanced visualization tools also will migrate out to the enterprise; server-based solutions will allow radiologists and clinicians to access advanced visualization tools anywhere and facilitate web-based communication and dissemination of information.

Truwit does foresee new cardiac advanced visualization tools to help radiologist master the 64-slice monster. New applications will facilitate cardiac and soft plaque imaging to enable better diagnosis of coronary artery disease.

CAD: Expanding horizons

Radiologists will continue to be overworked in the future and imaging growth will continue at a rapid clip. That means radiologists will rely on CAD for the most basic functions like chest x-rays and bone films, says Truwit. The search for blood or stroke in a head CT or MR could be algorithm driven, which would speed up workflow. "The growth of MR, and its use in every part of the body, is astounding.

We need more MR algorithms because it takes a lot of time to read MR studies," continues Truwit. Other disease processes appropriate for CAD include liver and kidney disease, says Berland.

CAD for CT colonography could be right around the corner. As the American College of Radiology Imaging Network (ACRIN) CT Colonography Trial winds down, it could demonstrate the validity of virtual colonoscopy. If reimbursement follows, CAD for CT colonography would be the next likely step.

The development of additional CAD applications will not require a great technical leap; however, the developer must complete a tremendous amount of legwork, creating a database of thousands of cases to develop a CAD algorithm for specific conditions.
Interventional Radiology: Finding a home

"Interventional radiology has become a full-fledged clinical specialty," explains Robert Vogelzang, chief of interventional radiology at Northwestern Memorial Hospital (Chicago). Vogelzang stresses that interventional radiologists belong in the radiology department but foresees a hybrid situation arising in the future. "Some hospitals will have a dedicated interventional radiologist in the radiology department, but if the infrastructure is not there to support the specialty, the interventionalist may move to another department," predicts Vogelzang. The wandering interventionalist could find a home in one of several departments that has adopted the tools of the trade including vascular surgery, cardiology or orthopedic surgery.
What keeps an interventional radiologist in the radiology department? Their needs are simple, says Vogelzang: the best imaging equipment to support their techniques and full access to clinical equipment, offices and rooms, similar to an outpatient surgical area.

No matter where interventional radiology resides, new applications will continue to arise. Ultrasound ablation and MR-guided intervention demonstrate a great deal of potential. Northwestern Memorial Hospital recently opened a new MR-IR suite to facilitate MR-guided intervention. Patients will be able to transfer directly from angiography and fluoroscopy to the MR suite.
Wood says radiologists will rely on smart devices with smart sensors to inform them of their exact location in the body, enabling more precise navigation of needles and catheters. The smart sensors will be combined with smart drugs (nanoparticles) targeted to tumor proteins.   
 
"The multi-modality interventional suite [of the future] can combine less expensive modalities to facilitate a big leap in benefits without the cost," points out Wood. The NIH Clinical Center relies on a suite equipped with a multi-slice CT scanner with a rotational flat panel detector; diagnostic ultrasound; coaxial diagnostic and therapeutic ultrasound registered to the CT and an integrated stereotactic gamma camera. Other components of the suite include robotic arms integrated onto the CT scanner for precise placement of needles and an electromagnetic field generator mounted on the CT to facilitate navigation. (The price point for a robotic arm should pale in comparison to the going rate for its full-size surgical robotic peers.)

Ultrasound: Tried and true...and more

Ultrasound, like interventional techniques, has proven its merit and is the most widely used imaging modality worldwide, yet it could become a victim of its own success - at least as far as radiology is concerned. The non-radiating, rapid and inexpensive modality is ideal for pediatric, pelvic and cardiac applications, and it's proving useful in musculoskeletal examinations where it provides data about movement and flexion. Yet ultrasound is a fractured modality used across the enterprise in the ER, OB-Gyn, cardiology, vascular surgery and radiology.    

Technology continues to develop. As manufacturers move toward pure PC-based ultrasound technology, ultrasound will become more affordable and more widespread. Ample, affordable ultrasound is not necessarily a positive, contends Flemming Forsberg, PhD, head of research, Jefferson Ultrasound Institute at Thomas Jefferson University (Philadelphia). Users who are not properly trained could use it incorrectly with radiology professionals paying the price. The American Institute of Ultrasound in Medicine (AIUM) is trying to expand its ultrasound lab accreditation program, which could counter potential problems with less experienced users. Other technical advances will boost the utility of ultrasound. Full 2D array transducer technology, for example, provides users better control over the beam and facilitates complete angling flow measurements. "Looking at vessels from multiple angles will enable radiologists to answer vascular questions more accurately," explains Forsberg. Early work indicates elastography, which relies on sound waves as a palpitation tool, has some potential in evaluating breast and prostrate tissue stiffness to indicate the presence of a lesion. And focused ultrasound, which has been cleared for treatment of fibroid tumors, shows potential for drug delivery or gene therapy applications.

Ultrasound contrast, which has been in the Food and Drug Administration (FDA) approval cycle for a few years, remains an unknown. Trials in Japan demonstrate that contrast can yield a 10 percent increase in lesion detection, but the FDA seems reluctant to approve contrast in the US.

IT Tools

IT development is driving the radiology department today, and it will continue to play a key role in the future. Integrationis a primary concern. "IT development is the biggest challenge any radiology department faces. We need integrated approaches to data management, transfer and storage," says University of Michigan's Mukherji.

MD Anderson's Gelovani adds, "IT tools are critical especially as we integrate multi-modality images into patient management." Full integration is just the starting point, says Ramin Khorasani, MD, MPH, vice chair of the department of radiology at Brigham and Women's Hospital (Boston). "We need full integration of various software applications to improve efficiency and productivity." The next, and essential, level is the development of knowledge delivery IT tools to improve quality and consistency.

Knowledge delivery or decision support will be delivered to multiple points and in numerous ways. For example, it can help a physician select the appropriate imaging test, inform a physician if a similar study was performed recently or even indicate that a test will not benefit patients of a specific genetic makeup. These types of tools will likely be delivered via computerized physician order entry (CPOE). On the radiology side, knowledge delivery systems will help radiologists determine findings. Radiology tools may be embedded in CAD applications or in speech recognition or structured reporting tools. "Knowledge delivery systems will usher in the era of personalized medicine to help physicians provide optimal management and treatment," sums Khorasani. Knowledge delivery will help ensure that treatment is based on science and thus facilitate homogeneity in treatment, mitigating current differences in ordering, reporting and recommendations that can vary up to ten-fold.

IT will fuel acceptance of new imaging technology as well. Lepor points out, "We need workstations to provide information in an easy, user-friendly fashion. The more automated processes are the more likely it is that the average cardiologist will embrace 64-slice technology."

Conclusion

The radiology department of the future promises to be an exciting, clinically relevant arena. Molecular imaging and interventional tools will improve the diagnosis and treatment of cancer. The ability to link imaging with drug delivery mechanisms will forge intimate ties between radiology and clinical care. Add the continued radiologist shortage and image volume explosion to the mix and the paramount importance of IT becomes evident. IT tools will help decision-making on all fronts. New CAD applications will facilitate decision-making and workflow, and advanced visualization makes viewing of large datasets feasible. Finally, decision support or knowledge delivery will enable consistent yet personalized care.

Inside the 21st Century Department

Springhill Medical Center in Mobile, Ala., has jumped headfirst into the 21st century and is shooting for the 22nd, says Jack Dempsey, administrative director of radiology. The hospital aims to be the first in the country with a 64-slice CT scanner and 3T MR scanner. But the newest imaging tools are only half of the picture of the high-tech shop. Springhill deployed wireless carts throughout the facility; nurses and physicians use the carts to enter notes, review lab results and x-ray reports and images.

"The goal," says Dempsey "is to build an EMR for the hospital and the community." The county is blanketed with fiber optic cable, which will link the hospital, an offsite PET-CT center and an outpatient center. Physicians will have a single sign-on for all three facilities. "The only other IT building block is a virtual private network (VPN)," claims Dempsey. The VPN ensures that the center meets HIPAA requirements.

Dempsey outlines the benefits of the approach. "We'll be able to take advantage of advances in CT [with the 64-slice scanner]. The 3T magnet provides improved image clarity and will last five to seven years. Our configuration means faster service and turnaround time and increased business."