A View from the Cockpit: The Radiology Department of the Future

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The fact that technology changes on average every 18 months makes the radiology department arguably the most fluid branch of medicine today. The challenges including disappearing department boundaries, the changing culture in terms of inputting and acquiring radiologic information, and the need for 24x7 reading and interpretation for trauma and emergency room patients make for some formidable decisions for the future. Combine those elements with ongoing capital concerns, and the future may seem daunting.

However, facilities are heeding the signs and finding ways to keep radiology departments competitive, efficient and cost-effective into the future. Integrated digital approaches and enterprise initiatives to improve service to referring physicians and patients are moving departments into the future. But no one said it would be easy.

Increasingly, radiologists are finding themselves a combination of medical expert and IT virtuoso - flying through images, accessing patient records, ordering tests online, billing patients and using constantly evolving technologies accessible at diagnostic workstations. Enterprises continue the conversion to a digital environment and the increasing use of computers to assist in the handling and analysis of data. PACS, RIS and HIS integration make patient records a few clicks away and right away, not hours or days later.

Like a pilot in the cockpit, checking that all systems are in place, working and ready to go, radiologists and cardiologists require reliable data to successfully complete their missions - the richer the information, the better the flight plan.

At Yale University School of Medicine in New Haven, Conn., Bruce McClennan, M.D., professor of diagnostic radiology and chief of CT scanning, sees the radiology blueprint constantly changing. "You build departments for today, and tomorrow they are obsolete, but we're getting smarter, so we're building slower, tearing down walls slower, but making sure within those walls that we have every piece of network capabilityâ?¦that we can possibly think of because we know we're going to need [it]," McClennan says.

In the future, more advanced imaging will assume a larger role in the practice of radiology, creating a different approach for patients. Radiology will be moving beyond the human body into specimens, molecules or genomes of different patients, eliminating the need for a patient's presence in the radiology department.

"Our nuclear medicine and our bioresearch soon [will] be clinical practice sections of departments," McClennan says. "The department of the future ought to be some kind of combined diagnostic department - radiology, nuclear medicine, pathology and electron microscopy."

Radiology will continue to make room in the budget and the department for the noninvasive, vascular and interventional capabilities. "[For carotid disease], CTA [CT angiography] and MRA [MR angiography] are basically replacing invasive means," says Vijay Rao, M.D., professor and chair of the department of radiology at Thomas Jefferson University Hospital in Philadelphia. "I think within the next three years, CT is going to be the way of looking at coronary arteries. The technology is there. It's just a question of fine tuning it to be able to demonstrate the anatomy in all planes and optimizing it."

The must-have modalities will likely include those that deliver a combination of structure and some assessment of function or metabolic profiles. Fusion devices such as CT-PET and MR-PET, as well as higher resolution 3 tesla magnets, will be essential equipment for some departments to stay competitive as applications for fusion devices and 3T increase.

Virtual technology will garner more attention. "The department of the future is going to need the capacity to do all the virtual imaging, such as virtual colonography, because I believe that's going to be equivalent to standard colonography," says Stephen Amis, M.D., chairman and professor of radiology at Albert Einstein College of Medicine and Montefiore Medical Center in New York City. "That means you need 3D reconstruction capacity on all of your CT machines," Amis says. "These are expensive pieces of equipment that people are going to have to continue to add to their department, replacing older CT with multislice CT and volumetric CT."

Look to the increasing power and sophistication of the imaging techniques to drive the volume of imaging data, which continues to become richer. And more in this case is better.

"I believeâ?¦we will be doing more whole body scanning because [it] provides an enormous amount of information to clinicians that they're not used to having," says R. Nick Bryan, M.D., Ph.D., the Eugene P. Pendergrass Professor and chair of the Department of Radiology at the University of Pennsylvania School of Medicine. "I'm not talking necessarily about whole body screening, but the types of data, the extent of data from MR and CT, new optical imaging techniques and advanced digital imaging of patients will become almost the norm for any patient with significant illness."

TOOLING AROUND

As boundaries become less defined, expect to see more devices such as small hand- carried ultrasound units spreading to clinicians and nonradiologists. Radiology tools will be distributed to where they are more accessible to patients.

"We will send the image data to the radiologist who doesn't have to be anywhere near where the instruments are," Bryan says. "A department can be widely disseminated in terms of where the instruments are vs. where the radiologists are. They will extend beyond institutions, states and even countries, where people are now reading scans that are done from outside the United States in Europe and Australia and vice versa."

The instant dissemination of images and reports provides an interesting problem for radiologists - how to deal with rapid dissemination of data well beyond the department.

"How do we make sure our added value is with that information?" Bryan says. "How do we make sure the patients know what to do with that information, because it's far beyond the confines of the boundaries of the department. It's a significant paradigm shift."

Currently, the University of Pennsylvania's radiology department is completely digital. The way they look at images will change greatly in the future when the department incorporates more computer assisted diagnosis (CAD) and analysis. "It will be more quantitative interpretations, and I think the significant change is that not only the images but [also] our reports will go more directly to our patients, as well as to our referring physicians, which is not the case now."

Direct dissemination of images and reports to the patients is a dramatic culture change for radiology. With the technology and workflow change, a radiologist could hand the patient a CD containing the images and report. Because a radiologist typically does not know a referred patient very well, the referring physician delivers the images and report to the patient. However, HIPAA mandates each patient's right to medical records.

"I don't know how we're going to do it that it fits best with their overall healthcare and psychology of that healthcare," Bryan says. "That is something we're going to be working on over the next several years."

Speech recognition is something everyone is either in the process of acquiring or, at the very least, considering for the future. Bryan credits speech recognition with the department's ability to deliver reports within an hour or so. "There's no question that the efficiency and workflow are enormously improved by it," Bryan says. "On the other hand, it definitely increases - at least at the present time [using free text dictation] the work on the radiologist." The eventual plan at the University of Pennsylvania is to change from a free text dictation to a more structured reporting environment, where one uses macros and template-like reporting, which means another culture change.

The capital burden required to make the needed transition in radiology departments won't disappear, but the weight of that burden may lessen somewhat. "I think the price is coming down and financing methods are evolving such that it will become increasingly feasible for virtually all departments to participate in this digital environment," Bryan says. "I think they'll have to, but it's still a significant challenge."

The increased volume of studies and data for radiologists across the board will be a driving force for the future, particularly with a relatively tight workforce. "You know, we're not training [greater numbers of] radiologists to do this work," Bryan says.

SHARED VISION

For Presbyterian Hospital of Dallas, which does between 110,000 and 115,000 studies per year, the future is moving toward a virtual radiology department, according to June Boyd, electronic imaging manager. "I'm not saying that radiologists and managers should not be on site, but I think we'll see a much more varied approach to radiology," Boyd says.

Presbyterian has a total of 25 radiologists on staff. The system also includes a smaller start-up facility and an imaging center. The medical system has decided to implement a PACS to provide better service to the patient by offering specialties via a remote network. "We can have the same radiologist have all specialties available to the patient and not have 10 radiologists sitting at the start-up facility, which is not cost-effective for the radiologist or for anybody else," Boyd says. By having remote radiologists with the expertise managing the files, the facility assumes a much more global approach.

Some of the remote buildings presently do not have the IT infrastructure in place to receive and deliver images in a timely manner. That will happen. But first IT had to adopt a mindset that recognizes infrastructure needs to move large imaging files that dwarf text files in comparison.

"I would say there are facilities being built out there right now where there's [little or no] experience with PACS, and the infrastructure will be found to be lacking," Boyd says. "And should that facility undertake a PACS project in the future, it will still require considerable upgrading to be done before they can be effective with a PACS, and I hope the architectural community will consider that as well. That's one area that the greatest impact can be made in preparing for what will happen in the future. I'm talking one, two or three years, not 10 years out."

BEYOND BORDERS

Radiologists at Presbyterian and elsewhere are looking for ways to extend their services. At Presbyterian, radiologists read MRI images from 400 miles away. The IT department has security concerns regarding opening up the network.

"They're not very open-minded about that, and I understand why," Boyd says. "However, realistically they need to deal with this, because a radiologist is in business and needs to reach out. [The ability to] get 10 opinions for a patient that would not normally have access to the specialty area â?¦ will change the practice of medicine. There will be no such thing as basing a decision on a best judgment when all the physician [whatever the location] has to do is e-mail or in some manner request expert opinions on those images."

Images, which are compressed and lossy, come from west Texas via a DSL line to radiologists at Presbyterian for reading. Boyd says the concerns stem from the inability to control the system where the images originate, such as a doctor's office on the outside. "We have to find some way to integrate our medical community in a more realistic fashion. If you're already on our network, we can ship images just about anywhere, but the global community will be the IT challenge of the future," Boyd says. "I doubt the future will be sitting in one place."

The hospital is working on integrated products, HIS/RIS, PACS and speech recognition. "Voice recognition dictation systems are the future, no matter where you are or where you're looking at images," Boyd says.

PAPER IS PASSE

While some facilities consider a paperless environment for the future, Santa Monica-UCLA Medical Center has it. Recognizing that early diagnosis depends of the delivery of timely images and reports, the department of the future at Santa Monica-UCLA will be one that minimizes delays at every part of the cycle. "[That includes] when a test gets ordered, through [being] read, dictated, transcribed and sent to the physician," says Jonathan Goldin, M.D., medical director of radiologic services. The electronic environment is the Center's answer.

Although paperless is an area that most people seem to accept is going to happen and most people can see its potential for increased efficiency, the actual practice of designing the paperless environment of the future could be one of the biggest obstacles to overcome in the radiology department.

"It's not just in the department," Goldin says. "It also rotates around the physician practice or the referring physician base. Physicians who have been in practice for years are very used to seeing their film or a paper report. They're not all that familiar with e-mail or electronic structures, so you have to re-educate and retrain people to become familiar with something they do automatically â?¦ It's all about re-engineering people's workflows and work habits. That's a big area."

And as work hours in radiology departments become 24 x 7 service for trauma and emergency room patients, the days of the 8-to-5 radiologist might be going the way of the lightbox. "Imaging is diffusing everywhere and nearly everybody has access to those images and no longer has to wait for the radiologist's report," Goldin says. "If the radiologist's interpretation lags too long or remains unconnected with the patient work-up profile and is too generic, the need for the radiologist starts to become questionable."

The challenge as a field, according to Goldin, will be to demonstrate that radiologists are essentially IT medical consultants, especially as the boundaries of the radiology department continue to fall. Radiologists are, after all, the ones who understand the imaging technology better than any other physician, and possibly better than anyone.