Digital Department

How we work will revolve around the human element
It’s 2010. Do you know where your images are? Better know where your patients are.

By Deborah R. Dakins

Sidebar: New tools target docs

Stepping apart from a group of clinicians on rounds in the cardiac ICU, the radiologist points his Palm Pilot like a remote control toward a flat-panel display mounted on a nearby wall.

“Let me show you what we’re talking about here,” he says, nodding toward the patient under discussion.

The display panel comes to life with a series of pulsing MR images of the patient’s left ventricle. Using the Palm to navigate, he points and clicks to highlight the more subtle findings on the images and reviews the implications of competing treatment strategies. After mapping out a management plan, the group moves on.

The radiologist returns to his portable workstation, which is tethered to power, data, telephone, and air circulation lines built into a section of raised flooring in the ICU. The workstation is equipped with a display panel for image viewing; voice activation and touchscreens obviate a keyboard. A digital drawing tablet is available for annotations, and two winged insulation panels muffle background noise.

After logging in using a fingerprint authentication device, the radiologist scans his personalized menu and downloads his imaging work list. He will spend part of the day here, interpreting scans and consulting with clinicians. Later he will move the workstation to the orthopedic clinic, another area of high demand for his consultative services.

The scenario may sound futuristic—and it is. But it isn’t all that far-fetched. The technology already exists or is on the near horizon. All that’s missing to make it happen are willing radiologists.

The portable workstation is the brainchild of the Intelligent Workplace project at Carnegie-Mellon University, which is testing it for commercial business applications. Vendors such as Stentor are in the R&D phase of incorporating flat-panel displays into diagnostic workstations, replacing today’s CRTs. Wireless applications like Internet navigation using personal digital assistants (PDAs), cell phones, and pagers are already in use. Meanwhile, information technology is being adapted for a wide range of artificial intelligence applications for computer-assisted diagnostics.

The key drivers behind changes in where and how radiologists will work, however, are digital imaging and distribution technologies, which have already cast their ripple effect across radiology. To date, only about 2% of 1700 U.S. hospitals and outpatient imaging centers have gone filmless, according to a survey by IMV Information Services of Des Plaines, IL. But experts in academia predict that by 2010, between 70% and 80% of tertiary-care facilities will boast filmless operations, meaning that at least 80% of a site’s imaging exams will be electronically acquired, interpreted, stored, and distributed. It’s expected that community hospitals will take an additional 10 years to catch up.

Numerous studies have shown that PACS and direct digital technologies can improve department efficiency and radiologist productivity. Soft-copy image display allows radiologists and other physicians to access, organize, and manipulate images and related clinical data, said Dr. Osman Ratib, vice chair of information technology at the University of California, Los Angeles.

With volumes for imaging services at an all-time high, however, the time savings from these technologies have had an unintended side effect. Radiologists work smarter but also harder, a trend that is expected to increase in coming years.

Before PACS, radiologists at Massachusetts General Hospital could relax between cases during the 20-minute intervals required to load films on light boards, said Dr. Amit Mehta, director of the advanced imaging laboratory at MGH. What used to be downtime has been eaten up by a 30% increase in scan volume at the facility in the past five years.

Widespread accessibility to images by anyone throughout the healthcare enterprise has had another unintended consequence: Clinicians no longer need to wait for the radiology report if they’re in a hurry to make a treatment decision. They can call up the images themselves on office or home-based PCs.

These changes portend—if not demand—a greater role for radiologists as mobile consultants who promote the value of their imaging acumen to clinician colleagues, said Dr. Bruce Reiner, director of radiology research for the VA Maryland Health Care System.

“We must take a more active role as consultants instead of image readers,” he said. “A decentralized department that supports the radiologist in providing clinical services, wherever they are needed, is the vision of the future.”

Digital Design

Digital images erode, reshape, and challenge assumptions about the best place for radiologists to work, said Morris Stein, president of the Stein-Cox Group, a Phoenix architectural firm specializing in healthcare facility design. Because data are easily moved, radiologists can be located in areas that are more convenient to staff and referring physicians. New design configurations incorporate multipurpose workstations and information hubs to promote greater collaboration with clinicians.

Conventional reading rooms have multiple limitations, particularly when it comes time to shift to digital operations, Ratib said. Problems range from inadequate lighting to poor location of reading workstations and lightboxes, excessive reflection and glare, minimal sound insulation, and overcrowding. Rooms are often unable to accommodate the range of activities performed in them.

In addition, conventional departments are not designed with the free flow of information in mind. In a digital regime, the old model of a centralized department that revolves around images is giving way to a distributed data environment with patients at the core, Ratib said.

“In the past, we tried to make images the centerpiece and imported the rest of the patient data,” he said. “We are reversing that strategy, and it’s meant a change in culture as well as infrastructure.”

Ratib is designing a network for image management and workflow that embodies this concept for UCLA’s new main hospital, scheduled to open in 2005. Unlike the existing structure, which serves dual roles as teaching facility and county hospital, the new site will offer acute care services only. Three adjacent buildings will house outpatient services and short-term hospitalizations. Imaging and information systems in the new hospital will be filmless, paperless, and fully electronic, and communications networks will revolve around patients, not PACS.

New workstations designed in a four-unit kiosk configuration will combine both diagnostic screens and large overhead flat-panel displays

to facilitate clinician conferences. Radiologists spend about 25% of their reading room time providing on-the-spot consultations. The new workstations using the larger flat panels atop the diagnostic displays allow productive discussion with large groups of physicians, Ratib said. In addition, the new high-performance kiosks will allow radiologists to access images from any workstation.

The shift eliminates prefetching protocols and the need to anticipate in advance how, and at which workstation, images will be viewed. For example, using the new multipurpose kiosks, a neuroradiologist can walk into a chest reading room and pull up his or her own scans to read. Such individual functionality is in keeping with broader predictions about the workstation of the future.

“That’s the future of the radiologist’s workplace: an integrated system that includes reporting, image display, and the ability to access an electronic medical record,” said Dr. Curtis Langlotz, an assistant professor of radiology at the University of Pennsylvania.

Patients, Not PACS

As radiology departments go digital, expect design changes that extend to public areas as well as reading rooms. Given trends in both digital imaging and consumer-directed customer service, the concept of radiology departments as merely a collection of rooms and tools must be discarded, according to architect Stein. Imaging must instead be seen as a coordinated system of services and quality-driven values. Digital imaging allows for more modular department design and creation of less threatening environments.

“The future radiology department is focused on the patient, not technology,” he said.

That concept has already been embraced by Florida Hospital Celebration Health (FHCH), located in Celebration, a suburb of Orlando, FL. Specifically designed as “the hospital of the future,” FHCH emphasizes wellness and prevention as much as its acute care services. Its radiology department boasts the latest technology and filmless operations and also features the Seabreeze Imaging Center, designed to emulate a beachside resort, complete with boardwalks, beach chairs, flip-flops, and surfer shorts instead of standard-issue paper gowns. Individual cabañas serve as changing rooms, and barium contrast is served like a tropical cocktail, complete with paper umbrella. [Fig. 2]

In the MRI and CT suites, a soundtrack of seagulls and surf surrounds patients during scanning. The suites are scented with suntan lotion and seaspray aromas wafting through the air. Perhaps most striking is the transformation of the MRI and CT units from hulking imaging devices to sand castles.

“You can’t create a state-of-the-art technical facility without looking at the personal needs of the patient,” said Sally Grady, director of imaging services. “We’re in the age of the ‘prosumer.’ People know what they want and they have a lot of choices. How do you make them come to you—and how do you make them want to come back? It’s a combination of high-end technology and a high-touch environment.”

Another goal is productivity, Grady said. The radiology department is designed with four pre-exam rooms adjacent to the CT suite, which houses a $1.2 million GE LightSpeed scanner. All scan-related prep and patient education is performed in pre-exam rooms with a staff nurse or technologist, so no time in the imaging suite is wasted. The department also boasts two MRI tables and duplicate sets of the coils most commonly used. One set of coils is kept in the imaging suite, the other in a pre-exam room.

“I can have a patient in the magnet while the next one is in the pre-exam room on the second table, with the coils already attached,” Grady said. “All we have to do is swap tables, saving up 10 to 15 minutes on a $2 million magnet.”

The radiology department maximizes the cost savings inherent in filmless operations by burning images on CDs for patients instead of printing film. The CDs cost about $1.50 each.

The biggest challenge facilities face with filmless operations is how to get images off campus and into the hands of those who need them, Grady said. Last summer, FHCH invested in an Internet-based image distribution system to solve that problem. Referring physicians are issued electronic tokens that permit access via the Internet to any image acquired at FHCH that they need to see.

Future Philosophy

Internet-based distribution of images dissolves the barriers between radiologists and clinicians. As they relinquish control of images, radiologists must reevaluate their contribution to the patient care dialogue.

That means a shift away from today’s emphasis on how fast images can be read and how soon reported. With the advent of new technologies like speech recognition and network image distribution, such real-time service becomes a given. The new focus is on communication and clinical involvement.

“Discussions between physicians, clinicians, and surgeons is a part of our job,” Ratib said. “If we don’t support that, we fail in our clinical service.”

Using technology tools to support greater clinical involvement is radiology’s next big challenge, Reiner agreed. The stakes are high. With Web-based distribution that makes images accessible to clinicians on the desktop PCs or at home, the potential exists to make radiologists obsolete.

The results of a study evaluating the impact of filmless radiology on in-person clinician consultations supports that prediction. The consultation rate for general radiography dropped 82% after the Baltimore VA Medical Center shifted to filmless operations. Consults tied to cross-sectional imaging study dropped 44%, despite an increase in study volume.

The ability to access current and prior images provided by the department PACS was the primary reason for the decrease, said Reiner, who authored the study.

“Radiologists no longer have a captive audience that has to come to them for information,” he said. “As a result, we have to become more proactive and make sure we are very much a part of patient management.”

That means greater visibility as well as accessibility—via pagers, cell phones, e-mail, or Internet. One of the biggest complaints voiced by referring physicians is the inability to track down radiologists when they are needed, said Scott Raymond, vice president of AGI Healthcare Consulting in Carlsbad, CA. Technology can and should play a role in boosting speed and quality of imaging services. Foremost among these is crafting reports that add value to clinical decision-making.

Quality issues will continue to evolve, if not increase, in importance, according to Dr. Robert Pyatt, president of Chambersburg Imaging Associates, a 13-member radiology group in southeastern Pennsylvania. Pressure by the Institute of Medicine to reduce errors will not lessen in the future and computer-assisted diagnostics could thus prove a boon to radiologists.

In addition, the practice landscape in the future will feature a growing emphasis on evidence-based protocols for performing CT, MRI, and ultrasound, Pyatt said. Increasing importance will be placed on compliance with imaging standards by organized radiology.

Ultimately, the future of radiology rests in the hands of its practitioners. Those who cannot adapt to a higher standard will lose.

“It’s going to be survival of the fittest,” Reiner said. “If we really believe in the skills and expertise we bring to the equation, we want to raise the stakes a bit. If we can rise to the occasion, our role among our physician brethren is only going to improve.”

Sidebar: New tools target docs