Trends in radiology used to be simple and predictable.
Trends in radiology used to be simple and predictable. They came from within, from technologies and issues related to modalities: MR, CT, ultrasound, nuclear medicine, and radiography. Even the early adoption of PACS was modality-driven, linked inextricably with the adoption of digital x-ray.
Consumer demand for open MR broke this pattern, launching midfield as a viable clinical option. Today radiology seems primed for new developments, this time driven by the consumer, this time in information technology. Wide-scale access to the Internet, made possible by inexpensive PCs and mobile communications devices, has whetted an appetite for health information, empowering patients to research medical questions while giving them the means to own the results of imaging exams and lab tests. Catalyzing the reaction among information technologies and the desire to use them in healthcare is a political initiative to make healthcare more efficient through the widespread use of IT.
Together these will spawn three great trends: consumer access to healthcare information, integration of information systems, and adoption of decision support tools. These trends promise to fundamentally change the practice of radiology.
The Internet has opened doors to information like no other technology. Internet searches provide instant means of learning about nearly anything. Mobile devices have merged functions of the cell phone and PC.
"It is ubiquitous computing," said Dr. David Hirschorn, director of radiology informatics at Staten Island University Hospital.
In keeping with this potential, patients are demanding the same accessibility to their health information as they have come to expect from service providers such as bankers and travel agents. Patients want to perform basic healthcare tasks like scheduling, communication, and bill payment, said Julie Pekarek, chief marketing officer for Merge Healthcare. Eventually they will want unfettered access to their health records, she said.
Dr. Eliot Siegal, vice chair of radiology at the University of Maryland and chief of imaging for the VA Maryland healthcare system, agrees.
"In the next two years there'll be an expectation by consumers to have access to lab data and radiology reports-and even images and other types of health information-online," Siegel said. "I just see it as a continuation of IT expectations that people have about the ubiquity of information."
But reports designed for physicians may do little to help patients understand their conditions, according to Dr. Keith Dreyer, associate chair of medical imaging at Massachusetts General Hospital and an assistant professor of radiology at Harvard. Other concerns pertain to patient privacy, specifically defined by HIPAA rules. Concerns for patient privacy may be amplified by the introduction of more powerful and sophisticated consumer electronics.
The day may soon come when mobile devices not only display images but capture, gather, and aggregate information so well that radiologists and referring physicians will interact sparingly, if at all, with RIS and PACS, according to Dreyer. The widespread availability of patient data may even change the way radiologists work.
While a radiologist today is not likely to read a chest radiograph on an iPhone, systems that are larger and brighter, such as Apple's iPad and whatever succeeds it-or even devices that project images onto a flat surface-could support the diagnostic process, he said.
"You could have a mobile device that would be totally adequate for primary interpretation," Dreyer said. "These devices are definitely game changers for healthcare IT, and particularly for imaging informatics in medicine."
Referring physicians could gain the most in the near term. They will be able to use mobile devices to get instant information about their patients. But radiologists will benefit as well, albeit indirectly.
Being able to send radiology reports and images to mobile devices, Hirschorn said, will be a selling point for the services of a radiology group or hospital.
Mobile devices promise to bring radiologists and referring physicians together like never before. But the biggest gains will come from seamlessly connecting RIS/PACS and electronic medical records (EMRs).
"Referring physicians want access to images," Dreyer said. "And they don't want to have to log in separately to see them."
This is already possible at Crystal Run Healthcare in Middletown, NY. Radiology reports prepared on its Carestream RIS/PACS are transferred directly to its EMR system, where any of the 180 physicians in Crystal Run's dozen facilities in the area can read them.
While helpful for referring docs, the RIS/PACS is one-way, it doesn't provide radiologists with access to the EMR system, which Hirschorn says could help when interpreting images. But Carestream is working on a program that would give radiologists what they want from an EMR system, according to Joe Maune, manager of strategic initiatives for the company's digital medical solutions group. The RIS/PACs would be integrated at the desktop level of the EMR.
"Applications would appear seamless to the radiologist, who, looking at the RIS and PACS, would also be linked to the EMR system," Maune said.
In the meantime, there are plenty of benefits to be gained from allowing the easy and consistent flow of medical images outside the radiology department. For one, it would eliminate problems surrounding the transmission of patient data now done using DVDs and CDs. This process is causing no end of trouble-and some harsh feelings-between radiologists and referring physicians.
"It is really ironic because referring physicians are talking nostalgically about the ‘good old days' when they had access to patient images on film," Siegel said. "They're saying now that patients are showing up with CDs and DVDs that they can't read and they're almost implying that it's a conspiracy, that we radiologists are creating portable media that they are not able to read."
Massachusetts General Hospital has solved the problem with software that displays images from optical media regardless of how or where the images were created or stored. This software, engineered at MGH, has been licensed to Life Image, which is based in Newton, MA. It automatically detects CDs or DVDs that hold DICOM data, uploads the images, shows the patient name, then displays the images in the common viewer, asking finally if the images should be imported into a resident PACS.
The longer term solution is to make image transfer by DVDs and CDs unnecessary. This requires an interconnected, broadly based EMR system. This merging of information systems will resolve the image transfer problem, but whether it will bring greater efficiency is debatable.
Filmless departments were no more efficient or frugal than film-based ones until the processes associated with film were changed. PACS made that happen.
"Today's PACS has morphed into a workflow enabler, using IT as a foundation to integrate disparate sources of information and applications, allowing for a more informed and timely diagnosis," said Lenny Reznik, director of enterprise imaging and information at Agfa Healthcare USA.
This process may advance much further with the development of integrated information systems. Siegel envisions a day when the data contained in a nationally connected web of EMRs can be mined for medical knowledge. This knowledge would then be put into a national database for use in making diagnoses and choosing therapies.
Capturing this information in a usable form will depend on technology. Harnessing it for the improvement of healthcare will depend on the selflessness of providers, said Lothar Koob, a general partner at Extera Partners, which advises healthcare companies and venture capital firms on due diligence and strategic matters. It will also depend on physicians' willingness to follow software-rendered advice.
Software that guides the ordering of imaging exams is already taking root. At MGH, high-cost imaging exams such as CTs and MRs are ordered using an electronic entry and decision support system. Orders are graded on an appropriateness scale, with nine being the most appropriate and one the least. When choices are given low ratings, referring physicians are provided a list of suggested exams that might be more appropriate. So far, it's working.
"We have shown a tremendous decrease in high-cost imaging utilization per member per month," Dreyer said. "The knowledge is being transferred from peer-reviewed articles and from radiologists and other specialists to these folks who are doing the ordering with tremendous consistency," he said.
The technology, developed and used at MGH, is commercially available through a licensing agreement with Nuance of Burlington, MA. Dreyer notes that this module is available for use in the various systems for sale by vendors of EMR systems.
There can be pushback from physicians who order imaging exams, he noted, just as there may be resistance to change in process by any professional. Most referring docs, however, view the system as a convenience, in that it gets around having to look up information about the most appropriate imaging exam for patients under certain circumstances.
In the end, it's this kind of recognition that will determine which technologies succeed and which trends turn into everyday practice.