Dr. Siegel
is a Professor of Diagnostic Radiology and the Radiology Associate
Vice Chairman for Informatics, Diagnostic Imaging, University of
Maryland Medical Center, and the Director, Baltimore Veterans
Affairs Medical Center, Baltimore, MD. He is also a member of the
editorial board of this journal.
In May 2008 I served as the moderator of a roundtable discussion
on imaging informatics-one of the hottest topics in diagnostic
imaging. The roundtable, which brought together a distinguished
panel of experts, was held in conjunction with the annual meeting
of the Society for Imaging Informatics in Medicine in Seattle, WA.
The information from this roundtable has been published as this
special supplement to
Applied Radiology.
Imaging informatics is having a major impact on all of our
practices and, in my opinion, is a driving force in the future of
diagnostic imaging. In planning for the roundtable, we chose topics
that were important, practical, and, at times, controversial.
In an article about re-engineering radiology for an electronic
world, Dr. Paul Chang from the University of Chicago focuses on how
we can avoid having radiology services become a commodity and the
importance of using imaging technology to provide added value to
our customers.
Dr. Paul Nagy from the University of Maryland delves into the
use of informatics to improve the quality of radiology. He points
out that if we're not careful, quality can fall by the wayside as
we transition from film-based to digital imaging.
Dr. Khan Siddiqui recently left the University of Maryland to
begin work on healthcare informatics with Microsoft. In his
article, he discusses advanced visualization-what it is, how its
role is changing, and why it has become such an integral and
important part of image interpretation. He also offers advice on
how to choose the best possible system for your practice.
Although some radiologists have only recently purchased their
first picture archiving and communications systems
(PACS), many have been through several different PACS over the last
15 years. Dr. Steven Horii from the University of Pennsylvania
describes how difficult and painful the addition of a
PACS or the transition from one PACS to another can be, and offers
frank "prenuptial" and "postnuptial" advice on how to minimize the
disruption to patient care.
Dr. David Weiss from the Geisinger Health System weighs in on
the pros and cons of speech recognition systems. Currently more
than half of academic radiology departments across the country use
speech recognition technology. However, its adoption has been
controversial and the results mixed. Dr. Weiss describes how to get
the most out of speech recognition systems.
Finally, Chris Hafey of Vital Images offers a vendor's
perspective on the key steps to enterprise-wide advanced
visualization, while Robert Cooke of FUJIFILM Medical Systems USA
explores how the Internet is revolutionizing radiology.
It has been my distinct pleasure to work with such a
distinguished panel of experts. I would like to thank Vital Images
and FUJIFILM for sponsoring the roundtable, Anderson Publishing for
producing this special supplement, and all of the roundtable
participants for providing thoughtful advice and practical tips on
how to use imaging informatics to improve the quality and
efficiency of radiology services.
Dr. Chang
is a Professor and Vice-Chairman, Radiology Informatics, and
Medical Director, Pathology Informatics, University of Chicago
Pritzker School of Medicine, and the Medical Director, Enterprise
Imaging, for the University of Chicago Hospitals, Chicago, IL.
In radiology informatics and information technology (IT), we are
constantly challenged to provide a sustainable infrastructure that
supports the needs of the radiology department and enables imaging
throughout the healthcare enterprise. In the early days, many of us
thought that radiology informatics was defined merely by
digital image management and its promise to eliminate X-ray
film. Once we accomplished that goal, we realized that
optimization of workflow was even more important.
Too often, electronic practice tools are viewed as turnkey
solutions. In reality, installation of a picture archiving and
communication system (PACS) or a speech recognition system will not
fix a "broken" radiology practice. The improper
application of electronic-based systems can make
deficiencies in workflow even more glaring.
Unless we are willing to dramatically re-engineer the radiology
department and our own attitudes and practices, we will not only
fail to successfully leverage and exploit these advanced imaging
tools, we may threaten the perceived value of radiology and
participate in its marginalization or commoditization.
From a strategic perspective, our true goal is to build a
technology infrastructure that ensures the relevance and value of
radiologists in taking care of patients. Those of us in informatics
and IT need to incorporate into our strategic planning a view of
radiologists asvalue innovators.
Value innovation
The concept of value innovation was first introduced by
Michael Porter in his 1985 book,
Competitive Advantage: Creating and Sustaining Superior
Performance
.
1
Value innovation is the never-ending task of re-examining what we
provide that is of value to our customers. We must always ask
ourselves: Are we relevant? Do we add value? And we must
continuously re-engineer our workflow and our attitudes
to add that value.
In a modern economy, there are 2 ways to compete. If your product
or service is perceived as a commodity-that is, undifferentiated
from competing products or services-the only legitimate basis on
which to compete is price. Toilet paper, for example, is a
commodity.
Another way to compete is to provide a product or service that is
perceived as having additional value that can be differentiated
when compared with other products and services. An iPod (Apple
Inc., Cupertino, CA), for example, is perceived to have more value
than other MP3 players.
The question is, as radiologists, are we providing a commodity that
can be out-sourced anywhere or are we providing true value? The
answer depends on how we see ourselves and what kinds of service we
provide. In arriving at that answer, it is important to ask
customers what is important to them and how well we're succeeding
in meeting those needs.
Once we have defined those axes of value, it is possible
to plot a value curve. Figure 1 shows value curves for 3 different
types of radiology practices.
2
The value curve for a typical academic radiology practice shows
very high value in the number of imaging services provided.
However, academic practices tend to fall short when it comes to
other components that are valued by customers, such as examination
ordering and patient comfort.
The services provided by a competitive, successful community-based
practice are quite different from those provided by an academic
practice, and they result in a characteristic value curve that is
also different. The "competitive" practice may not deliver as many
imaging services, but it excels in services that are perceived as
being of value to the customer, including examination ordering and
scheduling, patient comfort and convenience, and report turnaround
time.
True value innovators go even further, identifying where they are
on the value curve, where they want to be, and the gaps in between.
Then, and only then, do they acquire technology that best suits and
addresses those gaps, whether it be PACS, teleradiology, a
radiology information system (RIS), voice recognition, structured
reporting, Web-based physician order entry, multimedia Web reports,
or patient Web portals(Figure 2).
The iPod effect
Before identifying gaps in value, it is important to understand who
the customer is. In the context of radiology, our customers are our
referring physicians and, ultimately, our patients. Today, patients
are active health consumers, and, like other consumers, their
characteristics have changed over the last 10 to 15 years. Let's
call it the iPod effect.
From functional point of view, the iPod could be considered an
inferior product. For example, it doesn't come equipped with FM
radio, and it locks users into a particular application, iTunes.
Yet the totality of the experience is viewed as seamless,
attractive, and very positive. The reason the iPod is successful is
that it addresses 3 major drivers of the modern-day
consumer-characteristics that drive our modern-day healthcare
consumer as well.
The first driver of the iPod effect is real-time
delivery, or "I want it now." In the past, if customers ordered a
music CD and received it in the mail a few days later, they were
happy. Then it became possible to place an online order before
midnight and receive the CD by express delivery the next day. Now,
we can go to iTunes and download music onto the iPod immediately.
Real-time delivery of service and product is a critical driver and
one of the reasons the iPod has been so successful.
When it comes to medical care, that same expectation is valid. Many
of us in hospital-based radiology practices have confronted the
increasing demand to provide same-day service. A patient comes in
in the morning for a magnetic resonance imaging (MRI) study or a
positron emission tomography/computed tomography (PET/CT) scan, and
the patient wants the interpretation in his or her oncologist's
hands that afternoon, so therapy can begin immediately (Figure 3).
Clearly, the drive for real-time delivery of service is going to
continue and is one of the reasons certain technologies such as
speech recognition have become so important.
The second iPod characteristic is no-compromise service. From the
elegant interface to the seamless integration with an
industry-leading, comprehensive iTunes library, the iPod offers
users a listening experience that is without peer.
In healthcare, patients have developed similar expectations. In the
past, there was an asymmetrical distribution of healthcare
information-that is, the doctor always knew more than the patient.
This is no longer the case. Who is more motivated to know
everything about a disease than the person who has the disease?
With the resources available on the Web, many patients are
extremely knowledgeable. After all that research, they want
optimized, no-compromise service. As a result, we can no longer
differentiate ourselves as physicians who add value by simply
knowing more than our patients. Instead, we must take on the role
of consultant and manager, becoming the person who helps shepherd
the patient through a complex process. Patients will no longer
settle for second-best.
The last driver is personalized service. With the iPod, we can
select our own music. We no longer have to listen to someone else's
selection on the radio. With amazing advances in genetics and
proteomics, physicians will be able to provide customized therapy
for patients. That same driver is going to be relevant in
radiology. For example, optimized image protocols that are tailored
to the specific patient will require much more capable
integration of information systems.
Information throughput
Another major driver in radiology is the concept of pay for
performance, or "no outcome-no income." Can radiologists
successfully play this game? I believe we can. However, critical
requirements for success will include massive improvements in
efficiency, productivity, and cost-effectiveness-in other
words, optimized information throughput.
Electronic-based technology and informatics can be important
enablers of value innovation, if we're willing to re-engineer our
processes. When it comes to improving efficiency in
information throughput, we must go beyond such simple measures as
enhancing patient throughput or reducing report turnaround time.
The turnaround time that really matters encompasses the entire
service chain. It spans from the time a physician decides to order
a study to the time at which information is available from that
study to help the clinician create a patient management plan. To
truly improve turnaround time, we must re-evaluate examination
ordering and scheduling, patient registration, examination
acquisition, examination interpretation, report authoring, and
report delivery.
Collaboration
It is clear that we must do away with film and paper.
Instead, we must embrace electronic-based informatics systems. To
do this, we need much better integration of electronic information
systems and modalities within those systems. To date, a lack of
integration is one ofvendors' biggest failures.
Time-motion studies repeatedly show that technologists waste too
much time typing information from one electronic system to another.
We also need greater integration in communicating context. It makes
no sense for technologists to have to tell a RIS that they have
completed a study. "Performed procedure" steps and other kinds of
technology can do that automatically.
In addition, we will need to make major improvements in how we
communicate. Simply sending out reports in a timely fashion willno
longer be adequate. We must be much more engaged and collaborative.
In considering the difference between communication and
collaboration in radiology, it is useful to think about the
evolution of the Web. Radiologists typically use a PACS the way
people used an old-fashioned Web 1.0 application. We sit in a dark
room, and information orimages come to us. Our clinicians are not
interacting with us, and we're not collaborating with them. This is
one reason radiology can be easily commoditized and marginalized.
Today, kids don't use the Web to passively receive information in
isolation from one another. They use such applications as Skype
(SkypeTechnologies, Luxembourg), instant messaging, MySpace
(MySpace, Inc., Los Angeles, CA), and YouTube (YouTube, LLC, San
Bruno, CA) to foster virtual collaboration and active
participation.
Radiologists and vendors must re-evaluate applications from this
Web 2.0 perspective, re-engineering them in a way that fosters
collaboration with clinicians (Figure 4). The goal is to match the
appropriate communication method to a specific clinical
context. Messaging, Web conferencing, multimedia reports, and other
electronic communication models can all be very helpful.
Conclusion
Radiology must be willing to continuously re-engineer and reinvent
itself to fully exploit electronic technology. Information systems
canplay a significant role in helping radiologists to
evolve from being simple providers of information to true
collaborators. If we choose to make this transition, we will avoid
being marginalized and commoditized. Instead, we will be able to
show that we add true value to patient care.
REFERENCES
- Porter ME.
Competitive Advantage: Creating and Sustaining Superior
Performance
. New York, NY: Free Press; 1985.
- Schomer DF, Schomer BG, Chang PJ. Value innovation in the
radiology practice.
RadioGraphics
. 2001;21:1019-1024.
Roundtable Discussion following the
presentation:
Re-engineering radiology in an electronic world: The
radiologist as value innovator
Paul J. Chang, MD
ELIOT L. SIEGEL, MD:
Paul, that was a wonderful kick-off to our roundtable discussion,
and you raised some really interesting points. It reminded me that
prior to going digital, in a film-based environment, we provided a
lot of services that we don't really provide now. Radiology was the
epicenter of the hospital for discussion of interesting patients
and their imaging studies. As a radiologist, I felt very much more
my role as educator than I do today, and I felt more directly
involved with patient care than I do today. As time goes on,
there's a tendency, while trying to maximize productivity, to try
to sit in front of a workstation and just bang out the cases
without adding that additional value that you mentioned. So I'm
really excited about the potential for us to use our digital and
electronic tools for more than just diagnosis and reporting and to
be able to use them to significantly improve our ability to provide
that added value.
You talked about commoditizatio and used the example of the
superstore Wal-Mart as a metaphor for commoditization of products
in general that has a negative connotation. In many ways, however,
Wal-Mart has served as a groundbreaking innovator. Wal-Mart was one
of the first companies to use bar coding and electronic check-out
and to provide a very wide variety of different services such as
optometry, its $4 generic drug pricing, groceries, and pharmacies,
all in a single venue. When I walk into Wal-Mart, a greeter says
hello and asks me how I'm feelingt oday, something we don't do in
our imaging department. Isn't it true that commoditization isn't
necessarily antithetical to innovation and personalized
services?
I wonder as we move toward providing all of these sophisticated
and wonderful additional services that you describe, whether or not
we will have to consolidate our practices in order to support a
more sophisticated and complex IT infrastructure. As time has gone
on, the trend has, indeed, been toward larger and more
sophisticated radiology practices with more sophisticated IT
capabilities. While I think it is absolutely essential, as you
point out, to the future success of radiology, do you think that
this effort to add value will decrease the number of "boutique"
smaller radiology practices and move us in the direction of larger,
more"commoditized" practices?
PAUL J. CHANG, MD:
Eliot, your aise a very good point, and you're absolutely right:
Wal-Mart adds a lot of innovation. An important reality we in
radiology attempt to deny is that in any economic system, any
market, any economy, there are winners and there have to be losers.
Wal-Mart is definitely a winner in today's economy. However, you
can't have winners without losers. We try to say that if we all
provide "adequate" service, if we all isolate ourselves, and if we
all create antimarket barriers, then we can all do our thing and
"survive." However, now that medical images can be delivered at the
speed of light, the 3 drivers I mentioned are in play; our
customers are now health consumers that can do their due diligence.
If we are not providing timely service, not providing world-class
advanced visualization, and not providing added value, then we're
not providing the kind of service the customer can get across the
street, if not across the world. In that situation, we will have an
environment in which there will be winners and losers.
If we follow the Wal-Mart model, radiology becomes a commodity.
In that case,it doesn't matter whether or not your advanced
visualization is done in India, Australia, Israel, or across the
world. If Icould look into my crystal ball, I think we'd see some
consolidation through which a lot of services will be provided that
way, because people will determine that the value provided by such
services is sufficient. But I believe you will have an alternative
and potentially more attractive opportunity if you offer high value
boutique or niche practices with or without consolidation. These
practices will provide value-added services with respect to
advanced visualization or advanced expertise and evaluation.
I am absolutely convinced that with technology such as the
Internet, as we move from analog to digital, the artificial
barriers that sustained mediocrity are going away. So there will be
losers. I would rather be a winner than a loser. Whether that
winning strategy is to consolidate and provide a Wal-Mart-typec
ommoditization is a question. That's a valid approach; some people
are very successful at it, and some customers are content with the
service provided.
From a very selfish perspective as a radiologist, I like it when
docs come to the reading room for a consultation: Ir eally feel
part of the patient care team. I think it's the most satisfying
part of our day. I believe there will be a role for a more
optimized boutique of approaches to service in radiology that
avoids the Wal-Mart model as a more value-driven proposition.
PAUL G. NAGY, PhD:
I really like the concept of an educated and motivated patient. I
think that provides us with enormous opportunities in radiology,
but also presents us with a challenge. We need t ofigure out what
our role will be in terms of direct contact with the patient. The
University of Pennsylvania has created a unique initiative through
which they're beginning to send the reports directly to the
patients. As that speeds up in realtime, how is that going to
present us with challenges with referring physicians?
CHANG:
It is a challenge. One of the people in our field, Dr. Leonard
Berlin,has really thought and written a lot about our role as
radiologists. As you mentioned, Paul, our traditional role was as
the "physician's physician" in the sense that the interpretation of
our studies should be exclusively presented to the referring
physician and that this physician would present the results, good
and bad, to their patients. Dr. Berlin has raised some issues about
that in that quality is important, timeliness is important, and, oh
by the way, we're physicians too.Should we not start being more
proactive and more directly interactive with our patients? I can
see it both ways. In myo wn practice, I like to talk to the
patients. I feel that it's the best way to be engaged and to remind
ourselves that we're not just sitting around in a dark reading room
looking at cases. We need to rememberthat what we do impacts
patient care.
The challenge, as you mentioned, is that we also don't want to
create a problem with our collaborative spirit with our ordering
physicians. There is a mechanism for that and that's always been
communication. I believe radiologists should communicate often-not
just with reports, but in the tumor board and in daily conferences,
which necessarily don't have to be synchronous. One of the big
opportunities of electronic systems is that they allow us to have
reliable and rich asynchronous collaborations. Eliot, I know you've
been on wikis and blogs, and these are mechanisms by which
asynchronously one can create a community of interaction. It is
crucial for radiologists to improve our communication so that we
are viewed as true collaborators with our clinicians, and are seen
working together to determine the best mechanism to deliver
information jointly to patients.
The great model for this is to look at what our colleagues do in
breast imaging. They have come up with a balance in that they
communicate directly with the patient, they examine the patient,
and they work very closely with the surgeons and oncologists. Now
the challenge of informatics is they do that at the expense of
efficiency because they typically use manual processes, and a lot
of people are involved.
One of the challenges to the informatics community is to try to
take the spirit of what they've accomplished with true
collaboration, not only with their patient sbut also the referring
physicians, and make it so it's more efficient and sustainable by
embracing electronic based potentially asynchronous mechanisms.
DAVID L. WEISS, MD:
Expandingo n that, Paul, you mentioned there's a need for
multidirectional, real-time collaborative communication. I think
everyone agrees with that. It's my feeling that many RIS products
have failed in providing information services that radiologists
need. A number of PACS have failed in providing the "C" for
communication,and we're left with disparate software. We have one
vendor for our reporting, another company for critical results
communication, another couple of vendors for decision support, and
another for teaching file software. It would be nice to have all of
these integrated under one umbrella. What umbrella do you see best
for encompassing all of these into one system?
CHANG:
Well, I'm very biased about this. I think it is unrealistic to
expect a RIS or PACS to be all things to all people. In fact, the
analogy I like to use is audio components: you don't buy everything
from one vendor because no one vendor can make the best speakers,
the best amplifier, and the best blue-ray player. You buy the best
component and take advantage of the fact that these components will
interoperate.
I don't actually know what a RIS is anymore. Vendors, attempting
to respond to our demands for improved functionality, have added
increased functions that go well beyond the traditional definition
of a RIS. The RIS has "become anything you want it to be." So the
definition of RIS has become something that is very difficult for
me to understand or grasp.
It's the same thing with the PACS. That's why you hear things
about "RISdriven" workflow or "PACS-driven"workflow. I get a bit
confused by these terms. Instead, we should say that in order to
support complex workflow, we have a lot of services that we need.
The key is interoperability. There's nothing wrong with having a
separate vendor that does speech recognition, communicatio nof
services, or alerts; we don't necessarily need a RIS or PACS to
provide these services. What's wrong today is that these services
don't talk to each other. Idon't think the solution is to expect
our PACS vendor or RIS vendors to suddenly expand their portfolio
of services, because the more they go away from their core
competency, the less likely they are to be able to accomplish these
critical services correctly.
What we really need is improved interoperability. There are a
lot of strategies, and Paul is an expert in what we can do toa
ccomplish this kind of interoperability. There are initiatives:
Integrating theH ealth Care Enterprise (IHE), service-oriented
architecture (SOA). There are a lot of different mechanisms or
strategies one might use to address the issue of interoperability.
But, Dave, to answer your question, I think the real issue is not
that the RIS or the PACS aren't doing enough. The issue is that the
pieces are there, they're just not talking together.
The real push is to get our vendors to embrace interoperability,
either through approaches such as IHE or SOA or to have another
vendor entity that offers expertise in how to integrate. If you
look at industries outside of medicine, that'swhat they've done. I
believe interoperability will be the key driving requirement for
the next decade in our field.
SIEGEL:
Thanks, Paul.
Dr. Nagy
is an Associate Professor, Director of Quality and Informatics
Research, Department of Radiology, University of Maryland School
of Medicine, Baltimore, MD.
One of the roles of an informatics architect is to provide an
infrastructure that enables radiologists to read images immediately
whereverthey are. Such rapid access to digital imaging reduces
delays in interpretation, speeds report turnaround time, and
hastens clinical decision-making, all of which clearly improve
efficiency.
Over the years, however, it has become equally clear that an
accelerated work pace, a focus on productivity, and the use of
distance medicine can sterilize work relationships. When a
technologist no longer comes into the reading room to hang
films, something gets lost in the relationship between
radiologist and technologist. When referring physicians no longer
engage the radiologist in consultations, something gets lost in
that relationship too. These changes threaten to compromise
quality.
In our desire to leverage information technology (IT) to be as
productive as possible, we have threatened our work relationships.
This does-n't need to be so. Essentially, IT was born to
communicate, whether by voicemail, e-mail, text messaging, instant
messaging, or paging. We can do a better job of using some of these
communication vehicles to create a culture of quality within
radiology-to make it easier to do the right thing while being as
productive as possible. This article will discuss 3 tools we have
developed at the University of Maryland to enhance quality through
informatics.
Quality-control reporting
The first challenge many radiology practices face when
they "go digital" is incorporating the quality-control practices
that were used in the film environment. In the past,
radiologists could note on the film if the images were
poorly collimated or were substandard in some otherway. In an
electronic environment, there is little feedback between
radiologists and technologists.
The result can be a downward spiral in quality. Often,
radiologists submit quality-control reports using the same
paper-based forms they were using years ago. The reports go to
modality supervisors, who discuss them with the technologists. But
the radiologists typically don't receive any feedback on actions
taken and don't observe any improvement. As a result, it is
difficult for radiologists to see the value in submitting
future quality-control reports.
Once radiologists become apathetic about reporting quality
issues, many things can go awry. If technologists don't get
feedback on the quality of their work, they are likely to either
think they're doing a great job or that radiologists in their
institution don't care about image quality. Radiology supervisors
may know that radiologists are unhappy, but they have no data to
use in taking action. The result is a disappointing stalemate.
Information technology systems must be able to handle
communications feedback to ensure quality processes. The key
ingredients for change at the University of Maryland were a picture
archiving and communications system (PACS) and a simple Web-based
issue tracking tool that enables radiologists to submit
quality-control issues, assigns issues to owners, and
notifies users when the issue has been resolved. We also
supplied our technologists and modality supervisors with digital
pagers. When a radiologist reports a quality issue, the system
pages the technologist and modality supervisor immediately.
To encourage radiologists to report quality issues, it is
important to remove as many barriers as possible and to make
reporting simple. With this in mind, we synchronized quality
control with our clinical workflow by adding a button to
our PACS that launches a Web-based quality-control tool called
Radtracker
1
(Figure 1).
The issue-submission Web page provides the user name, the study
session number, the patient medical record number, and the
modality. Within a single pull-down menu, the radiologist can
select what is wrong with the images-poor patient positioning, for
example-and can add comments. When the radiologist clicks on
"submit," the modality supervisor and technologist receive a text
message about the issue and how to correct it. The technologist
then resolves the issue, and the radiologist receives an e-mail
about actions taken.
Using this system, we have gone from approximately 5 to 10
paper-based quality-control reports per month in 2006 to 300 per
month today. This does not reflect deterioration in
quality; in fact, only roughly 1% of our annual volume of studies
has a quality-control issue. Instead, better quality-control
reporting has enabled us to focus on the root cause of
quality-control issues and to track how quickly we respond to these
issues. In approximately 40% of cases, we resolve the issue within
an hour.
We have also uncovered new types of quality issues, beyond those
related to image acquisition. Data quality issues can affect the
radiologist's workflow. For example, if the technologist
doesn't sign off and complete a study in time, the radiologist
might not be able to finalize it. Using this process,
we're better able to understand problem areas in the
department.
We have used the quality-control data to create knowledge bases
that we can click through and explore. When we do in-service
training,we use the knowledge bases to find various types
of cases. Using URL-based integration, we can even launch the PACS
system simply byclicking on a case file.
Every few months, a radiologist, technologist, modality
supervisor, and physicist meet for an hour to work through all of
the quality-control issues in a given imaging section. This offers
radiologists an ideal opportunity to lead a discussion on how
quality-control issues arise. In the past, our modality supervisors
were very good at fixing problems on a day-to-day basis
but didn't necessarily understand the magnitude of the issue. Now,
when they see that a problem is occurring many times a year, they
realize it's worth the effort to determine why the problem is
happening and how to remove the root causes.
We also use this system for generating report cards (Figure 2).
These report cards enable our technologists to see how well they're
doing, how many quality reports they're getting from radiologists
over a period of time, and how they compare with other
technologists. We have found that most technologists are very
responsive. Once they see the data, they try to understand how they
can do a better job. This is a very powerful tool for creating a
culture of quality.
For radiologists, this system provides a mechanism to report
quality issues and removes any reason for being apathetic. We now
have data-driven discussions with the radiologists to try to
understand the root causes of quality issues. The radiologists feel
that the technologists are working with them, that we are a team,
and that we have a good feedback mechanism and good
communication.
Technologist peer review
The second quality-control tool that we have implemented,
technologist peer review, also harkens back to the days of
film. Acquiring images has always been an art that
requires training and feedback to perfect. In the past, as senior
film technologists processed films, they would
review images and take junior technologists to task for quality
problems. Through peer pressure, junior technologists would be
motivated to improve their performance.
Peer pressure is an enormous motivator that we don't use well
enough in healthcare to improve performance. At our institution, we
use informatics as a tool for applying peer pressure. We no longer
have the luxury of doing in-line quality control while processing
film. Radiologists need to read images right away and
report them immediately. However, we can do retrospective quality
control.
To achieve this goal, we have built a fully automated Web-based
Tech Quality Assurance (QA) tool that captures all the studies done
by a section, then randomly assigns approximately 5% of them to a
volunteer to review (Figure 3). Reviewing technologists are given a
worklist with the procedure names and dates. Because of
synchronization between information systems, they can launch the
study in the PACS system simply by clicking on the integrated
URL.
Once the study has been launched, the technologist reviewer
rates it on a scale of 1 to 5, with 1 being poor and 5 being
excellent. The ratings cover patient positioning, image
clarity/artifacts, contrast, annotations, markers, and radiation
safety. The reviews are then approved or disapproved by a modality
supervisor. This step enables us to train our volunteers to become
better reviewers.
We have used this technique to review >5000 studies so far.
We have found that we're doing well on contrast, data quality, and
annotations, but have room for improvement in markers, positioning,
and radiation safety (mostly collimation).
We can also use the Tech QA tool in preparing individual
technologist report cards. This is a way of giving very tailored
feedback on how to improve their processes. We can also use this
tool as a knowledge base to identify the best and worst studies in
each section, so thattechnologists can learn by both doing and
seeing.
Communication
Communication between radiologists and referring physicians
plays another important role in quality. Take the case of a
critical finding that warrants rapid communication. The
Joint Commission on the Accreditation of Healthcare Organizations
(JCAHO) requires that radiologists document not only that a
critical finding has been delivered but also how long it
took to deliver the finding.
Delivery of critical findings can be especially
challenging in a large in-patient medical center. At the University
of Maryland, we have roughly 1100 attending physicians and another
900 residents. Often the physician who orders a study is not the
right person to take delivery of the critical finding.
This is a source of frustration for radiologists.
To help in identifying the right person to receive information
to critical situations, we have developed data mining tools that
identify who is involved in patient care (Figure 4). This tool can
perform a real-time query of the electronic medical record to
determine where the patient is located and which service team is
caring for the patient. Often, it is more important to identify the
appropriate service team than to identify the individual
physician.
We can also use the critical alert tool to determine who has
been in contact with the patient in the last 24 hours. Knowing
which physicians and nurses are giving care to the patient offers
an important clue in determining to whom to deliver critical
information. We can also look atthe PACS to see who has been
looking at the images and the computer-based order entry system to
see who has been placing physician orders for the patient.
When the radiologists launch the critical alert tool from our
PACS, they are presented with all of the patient information and
names of clinicians who have been involved in patient care, along
with information on how old the contact data are. Once we have all
this information, we mine a centralized physician contact database
with phone numbers and an integrated online paging system. The
radiologist simply clicks on the "contact" button next to each
name.
In addition, we have built a blogging tool that can be launched
from the PACS and documents all the radiologist's efforts to
communicate critical findings, as well as to document
that it was successfully delivered, to whom, and when.
Healthcare IT systems are a gold mine of information. If we can
provide some of that information in a relevant format to
radiologists, it can help them to make decisions and to communicate
information quickly in a critical environment.
Conclusion
Communication plays a vital role in how we deliver radiology
services and in the quality of those services. Information
technology is immensely qualified to deliver tools that
improve quality and communications. The time has come for
radiologists to insist that vendors provide these tools. PACS
stands for picture archiving and communication system. It's time to
put the communication back in PACS.
REFERENCE
- Nagy PG, Pierce B, Otto M, Safdar NM. Quality control
management and communication between radiologists and
technologists.
J Am Coll Radiol
. 2008;5:759-765.
Dr. Chang
is a Professor and Vice-Chairman, Radiology Informatics, and
Medical Director, Pathology Informatics, University of Chicago
Pritzker School of Medicine, and the Medical Director, Enterprise
Imaging, for the University of Chicago Hospitals, Chicago, IL.
In radiology informatics and information technology (IT), we are
constantly challenged to provide a sustainable infrastructure that
supports the needs of the radiology department and enables imaging
throughout the healthcare enterprise. In the early days, many of us
thought that radiology informatics was defined merely by
digital image management and its promise to eliminate X-ray
film. Once we accomplished that goal, we realized that
optimization of workflow was even more important.
Too often, electronic practice tools are viewed as turnkey
solutions. In reality, installation of a picture archiving and
communication system (PACS) or a speech recognition system will not
fix a "broken" radiology practice. The improper
application of electronic-based systems can make
deficiencies in workflow even more glaring.
Unless we are willing to dramatically re-engineer the radiology
department and our own attitudes and practices, we will not only
fail to successfully leverage and exploit these advanced imaging
tools, we may threaten the perceived value of radiology and
participate in its marginalization or commoditization.
From a strategic perspective, our true goal is to build a
technology infrastructure that ensures the relevance and value of
radiologists in taking care of patients. Those of us in informatics
and IT need to incorporate into our strategic planning a view of
radiologists asvalue innovators.
Value innovation
The concept of value innovation was first introduced by
Michael Porter in his 1985 book,
Competitive Advantage: Creating and Sustaining Superior
Performance
.
1
Value innovation is the never-ending task of re-examining what we
provide that is of value to our customers. We must always ask
ourselves: Are we relevant? Do we add value? And we must
continuously re-engineer our workflow and our attitudes
to add that value.
In a modern economy, there are 2 ways to compete. If your product
or service is perceived as a commodity-that is, undifferentiated
from competing products or services-the only legitimate basis on
which to compete is price. Toilet paper, for example, is a
commodity.
Another way to compete is to provide a product or service that is
perceived as having additional value that can be differentiated
when compared with other products and services. An iPod (Apple
Inc., Cupertino, CA), for example, is perceived to have more value
than other MP3 players.
The question is, as radiologists, are we providing a commodity that
can be out-sourced anywhere or are we providing true value? The
answer depends on how we see ourselves and what kinds of service we
provide. In arriving at that answer, it is important to ask
customers what is important to them and how well we're succeeding
in meeting those needs.
Once we have defined those axes of value, it is possible
to plot a value curve. Figure 1 shows value curves for 3 different
types of radiology practices.
2
The value curve for a typical academic radiology practice shows
very high value in the number of imaging services provided.
However, academic practices tend to fall short when it comes to
other components that are valued by customers, such as examination
ordering and patient comfort.
The services provided by a competitive, successful community-based
practice are quite different from those provided by an academic
practice, and they result in a characteristic value curve that is
also different. The "competitive" practice may not deliver as many
imaging services, but it excels in services that are perceived as
being of value to the customer, including examination ordering and
scheduling, patient comfort and convenience, and report turnaround
time.
True value innovators go even further, identifying where they are
on the value curve, where they want to be, and the gaps in between.
Then, and only then, do they acquire technology that best suits and
addresses those gaps, whether it be PACS, teleradiology, a
radiology information system (RIS), voice recognition, structured
reporting, Web-based physician order entry, multimedia Web reports,
or patient Web portals(Figure 2).
The iPod effect
Before identifying gaps in value, it is important to understand who
the customer is. In the context of radiology, our customers are our
referring physicians and, ultimately, our patients. Today, patients
are active health consumers, and, like other consumers, their
characteristics have changed over the last 10 to 15 years. Let's
call it the iPod effect.
From functional point of view, the iPod could be considered an
inferior product. For example, it doesn't come equipped with FM
radio, and it locks users into a particular application, iTunes.
Yet the totality of the experience is viewed as seamless,
attractive, and very positive. The reason the iPod is successful is
that it addresses 3 major drivers of the modern-day
consumer-characteristics that drive our modern-day healthcare
consumer as well.
The first driver of the iPod effect is real-time
delivery, or "I want it now." In the past, if customers ordered a
music CD and received it in the mail a few days later, they were
happy. Then it became possible to place an online order before
midnight and receive the CD by express delivery the next day. Now,
we can go to iTunes and download music onto the iPod immediately.
Real-time delivery of service and product is a critical driver and
one of the reasons the iPod has been so successful.
When it comes to medical care, that same expectation is valid. Many
of us in hospital-based radiology practices have confronted the
increasing demand to provide same-day service. A patient comes in
in the morning for a magnetic resonance imaging (MRI) study or a
positron emission tomography/computed tomography (PET/CT) scan, and
the patient wants the interpretation in his or her oncologist's
hands that afternoon, so therapy can begin immediately (Figure 3).
Clearly, the drive for real-time delivery of service is going to
continue and is one of the reasons certain technologies such as
speech recognition have become so important.
The second iPod characteristic is no-compromise service. From the
elegant interface to the seamless integration with an
industry-leading, comprehensive iTunes library, the iPod offers
users a listening experience that is without peer.
In healthcare, patients have developed similar expectations. In the
past, there was an asymmetrical distribution of healthcare
information-that is, the doctor always knew more than the patient.
This is no longer the case. Who is more motivated to know
everything about a disease than the person who has the disease?
With the resources available on the Web, many patients are
extremely knowledgeable. After all that research, they want
optimized, no-compromise service. As a result, we can no longer
differentiate ourselves as physicians who add value by simply
knowing more than our patients. Instead, we must take on the role
of consultant and manager, becoming the person who helps shepherd
the patient through a complex process. Patients will no longer
settle for second-best.
The last driver is personalized service. With the iPod, we can
select our own music. We no longer have to listen to someone else's
selection on the radio. With amazing advances in genetics and
proteomics, physicians will be able to provide customized therapy
for patients. That same driver is going to be relevant in
radiology. For example, optimized image protocols that are tailored
to the specific patient will require much more capable
integration of information systems.
Information throughput
Another major driver in radiology is the concept of pay for
performance, or "no outcome-no income." Can radiologists
successfully play this game? I believe we can. However, critical
requirements for success will include massive improvements in
efficiency, productivity, and cost-effectiveness-in other
words, optimized information throughput.
Electronic-based technology and informatics can be important
enablers of value innovation, if we're willing to re-engineer our
processes. When it comes to improving efficiency in
information throughput, we must go beyond such simple measures as
enhancing patient throughput or reducing report turnaround time.
The turnaround time that really matters encompasses the entire
service chain. It spans from the time a physician decides to order
a study to the time at which information is available from that
study to help the clinician create a patient management plan. To
truly improve turnaround time, we must re-evaluate examination
ordering and scheduling, patient registration, examination
acquisition, examination interpretation, report authoring, and
report delivery.
Collaboration
It is clear that we must do away with film and paper.
Instead, we must embrace electronic-based informatics systems. To
do this, we need much better integration of electronic information
systems and modalities within those systems. To date, a lack of
integration is one ofvendors' biggest failures.
Time-motion studies repeatedly show that technologists waste too
much time typing information from one electronic system to another.
We also need greater integration in communicating context. It makes
no sense for technologists to have to tell a RIS that they have
completed a study. "Performed procedure" steps and other kinds of
technology can do that automatically.
In addition, we will need to make major improvements in how we
communicate. Simply sending out reports in a timely fashion willno
longer be adequate. We must be much more engaged and collaborative.
In considering the difference between communication and
collaboration in radiology, it is useful to think about the
evolution of the Web. Radiologists typically use a PACS the way
people used an old-fashioned Web 1.0 application. We sit in a dark
room, and information orimages come to us. Our clinicians are not
interacting with us, and we're not collaborating with them. This is
one reason radiology can be easily commoditized and marginalized.
Today, kids don't use the Web to passively receive information in
isolation from one another. They use such applications as Skype
(SkypeTechnologies, Luxembourg), instant messaging, MySpace
(MySpace, Inc., Los Angeles, CA), and YouTube (YouTube, LLC, San
Bruno, CA) to foster virtual collaboration and active
participation.
Radiologists and vendors must re-evaluate applications from this
Web 2.0 perspective, re-engineering them in a way that fosters
collaboration with clinicians (Figure 4). The goal is to match the
appropriate communication method to a specific clinical
context. Messaging, Web conferencing, multimedia reports, and other
electronic communication models can all be very helpful.
Conclusion
Radiology must be willing to continuously re-engineer and reinvent
itself to fully exploit electronic technology. Information systems
canplay a significant role in helping radiologists to
evolve from being simple providers of information to true
collaborators. If we choose to make this transition, we will avoid
being marginalized and commoditized. Instead, we will be able to
show that we add true value to patient care.
REFERENCES
- Porter ME.
Competitive Advantage: Creating and Sustaining Superior
Performance
. New York, NY: Free Press; 1985.
- Schomer DF, Schomer BG, Chang PJ. Value innovation in the
radiology practice.
RadioGraphics
. 2001;21:1019-1024.
Roundtable Discussion following the
presentation:
Using informatics to improve the quality of
radiology
Paul G. Nagy, PhD
ELIOT L. SIEGEL, MD:
Thanks, Paul. That was really an excellent presentation. You have a
talented and sophisticated information technology operation in the
department of radiology at the University of Maryland and
consequently have the good fortune to have access to all of these.
But many of the people who will be reading this may not have that
same level of expertise in thei rpractices. So if others wanted to
create a level of functionality that in some ways paralleled what
you've described, how would they get that? Should they talk to
their PACS vendor or RIS vendor? Or find a third party? Or should
they hire the best and brightest IT folks for their own department?
How would you recommend that someone proceed who wants to take
advantage of all the wonderful potential that you talked about?
PAUL G. NAGY, PhD:
Well, I think it's the responsibility of academic institutions to
explore new technologies and to evaluate their effectiveness for
radiology practices. So it's our responsibility to be able use
these types of tools and determine whether they make sense andif
they're actually valuable to clinical practice. A lot of times it's
a failure of imagination; it's very hard to know what to ask for if
you haven't seen it before. Intrying to demonstrate these tools,
prototype them, and evaluate them, I hope we are shaping the
conversation of what users and customers can ask for. You should be
asking your existing vendors for these tools. Their job is to help
you use informatics to enable your job. Ithink that conversation is
how most of our economy works, in that it creates an environment in
which enough people ask the vendors for these tools. Then marketing
people get all excited because they're losing a competitive
advantage or they see this as a differentiator, which several
vendors do now. As the PACS marketplace fills up, they're going to
be looking for these advantages and that will drive their
engineering. The problem is that it takes a long time; it might
take a year or more in many circumstances. Customers need to ask
vendors how they can help them measure and improve the quality of
their operations.
I do think it is very important to adapt these tools for your
local environment. So it's very expensive and inefficient to make
your vendor do all this work because it's very hard for them to
provide all these solutions for you. It is very valuable to have
some talented, local ITs upport people who understand the
radiologist's environment and can help you provide tools.
My recommendation is to hire a high school student. It's amazing
what they can do to integrate solutions and to use some of these
social and IT tools for Web development. They can help improve your
communication within your department. That's a very
low-risksolution, investment-wise, for how much they can accomplish
with a little glue in your current systems.
STEVEN C. HORII, MD:
I do ultrasound as a clinical specialty. So I interact with the
sonographers that I work with directly. Things like quality issues
come up very quickly and are corrected almost on the spot. That's
the way we practic eultrasound. But an important aspect of what you
talked about gets back to what Dr. Chang mentioned, and that is
making this asynchronous. Right? Right now, my feedback to my
sonographers is synchronous. I sit with them and say,"Could you get
me a picture next time ofthe hepatic veins?" I think the advantage
of the tool you have is that you are able to make this an
asynchronous process. Do you see it that way?
NAGY:
If you have the data recorded somewhere, you can do all kinds of
reporting, which can help you really understand some nuance of how
your department operates and what's frustrating your radiologists.
Tagging images in a PACS is a lightweight structure that can be
harvested to provide quality feedback. The customers I care about
are ther adiologists, and I want to know what their frustration
level is working in the environment they have. It is very important
to make sure that their voices are heard in a quality-control
chain. You certainly don't want to neglect some of the synchronous
relationships. We try to have as many opportunities as possible to
bring the radiologist and the technologist together to learn to
understand this process. The reality is that technologists and
radiologists are being driven apart by a variety of forces that
really require these asynchronous feedback tools. Once you have
this data, data drives behavior, and data drives culture. If you
can use this data in the right way, it really helps you create a
culture of quality in the environment. So not only is it important
to have it asynchronous because of people's productivity roles, but
also being able to have this data helps you move forward as a
department so you can know what you're doing.
KHAN M. SIDDIQUI, MD:
I have a comment and a question. What Paul has shown-the ability to
integrate and mine data for different purposes-opens up a whole
idea of other clinical information that is needed at the time of
interpretation. We just get a small historical feel in our PACS
order system, which may not reflect what is going on with the
patient. To be able to access the latest clinical notes, bring in
the latest lab values, and bring in the latest surgical notes will
actually give the radiologist much more insight into what is
happening in the case.
SIEGEL:
That is part of the imageinterpretation workflow.
SIDDIQUI:
Exactly. What Paul is doing in bringing these in is showing the
PACS vendors and others to go to the Web 2.0 frontier. You need to
be able to do much more integration, and enable us to deal with the
integration of systems.
Paul, have you done any analysis interms of value proposition? A
lot of departments will say, "Yeah, that's great, but how much
money do I save?" Have you examined productivity or costanalysis
from these tools?
NAGY:
We did, and it is very hard to determine return on investment for a
lot of the quality tools. The Joint Commission Critical values is a
good example,it's very hard to do a cost calculation, unless you
look at the fact that the average lawsuit is $2 million for a
miscommunication. But that's usually more of a stick than a carrot.
The other factor is satisfaction in terms of physicians and
radiologists. It's hard to look at the productivity goals for some
of the types of quality tools that I showed today. We have improved
performance and quality, which have indirect effects on
productivity.
You did mention the need, and I want to stress that more for
interoperability integration. One of the reasons we're embracing
the Integrating the Healthcare Enterprise (IHE) initiative is that
we need to reduce the cost of integration by an order of magnitude,
because we need an order-of-magnitude-greater level ofintegration
to make our processes transparent. We need 10 times as many
interfaces than you're currently doing. If each one of them costs
$20,000 today and it takes you 6 months with 2 vendors, you'll
never get to the point at which you can interoperate enough to
truly have an environment in which you have a holistic view of the
patient experience. IHE accelerates the adoption of IT standards,
which lowers the cost greatly.
PAUL J. CHANG, MD:
When most of us around this table do budgets and we're trying to
pitch things, we rarely have to give a return on investment (ROI)
argument when patient safety is the issue; one cannot compromise
quality or safety. So it's usually not an ROIa rgument. It usually
is a total cost of ownership (TCO) analysis. Usually, it is
"easier" to play the TCO game than the ROI one.
One of the perspectives I have when you look at the whole
quality chain is that it's not just the technologist. Ramin
Khorasani has really educated me on this. We have a similar tool
that Paul describes at our institution, and a lot of the errors we
have found, especially with cross-sectional imaging, happen because
of miscommunication of the protocol, not matching the right
protocol that was done by resident or a radiologist and the
technologist. Have you found a similar kind of issue where there is
a disconnect between the protocol and the actual
implementation?
NAGY:
Absolutely. I think protocoling is a very important. I have seen
encouraging things from our RIS vendors in terms of their ability
to understand the protocols of preacquisition workflow step that
the radiologist could and should get involved with. Certainly
residents in our department view a lot of that, as well. I think
that one of the greatest ways to improve quality is to reduce
variation. The more standardization you do, the more it improves
your quality by having repeatable processes. Protocoling is an area
in which a lot of the variation is unnecessary. So trying to reduce
the protocol or trying to tailor them specifically to the patients
is certainly animprovement in the diagnostic accuracy of the
information you acquire.
CHANG:
I really like your technologist peer review. Have you incorporated
the radiologist RADPEER process within this? As you keep saying,
the idea is that we need interoperability, which gives us the
ability to do it within the context of our workflow. When I'm
looking at my PACS, I press a QC button and that's the time that
I'm going to do it. Have you incorporated and extended this model
to radiology peer review as well?
NAGY:
We've done it for 2 different levels. One is for RADPEER, and one
is for resident review. We have residents who do Emergency
Department call overnight and radiologists come in the morning.
Sometimes residents will have left by the time the radiologist has
reviewed their work. But the radiologist wants to ensure that the
resident reviews the finding and make sure there's a handoff in
that process. So we built the tool for resident sign-off.
We also use RADPEER. I haven'tf ound it as successful as that.
We do use it for our monthly quality reviews. It hasn't been as
useful for information for continuous quality improvement because
the rates are incredibly low even though we review >1400 studies
a month. It helps us to identify gaps in some ways, because there's
a lot more variability when you've got RADPEER and you only have
0.05% of your studies with a 3 or a 4, which is the ACR criteria
for significance of missed findings. It's very hard to use that as
enough justification to understand what's missing in you
reducational process. I found it's been good behavioral information
and good personal information, but that it is not as useful for
departmental-wide continuous quality improvement initiatives.
SIEGEL:
Paul, some radiologist sconsider the referring physician to be the
"customer." So it occurred to me as you were talking about getting
feedback from technologists and also from radiologists that it
might be interesting to provide a mechanism to solicit feedback
from the clinicians as well. This could be on the perceived quality
of images or whether the study and report provided the answers to
their questions successfully. I find it interesting that most
departments don't get feedback from their clinicians in a more
formal or semiformal fashion, or at least informal but solicited
feedbackfrom the clinicians about their perception of quality in
the imaging department and whether or not we're actually meeting
their expectations.
NAGY:
I think customer relations management is a whole new frontier for
radiology. I am a big fan of peer reviews.I think the technologists
know what good work is; they're trained in the art of it. I would
want our peers to review our work, because that's a little bit more
informal way of quality improvement than from our customers.
Customers are a little bit harder in terms of providing feedback,
in terms of understandin gwhat their needs are. Do the results
answer their questions? Do they help them make management
decisions? There's a lot of work that we can bedoing to improve
customer relations management. We need to really tailor our
services to our customers more tightly, understand exactly what
they're looking for, and answer their questions better. I think
there are some feedback tools. We do try to use "return receipt" to
see when they've looked at the results of the images.
In the ED, we look to see whether the emergency physician looks
at the images. They look at it very synchronously to when the
radiologists look at it, so knowing who's been looking at images is
an important part of our communication process. What's interesting
is that IT is sitting on a gold mine, and radiology is not using
any of this information. I think it's going to be a great
differentiator for practices that can use this IT knowledge in
terms of business intelligence. This knowledge can be used to help
tailor their services to be more competitive and to understand how
to use their resources wisely to get the biggest bang for their
buck.
SIEGEL:
We provide feedback in different dashboards in the department. It
might be interesting to actually have ac linician dashboard. While
they are our customers, it's actually part of our responsibility
for optimal patient care to understand how they are receiving and
utilizing the imaging studies and results. Do those who request the
study actually look at the results of the study? Do they look at
the images? If we make a recommendation for follow-up, do they
actually follow our recommendation?
NAGY:
That's a good quality indicator. Follow-up is very interesting as
well. That's going to be an interesting area forinformatics to be
engaging, to understand how much of a value is the radiology and
the practice of the patient?
SIEGEL:
Paul was talking about pay-for-performance for radiologists, but it
may be that part of pay-for-performance for clinicians might have
to dow ith how they utilize our radiology services. Mining that
vast amount of IT information you were talking about to provide
feedback for and to those clinicians might be interesting.
NAGY:
Absolutely.
HORII:
We do use feedback from our referring physician colleagues, but
it's part of our incentive process. But you can look at as a
quality improvement issue in that we seek feedback from the
referring physicians. That feedback goes directly into our
incentive parameters.
When this article was written,
Dr. Siddiqui
was Chief of Imaging Informatics and Cardiac CT/MRI at the
Veterans Affairs Mary land Health Care System, and Co-Director of
the Imaging Informatics and MRI Fellowships at the University of
Maryland School of Medicine, Baltimore, MD. He is now Principal
Program Manager, Health Solutions Group, Microsoft Corp.,
Redmond, WA. He currently chairs the IT and Informatics Committee
for the American College of Radiology and also chairs the
Advanced PACS-based Imaging Informatics and Therapeutic
Applications Conference of SPIE Medical Imaging 2009.
In the early 1970s, computed tomography (CT) studies generated
just a few images that radiologists could spend time examining in
detail. Today, a typical trauma CT study at the University of
Maryland Shock Trauma Center consists of 2000 slices. A typical
cardiac CT study may generate ≥6000 images. The
difficulty of evaluating so many images has spurred the
movement toward volumetric or 3-dimensional (3D) interpretation of
imaging data. More and more radiologists are taking advantage of a
multitude of tools that enable advanced visualization, advanced
functional analysis, and quantification of pathology.
Vendors have developed a variety of workstations to support 3D
imaging. The traditional workstation is a "thick client" to which
images are delivered for image rendering and display. There is,
however, a growing trend toward use of a "thin-" or "smart-client"
configuration, in which image rendering takes place on
the server or "back end" at the data center. Images are streamed to
the workstation for display. Another option is to display all
images on the picture archiving and communications system
(PACS).
Image visualization
There are two basic forms of image visualization solutions: 1)
client-side rendering, and 2) server-side rendering.
Client-side rendering
How image rendering takes place can have an important impact on
workflow. Client-side rendering creates a big
disadvantage of limiting one user at a time to use a costly
workstation. There are multiple workflows for client-side
rendering depending on who actually interacts with the workstation.
In one version of client-side rendering, a technologist does all
the processing. The scan is performed on the CT scanner, and data
are sent to the advanced workstation and to the PACS. Processed
images are then created by the technologist and pushed to the PACS
again, where the radiologist interprets them. In this
workflow, the radiologist is at the mercy of the
technologist, who decides the format and orientation of images the
radiologist will see.
Another form of client-side rendering involves the radiologist
directly performing image processing. In this case, images acquired
on the CT scanner are sent to the PACS. Either the radiologist
reads the images on a 3D workstation situated adjacent to the PACS,
or the images are pulled from the PACS to a separate 3D workstation
for processing. Client-side rendering forces clinicians and
radiologists to physically go and find the workstation,
which could be anywhere in the hospital and is sometimes
difficult to find. This creates a hindrance to
the use of advanced image processing.
When the PACS and 3D workstation are not tightly integrated,
workflow can suffer. Typically the radiologist views
2-dimensional (2D) images on the PACS. However, in order to do
multiplanar processing or 3D visualization, measure stenoses, or
use other advanced tools, the radiologist must go to the 3D
workstation, which may or may not be located nearby.
A semi-integrated PACS and 3D workstation is more convenient
because it makes possible simultaneous examination of the data sets
on both the PACS and advanced workstation without having to
physically move from one place to another. However, the workstation
must be very robust for client-side rendering. In addition, unless
there is integration of contextual data between the systems, it
will be necessary to duplicate the input of patient and study
information from the PACS into the 3D application.
There are certain advantages to using client-side rendering.
First, most 3D workstations available today are designed for this
use. Technologists and 3D lab personnel can preprocess image data
before the radiologist looks at them. Once the data have loaded,
all functionality is performed locally on the 3D workstation. And
many 3D workstations are sold at a discount when purchased at the
same time as a scanner.
There are also disadvantages to client-side rendering on a
traditional 3D workstation. First, it is necessary to buy multiple
workstations for multipurpose or multidepartmental use. Still,
workstation locations are often limited and may be inconvenient.
Typically, an institution buys just one or two 3D workstations, and
all users must share them.
To handle all of the image data, a powerful computer with
multi-gigabytes of random access memory and, usually, multiple
processors is needed. The distributed architecture can create
problems, as not everyone may be reading from the same dataset. For
example, if data are sent to a 3D workstation for rendering, and
the patient is later re-imaged or an abnormality is
identified and annotated at the PACS workstation that
information may not be available to the radiologist working at the
3D workstation. Lastly, a robust network is required, given the
amount of data that must be transferred to the 3D workstation for
processing.
Server-side rendering
The biggest advantage of server-side rendering is that data are
available wherever they are needed, anytime they are needed. In
addition, everyone who is accessing the data is interacting with
the same data from the same server. Information can be saved on
that server-a defining pathology or measurements of
ejection fraction or perfusion, for example-and all users have
access to it.
Server-side rendering is less network-dependent because only a
small amount of data is transmitted at a time, and the streaming
technologies that most vendors use don't require a robust network.
In addition, workstations do not need robust computing power, as
most of the processing work is done at the server. The biggest
advantage for server-side rendering solutions is that advance image
processing applications are available to the entire healthcare
enterprise and can significantly enhance patient care by
making advance image data available to every physician. Image
processing can even be done from home while securely connected to
the server at the host institution.
One disadvantage of server-side processing is the limited number
of applications currently available. This is rapidly changing,
however, and at the time of the publication of this article, all
applications available on stand-alone workstations may be available
on server-side rendering clients. Many vendors are putting advanced
cardiac analysis applications and virtual colonoscopy applications
on server-side rendering clients, for example. Another disadvantage
is that there may be a reduction in performance when more than the
optimal number of users are accessing the same data and on the
server configured for a lower number of concurrent users.
In a high-volume practice, such delays may reduce radiologist
productivity.
Survey: Integration
To better understand the need for tighter integration between 2D
and 3D interpretation, we deployed a survey on the Internet in 2006
jointly with the Departments of Radiology at VA Maryland Healthcare
System, Baltimore, MD, and Stanford University School of Medicine,
Stanford, CA.
1
We wanted to know whether radiologists and cardiologists perceived
a need for a seamlessly integrated 2D/3D application or a 3D
advanced visualization application from a single PACS vendor.
We received 503 responses to the survey, approximately two
thirds from radiologists and one third from cardiologists. We were
surprised to find that 96.2% of radiologists and 92.3% of
cardiologists reported reviewing CT or magnetic resonance (MR)
images using 3D and multiplanar reformatting. We also asked who
usually creates multiplanar, 3D, or volume-rendered images for
interpretation. Both radiologists and cardiologists reported doing
image processing themselves during the interpretation in the
majority of cases, rather than relying on technologists (79.2% and
69.2%, respectively). We found no significant difference
between academic radiologists and private-practice radiologists in
the likelihood of processing images during interpretation (78.1%
and 81.0%, respectively).
These responses suggest that both radiologists and clinicians
want integrated 2D/3D workflow that makes use of the same
application. In addition, they want to be able to interact with
those images rather than use precanned screen captures from a
workstation.
In 2006, we conducted a study that asked the question: If a PACS
with a seamlessly integrated 2D/3D capability were available, what
would the ideal display layout look like? In designing the study,
we made the assumption that radiologists would use 2 monochrome
high-resolution displays and 1 color display. In hindsight, we
should have assumed the use of 3 color monitors. As a result, there
is some discrepancy between our study data and what we would expect
to find today.
2
The study involved 8 radiologists from 3 different medical
institutions using 6 different PACS systems and 4 different 3D
systems. The selection of a breadth of users with multiple systems
provided us with better information on workflow.
As expected, in a survey of 8 radiologists and 18 protocols,
there was a large amount of variance in the initial "blank slate"
evaluation, primarily in the layout and positioning of particular
image series. However, there were similarities in
windowing/leveling, orientation, and 3D presentation states.
When the initial results were compiled and the participants were
presented with a consensus layout, there was a high level of
agreement. We were surprised to find that all 8
radiologists wanted the images to be laid out in a 4-on-1 display
on both monochrome monitors, with volume-rendered image on the
color monitor.
Second, all radiologists wanted images presented in axial,
coronal, and sagittal planes for every case. Third, all users
requested multiple preset windows and levels. However, not all
window/level settings were requested for every orientation; instead
study participants wanted them to be tailored to the task at hand.
For example, they requested bone window/level settings on sagittal
images of a CT of the chest, as this is the best orientation for
evaluating compression fractures of the spine. When evaluating for
lung nodules, they requested lung and soft tissue windows.
Finally, they requested that 3D series also be tailored for
specific tasks-for example, axial maximum intensity
projections (MIPs) to evaluate for lung nodules and coronal MIPs
for vascular interpretation.
We then brought all 8 radiologists together and asked them to
agree on a consistent layout. Some of protocols they decided on are
shown in Figures 1 through 3. Figure 1 illustrates the presentation
of a chest CT with prior studies. The radiologists said they would
want to see current and prior images simultaneously on the same
monitor. They would also want to see a multiplanar interpretation
along with a MIP on the other monitor, and a volume-rendered image
on the color monitor. Figure 2 shows an extremity CT without any
prior studies, while Figure 3 shows an abdominal CT with prior
studies.
Study participants also indicated that all 3 monitors should
have color displays, so that advanced visualizations could be put
on any portal available, not just a single monitor. These studies
clearly identify a need for a 2D/3D integrated solution and
radiologists' preferred layouts and types of displays. The next
step was to determine whether radiologists actually worked in this
way. To answer that question, we looked at the interpretation
process in real time at our institution.
In the past, workflow studies involved human observers
with stopwatches. That approach not only takes a great deal of time
and personnel, it interferes with daily workflow and is
full of errors and bias. In fact, this approach creates a
"fish bowl" phenomenon in which radiologists actually
change the way they interpret studies in response to being
observed.
To avoid this problem, we created a new method that uses
automated data extraction and data mining from the PACS and the 3D
application to assess the interpretation process in real time. It
documents the actual interpretation process and assesses the
variability of interpretation throughout the day, without the need
for personnel observing a radiologist. In addition, radiologists
are not aware of being observed by anyone, even though they know
they are being tracked by the application.
We identified lists of desired auditing functions,
including use of workstation tools, navigation strategies,
time-stamped functions, and percentage of time spent looking at
advanced visualizations versus multiple imaging planes. We used the
audit logs from the PACS and 3D systems that were originally
developed for "debugging" purposes. In their raw form they are
essentially unreadable, but we converted them to a much more useful
format from which we can extract information to understand how the
radiologists interact with images based on slice information,
navigation time, etc.
The initial phase of the study was conducted in 2003, 1 year
after implementation of server-side rendering and thin-client
enterprise advanced visualization application. We found that 36% of
all CTs done in the department were being examined in a nonaxial
mode by radiologists, as were 1% of studies reviewed by
nonradiologists.
We repeated the study in 2005 and found that 90% of all CT
studies done in the department were being examined in a nonaxial
mode by radiologists. Among nonradiologists, 21% of all CTs were
being examined in a nonaxial mode.
To determine whether these results were unique to our
department, we looked at audit logs from 3 different institutions.
At site A (our institution), 90% of all studies were being looked
at by clinicians or radiologists in nonaxial mode. At site B, an
academic institution, nearly 25% studies were being looked at in
advanced visualization mode. At site C, a community hospital, only
6% of studies were being looked at in advanced visualization mode.
When utilization of 3D visualizations was tracked over time, we saw
increasing utilization of advanced visualization at site A, whereas
utilization at the other two sites was nearly flat.
In the middle of the study period, site B integrated its
clinical applications with the PACS and changed its procedures so
that all studies done on the scanners were automatically sent to
the server-side rendering application. It also added a 3D button on
the PACS that the radiologists could use to launch cases on the 3D
applications. After site B implemented the new policy and made it
easier for radiologists to do 3D interpretation, we found that the
utilization trend became similar to that of site A, where all
studies automatically went to the thin-client application.
At site C, the advanced visualization server was in an on-demand
mode. All studies were reconstructed on the scanner; therefore,
many MIPs, multiplanar reconstructions, and other nonaxial images
were sent to the PACS directly rather than to the thin-client
application. When radiologists needed to view studies on the
thin-client applications, they would ask the technologist to push
them from the PACS. At site C, 3D utilization remained low
throughout the study.
These results showed that if an institution enables technology,
makes it available, and incorporates it into the
work-flow, radiologists will use it. Studies by Dr.
Siegel
3
have shown that use of an advanced multiplanar interpretation
process actually saves time, for example, cutting the time spent
reading a chest CT from an average of 7 minutes to an average of 5
minutes after implementation of a thin-client solution.
Current and future trends
It has become obvious to vendors and the academic community that
making image data available anytime, anywhere is key. True
thin-client workstations with server-side rendering and
enterprise-wide distribution are the current trend.
As time goes on, and more and more studies involve dual-source
scanners and multispectral imaging, there will be too much data for
workflow to focus on the examination of axial, coronal,
and sagittal images. Instead, workflow will need to
become anatomy-driven and pathology-driven.
To do that, it will be necessary to automatically identify where
the desired anatomy is. Some vendors are developing tools that
preidentify anatomy before radiologists open the study, so that
workflow can be based on anatomy. It will also be
important to prespecify how radiologists want to see certain
anatomy or pathology, rather than simply viewing traditional
planes.
Another trend spurred by increasingly robust Internet technology
is truly browser-based advanced visualization with "zero
footprint," without the need for a client installation or even a
"plug-in" for image viewing. This truly enables enterprise-wide and
Web-based deployment of imaging solutions, and even opens the
possibility of sharing images with patients.
REFERENCES
- Lau D, Siddiqui KM, Herfkens R, et al. Survey of 3-D
visualization usage. Presented at the 92nd Scientific
Assembly and Annual Meeting of the Radiological Society of
NorthAmeria. Chicago, IL; November 26, 2006.
- Boonn WW, Siddiqui KM, Vandermeer P, et al.
Defining and evaluating custom 2D, 3D, and advanced
imaging digital display protocols. Presented at the SPIE
MedicalImaging 2006: PACS and Imaging Informatics conference. San
Diego, CA; February 14, 2006.
- Musk A, Siegel E, Siddiqui KM, et al. The use of workstation
auditing tools to determine how 3D/multiplanar workstations are
used in the routine interpretation of CT of the thorax. Presented
at the 90th Scientific Assembly and Annual Meeting of
the Radiological Society of North Ameria. Chicago, IL. November
28, 2004.
Roundtable Discussion following the
presentation:
Advanced visualization: Making the right choice
Khan M. Siddiqui, MD
ELIOT L. SIEGEL, MD:
That was a great talk, Khan. It brought up a lot of really
interesting questions. My personal computer has an operating system
that allows me to specify which application I want it to use,
whether it's an MP3 file for music, a .jpeg file for an image, or a
movie file. That's really great because I get to pick and choose
the application that I want for certain types of media. Do you see
a time coming any time soon where I'll be able to sit down-and
whether it's PACS that's driving my image interpretation list or my
radiology information system or reporting system-that the best of
breed application for visualizing those types of images-whether
they are nuclear medicine, MRI, ultrasound etc.-will be invoked
automatically? Do you see a PACS being used to call up the best
application for the specific images or should it be a separate
software portal? Should PACS vendors be moving in a direction that
expands our options beyond their own company's applications?
KHAN M. SIDDIQUI, MD:
I think that's a great point, Eliot. I do believe thatit's a
function of the PACS vendor to provide that functionality so the
appropriate application is launched based on what the need is. But
this comes to the whole point that Paul talked about, the Web 2.0
concept of application, for which you need to have additional data
to understand what application is required for this study. So you
need to understand why the study was ordered, not just based on
"rule-out pneumonia," for example-you need to understand more about
the study.
Is it known how this study was acquired? Are the technologist's
comments available and do they note the clinician's ordering
process? When was it ordered? Was it in the acute setting or the
chronic setting? A lot of information will be needed to understand
what application needs to be launched to do that. For that, we need
the integration that we talked about. You need the sophistication
of data-mining capabilities, and then it needs to be determined if
the PACS or third-party application will actually launch. The PACS
advanced viewer is where I think it needs to be.
A lot of the things that I talked about, even though we were
calling it advanced visualization, have actually become basic
visualization. Roughly 90% of radiologists are doing this on every
single case. So it is no longer advanced visualization. If it's a
basic need, then do you look at everything the same way? No. When
clinicians examine patients, they examine based on the context of
why the patient is here. When we look at chest CT as chest CT,
that's not in the context of why the study was ordered. Currently,
workflow is difficult to implement because of a lack of innovative
technologies available to understand what needs to happen. As
customers, we need to push the boundaries and get the PACS vendors
to think out of the box, to deploy more workflow-enhancing
solutions so we can personalize the interpretation, as Paul
mentioned. Personalized medicine is working on personalized
treatment of patients. What about interpretation? Personalized
interpretation of patients is based on why the study is done, what
the genomic or proteomic information of the patient is, and what
information the clinician needs based on his or her personal
customized treatment? So I think that's where the trend needs to
go.
DAVID L. WEISS, MD:
I have a comment to reinforce what Khan said. Ifeel that our main
impediment to using more volume rendering and advanced
visualization is the fact that we have togo through several steps
and the delay in bringing those images up. My question is in two
parts. First, I noticed that you were trying to get consensus from
your groupas to how these images should be displayed. If these
could be incorporated into hanging protocols, then that display
could be individualized. What is the status of that with PACS
vendors?
Second, in the earlier part of your talk, you were using 2
monochrome or 2 diagnostic and 2 color monitors, and then went to 3
monitors. The 2-monitor system is really from Eliot's work in
showing that that's a good balance of cost and efficiency, but that
was in a simpler time using portable chest interpretation as a
model. Now with so much complex information, my radiologists are
asking for 4 and even 5 monitors. How do you feelabout that?
SIDDIQUI:
Hanging protocols are an extremely complex question and a lot of
our work is done on understanding that. I realize that the simpler
it is, the easier it is. The question needs to be how easy is it
for you to change your displays to your need? Rather than
predefining canned protocols and then, once it fails, then it takes
you half an hour just to get the images to work. Instead of
spending too much time in understanding where information is, we
found in our study that everybody wanted it differently hung. But
there were certain commonalities. We tried to come to a consensus
agreement with that. It was a challenging task and people didn't
want to give up how they are used to looking at images.
So we came up with the idea that there may be a basic layout
that could gain consensus in how the images are hung. For example,
in our study, everybody wanted a 2-by-2 layout, so that layout
could be made standard. But how the images are displayed should be
easily changeable by the clinicians or the radiologists when they
are looking at images. I think some vendors have done a very good
job at making it very easy to implement hanging protocols and
display layouts. Adding the multiplanar and 3D capabilities is not
there yet. Unless somehow it's defined in the description of the
series and the sophisticated PACS system has the capability to
understand that, it becomes more challenging. But the majority of
the vendors don't even cater to advanced visualization as part of
the hanging protocol. It's considered a separate application, and
they launch it wherever we set up that application.
WEISS:
So you don't see that incorporation happening any time soon?
SIDDIQUI:
I think we need to push and ask for it; that's what will drive it.
But, yes, it needs to go into that direction. With regard to your
second question about multiple monitors, this wasn't a talk on
monitors, but we've done a lot of work to determine, from a human
visual-perception point of view, if it makes sense to look at 4
monitors or 3 monitors. We found that your short-term memory only
is about an average of 100 milliseconds for human beings. So if it
takes you 100 milliseconds to look from one image to the next
image, you've already lost the ability to compare. We've done some
studies to show that actually you do not remember what the previous
image was if that was the case. So if you are trying to compare
something from monitor 1 to monitor 4, there is enough lag
that-from a human visual perception point ofview-you actually don't
even remember what the first image looked like. Four or more
monitors make you do multiple tasks and long motions, and you are
straining your neck by doing a lot of repeated motions. We have a
radiologist who prefers full-monitor workstations who now has neck
problems. Now he's moved down to a 2-monitor workstation because
he's physically hindered by that.
But I think the display layout and, as Eliot talked about,
customized and personalized layout of images can happen in 2
monitors. So 2 or 3 monitors for work-flow-type of applications is
probably the best way to do it. But I think the jury is still out
on what the monitor configuration needs to be. We haven't had
enough experience in understanding workflow and multiple monitors
with these advanced applications to really know.
Most of our advanced applications don't work on more than 2
monitors. They're hard-coded to launch on only 1or 2 monitors. So
they don't even have the flexibility to expand to a full-monitor
layout to look at all of this information.
SIEGEL:
Interestingly, the radiologist who still uses the 4-monitor
workstation configuration and has had the problems with neck strain
was one of the radiologists in our study that helped to document
the fact that a 2-monitor configuration is just as fast and
effective and productive for a radiologist as a 4-monitor
configuration. But there is that psychological need because many of
us grew up reading film using alternators and other systems that
displayed numerous films simultaneously. So a lot of people still
want to work with multiple monitors. However, I believe that we're
really able to look at only a single monitor at a time, and a very
intelligent combination of software and eye-tracking technology
could provide everything those radiologists would need for
evaluation and comparison of multiple current and previous images
using a single monitor.
WEISS:
I always believed that with ideal PACS software, 1 monitor would be
sufficient. Perhaps we should be looking to move toward that. If
the software could interpret what you wanted to see next, you
wouldn't have to go back and forth.
SIEGEL:
With some sort of rapid blink mode, for example.
SIDDIQUI:
Eliot always gives a standard challenge to PACS vendors that they
need to be able to display all relevant clinical and historical and
current pertinent information in 6 seconds in a single,
easy-to-digest display.
SIEGEL:
So it's not only the image but also the presentation of the
information. What do you need to optimize the efficiency of that
presentation? Vendors should not be limited to only visual display
of information but could also supplement that with sounds,
vibration, andother types of parallel output to multiple
senses.
STEVEN C. HORII, MD:
I have a question about the cardiologist data and what they were
using the 3D reconstruction for. Were they interpreting the studies
or reviewing them?
SIDDIQUI:
They actually interpret the studies also. It all depends on how the
departmental workflow is and how the technology is deployed in the
institution. If is applied and only radiologists are using this
technology to interpret images and to provide these reports, once
you enable clinicians to be able to look at images themselves, they
want to read them themselves. Our vascular surgeons do the same
thing. No matter what we say, they want to look at the images
themselves and understand what the anatomy is and see the vascular
disease that we're talking about. It is the same thing with
cardiologists; they want to see for themselves. Even though we
interpret in conjunction with echo and coronary angiodata, they
still have the clinical knowledge and understanding of what is
happening with the patient. Interpretation really requires that
deep understanding of what is happening to the patient now.
PAUL G. NAGY, PhD:
I agree with you that we've gotten a lot of improvements moving
from a workstation to a server-side rendering environment. We no
longer have radiologists tethered to a workstation. We no longer
have lines of radiologists waiting behind a workstation, or other
ludicrous things. We do still have challenges, though, with
interoperability with server-side environments. I have 3 issues I'd
like you to address to the radiologists about what they should be
asking for. One of the challenges we have is the issue of
auto-routing our images. We're still finding that we're autorouting
like we did in theearly 1990s.
The second challenge we have iswe're not really saving our work
product. Radiologists spend 20 minutes in 3D space carving and
slicing a model, andt hen they might save a screen capture to a
PACS. If they relaunch that study on a different workstation, they
will have to rebuild all that work that they did. The third
challenge we've had has to do with measurement methodology even
within the same vendor. If you did a study for which you measured
stenosis on a vendor's system, then over time their version 2.0
might make a different measurement methodology. So there are still
interoperability challenges with 3D vendors that I was hoping you
could address.
SIDDIQUI:
Oh absolutely. Auto routing is a big issue. I think you're keeping
2 data sets: 1 data set for your advanced visualization and 1 data
set for your PACS visualization. As Paul said, there are issues
with synchronicity. Do we need to establish the same images
available on 2 systems? I think they need to move toward a
single-storage model in which both applications are accessing the
same data. But then the issues become the robustness of the storage
system, the network performance, how you access th edata from the
PACS, and is it robust enough and fast enough to render 4000images
simultaneously and show them?
So there are some technological challenges, but I think the
solutions are out there. We need to push the vendors to explore
these things. Paul, I know you've pushed a lot on the vendors to
think about single-storage models and access information. I think
this is so much influx. The complexity of the data and the analysis
is increasing, and the need for data is increasing. We have just
not kept up with the infrastructure needs for that kind of
data.
SIEGEL:
Paul, to address your second question, what you're implying is that
there should be a mechanism to save a presentation state. So rather
than just storing the resulting image itself, you should be able to
store something that would allow a clinician or other radiologist
or other viewer to be able to take over from that saved state and
perform additional manipulation or processing of the image. Khan or
Paul, or anybody else, do you see any possibility in the near
future of creating a standard for saving an advanced visualization
presentation state?
NAGY:
Well, my biggest concern is that there's such wonderful innovation
going on in advanced visualization butit's becoming a bigger and
bigger island. I think this is going to be a real challenge in a
Web 2.0 world, when we need to collaborate and share. I think that
is the challenge: how do you match standardization, which typically
runs counter to innovation? Standardization is slow and is the
lowest common denominator for what we can share. Innovation runs
ahead of everybody else. There needs to be a bit of a mechanism to
harmonize those two efforts.
PAUL J. CHANG, MD:
Paul's absolutely right. One of the biggest frustrations I see is
that the so-called advances in advanced visualization are actually
enhancing its isolation from the workflow. Also, the problem is not
just rendering. The problem we're having is actually the transfer
syntax, the transmission of these large datasets from one place to
another; it's not where the rendering is done.
The other comment I would make is that people tend to assume
that advanced visualization equals static volumetric or morphologic
visualization. In reality, it's more than just that. In fact, 40%
of our work is PET/CT and MR spectroscopy. In fact, I actually
believe our differentiation as value providers in radiology will be
more in line with what we do to combine and integrate all the
information, not just morphologic but also functionaland
physiologic.
Which brings me to my question. Many years ago, when I was
building PACS, it was a basic, simple thing: getting a Web client
to look at X-rays and simple CTs on the Web. When we first
developed our first prototype that ultimately become Stentor, I got
an e-mail from the ED doc saying, "Thank you forinventing this. Now
we don't need you damn radiologists anymore." That actually
prompted us to realize that we need to think about our value. Is it
deliveringimages? Or is it providing communication and actual
collaboration?
When we put in our server-client 3D web service, a different doc
at the University of Chicago said, "Thank you for doing this. Now
we don't need you damn radiologists anymore." You mentioned the
importance and the inevitability that we're going to go to
server-side, the inevitability that we're going to have
enterprise-wide distribution of the ability to look at volumetric
rendering. As these advances in automatic "one button" segmentation
and visualization continue, what is my value added as a
radiologist? I'm going to tell you something, as an oncologic
imager and a body imager, Idon't enjoy reading 3D vascular
run-offs. This is because I feel I add relatively little value as a
radiologist beyond what the 3D image provides.
The argument could be made that, in some ways, how do we
differentiate ourselves with advanced visualization? How do we add
value? How do we prevent losing our differentiation as our vendors
integrate these systems? As Ramin Khorasani says, if you get better
computerized physician order entry and understand the protocol and
you understand what the question is you want to answer,
segmentation and preprocessing can get increasingly automatic. If
we actually do achieve "one button rendering," how do you address
the argument that this potentially could actually add to our
commoditization? At least from a morphologic context of imaging, if
it's all there in the automatically rendered 3D image, and my value
is just in what the arrow shows, what is my value to patient care?
What is the role of a radiologist as a value provider when all of
this is automated and actually provides exactly what the clinicians
want? Do we need these damn radiologists anymore?
SIDDIQUI:
As long as all we're doing is pointing to that stenosis arrow,and
here is the stenosis, you're going to do that. But if we have more
understanding of what is happening to the patient, and our
interpretation is personalized to the patient, we're providing more
value and we are becoming, as you talked about, physicians'
physicians. Then we are making them understand what is happening
and we have the understanding and expertise. If a vascular surgeon
calls you and looks at a stenosis, if you don't have any
understanding of what is happening to the patient and there are 10
stenoses seen so that which one is the critical one is based on a
patient's clinical information, then hedoesn't need you, because he
already has that information. But if you are providing that added
data, added information in the context of the patient, then he can
do his other tasks of treating patients and doing surgical
procedures, and not spend time looking at images, because he now
believes what you are saying.
The issue clinicians mention to me is that if we say that there
are 10 stenoses,and that's it, then the patient comes in with some
mild weak symptoms and cardiac imaging, the clinician needs to know
what needs to be fixed. So that's why I have to go back in and look
at all the images and figure out what's going on. That's why my
value is not there anymore. But if I understand what the other
imaging modalities have previously shown, what the patient context
is, and what the patient's historical information is, then I can do
my interpretation then based on that context. Then the clinicians
do not need to go through that process to do it, and they can do
other things. So we need to develop our own value. Are we just
interpreting images? Or are we actually providing information that
clinicians either would take extra time to find or would need more
information to get their job done?
As you said, it's a really challenging task. When we go and give
talks at cardiac CT meetings, if we ask the audience how many
people are cardiologists and how many radiologists, 80% of the
people in the audience are cardiologists.
SIEGEL:
Do you think making advanced visualization ubiquitous throughout
the hospital and giving full access to the cardiologist increases
or decreases your value as a radiologist providing those
services?
SIDDIQUI:
We've deployed this since 2002, so we have 6 years experience. I
now have more people asking me questions and relying on my
interpretations. Even when I'm traveling giving talks, I get
questions all the time. It's not uncommon to see me sitting at a
conference in the audience with my laptop open and actually reading
a case because some clinician wants me to give my opinion on a
study. So, I've seen people asking me and interacting with me more
now, even with more utilization of the advanced visualization. This
point was raised on the closing session at the SIIM meeting 2 years
ago in Orlando questioning if a radiologist will be a radiologist
in 15 or 20 years or will he be an imager? We see the same thing in
virtual colonoscopy with gastroenterologists. They want to be able
to read it themselves. So, what is a radiologist going to be called
10 or 15 years from now? We've already seen special training
programs started in neuroradiology and interventional radiology in
which folks don't do basic general radiology but rather combine
specialized radiology training with clinical specialty. So, what is
a radiologist in 20 years fromn ow when all this becomes
ubiquitous? Are you going to be just an oncologic imager and that's
all you do, but you have the understanding of the patient and also
maybe taking care of the patient the same time? Or will there still
be what is traditionally known as a radiologist?
SIEGEL:
Your opinion is that making advanced visualization available to our
clinical colleagues will not in any way decrease radiologists'
added value?
SIDDIQUI:
It depends. The function may change for radiologists and what they
do 15 or 20 years from now, but they will never be just imagers.
That's what I think. I do not think by giving ubiquitous access for
advance visualization to clinicians we will decrease radiologists'
added value.
CHANG:
We have to be more engaged in taking care of patients. A
radiologist who is just an imager, who simply recapitulates
morphologic findings as an interpretation will be of very little
utility in the future, or even today. The radiologist who is going
to have value is engaged as a true collaborator, someone in the
tumor boards who understands therapy, who understands about the
outcome and the correlation between therapy and diagnosis. There
are going to be a lot of losers in radiology if they feel that
they're just imagers. Then they will be commoditized because the
advances in advance visualization, volumetric rendering, automated
segmentation, and visualization will render those people obsolete.
Imaging sevices will be a commodity because it's easier to get a
cardiologist or a vascular surgeon if these tools are there for
them to see all the stenoses. The radiologist who is more tuned in
to the therapy and to the management of the patient as a whole is
the one who's going to survive and thrive. These other imagers are
not going to be around.
Dr. Horii
is a Professor of Radiology and the Clinical Director of Medical
Informatics, the University of Pennsylvania Medical Center,
Philadelphia, PA.
Increasingly, radiology practices are deciding to add to an
existing picture archiving and communications system (PACS) or to
change PACS vendors entirely. These are among the most challenging
transitions a radiology practice will ever face. This article will
discuss why it maybe desirable to upgrade a PACS, how to manage the
project, and some pitfalls to watch out for.
Adding to a PACS
The decision to add to a PACS is often driven by imaging
subspecialties. Existing PACS often fail to meet the needs of
radiologists who interpret ultrasound or nuclear medicine studies,
for example. An ultrasound system must be able to handle not just
color imaging but multiple cine loops, Doppler wave forms, and
other complex tasks that PACS supplied by the major vendors often
don't handle. Nuclear medicine studies involve similar challenges,
particularly in the mathematical analysis of images. Cardiology is
also placing new demands on PACS, as cardiologists have different
requirements from radiologists when interpreting images. At the
same time, new capabilities for advanced visualization may drive
the need to add to or change a PACS.
Upgrading is difficult because the PACS interacts with
so many other systems and devices. There are a tremendous number of
interfaces involved, and that complexity affects information
flow. Network loads may change, for example, and a larger
amount of storage may be needed. Studies may begin to incorporate
new images, as advanced imaging techniques enable radiologists to
create 3-dimensional (3D) series from data that was already part of
the image acquisition.
Similarly, new imaging equipment raises new issues. If
cardiology is being integrated into the PACS, images should
flow to the archive directly from the angiography
systems. To do that, it is necessary to interface with equipment in
the catheterization laboratory. Table 1 summarizes some tips for
adding to a PACS.
Avoiding pitfalls
PACS and radiology information systems (RIS) do not exist as
stand-alone systems. They interface with a number of other systems,
including hospital information systems, pharmacy systems,
admission-discharge-transfer systems, billing systems, and others.
Software and hardware changes have the potential to affect the way
those interfaces operate.
It is critical to consider how information will move among
several PACS. Should we go back to the old store-and-forward days
of routing images to where they're needed? How do we do that with
different kinds of PACS? How do we get the information where it's
needed, when it's needed?
At a minimum, interfaces usually require the setting of
parameters by both vendors involved. The software on both sides of
the interface is expecting certain behavior and data across that
interface, and is sensitive to very small changes.
When managing interface changes, keep in mind that vendors
generally accept responsibility only for their hardware and
software and for managing their side of any interface. They will
not be responsible for what is on the other side of the interface,
unless an agreement to that effect has been negotiated or the same
vendor manufactures both pieces of equipment.
The process of installing a new system, new software release, or
new hardware usually results in downtime. Management of this
process is important because it affects all users. Be aware that a
system that worked perfectly during testing can still develop
problems during installation. It is unlikely that any vendor can
exactly reproduce your system configuration for
testing.
There are many stories of major problems that developed after
the addition of a new system or a change in software on an existing
system. Usually, the systems themselves work, but the interface
fails. For example, when we installed a new CT scanner at the
University of Pennsylvania, the PACS stopped acquiring images. Both
devices were DICOM conformant, but the network interface had been
set for a particular scanner. When we changed that scanner, we had
to change the parameters on the network interface to suit the
performance of the new machine.
To avoid such problems, it is essential to completely understand
the projected work flow and movement of information
across the interfaces between systems, especially between a new
PACS and the existing one. There must be a strict policy in place
covering any changes and upgrades. Vendors should understand the
policy and sign off on it. Such an agreement can avoid the common
problem of a vendor who performs preventive maintenance on a
scanner and, without the explicit consent of the radiologist, also
installs some new software. Often it is only when the scanner stops
sending images to the PACS that the radiologist becomes aware of
the software upgrade.
Consider having a test system that enables the testing of
changes before they're actually implemented in operational systems.
As mentioned earlier, this will not catch all of the little,
irritating problems that might occur, but it will catch the big
ones that prevent the system from operating.
Understand that knowledge is power. A radiologist who is
knowledgeable about the interfaces between systems, what those
interfaces do, and what information flows across them is
in a much better position to determine whether a new system is
likely to impact an existing system.
It is also important to understand that interfaces have both
upstream and downstream dependencies. A change on one side may
affect the way devices operate on the other side.
Changing to a new PACS
If adding to an existing PACS is challenging, changing to a new
PACS vendor is daunting. Many radiology departments are doing just
that, however. There are several reasons why. A vendor may go out
of business or be purchased by another company, for example. In
addition, an existing PACS may no longer support the department's
current work, or it may not expand to meet new needs. If the PACS
cannot handle the advanced visualization needed for cardiac
imaging, a new PACS may be needed.
A corporate decision may drive the change to a new PACS. If the
hospital is purchased by a larger entity, hospital administration
may sign an exclusive purchase agreement with a particular vendor.
One radiology practice may take over an existing one with a very
large installed base. A new radiology chairman may have a preferred
system and initiate the change in the PACS vendor.
The University of Pennsylvania has changed PACS vendors 3 times.
The first time, the vendor for our ultrasound mini-PACS
left the business. Our main PACS vendor could not handle ultrasound
images in the way we needed, so we had to make a change to a new
ultrasound mini-PACS. In another case, our health system
established an exclusive relationship with a single imaging
equipment vendor, and we were required to change vendors for our
departmental PACS. We eventually changed back when the new system
could not meet our needs.
Challenges
There is no question that changing to a new PACS is painful. The
most intense pain does not come from the capital costs. Nor does it
come from the need to dispose of old equipment or to part ways with
the existing vendor.
What is really difficult is the migration of multiple
terabytes of data that reside in an existing archive. This may seem
puzzling. We can store and retrieve DICOM images, so why can't we
easily retrieve DICOM objects? Many PACS store DICOM attributes in
proprietary database tables, reassembling the DICOM objects only
when they are requested. Vendors do this because it optimizes
system performance. Remember, DICOM was designed for the
communication of images, not as a database format.
Typical database problems include irregularities in patient
names. Is Homer Simpson the same person as Homer J. Simpson? What
about Homer Simson, spelled without the
p,
who has a different identification number but the same
birth date and the same address? Are they all the same person?
What about a head CT study that actually contains images of the
head, chest, abdomen, and pelvis? What about studies that were
entered into the database with incorrect order or request numbers?
And what about studies that were stored on read-only memory but
whose attributes were updated after the initial image acquisition?
When those studies are read off the disc, they will come back with
the older values in the DICOM headers.
There are numerous other examples, all with some sort of
information mismatch. During the migration progress, each of these
will need either manual intervention or processing through
additional software.
As might be expected, interfaces present special problems. All
interfaces between the new PACS and other information systems and
imaging equipment will, at the least, need to be tested. In
addition, a new round of interface license fees may be imposed by
other vendors, forexample, the RIS vendor.
The phasing out of old equipment can create another problem,
particularly if the new PACS installation runs behind schedule. In
our case, we had been observing archive failures resulting from
mechanical problems in the existing jukebox. We didn't
fix the problems because we expected the new system to be
in place before the existing system failed completely.
Unfortunately, we missed the target date for installation of the
new PACS. Archive failures began to occur with increasing frequency
and began to affect clinical operation.
At that point, it was unclear who would handle problems with the
existing system during changeover. The old system vendor was no
longer under service contract, and the new system vendor was not
enthusiastic about paying to repair a system it was going to
replace. It took several months of negotiation with both vendors to
get the situation resolved. In the end, we had support of both
systems.
Recommendations
Based on our experience, it is wise to get a "prenuptial
agreement" from the PACS vendor (Table 2). This agreement should
provide for guaranteed access to the database and the data. If a
vendor is going out of business, it is important to get the
database schema from them before they shut down. Details of all
intersystem interfaces are also needed, including all DICOM and HL7
messages and their content.
The agreement should include an option to continue service
contracts on a month-to-month basis, with cost constraints. Service
should be on the same terms as during the system's active life. If
service had been available 24 hours a day, 7 days a week, it should
continue at this level as long as the system is in clinical
use.
The agreement should also provide for guaranteed engineering
support during the transition, including a commitment to work with
the new vendor. Such service will not be free of charge, but it is
wise to negotiate a schedule of charges in advance.
No matter how information migration is managed-whether by the
existing vendor, the new vendor, or a third party-provision should
be made for DICOM objects that contain private groups and elements.
Private DICOM groups are permitted in the DICOM standard, and many
vendors use them. Ideally, a storage system will store these and
return them on request. Determine how these will be migrated to the
new system. Make sure the vendor does not simply discard private
DICOM groups.
Establish realistic and firm change-over dates, as
well as contingency plans in case those dates are missed. This
should include an agreement about who will pay for service of the
old system if changeover dates are not met.
Consider changing the disaster recovery backup to a DICOM media
storage application profile system. Store all information
as DICOM filesand DICOM objects, rather than in
proprietary formats. Consider using a vendor-independent storage
solution that supports different vendors'PACS. There are commercial
vendors that provide such products, and some of the main PACS
vendors can do so as well, upon request (and payment of the cost of
such options).
Be prepared for failures of the old system before completing
changeover to the new system, and know how to handle those
failures. Do not ignore maintenance of the old system. Continue to
check that backup systems are working.
Don't count on reusing old PACS hardware. Not only is the old
hardware likely to be obsolete, it will be needed when the old
system is run in parallel with the new system during testing and
startup. In addition, if the original PACS was acquired through an
operating lease, the equipment must be returned to the original
vendor unless a purchase agreement is negotiated.
Consider beginning database conversion well in advance of
changeover. Set a target for the amount of data to be converted
prior to the changeover, typically 1 to 2 years' worth, with the
rest converted on either an ad hoc basis or in a background
process.
Determine who will perform database clean-up and how it will be
paid for. If health system staff will be doing the clean-up,
consider negotiating a charge-back rate to cover labor.
Considering having a database survey done ahead of time to
determine how many problems exist in the database. This will
provide perspective on how difficult the changeover is
likely to be.
It will likely be necessary to run parallel systems for a while.
Determine who will pay for the extra network infrastructure and
hardware that may be needed to support a network that is twice its
usual size.
If the change in PACS is a result of a decision by the health
system or hospital administration, make sure they are aware of the
full costs associated with making the change and are willing to
support those costs.
Finally, appoint an "informatics historian" who will record the
dates of all systems and hardware installations, keep track of all
software version descriptions, and maintain a record of problems,
as well as their follow-up and resolution. Such records are
extremely valuable and have saved some institutions
significant expenses on service contracts.
Conclusion
Adding a PACS to an existing enterprise is not a trivial
endeavor. It requires knowledge and planning, chiefly
with regard to interfaces and data flow. It is possible
to minimize the negative impact of a PACS addition, but it is
difficult to completely eliminate it. A change in PACS
vendors is, without question, painful. The most effective way to
minimize the pain is to thoroughly plan for the change and prepare
for all that it will entail.
Roundtable Discussion following the
presentation:
Avoiding pitfalls in adding to a PACS or changing PACS
vendors
Steven C. Horii, MD
ELIOT L. SIEGEL, MD:
Thanks, Steve. That was a very comprehensiv eand timely summary.It
raises a numberof different questions. One thing that occurred to
me right away was the question of adding to or replacing your
radiology information system (RIS). Have you had any experience
with that? Do you have any advice? Have you at the University of
Pennsylvania had the opportunity to look at that possibility?
STEVEN C. HORII, MD:
We have looked at it and rejected it almost out of hand, because if
we thought changing a PACS vendor was tough, changing your RIS is
even tougher because it has numerous interfaces and it affects
numerous pieces of your operations. It's very difficult. We did go
through upgrade of an RIS, which was a major change in the system.
That was still painful, even after a year or so of advanced
planning, and now probably a year-and-a-half out in operation.
We're still finding little things that cause problems. It's very
difficult to do. Idon't talk about it extensively because if you
can avoid it, I certainly recommend avoiding it rather than taking
it on. I mean, if you have to do it, you have to d it. But it's
very, very difficult.
SIEGEL:
Paul, we're contemplating this at the University of Maryland. Are
we going to keep the legacy system up and running? Or are we going
to migrate from the legacy system to the new system?
PAUL G. NAGY, PhD:
We're migrating all the reports from the old system to the new
system. It is an extensive process. I would say it's similar to a
PACS migration, actually. The problem with the RIS is that there
are so many different workflow components, including scheduling and
registration. I think the bigger problem is that, with the earlier
RIS, we were an island. We did all of our own scheduling and all of
our own registration. We basically had our own master patient index
inside the RIS. When you migrate to a new RIS now, most modern
systems are really parts of an enterprise. So we're going to have
to talk to enterprise scheduling and do a lot more interoperability
than we had to do in previous versions. It's kind of hard to go
from our own show to being a cog in a wheel. Probably the hardest
piece for us to re-work is to rework our workflow to be part of an
enterprise data synchronization stream.
HORII:
In upgrading our RIS, we also went through a major change in the
userinterface. It had been a terminal-based kind of roll-and-scroll
interface to a multiple windows-based system. It was a large change
for the users. As much as we tried to reduce the impact of that by
doing change management, we still could have done more. I recommend
educating your staff as far in advance as you can, and actually
getting them to see the product and understand what it's going to
do. We tried to do that. But, as you know, in the radiology
department, the scheduling just to get people into training is
very, very difficult. If we had to do it over again, we would
probably insist on better change management and better education of
our users.
DAVID L. WEISS, MD:
Steve, many sites out there have purchased their PACS before this
information has become codified and have not protected themselves
as you have suggested. Many of those sites aren't planning on
changing PACS in the nearf uture but may be facing that in 2 to 4
years. Can you expand on what can be done now to back-fill to
protect yourself if you haven't done this in the past but may want
to change PACS 3 or 4 years from now?
HORII:
Well, there are things you can do. A lot of PACS are installed with
periodic hardware refreshes, for example. So the vendor will come
in after 3 years and offer to replace your workstation hardware,
expand your servers, or upgrade something at a discounted cost.
Often, those are opportunities at which you can say, if we're going
to do this, we'd like to negotiate some new conditions. We've got
to put in new workstations, and we're going to put in a new
archive. We've done this and we took those opportunities to say
we'd love to stay with you guys, but if you're going to do this, we
want these new things included. For us, one of them was a change to
a DICOM-based archive instead of a proprietary one. We managed to
get that negotiated as part of a hardware change-refresh scenario.
So you have some opportunities.
The other thing, of course, you can do is negotiate for service.
The vendors are very interested in the service side of your
business. Service contracts generally are profit-making for many of
the vendors. Those things are often negotiated on a shorter-term
basis than the whole lifetime of your PACS. So that's another point
at which you have so much opportunity to renegotiate what you may
want to do in the future.
SIEGEL:
Is it a fantasy to think that leasing arrangements or
pay-per-volumeo f studies arrangements make it any easier to
migrate to a new PACS system? Is that something that one should
consider?
HORII:
The amount of labor required is similar. The advantage you have
with lease agreements, though, is that you still have some leverage
over the company since it's a continuing thing. If they have the
hardware in ther eand you paid for it, at that point, you're at
their mercy. If it's a leasing agreement, they know that you could
change out of it the next time the lease is up. So it puts a little
more pressure on the vendors. But when it actually comes time to
change, it's still not any easier.
SIEGEL:
One of the things I was wondering about is disaster recovery or a
backup. It's one thing to migrate your database, but can you
migrate your disaster recovery system and your backup? When you go
to a new PACS system, then do you have a backup? Or do you also
need to create that backup simultaneous with migrating to the new
system?
HORII:
That's a tough, tough problem, and it's a reason why some people
have said that if you have a disaster recovery storage out there,
that you should maintain enough of your presents ystem that you
could pull data back from it if you need it, but don't bother to
migrate it all. Your need for the backed-up studies tends to be
fairly low. You're only really going to need it if things go bad
very quickly.
SIEGEL:
Presuming you have the software to be able to access it.
HORII:
Yes, presuming you have the software to be able to access it.
That's the advantage of going forward. If at all possible, look at
your disaster recovery solution as a vendor-independent one so that
you could pull it back from any vendor. Remember that your need for
that is likely to be rare-at least you hope thatit's rare. But when
you do need it, you need to be able to get it back fast enough that
you can be back in business, or why have it at all? If it takes you
as long to retrieve the stuff as it did to put it in there, it's
not a very good backup solution. So some consideration has to be
given to making that work, because it has a potential to exist for
a longer time than your present PACS implementation. It's something
that's vendor-independent.
NAGY:
For archiving solutions, when you're archiving the files in DICOM,
it's a very admirable thing to do. The challenge is that if you do
a file-based migration later on without that PACS vendor, you're
going to lose all the patient demographic updates. We find as many
as 20% of our patients change their names or information. We're a
large trauma center,so we often find out who they are after we've
imaged them. If you work with an enterprise archive vendor, make
sure that they're also capturing an Health Level 7(HL7) feed, and
capturing ADT (patient administration messages) in the patient
updates.
My question for you has to do with migration time. There's this
very annoying rule of thumb coined by Fred Behlinof one third-that
if you have 3 years of data on your PACS, it's going to take you 1
year to get that data off. If you've got 6 years, it's going to
take you 2 years to ge tit off. Some of it is because of the slow
transfer rates of earlier archiving strategy technology, such as
digital linear tapes and magneto-optical drives. Some of it is the
fact that it loads the performance on the old PACS to a point at
which the radiologist can't use it while you're trying to transfer
data off of it. Some of it has to do with the curation of the data
that has to be done to get it off. It's been frustrating how it's
been reinforced several times that it takes this long to get this
data off. Steve, my question is how long did it take you to get the
data off? And what were the limitations in trying to get it
off?
HORII:
One of the problems that we had was that it was taking longer,
actually, than that estimate. That was becauseof the number of
problems we had in the database: the number of unspecified studies,
the number of studies with incorrect patient names or patient names
that had changed, all those sorts of things. So it actually took us
longer. The vendor didn't use Behlen's estimate, but used an
estimate that was also based on having access to the old PACS
server 24 hours a day. We said, "Well, we're still using that
system. You can't do that." So it automatically nearly doubled the
amount of time it was going to take. So, yes, that'san important
consideration. I would say that the one-third rule is probably a
conservative estimate. It's unfortunate, but that's apparently what
we live with now. If you look at what some of the vendors are
proposing now, especially the ones who proposed just storage
solutions, they're now including things like a layer that manages
changes in the fixed content files that would allow you to make a
migration more quickly than that. It can basically just change the
upper layer and change the database tables. But the problem is if
you have an existing installed base of it, it's not like that, and
it's tough to change it.
NAGY:
I'd recommend archiving backwards in time, to go from the present
backwards. That way, the most relevant information is probably the
more recent. I have another question. In early 2002, the IHE came
up with a couple of profiles called Consistent Presentation of
Images. With this, when a radiologist is looking at 1000 images,
they select the 4 that are important to them. They might do
mark-up, like circles and arrows, and those annotations are then in
the system. When you change PACS vendors, without IHE, how do you
maintain that work product?
HORII:
The problem is that it will often go away unless it's made as a
DICOM presentation state. Unless you basically change the objects
and include those as a DICOM overlay, they're going to be part of
the proprietary database of your PACS vendor. That's the case with
most systems. The key image note and presentation state storage, if
it's done right, is a DICOM thing, and you should have it. But I
don't know that a lot of the vendors actually support presentation
state storage.
NAGY:
The newer ones do. It's a surprise to me when radiologists don't
own their work product in their system, and they're going to lose
it when they migrate to a new PACS vendor.
SIEGEL:
That's a great point. Well,thanks, Steve.
Dr. Weiss
is the Clinical Section Head for Imaging Informatics at Geisinger
Health System, Danville, PA. He is also a member of the editorial
board of this journal.
Currently, there are a handful of ways to create a radiology
report. For decades, the standard has simply been transcription,
coupled in more recent years with digital dictation. Another
option, structured reporting, is used by many radiologists in
mammography but is not widespread in general radiology. This
article will focus on speech recognition, which is being adopted by
more and more radiology departments, in both academic medical
centers and private practice.
One of the purported advantages of speech recognition is cost
savings. In reality, a speech recognition system may, at least in
part, shift costs rather than save them. This is because instead of
paying a transcriptionist, a radiologist spends time editing and
typing. However, without question, improved turnaround time is an
advantage of speech recognition, as has been documented in a number
of studies.
1,2
One of the disadvantages of speech recognition is a time
penalty. A majority of radiologists report spending more time
creating and finalizing reports using speech recognition
as compared with conventional dictation, with a resulting decrease
in overall radiologist productivity.
3,4
However, the most serious problem with speech recognition is its
potential to distract the radiologist from viewing images. If the
radiologist's eyes are on the dictation screen rather than on
images, the risk of error increases.
5
Acceptance of speech recognition by radiologists has been
complicated by a misalignment of incentives. Radiologists only
indirectly benefit from the advantages of speech
recognition. If cost savings help the department to stay under
budget, radiologists might receive a bonus, but it will be slow in
coming and will be shared by many others. Similarly, improved
turnaround time will help to achieve departmental goals, but
diagnostic accuracy and productivity are more important to most
radiologists.
On the other hand, the disadvantages of speech recognition fall
directly on radiologists, as they suffer the potential for a time
penalty, productivity decrease, and distraction from image viewing.
Administrators and information technology staff must pay attention
to this misalignment of incentives and find a solution to
it if they want radiologists to adopt speech recognition.
Case studies
The following case studies illustrate both the success and, in
some ways, the failure of speech recognition.
Community hospital
The first case study involves Chestnut Hill Hospital,
a small community hospital in Philadelphia, PA, with a general
radiology practice of 4 to 5 radiologists reading 100,000
examinations annually. In 1998, we installed speech recognition,
shortly after hardware and software advances made it practical for
radiology use. The next year we installed a picture archiving and
communications system (PACS) and, in early 2000, we integrated the
2 systems.
All of the radiologists agreed to implement speech recognition.
We discontinued using a transcriptionist after about a week. What
followed was 4 weeks of difficulty. First, we ordered the
wrong microphones for data entry (ones without a barcoder). We
weren't proficient in using the product as it was
designed. Macro techniques were still in their infancy. The
navigation controllers we use today were not available. And,
initially, there was no integration between the PACS and speech
recognition.
Nonetheless, report turnaround time decreased from approximately
72 hours to 20 to 24 hours immediately after implementation of
speech recognition (Figure 1). There was no further
significant reduction in turnaround time during the
first 6 months after installation of the PACS. However,
after we streamlined workflow to make the best use of the
PACS, we did see a major drop in turnaround time to an average of
<4 hours for all studies.
A major change in workflow involved the radiologists'
work schedules. We were accustomed to leaving the hospital at 5 pm
each day, when the film library stopped distributing
hardcopy studies to be read. Several months after installation of
PACS we realized that, since PACS produced images hour after hour,
we could reconfigure our work schedule. All but one
radiologist began to leave the hospital at 4 pm, while the on-call
radiologist stayed until 7 pm. This new schedule consisted of the
same total number of work hours, but resulted in much better
turnaround time.
Large medical center
At Geisinger Medical Center, we have digital dictation and use
structured reporting for mammography. We installed speech
recognition in the third quarter of 2004, and radiologists were
encouraged, rather than given a mandate, to use it. Therefore, at
each workstation we still have both a speech recognition microphone
and software, and a conventional digital dictation system.
An interesting pattern developed. After 6 months, half of our
radiologists were using speech recognition 80% to 90% of the time,
and the other half were using it ≤30% of the time (Figure 2). This
was a bit surprising. It is more common to see a bell-shaped usage
curve, with most of the radiologists accepting speech recognition,
a handful really embracing it, and a handful really struggling with
it.
What happened at Geisinger? We did get buy-in from the
radiologists initially, but we may have had unrealistic
expectations of accuracy that led to frustration with the product
after implementation. A training session with a trainer who knows
the software inside and out- and software that has become highly
accurate in recognizing that trainer's speech-is far different from
a new user's initial experience. In addition to problems with the
speech engine, we also had some disruption attributable to the PACS
and the radiology information system (RIS).
These were not the real reasons speech recognition was not
widely used at Geisinger, however. The main problem was that we did
not communicate a consistent message that the department would be
adopting this technology. We also had no defined endpoint
for eliminating digital dictation and have continued to support 2
separate reporting systems.
Ensuring success
Table 1 outlines some of the steps that can be taken to ensure
adoption of speech recognition. First, provide meaningful
incentives to users. The incentives could include bonuses, extra
time off, or a reduction in productivity requirements for
radiologists who use speech recognition. Don't allow use of the
system to be voluntary.
Have realistic expectations and plan for a drop in productivity.
Most studies show at least a 10% reduction in radiologist
productivity after implementation of speech recognition. There are
some exceptions, however. For example, at the community hospital
profiled earlier, my colleagues and I all felt strongly
that we were more efficient when using the integrated
PACS-speech recognition product.
The University of Pittsburgh showed at least a time-neutral
effect after installation of speech recognition using a hybrid
transcriptionist-radiologist editing process and some
modifications in workflow.
6
Massachusetts General Hospital (MGH) recently did a productivity
study of PACS and speech recognition in collaboration with New York
University. They were able to show that at MGH the use of PACS had
a positive impact on radiologist productivity, while speech
recognition had no statistically significant effect on
productivity.
7
Plan for training and ongoing support. Even experienced users
will have problems now and then. When new radiologists join the
department or locum tenens radiologists arrive, they will need
support on the system.
Set a deadline for the removal of conventional transcription and
transition to speech recognition. Consider using a hybrid model for
report editing. One way to use speech recognition is to have
radiologists dictate, edit, correct, and sign their own reports.
Another way is to have radiologists dictate reports, and then use
"back-end" transcription for editing. In this process a
transcriptionist listens to an audio file while viewing
the text and making corrections. Although this approach relieves
radiologists of clerical work, it reduces cost savings and results
in variable turnaround times. Consider combining these 2
approaches, so that radiologists who are proficient with
speech recognition can work independently and those who are
struggling or in a time bind can send reports to back-end
transcription.
Christiana Care Health System in Wilmington, DE, provides an
example of a hybrid model for report editing. All radiologists use
speech recognition but are given the choice of self-editing or
back-end transcription. Approximately half of the radiologists
choose to use self-editing 80% to 90% of the time, and about half
of the radiologists send their reports to back-end transcription.
8
Take steps to maximize efficiency. With speech
recognition, efficiency is determined by accuracy,
navigation, integration, and macro use. To maximize accuracy, it is
best to use a headset microphone. This will improve accuracy by
standardizing the distance and the position of the microphone in
relation to the mouth. With a hand-held microphone, approximately
half of the errors can be attributed to not holding the microphone
in the correct position.
Make corrections properly, either using the correction mode or,
in the case of some speech recognition systems, the vocabulary
editor. This is a way of training the system to learn each user's
specific speech patterns.
Pay close attention to ambient noise. It may be helpful to have
the walls of the reading room covered in acoustic paneling and to
have acoustic tile or carpeting installed on the floor.
If ambient noise remains a problem, consider putting in a fan or
some device that generates "white noise."
Speech recognition requires not just dictation but navigation
through the text and various screens of the speech recognition
system, as well as simultaneous navigation through the PACS. It is
important to consider how to make this process seamless through use
of a mouse, a microphone with programmable buttons, or some other
navigation aid.
Integration is another critical factor in efficiency.
It is fairly easy to use a stand-alone speech recognition system.
It is much more difficult to achieve interoperability
between the speech recognition system and the PACS or RIS. The
interface with the RIS needs to be bidirectional, enabling the
accession number to pass from the RIS to the speech recognition
system, and in the other direction, for text and any other
information to pass back to the RIS.
Even simple integration algorithms can eliminate unnecessary
tasks. Without them, it is necessary to first open a case
in the PACS, then open dictation in speech recognition, and then
add demographic information. Integration enables distillation of
the workflow into simply viewing images, dictating, and
signing the report. The case is closed automatically, the next case
opens automatically, and the radiologist views the images,
dictates, and signs the report.
Macros and templates are essentially canned reports that the
radiologist can pull up anytime and modify. With speech
recognition, the use of macros magnifies the time
savings. Not only does it save time in dictation, it saves time in
proofreading.
Figure 3 shows the modification of a macro for a CT
scan of the abdomen and pelvis. The macro states: "Aorta is normal
in size." To modify that text, the user verbally selects the
sentence and substitutes: "There is an aneurysm of the lower
abdominal aorta measuring 4.8 centimeter in diameter." The user
also changes the impression from: "No significant
abnormality in CT scan of abdomen and pelvis" to "Abdominal aortic
aneurysm. No other significant abnormality…."
All of the radiologist's edits are done verbally, without the
eyes ever leaving the images. Not only is this method much faster
than dictating an entire report, the radiologist has only 2 phrases
to proofread.
Conclusion
Effective use of speech recognition can yield major improvements
in report turnaround time. This technology is not always well
accepted by radiologists, however, in part because it can reduce
productivity, at least initially.
To encourage radiologists to adopt speech recognition, it is
essential to offer meaningful incentives. It is also helpful to
identify departmental champions who can generate excitement about
the new technology, to set a firm date for discontinuing
conventional transcription, and to maximize efficiency by
improving accuracy, streamlining navigation, integrating speech
recognition with the PACS and RIS, and taking advantage of macro
functionality.
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emerging necessity within radiology: Experiences of the
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recognition in MR imaging reporting: Advantages, disadvantages,
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AJR Am J Roentgenol
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production times: Voice recognition vs. transcription.
Radiol Manage
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Radiol Manage
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efficiency have to suffer with speech recognition?
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IL; November 27-December 2, 2005.
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imaging informatics on radiologist productivity. Presented at the
93rd Scientific Assembly and Annual Meeting of the
Radiological Society of North America. Chicago,IL; November
25-30, 2007.
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Roundtable Discussion following the
presentation:
Speech recognition: Evaluation, implementation, and
use
David L. Weiss, MD
ELIOT L. SIEGEL, MD:
That was a very comprehensive summary of the topic. If I'm in the
process of trying to purchase a speech recognition system, I might
hear from some folks that there's really not very much difference
from one system to another and they would suggest I buy the one
that is most cost-effective. But I might hear from others that
there are significant differences and that some of the differences
might be an added value beyond the speech recognition. So my first
question is whether you believe that there are substantial
differences from one vendor to the other with regard to basic
speech recognition accuracy rather than the other added value items
that the vendors provide? As a customer who's looking to purchase
speech recognition, what questions do I ask and what kind of things
do I look for?
DAVID L. WEISS, MD:
That's a great question. In terms of accuracy, that really is a
function of the speech engine, which is the software that turns our
words into text. And until recently, most if not all of the speech
recognition products for radiology used the same speech engine.
That said, there are some differences because they take that basic
speech engine, and they modify it with a radiology vocabulary and a
radiology speech model. In other words, it's looking for my text in
the context of a radiology report.
For example, if I tried to take a radiology-modified speech
engine and dictate "Mary had a little lamb, its fleece was white as
snow"-and I've tried to do this-it would try to put it in the form
of a radiology report, and it would try to use medical terms.
SIEGEL:
I guess some of us have had the opposite experience where
we'vetried to do a medical report and it comes out "Mary had a
little lamb."
WEISS:
Well, that's one of the reasons why it's not quite appropriate to
buy an off-the-shelf product and use it for radiology, although
it's certainly possible. You can train it yourself in terms of
vocabulary and syntax to do that.
The other issue is that these speech engines, as I alluded to,
learn your voice and your particular way of dictating over the
course of months and years. So it's really difficult to evaluate a
speech engine in a 1-hour or half-day trial. You're right. There
are other workflow issues in which these products do differ.I have
noticed a number of those in terms of navigation, in terms of
integrating with other types of communication software, including
decision support, critical report communication, and things of that
sort. So you need to evaluate your own needs in your department.
Don't worry about the accuracy so much, although you do want to
check that, and then buy the product that suits your workflow the
best.
SIEGEL:
So a trial period would not necessarily be effective in selecting
the best one?
WEISS:
A trial period would be helpful if you could do it, but it would
have to be a 6-month trial, really, to decide how good the accuracy
was going to be. Even then, it's so variable and so subjective that
it would be difficult.
SIEGEL:
How about the learning curve for speech recognition? You mentioned
that we get a little bit more accurate and our productivity goes up
a little bit. Is that something I can look forward to by the end of
the first day or by the end of the first week? Or is it 3 years or
5 years?
WEISS:
The first time I used it, it took me about 4 weeks to get used to
it. Interestingly, this correlates with other observations such as
the time it takes to get used to changes like holding your fork in
the opposite hand. I would say that it's variable for many people
and it varies on the basis of, for example, how you dictate. The
system is sort of like training a dog. Dogs like the same thing
every time. You can't ask a dog do you want to go for a walk? Then
ask, do you want to go for a perambulation? They want the same word
all the time. They want their dish in the same spot, and they want
to eat at the same time. So if you're a radiologist who dictates in
the same manner, in the same format for all your chest X-rays, the
system is going to love that, because it's going to learn that. If
you're all over the map and you ramble here, and then the next
study you're dictating something else, it's not going to like that.
So the learning curve is going to be much shorter for the
radiologist who is concise and consistent.
SIEGEL:
Are you significantly faster now than you were 4 weeks into doing
speech recognition?
WEISS:
Well, marginally so. First of all, I've changed locations, I've
changed PACS vendors, and I've changed integration. So that plays a
big role in how efficient you are. Not just accuracy. Iwould say
I'm about as accurate now as I was before, but I'm not as
efficient.
STEVEN C. HORII, MD:
I have a question about the way these things operate. We use speech
recognition. In the days of digital- or tape-based transcription, I
was looking at the images and I would dictate. With speech
recognition now, I look at this little screen to see the text
coming up as I'm dictating. But there are numerous systems that
have a mode with which you can hide the recognition until you're
done. I'mwondering, what do you see your colleagues using? Which do
they prefer?
WEISS:
On most of the systems now, you can either choose to see the screen
as the text is coming up, or choose not to see it. The worst thing
to do is to actually look at the text as it's showing up on the
screen, as it's being "typed." This is partly because there's a
delay of a coupleo f seconds after you speak, so it's confusing,
but mainly it's not good because your eyes should really be on the
images and not on anything else. Your mind should be on the images,
too.
I choose to actually have the screen showing. I use a bright
color of the screen and I put it off on the third monitor just to
remind me that I've turned the microphone on. There's nothing worse
than dictating 4 complex paragraphs, and then realizing that you
forgot to push the microphone button. So I like t ohave that
feedback out of the corner of my eye with color. If I see
radiologists staring at the text coming up, I'll recommend that
they hide the text while they're dictating.
HORII:
I suspect people watch the text because it allows them to catch the
errors. So you either correct them on the spot or go back later to
correct it. When you go back later to correct it, you know where
the errors are because you've seen them come up as you're
dictating. Ithink that's why people do it.
WEISS:
Probably. That's why it's so important to use macros as much as
possible and to dictate as few words as possible. Then you have
less to correct.
KHAN M. SIDDIQUI, MD:
I have a comment about the macros, and it absolutely makes a
difference. A lot of vendors make an effort to show the difference
between the macro text and the dictated text. So when you're
correcting it, you're looking only at the colored version or
highlighted version that you basically put in. It speeds up the
correction process. I agree with you 100% that without macros,it
can be very challenging to do.
The question that I get asked a lot is when you're doing a
speech recognition implementation, how do you integrate your
workflow? Should it be based on your speech recognition product's
work-list? Or based on the PACS worklist?
WEISS:
Or a RIS-driven worklist. My answer to that is that you should use
the worklist that is most functional for you. In other words, if
you have a great PACS system and an OK RIS and a not-so-good speech
recognition product, then you should use the PACS worklist. If your
PACS worklist isn't functional, some of the newer speech
recognition products offer really nice worklist functionality. For
example, many places now are no longer reading off of oneP ACS;
they have their original PACS,then they've acquired another
hospital, and they're reading from an imaging center, so they have
3 or 4 or 5 different PACS worklists. The speech recognition
products coming out now can unify that into more of a communication
package. So you could read from the speech worklist, and it will
pull different images and different demographics from multiple
PACS.
SIDDIQUI:
One thing I've seen is that people make decisions to purchase
purely on the accuracy of the speech recognition of the system. But
a lot of the products out there actually provide a lot of
workflow-enhancing features. Personally, I think people should
consider looking at how it impacts their productivity in terms of
which tools are available in the product rather than just the
speech recognition part of it.
WEISS:
Exactly. It's a mistake to purchase a product because of what you
perceive the accuracy will be based on a 1-hour session, a half-day
session, or even a demo, if they leave you a demo copy for a day.
It's going to change. It's like a violin. You buy a violin, and if
it's a good one, it will sound different a year from now after
you've played it than it does as a new product. It's the same with
this product.
PAUL G. NAGY, PhD:
You showed a large gulf between your bimodal distribution, between
people who choose to use it >90% of the time and people who
choose to use it <10% of the time. What would you describe as
their major demographic difference? Would it be their gender, their
nationality, their age, or just their technological
sophistication?
WEISS:
None of those. It's interesting, but there really isn't a
correlation between age and use. Someone asked once whether the
people who use it are less productive or more productive? When I
look at that, actually the people who use it more are more
productive.It's like the old adage; if you want something done,
give it to the person who's the busiest. It's all over the map.
NAGY:
So infrequent users have the hardest time with it?
WEISS:
Well, it's a self-fulfilling prophecy. If you don't use it
exclusively, you will not learn it. I think the fact that we made
it voluntary means that those people who are hesitant to use the
product will never get better at it. They're not going to swim if
they're never thrown in the water. I have not substantiated this,
but I think some radiologists are a little hesitant to dictate a
report and then sign it right away and have it sent immediately to
the referring provider. Then they may say 3 minutes later, oh gee,
I forgot to mention the gall stones!
NAGY:
So we should have a little "whoops" button?
WEISS:
You could have a delay in that. We don't in our product, and I
wonder whether that's the issue. The other issue is that of the 3
systems we have, the speech recognition is the only system that
allows everybody to see your productivity at any given moment. I
think some radiologists may be hesitant about other people seeing
how many studies they've read in the last 10 minutes. Youlook at
productivity by the month in the RIS, you can look at it to some
extent in the PACS, but this will show you clear as day. You can go
in and see what the guys next to you are doing. I think all of
those things are unspoken impediments to people using the
product.
SIEGEL:
Thanks for a great presentation and a great discussion.
Mr. Hafey
is Chief Architect, Vital Images, Minnetonka, MN.
Bringing advanced visualization to the healthcare enterprise
offers an incredible opportunity to enhance patient care and
improve efficiency. A goal of this magnitude is not
without challenges, however. To understand the challenges facing
advanced visualization, it is essential to appreciate the rapid
rate of change in computed tomography (CT) scanner technology.
Next-generation scanners-those with >64 slices-represent only a
tiny percentage of the CT market today, but they are expected to
capture an increasingly larger market segment in the next few
years.
The enormous amount of data generated by advanced CT scanners
creates several issues that must be accounted for. First, advanced
CT enables new applications that weren't possible before. Second,
such applications are driving the need for enterprise-wide access.
Third, distribution of data and clinical applications to the
enterprise must be managed more efficiently than in the
past. Otherwise, the data boom will overwhelm healthcare
networks.
As new scanners bring more data to the picture archiving and
communication systems (PACS) and to radiologists, there is an
increasing need for advanced visualization, so that the data can be
understood and interpreted. There is also a need to change the way
data are handled on the back end and presented to the end-user.
One of the most significant ways to address these
challenges is to transition from a sole focus on stand-alone
workstations to enterprise deployment. Advanced imaging
capabilities can be made accessible throughout the enterprise
through a combination of thin-client, Web-based, and remote-access
technologies, in addition to traditional thick-client
workstations.
Key components
There are 5 key components of an effective enterprise-wide
advanced visualization system: advanced technology, volumetric data
management, partnerships, professional services, and
performance.
Advanced technology
Several core technologies enable distribution of advanced
visualization to the enterprise. The first is graphics
processing unit (GPU)-based rendering. A few years ago, GPUs were
available only on high-end workstations. Now they are a standard
feature in virtually every PC. Graphics processing units are
getting faster and better, with advances mainly driven by the
gaming market. Harnessing this power is key to bringing advanced
visualization to the enterprise.
Volumetric data management
To efficiently scale up to the enterprise level and
provide the performance that users expect, it is necessary to stop
handling data on a slice-by-slice basis. Rather, we must focus on
volumetric representation. Volumetric representation makes the
system more scalable, increases its speed, and provides a more
consistent user experience.
Volumetric data management also influences how data
are handled inside the computer itself. A key innovation in the
microprocessor industry is the use of multiple cores. Today it is
fairly common to buy a PC with 2 or 4 cores. In a few years,
computers may have 64 or 128 cores.Through the use of optimized
multicore algorithms, advanced visualization and volumetric imaging
can harness the power of multicore technology as part of a
volumetric data management strategy.
Partnerships
Partnerships and relationships are another key component in
bringing advanced visualization to the enterprise. It is critical
for vendors to partner with the technological leaders in each
industry and to tie them together in a way that creates a
high-performance, powerful solution. For example, Vital Images
(Minnetonka, MN) has developed a number of technology partners.
NVIDIA (Santa Clara, CA), a Forbes 2007 Company of the Year, is the
leader in GPU technology. Intel (Santa Clara, CA) was the
first microprocessor vendor to introduce multicore
technology. Microsoft (Redmond, WA) offers the latest in Web
services. HP (Palo Alto, CA) is the world leader in server
technology.
Business relationships are also key. Toshiba America Medical
Systems (Tustin, CA), for example, is a leader in developing
volumetric CT scanning. McKesson (San Francisco, CA) is a
recognized industry leader in medical information technology
solutions.
Professional services
Access to professional services from the vendor is also critical
to the success of advanced visualization. These services should
maximize system performance and should include system planning,
installation, integration, workflow optimization, and
education. An advanced visualization vendor must have a
professional services team dedicated to solving customers'
problems, whether they purchase a turnkey solution or prefer a
customized solution that necessitates system
modifications before deployment.
Education is a key aspect of professional services. Not all
advanced visualization techniques are intuitive; therefore,
understanding the technology and how it works is essential. Vendors
must commit to training users to make the most of advanced
visualization. Users who can use the system effectively are
essential for its successful deployment in the enterprise. Vendor
educational services can come in many forms, including on-site
learning, classroom learning, distance learning, and online
learning. Education must be optimized to meet the customer's
needs.
Performance
This is the fifth component of an effective
enterprise-wide advanced visualization system. Customers who want
the best possible system performance must ask vendors several
questions, including: How are systems installed? How are upgrades
handled? Are there test systems? Is there access to engineers who
can immediately resolve issues? These are all issues that must be
addressed when considering taking advanced visualization to the
healthcare enterprise.
Conclusion
Considering these key components when incorporating advanced
visualization to the enterprise ensures a flexible
solution that is supported by broad clinical applications,
efficient data management, and consistent
performance.
Mr. Cooke
is Vice President of the Net work Business Unit at FUJIFILM
Medical Systems USA, Inc., Stamford, CT.
The Internet has revolutionized the delivery of many products
and services. As a service, radiology has taken part in the
Internet revolution. For example, radiologists once primarily
worked on-site in hospitals. Today, ambulatory care is increasingly
common, often separating the radiologist from the patient. As a
result, remote image interpretation is now routine, and it is
common to distribute soft-copy images across the health-care
enterprise. These trends create the need to image-enable
thousands-if not tens of thousands-of desktops throughout an
integrated health-care network-many of which are outside of the
walls of a hospital.
Consumerism is another critical trend that is being fueled by
the Internet. Today patients have easy access to a wide range of
medical information and are able to educate themselves about
radiology processes. As a result, they demand a high level of
service, including rapid turnaround of imaging reports.
Finally, the Internet may also be playing a role in the shortage
of radiologists, as some elect to work in the computer technology
industry. An estimated 380 million radiology procedures will be
performed in 2008, representing an annual growth rate of 14%. The
number of radiologists is growing at an annual rate of just 1.2%.
Under these challenging circumstances, it is essential that we
maximize radiologist efficiency, so that the quality of
care can remain high.
PACS redefined
In 1999, a picture archiving and communication system (PACS) was
easy to define. It consisted of a diagnostic workstation,
a list of unread studies, and digital departmental storage. It was
simply a system that enabled soft-copy interpretation of images. In
essence, the computer replaced the light box.
Today, defining a PACS is anything but simple. In
addition to remote reading, we are faced with new imaging
modalities that generate very large data sets with an increasing
amount of dynamic and functional content. As multiple healthcare
institutions come together to form integrated delivery networks,
they create multisite workflow for the radiologist and
others involved in patient care. There is an increasing amount of
information available to drive workflow and guide
decisionmaking, but it must be navigated in an efficient
fashion.
In addition, with the push toward the electronic medical record,
users are looking for portable, mineable forms of data storage.
They also want enterprise access to images and information, not
just in radiology but also in such clinical areas as cardiovascular
medicine, pathology, mammography, and others.
All of these trends create questions about what a PACS should
look like. As we consider this question, we should be thinking
about workflow, visualization, and infrastructure. As an
industry, we must think of a PACS not as a monolithic system, but
rather as a platform and an infrastructure for storage of data from
multiple clinical areas, as a separate platform for visualization,
and as a tool for overcoming workflow challenges.
Integration
Radiology studies often traverse many boundaries. A large
hospital may be served by a single radiology group, which, in turn,
may be covering multiple different large-scale facilities as well
as a small hospital that is struggling to retain radiology
services. The radiology group may also be outsourcing some of its
work to a nationwide reading service or so-called super group.
A typical radiologist reads on ≥6 different PACS systems. This
translates into at least the same number of platforms for
3-dimensional (3D) visualization, the radiology information system
(RIS), and the reporting system. The need for radiologists to
switch between various user interfaces creates both a great
challenge and a great opportunity for integration.
For example, the mandate to maximize radiologist
efficiency creates the opportunity for a new kind of
integrated worklist that takes into account all of the healthcare
sites the radiologist serves and brings together a variety of tasks
ranging from report signing to peer review to protocoling of
examinations. By drawing from combined user preferences and
workrule logic, this information can be presented in a dashboard
format for navigation by the radiologist (Figure 1). Combining
diverse systems into a common worklist/dashboard allows a
radiologist an integrated view of the work he or she has to
perform.
Once the radiologist gets to that work, it is very important to
have the right kinds of tools available, including advanced
visualization. These tools need to be integrated not only into the
PACS for use in normal day-to-day operations, but also into other
applications, given that new kinds of viewing models will be
incubated outside of the PACS in many cases.
These tools also need to be distributed, because diagnosis is
now distributed. Radiologists should not be constrained by the
limitations of the environment in which they serve. All necessary
information and tools need to be accessible in a way that
facilitates efficient and ergonomic interpretation. In
addition, our systems must be able to provide, at a minimum, a
collaborative connection between the radiologist and the
clinician.
Internet
It is interesting to visualize how all of these demands might
play out in the future and what impact the Internet will have
(Figure 2). Hospitals may seek a common infrastructure for
radiology, cardiology, mammography, and other specialties-one that
integrates images, structured reports, documentation, and
medication history into a decision support system. The desire to
integrate various imaging modalities into a common infrastructure
may be a reason healthcare institutions are looking to replace
their PACS.
They may also be looking to replace their radiology information
system and other technologies as a way not only of improving
workflow but also of maintaining their physician base.
Referring physicians may demand online interactive scheduling,
order entry, critical results alerts, advanced visualization, and
decision support-and hospitals may seek to provide these services
as a way of retaining their relationship with physicians.
Certainly radiologists are starting to invest in technology
platforms that help them gain a competitive edge through more
ergonomic and efficient interpretation, access to prior
studies, results generation, diagnostic visualization tools, and
decision support.
Better communication with patients is also an important emerging
opportunity. Interaction with physicians, education, and results
reporting can all be facilitated by the Internet.
Conclusion
A unique opportunity exists for our industry to connect all
healthcare stakeholders through the use of Internet technology. We
must act quickly, as technology is changing at Internet speed.
As vendors, we must define our goals and deliver
value. We must open our systems and enable integration
opportunities without creating technology stagnation. We must
continue to collaborate with stakeholders in the healthcare
industry. We must continue to adapt and exploit consumer
technologies. Perhaps most important, we must "humanize" radiology
by involving the patient, involving the referring physician, and
putting a human face on the radiology process.
REFERENCES
- Caesy S. Keynote speech: The impact of the Web on radiologist
shortages. Presented at the Digital X-Ray and PACS: An
Educational Forum. Scottsdale, AZ; February 26, 2005.
- Forman HP. Radiologists' salaries: Should we worry?
AJR Am J Roentgenol
. 2007;189:755-756.
- Sunshine JH, Meghea C. How could the radiologist shortage
have eased?
AJR Am J Roentgenol.
2006;187:1160-1165.
- Meghea C, Sunshine JH. Retirement patterns and plans of
radiologists.
AJR Am J Roentgenol.
2006;187:1405-1411.
- Licurse A, Saket DD, Sunshine JH, et al. Update on the
diagnostic radiology employment market: Findings through 2005.
AJR Am J Roentgenol
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- Batchelor JS. Rad workload shows double-digit increase.
September 22, 2005. Available on the Aunt Minnie Web site:
http://www.auntminnie.com/index.asp?Sec=sup&Sub=imc&Pag=dis&ItemId=67815.
Accessed May 2008.
Panel discussion
Moderator: Eliot L. Siegel, MD
ELIOT L. SIEGEL, MD:
Thank you very much for your talks, Bob and Chris. They were really
both interesting and provocative. I'd like to start out on
something that Bob mentioned- ergonomics as a buzz word. If you
take a look at the definition of
ergonomics
, it comes fromthe Greek word
ergon
, meaning "work,"and from
nomos
, which is "natural laws." Most people think about the physical and
physiologic aspects of ergonomics. But it's a lot more than just
office furniture. Ifyou take a look at the definition by the
International Ergonomics Association, they say that there are 3
subtypes. One is organizational, which we'll set aside for just a
moment. The other is physical, which is the one that most people
pay attention to. Then the third one is cognitive. Cognitive
ergonomics actually focuses on human perception, human attention,
cognition, motor control, memory storage, and retrieval. I'd like
to ask both of you, in terms of things like perception and
attention and cognition, where do you see next-generation systems
going? Given that definition of ergonomics from a cognitive
perspective, what are you doing with your companies to try to help
us radiologists? We're feeling increasing stress; we've talked
about how many studies we're reading out. We've done some work in
our reading room to try to make a nice environment as far as the
lighting, sound, and ventilation. But what are you doing to
minimize my stress from a cognitive perspective,and to help in
terms of designing your systems? How are you approaching that?
BOB COOKE:
If you look at the cognitive side, there are some very simpl
low-hanging fruit that we're facing right now in terms of alignment
of human interfaces. We all talk about integration as being very
good; however, if you move from one user interface scheme to
another, there are all huge opportunities for improvement in terms
of the way the mouse moves, the way the icons work, the color
schemes of the application. These context switches between user
interfaces slow people down and I think they also add stress during
your work day. So very simply, in terms of even our product design,
we're seeking to align our user interfaces and focus more on color
schemes that are more comfortable. We should try to take advantage
of these colors, because, as Ithink one of the presentations
mentioned, more and more monitors are now color. There are some
great opportunities to use color to flag a critical result or to
flag a critical task that might be upon you. I think this is really
the first area that we have to focus on as an industry, to look at
alignment of user interface design, and the color schemes that are
associated with those user interfaces.
SIEGEL:
Dr. Weiss mentioned tha the really strongly prefers and recommends
that we spend as much of our time looking at the images rather than
looking at the reports as they're being generated. I'd like to
expand on that from my perspective as a radiologist. I'd like to
look at the images as much as possible and spend as little time as
possible looking at pull-down menus or icons. SoI would love to see
that as part of the ergonomic solution also. Chris, how are you
dealing with that?
CHRIS HAFEY:
Vital has always been very focused on usability and what we call
read flow, or the minimum number of clicks to actually deliver what
the user wants. We spend an incredible amount of time on it, mainly
because there are so many opportunities to actually improve the
read flow and the way the system works. I think it's unique in the
sense that advanced visualization has such rich data to actually
automate things. By putting time into this, working with users, and
developing algorithms, we're able to make it as simple as opening
an exam orstudy, drawing an arrow, and being done with it.
SIEGEL:
Have you been tempted to incorporate some PACS functionality into
your advanced visualization solution, for example, the ability to
mark a study as dictated or to integrate it with areporting
workflow?
HAFEY:
We do have a reporting module in our system that functions a little
bit differently than traditional radiologywork flow. It has some
capabilities similar to that, but it's actually a bit more
patient-focused in the sense that a lot of the output result is
targeted as somethingy ou can give directly to a patient,
specifically in cardiology, but in radiology, too. Taking things
like internal findings that we find in the system, capturing them
in a way that is understandable to a user,and even reusable in the
system in the future, when we load up maybe a follow-up case, for
example.
DAVID L. WEISS, MD:
I'd like to expand on the question Eliot asked regarding keeping
the radiologist's eyes away from any pull-down menu and, even more
importantly, away from glancing at the keyboard to enter data or
make a request. On the 3D side, the conventional mouse now is
becoming inadequate in terms of a 3-dimensional image. There has
been some work with a 3-dimensional mouse. What are your companies
doing to incorporate some of those mechanical devices or even new
mechanical devices and concepts into the reading process?
SIEGEL:
In addition to just mapping those devices out to equivalent
mouseclick functions, but taking advantage of a greater level of
increased freedom?
WEISS:
Yes, or even more so. All of those devices were created to match
software, and then software was created to match those arguably
flawed devices. How about doing what the folks at Apple did, in
creating new hardware and new software matched to each other? In
other words, throwing everything out and starting over? What are
your thoughts on that?
COOKE:
I think we've got to breakdown a couple of different topics here.
Let's first look at the issue associated wit hkeeping your eyes on
the images. As radiology transforms itself from detection and
diagnosis to also now being involved inthe follow-up,
communication, and collaboration with the physicians ordering the
exams, dealing with critical results and with that communication
and collaboration may require you to have notifications and alerts
inside of your diagnostic process that require you to be
involved.
Obviously from an ergonomic perspective, you should be in
control of when those things pop up and when they don't. But from
time to time, it may be important that those issues pop up. They
may have to interrupt your reading process much the same way that
somebody comes and taps you on the shoulder toi nterrupt you during
your normal reading process.
The second thing is in terms of the 3D mouse. Obviously,
incorporation of basic 3D functions into the diagnostic workflow is
mandatory. In general, there are some great opportunities for PACS
systems and advanced visualization technologies to come together to
at least enhance the diagnostic process as it relates to
comparisons and synchronized ways to look through stacks of
thin-sliced data. I think there are some great opportunities
there.
In terms of integration with these external devices, one of the
nice choices we made early on in developing our system was to take
advantage of off-the-shelf operating system technologies and be
able to link these kinds of mouseclicks to operations within our
system. So our users are routinely using 7-button mice for
short-cuts, and mammographyusers are quite routinely using that
shuttle device that you mentioned.
SIEGEL:
How about Vital, Chris? Are you looking at other alternative input
devices to a mouse or track ball?
HAFEY:
Well, being on the engineering side, we absolutely love to look at
these things. They are exciting and interesting, and we think of
all sorts of interesting novel applications for them. None of them
have actually passed the usability test on the user side to
actually drive production. The other side of that is we've been
very successful with our automation algorithms to remove a lot of
the manual efforts of looking at these cases. We can quickly get
the user to point where they want to see exactly what they're
looking for.
SIEGEL:
You mentioned the importance of training and the fact that there is
training available for the radiologists locally on-site. But we
have thousands of users, potentially, at the University of Maryland
or Department of Veterans Affairs. Do we have somebody train each
of them? Or have you looked at computer-based training or online
training possibilities as we move from the radiology department to
the entire enterprise?
HAFEY:
First of all, I would love to have our product be so usable that no
training is required at all. So you could walk in and immediately
start getting value out of it.
SIEGEL:
Like a video game.
HAFEY:
Like a video game, absolutely. I think, actually, the video game
industry is a fantastic model to learn about how they take a very
complex situation, like an online role-playing game. They engage
the user who can have success early and then later on become much
more advanced and they can pull capabilities out of it.
SIEGEL:
They don't have to have a trainer come by your house to train you
rkid how to use a video game or even expect him or her to read the
user's manual.
HAFEY:
Exactly. I think those types of paradigms are important to us. We
do actively think about how can we anticipate what the user might
want to do, make it very evident and clear to them, so they don't
have to go to the help manual. So they can walk into it without
ever having any experience and still get value out of it. That
being said, that's primarily focused at a lot of what used to be
advanced and is now basic visualization. There are still advanced
things that require not just usability, like how do I use the
application, but clinically, what does this mean? What is this
procedure about? There are new procedures being invented with these
new scanners that require education, because you didn't learn it
when you went to school.
STEVEN C. HORII, MD:
I actually have a comment about the gamers. If you think about it,
in some of these games you're operating in 3D space, and you'vegot
6 degrees of freedom. You have translation in 3 dimensions and
rotation. Yet, the gamers do this. They fly around,s hoot down
enemies, and do all kinds of manipulation things all at the same
time. They have an intuitive user interface, and it's certainly
something that kids can grasp. We had an experience recently when
looking at a training issue and determined that when using an
advanced visualization system, a static paper manual is not good
enough. You really need to see how you interact. We had an
undergraduate working for us who found some available software that
allows us to capture all of the interaction as a movie. Then we can
save it as an AVI file or whatever. So we have built a whole set of
dynamic instruction files that go along with the paper manual. You
can look up a task: how do I do a colon fly-through? It will show
you. How did I do? We recorded an expert doing it and we can insert
a voice-over it to create a little instruction video. We've posted
those on our Web site. We were looking at our training, and it all
came out of work with this young undergraduate in biomedical
engineering who figured this out.
SIEGEL:
You're looking at undergraduates. Dr. Chang and Paul Nagy mentioned
they are scouting ever earlierat the high school level!
HORII:
Yes, but it's probably not a lot different in terms of what they
knowa bout systems.
KHAN M. SIDDIQUI, MD:
I have a comment on what Chris suggested earlier. One of the
frustrations I have reading cardiac CT and cardiac MR cases is that
the available reporting solutions on workstations are designed for
cardiologists. Cardiologists love the idea of getting a report ina
structured format. But then I also have to incorporate that report
into my radiology information system (RIS). So, a lot of times, I'm
doing duplicate reporting, one for cardiology based on the
templates that are available in the cardiac workstation, and then
again on the RIS. Is there any effort to integrate the reporting
systems so we just have to report once using speech recognition?
There is hardly anybody doing integration of advanced workstations
with speech recognition systems to take advantage of reporting
flexibility. IfI'm reading cardiac CTs all day long on the
workstation, because I can't do it on PACS, how do I look at prior
studies? How do I look at prior reports? Currently Isee a lag in
existing technologies that can provide unified workflow. Can you
comment on the future of how to integrate reporting and how to make
the workflow much more feasible when you compare prior studies and
prior reports from contextually relevant other studies?
HAFEY:
That's a great question and there are multiple aspects to it. First
of all, advanced visualization has traditionally been
volume-focused, not longitudinal orcomparator review-focused. There
are definitely some very exciting opportunities in advanced
visualization that you'll see more of in the future. One of the
challenges, though, is who does comparator review? It's the PACS
system. There's a disconnect in the interface between PACS and
advanced visualization. At best, what we can do is get launched by
URL with a patient ID. So I think yo uneed to create a tighter
integration between the two so we can get context about what priors
are available for this patient. Taking the advanced position, next
step, then we look for the findings in those priors and how they
relate to current procedures. Then we actually try to augment even
further. There are an incredible amount of opportunities there.
In the report data itself, there are a lot of opportunities to
get more up to speed with current IT infrastructure in terms of
HL-7 and getting reports out and interfacing them to the RIS. We
have developed technologies to expose our internal data structure
to Web services. These are not difficult to do. It's a matter of
people wanting to do it and pushing it through. A number of
customers are doing that right now.
PAUL G. NAGY, PhD:
I have a question. There are large cultural differences between
radiologists, physicians, and IT developers. Sometimes we see this
in the products, in that some products might not make sense or
upgradesmight have issues. So what efforts do you take to put the
radiologists into the mind of a developer?
COOKE:
As an example, forums like this are extremely valuable and
critical. The good news is the human body is the same across the
world, and the good news is that most radiology practices, believe
it or not, around the world, ar every similar in the way exams are
interpreted. On one hand, as a global developer, we have a great
opportunity in terms of interaction with our users and not having
to worry about designing multiple different systems to solve
multiple different problems. We're really only solving one problem,
which is the good news.
The second thing is that you have to think about it from a
couple of different perspectives. Obviously, the radiologist needs
to generate a quality result and struggles with keeping quality and
efficiency. Then there's the radiologist who is a business person
trying to advance his or her practice. We have to interact with
each and every one of those kinds ofroles. In some cases, they're
all thes ame; in many cases, they're different sets of players. For
example, we recently went down to one of our large readingg roup
users and we spent the weekend essentially working with their
radiologists, looking at the whole "click-ology"to try to remove
clicks from the process. We looked for opportunities for automation
to determine how we could improve the efficiency.
We're all talking about how advanced visualization can be
incorporated into the diagnostic process. That's great and will
help with efficiency. But, at the end of the day, there's still a
whole lot of stuff right inside your basic PACS that are also great
opportunities for efficiency improvement.
SIEGEL:
How does Vital handle that challenge?
HAFEY:
I'd say a big part of the success there is culture. You have to
hire developers and train them. You have to establish a culture
that says it's important to understand the end-user and to go above
and beyond to get there. We sendo ur developers on-site on a
regular basisto talk to users, get feedback, see what's going
wrong, and see how are they working. We also have an extensive
output program, so as we develop new features, we develop agile
methods to get the best result possible. In the end, I think you're
taking a world that is extremely complex-the radiology informatics
area-with another world that is extremely complex-technology. You
just need to have the right developers on staff who will go home at
night and keep up on the latest technologies, read Aunt Minnie, and
understand what's going on.
SIEGEL:
Thanks. I'd like to thank all of our participants for an incredibly
interesting discussion, and for underscoring the tremendous
importance of imaging informatics, both in the way we practice
radiology today and in shaping the future of diagnostic imaging.
Thank you all very much.