Applied Radiology

 Dr. Shrestha is the Vice President of Medical Information Technology, University of Pittsburgh Medical Center, Pittsburgh, PA, and the Medical Director, Interoperability & Imaging Informatics, Pittsburgh, PA.

Every few years, along comes a technological wave that can be considered nothing less than revolutionary. In this era of the always on consumer, mobility has quickly become a “must have.” Mobility penetrates almost every aspect of our modern life and has quietly reached a level of cultural acceptance and addiction that is second to almost no other technological advancement of late.

Smartphones and tablets have become the technological equivalent of jeans and t-shirts: easy to slip on, comfortable, functional, and essential to any wardrobe. According to one report,¹ >80% of practicing physicians actually use mobile devices, such as smartphones and tablets, along with various types of medical applications in these devices. Imagers are often earlier adopters of newer technologies, and radiologists have been quick to adopt mobile devices, for both personal and professional use.

Imaging vendors have also been busy, and FDA-approved applications are emerging that even allow for diagnostic interpretation of imaging studies on some of these mobile devices, enabling radiologists to deliver results even faster and providing clinicians increased means to review images via mobile devices during rounds and discussions with patients.

Newer practice models are being experimented on, and scientific publications² are emerging that highlight clever ways mobility and imaging are coming together. One such example is the vastly improved rapid communication with neurosurgeons resulting from the incorporation of smartphones, and the reviewing of 30-second videos containing patients’ neuroimages in the context of clinical information.

Building a fad-resistant mobility strategy

In healthcare in general, and in imaging in particular, the strategy should not just be about embracing the latest fads. It should be structured to keep imaging relevant at a time when we are seeing an active conversion of user-driven enthusiasm around mobile devices, and workflow considerations that could indeed be liberating in many ways. Embracing mobility for mobility’s sake is futile and short-sighted.When the enthusiasm dies down, one may just be left with unsupported devices, a HIPAA breach or two, and a screen full of unused apps.

So, does your healthcare institution have a mobility strategy yet? Any such strategy needs to focus on 4 key areas: (1) wireless infrastructure, (2) mobile-device management, (3) mobile-application development and management, and (4) support. The strategy calls for building a strong focus on reliability, security, and flexibility. Any such strategy in healthcare needs to be honed to keep up with the fast pace of technology change in this area, staying one step ahead of the game (where possible!).

A sound policy around device management has to be simple and clear. The ease of slipping in an Internet-enabled device that could potentially tap into PHI (protected health information) must not be taken lightly. The policy should address usability clearly distinguished between personal and professional devices as well as use cases, even with the emergence of the Bring Your Own Device (BYOD) trend.³ The goal is not to be limiting — but accommodating and safe. Like most successful policies, the aim should be to make it easier to do the right things, and difficult to do the wrong —while outlining clear and simple rules, backed by technology that enables the enforcement of these policies.

Healthcare institutions need to start dictating expectations and standards to vendor partners as opposed to the free-for-all, first-come-first served, lets-see-how-it-goes mobility deployment frenzy we are seeing today.

Workflow = work + flow

The promise of mobility in imaging centers is really in being able to comprehend and intelligently address opportunities to refine and define the imaging workflow. Dissecting the entire trail of the imaging workflow reveals specific opportunities to add value in a number of areas—and these include study ordering, scheduling, study capture, storage, image distribution, interpretation, report distribution, clinical image viewing, patient education, charge capture, image sharing, and many more.

In any of these cases, however, workflow simply needs to, well, work and flow! The mobile devices, along with the applications and tools, simply need to work—addressing the key aspects of reliability, performance, and functionality. And they also simply need to flow—ensuring that these devices and applications actually add value to the imaging workflow—simplifying and adding convenience to specific tasks.

Imaging-related mobile applications can currently simplify a PACS administrator’s life by allowing a number of remote monitoring and remote-control functionalities around quality control, data movement, and information management. A plethora of applications exists for the clinically inclined, from clinical workflow enablers for viewing, image sharing and remote reporting, to training (teaching cases, imaging atlases) and continuing medical education (CME). Consumer applications are emerging, too, allowing for controlled access to some imaging studies and reports, but these apps need to be part of a larger set of workflows, for example, around personal health records (PHRs).

As mobility-enabled workflows mature, users will start to embrace the convergence of devices and form factors, promoting a fluid workflow between the computer terminal, the tablet, and the smartphone.

The “always on” generation of clinicians

An entire new generation of radiologists and other clinicians is emerging; a breed that has developed an innate level of comfort with and acceptance of these mobile devices. With this trend come numerous new opportunities to improve critical clinical communications among troves of clinicians who are “always on.” Today’s generation of clinicians embraces social media and Web 2.0 communication methodologies perhaps even more readily than more traditional ways of communication in clinical radiology. This also opens up opportunities to dramatically decrease clinical miscommunications, for example, during patient handoffs.

Numerous medical schools and training programs are integrating iPads and tablet computers into their educational mandates—StanfordUniversity School of Medicine and University of California Irvine School of Medicine, presenting delighted incoming trainees with iPads,being two early examples of this trend.

Clinicians are literally learning new ways to practice medicine. In addition to palpation, auscultation, and percussion, tapping and swiping may very well have arrived as essential “clinical skills.”

Your smartphone will see you now

The mobile device is turning out to be man’s new best friend. Imagine the implications this has for patients. The patient empowerment movement suddenly has booster rockets. Patients already resort to online search engines to research health issues, symptoms, and perplexing terminologies found in radiology reports. I still smile when I recall the patient who asked me, “Am I worse off now that the report saysT2-weighted imaging? Is that better than T1?”

Armchair diagnosis is becoming well accepted, enabled by a plethora of customer-focused healthcare applications, including some very good ones such as iTriage. Newer technologies, such as voice recognition, make searching that much easier. AT&T recently released aWatson-enabled application programming interface (API), allowing developers to leverage applications that could bring the power of strong natural language processing (NLP) intelligence to everyday applications via smartphone.

There is more innovation yet coming on this front. An Israeli company recently unveiled a first-of-its-kind medical smartphone that renders it possible to independently measure 7 medical indexes: echocardiogram (ECG), heart rate, body temperature, blood sugar level, body fat percentage, blood oxygen saturation, and even stress. Companies such as Motorola, Nike, and BodyFit have been creating some interesting wearable health monitors connected to cloud-based applications, portals, and social media-enabled websites. Imagine how the incorporation of images would add value to some of these devices. Already, a number of successful cases have emerged of mobile devices being used for tele-ophthalmology, wound-image interpretation, and radiology image access and sharing.

Patient engagement will continue to be critical. The proposed Meaningful Use Stage 2 rules call for patients to have the capability to electronically view and download their health information and require providers to have secure electronic messaging capabilities to communicate with them. According to the National Coordinator for Health Information Technology, Farzad Mostashari, MD, the age of the engaged and empowered patient is upon us, especially with smartphones and ubiquitous access to information.

The evolution of apps

The application stores (app stores) are overflowing with medical apps. Indeed, there is what one could perceive as an extremely chaotic proliferation of apps, both for general consumers as well as clinicians. The rush to create and release apps has unfortunately also resulted in a lapse in the quality of some of these apps. More purposeful, intelligent, and well-designed apps are required that are perhaps connected to a broader set of applications, such as teaching resources, portals, PACS, etc.—not just standalone apps with limited functionality and narrow scope.

The Apple app store currently boasts close to 700,000 apps.⁴ The Google Android app store is not far behind, with close to 500,000 apps.⁵ Even the Windows marketplace has over 100,000 apps.⁶ As of July 2012, the Apple app store carried over 13,600 medical apps. Of these,almost three-quarters were created for consumers and patients (eg, wellness and fitness apps, general medical condition management apps,home monitoring apps), and the rest were targeted to healthcare professionals (medical reference tools, diagnostic tools, CME apps, and soon).

But one senses an evolution in the quality of these apps. From what today is often perceived as a chaotic mix of all sorts of apps, we are perhaps moving to some form of controlled chaos, with an organized methodological set of purposeful apps that are independently functional, but also serve as extensions of broader platforms and clinical or educational workflows.

Challenges

The challenges to wider and faster adoption of mobility in imaging, and healthcare in general, are rapidly being addressed. Of primary concernare security and privacy issues. Many organizations are also lagging behind in instituting clearly defined mobile strategies and governance policies. According to the HIMSS 2011 Mobile Technology Survey,⁷ 97% of respondents indicated that clinicians at their organizations accessed information using a mobile device, yet only 38% noted that their organization has a mobile technology policy in place that regulates the use of these devices and outlines the organization’s mobile strategy.

There are also concerns over wireless bandwidth, but the emergence of 4G bandwidth and better wireless technologies are addressing these concerns. Some tout business models around mobility as being a challenge, but perhaps this is more of an opportunity, both for standalone mobile applications as well as a value-added extension of broader platforms and tools. Healthcare institutions are exploring innovative ways to ensure these devices remain sterile, secure, and charged and ready when needed.

Opportunities

Smart, smarter, smartest—that’s the general trajectory of smartphone and tablet devices today. Healthcare stands to gain tremendously from newer, high-powered microprocessors with superior operating systems built for touch and optimized for these devices, ready to embrace cloud computing and armed with astute sensors, motion detectors, altimeters, gyroscopes, and voice-recognition capabilities.

The new iPad’s retinal display features a 2048 x 1536 resolution (Apple), with 4 times the number of pixels in the iPad 2, and a million more than in high-definition HDTV. Radiologists have not stopped drooling at the image quality. Devices are also emerging with state of the art cameras and video capabilities as standard, opening opportunities for a wide range of telehealth and teleconsult workflows.

In addition to more established platforms, such as the iOS and Android operating systems, Microsoft is making a big bet on mobility, and given the dominance of the Windows platform in healthcare establishments today, one would be foolish to ignore the Redmond wave—with Windows 8, Surface PCs, tablets, and a host of associated technologies and solutions, and opportunities to evolve user experiences to specific areas of healthcare.

There are tremendous opportunities in finding the perfect balance between mobile devices, and social media — enabling social and peer-level discussions, coaches and social gamification concepts related directly to targeted healthcare-outcome improvements, especially in certain high-cost, high-impact areas, such as adolescent obesity, chronic disease management, and many others.

Globally, there are 5.3 billion mobile subscribers—equating to 77% of the global population, including an ever increasing population of users in developing countries.⁸ Some are predicting that by 2015, more than a third of U.S. smartphone users will be running m-health apps.

The mobility-in-healthcare wave is upon us. There is no doubt that mobility will continue to have an increasingly profound effect on the practice of radiology and medicine.

Bibliography

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