Applied Radiology

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 from the 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. If you 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 simple 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 I think 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 that he 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. So I 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 or study, 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 are porting workflow?

HAFEY: We do have a reporting module in our system that functions a little bit differently than traditional radiology workflow. 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 something you 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 with keeping your eyes on the images. As radiology transforms itself from detection and diagnosis to also now being involved in the 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 to interrupt 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 mammography users 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 your kid 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've got 6 degrees of freedom. You have translation in 3 dimensions and rotation. Yet, the gamers do this. They fly around, shoot 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 earlier at the high school level!

HORII: Yes, but it’s probably not a lot different in terms of what they know about 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 in a 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. If I’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 I see 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 or comparator 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 you need 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 upgrades might 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, are very 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 of roles. In some cases, they're all the same; in many cases, they’re different sets of players. For example, we recently went down to one of our large reading group 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 send our developers on-site on a regular basis to 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.