Top Trends in Health Imaging & IT

When it comes to trends that matter most to imaging and IT, we again this year turned to our readers for answers. Some 434 imaging and IT decision-makers — representing a cross section of professionals within large, medium, and small hospitals and imaging centers — offered their opinions on 23 trends that encompass technology buying and operations, and shared their goals and challenges.

In this year’s annual survey, operations came out on top, but it is again obvious that operational, imaging, and IT priorities feed into each other. Two modalities high on this year’s wish list are multidetector CT and digital mammography. Successful deployments require a robust network and workflow adjustments.

Consider full-field digital mammography (FFDM). Implementing digital streamlines the mammography reading process, but it has a fairly lengthy learning curve. What’s more, sites often need to accommodate both analog and digital images in the early years, which tends to be complex and can slow workflow. Another option is digitizing priors. Multidetector CT brings other challenges. The acquisition speed of 16- and 64-slice CT enables facilities to increase procedure volume, while concurrently increasing the amount of data (and work) for the radiologist. Indeed, the data reveal that many sites are attempting to tame the multidetector beast; managing CT images is on nearly everyone’s radar.

So who participated? The majority of this year’s respondents were radiology administrators or business managers, but other areas are well represented. A fair percentage of CEOs, chiefs of radiologist, CIOs, and PACS administrators also shared their plans.

In addition to reflecting the needs of various imaging and IT professionals, the data from this year’s survey also cut across healthcare enterprises. Small, medium, and large hospitals as well as imaging centers and group practices are well represented. Despite the diversity of respondents, some priorities remain consistent across organizations. In fact, the top operational priority for many of the sites surveyed is radiology’s Holy Grail: improving departmental workflow. Increasing procedure volume is a close second, and both objectives drive purchasing decisions. For example, hospitals and imaging centers can facilitate workflow gains by improving the data network and adding or improving PACS image access.

Budgets under the microscope

Both imaging and IT acquisitions remain high on the list of funding priorities for hospitals and imaging centers. Nearly two-thirds of survey respondents indicated that their 2007 IT budget will increase, with a healthy portion anticipating an increase of more than 20 percent. An additional 27 percent of sites expect the IT budget to remain constant from 2006. Only a handful of respondents expect the IT budget to decrease in 2007. According to the survey, approximately one-third of IT budgets passed the $1 million mark in 2006. Twenty percent of respondents report a 2006 budget in the $1 million to $4.9 million range.

On the imaging side, more than half of the organizations represented expect an increase in the imaging devices budget, and another third anticipate stable funding for 2007. Once again, most 2006 budgets passed the $1 million mark with one-quarter of imaging devices budgets in the $1 million to $4.9 million range.

Imaging and IT budgets reflect the financial, professional, clinical, and technical realities of radiology. Workflow (which ranked tops last year as well) remains a hot topic as demographic forces — the shortages of radiologists, technologists, and nurses — meet the reality of exponentially increasing data generated by state-of-the-art scanners head on. Refining workflow is the Holy Grail at the vast majority of facilities. At the same time, the aging American population requires more imaging services, further exacerbating the issue and increasing demand on radiologists. Although the imaging profession may be strained, some sites have implemented solutions that effectively address the challenges of the 21st-century radiology practice. This month, Health Imaging & IT meets with a few of these leaders to discuss the top trends in imaging and IT and learn more about the forces behind the trends.
 

PACS: Radiology’s engine

PACS is the engine of the 21st-century radiology department. But PACS is moving beyond the confines of radiology and becoming an enterprise solution. While some facilities or departments plan to add or replace PACS, the more urgent needs are adding and improving image access and integrating a variety of departments into PACS.

Healthcare needs to contain costs and enhance quality; both goals fuel the expansion of PACS. Many sites aim to add digital access not only in radiology but also for referring physicians and in image-intense areas such as the ER, OR, cardiology, and orthopedics. At the same time, sites want to integrate images from radiology, cardiology, referring physicians, OR, ER, and orthopedics into PACS.

Cardiology represents one of the more problematic areas for PACS expansion and integration. Many cardiology departments operate mini-PACS, but these systems may not integrate with enterprise imaging systems, which could be a growing concern. “As cardiology crosses into other areas of imaging, it will be hard to maintain a functional mini-PACS arrangement,” predicts Gary Wendt, MD, MBA, enterprise director of medical imaging at University of Wisconsin School of Medicine and Public Health in Madison. That’s because supporting parallel systems requires a lot of duplication, consuming both financial and human resources. The solution, says Wendt, is to find a vendor that supplies a reasonable solution for both radiology and cardiology.

The PACS market offers a number of effective enterprise solutions that address several key issues for healthcare. “The interest in PACS diffusion stems from a combination of physician satisfaction, quality of care, the need for immediate information, and the cost of film,” explains Eric Conley, vice president of operations for Franklin Square Hospital in Baltimore, Md. Referring physicians don’t want to trudge to radiology to view and discuss images. No healthcare enterprise wants to spend $1.50 to $1.75 for each sheet of film printed. Printing the average CT study on film costs about $30, says Conley. Putting the study on CD comes in at a mere $0.39. Other advantages include improved image quality and the ability to manipulate images digitally.
 

Although there are clear advantages to expanding PACS, facilities need to address some issues. Major issues include displays, network speed, and storage. Monitors should meet the intended purpose; diagnostic readers need a more robust solution than clinicians who want to refer to images. Areas such as the OR and ER require solutions tailored to their needs, which may include 40-inch displays, cart- or wall-mounted systems, or computers-on-wheels (COWs).

Wendt points to a common pitfall sites encounter as they integrate other areas into PACS. Whether it’s monitors or PACS functionality, referring physicians often clamor for the solution radiology uses. But 3-megapixel displays or high-level PACS functionality may be more than clinicians need and cause frustration on a different level. For example, the ramped up PACS user interface used by radiologists includes more bells and whistles than most referring physicians need or want.

On the network front, the site needs to evaluate the necessary speed and bandwidth to transmit images in real time. Both calculations may represent a moving target. A similar evaluation addresses storage needs, too. In all cases, it’s wise to call in the experts. “We work closely with our PACS vendor to understand how new technology like 64-slice CT will affect the network and storage capacity,” says Conley.

Meeting network and storage challenges

As sites deploy 64-slice CT, they need to consider the challenges associated with the state-of-the-art scanner. For example, moving all of that CT data around may not be straightforward (or speedy) if the network and data storage systems are not up to the demands. In fact, Health Imaging & IT readers cited improving data storage and improving the data network as the top IT priorities for 2007.

LifeBridge Health System in Baltimore, Md., resembles many of its healthcare peers. The system is growing, opening new facilities and adding new imaging equipment and IT applications at a near breakneck pace, which has major storage and network implications.

Radiology systems present a significant challenge because they tend to consume storage and the network, says LifeBridge director of technology Chris Panagiotopoulos. The system’s PACS gobbled about 5 terabytes of data storage in one year; the next closest user is the clinical database, which consumed a mere 800 gigabytes — in five years.

Like many facilities, LifeBridge plans to implement 64-slice CT and FFDM in the six to 12 months. Both systems will tax the storage system. The site is evaluating next-generation storage solutions and aims to increase storage capacity by adding modules to its current enterprise system. Panagiotopoulos urges his colleagues to weigh the tradeoffs associated with various storage approaches. Offloading data from a storage area network to a lower-cost system may seem appealing from the initial cost analysis while upgrading to a high-end solution may appear cost-prohibitive. “Look at the total cost of ownership,” states Panagiotopoulos. Decentralizing the storage system can be more costly, as it requires more in-house management. The higher-priced, faster, next-generation solution may enable the site to leverage in-house resources and could be more cost-effective than the alternative.

As IT departments everywhere grapple with ever-increasing storage demands, they also need to consider the network. Many, like LifeBridge, operate aging network systems.

Panagiotopoulos explains the predicament. “A number of our switches and devices have been around for a long time and are no longer able to meet the speed requirements we project for the future. In addition, vendors no longer support the older systems.” LifeBridge aims to stay ahead of the radiology curve and plans to build a sophisticated network to support upcoming state-of-the-art imaging systems. The three-to-five-year plan centers on a 10-gigabit network, and the current phase consists of deploying equipment capable of supporting the upgrade network. For example, new blades for data center switches feature 10-gigabit capabilities.

The Imaging Modality Market

CT in the driver’s seat

There are a variety of factors behind the appearance of the many devices at the top of this year’s imaging priority list. CT continues to assert its dominance as the go-to modality and the radiology department workhorse. After just a couple of years on the market, the value of 64-slice CT seems clear. It is the device for noninvasive cardiac imaging. It could replace some invasive cardiac catheterizations and promises to accelerate diagnosis and care for many patients. Nearly 75 percent of sites adding CT plan to install a 64-slice scanner; another 15 percent aim to deploy a 16-slice scanner. That translates into tremendous growth in the installed base of 64-slice CT scanners. CT vendors should see a dramatic increase in installed systems next year.

“The primary selling points of 64-slice CT are its speed and volume coverage,” states Alec Megibow, MD, MPH, professor of radiology at New York University Medical Center in New York City. 64-slice scanners offer significant improvement in these features and make coronary artery scanning clinically feasible. On the clinical front, CT’s big feature can detect calcium, and it can be deployed for other applications such as CT runoffs and virtual colonoscopy, enabling sites that invest in the scanners to maximize their investment.

Megibow sees other reasons behind CT’s continued dominance of the imaging budget. “The product cycle time for 4- and 16-slice scanners was very short — just about 18 months, and the introduction of 64-slice scanners has eliminated the value of lower-slice scanners. 64 slices seems to be where the industry will settle. It isn’t vulnerable to the introduction of new products, and it images the coronaries reasonably well.” Indeed, buyers may no longer find 16-slice scanners with all of the bells and whistles, as some vendors have discontinued selling top-tier 16-slice scanners.

Although 64-slice CT brings clinical gains and enables noninvasive cardiac imaging, it is not without challenges. In fact, managing multidetector CT images surfaced as one of the top priorities in the top trends survey. Sixty-four-slice systems generate a tremendous amount of data, producing several thousand images in just a few seconds. The file size of the average 64-slice scan is 0.5 megabyte. Consequently, 64-slice CT sites need to develop and implement a comprehensive and proactive plan for managing 64-slice data. The heart of the clinical plan, says Megibow, is the 3D workstation, which allows radiologists and cardiologists to reconstruct the razor-thin slices and tap into the expanded applications made possible by 64-slice scanners such as CT angiography, coronary angiography, and virtual colonoscopy. On the IT side, 64-slice success requires a robust storage and network plan.

Digital mammography tips the scale

The other storage and network burden and workflow challenge that sits high on the priority list for many facilities is digital mammography. Although most of radiology is firmly entrenched in digital, mammography has been a holdout. But this year’s survey indicates that digital mammography is making the transition from academic medical centers and high-volume breast imaging sites to mainstream radiology. A quick look at some sales numbers proves the point.

Hologic saw a 75 percent increase in mammography revenues over the same period a year earlier, primarily because of increasing digital mammography sales. The company installed 154 digital systems in the third quarter, ending in June. At 342 units, its order backlog on the last day of the quarter, however, more than doubled the number of sales in the quarter.

The long-awaited results of the Digital Mammographic Image Screening Trial (DMIST) has propelled digital into the mainstream. Last year, DMIST gave digital an edge over film for women younger than 50, patients with dense breasts, and pre- or perimenopausal women.

There are multiple other factors behind the heightened interest in FFDM, says Shirley Pinette, manager of Yale-New Haven Breast Center in New Haven, Conn. It’s no surprise that workflow is an issue. Digital eliminates cassettes and translates into faster throughput. “It takes less time to complete a digital mammogram than an analog mammogram. A single digital unit can be used to increase procedure volume,” explains Pinette. A recent study done at Northwestern in Chicago and published in the American Journal of Roentgenology shows digital mammography saves technologists time — 35 percent — with digital mammograms completed in about 14 minutes compared to about 21.5 minutes for screen film.

What’s more, digital will bring added clinical value, says Pinette. “Right now, improved contrast resolution and image quality enable radiologists to better visualize calcifications. In the future, advanced applications like tomosynthesis and digital subtraction will require digital. If a site wants to be on the cutting edge, it needs digital mammography.”

Other advantages of digital include fewer technical recalls, improved archiving, and streamlined comparisons. Finally, digital is easier on technologists because it eliminates the repetitive wrist motions associated with cassette handling.

Pinette cautions that gains are not immediate. “Be patient. There is a learning curve [for radiologists and technologists].” The initial and often unavoidable analog/digital combination can be trying, as it requires everything: an archive, film library, and processors, and radiologists must compare analog priors to current digital mammograms. The Northwestern study did find that radiologist interpretation time more than doubles for digital — 2.3 minutes compared to 1.4 minutes for screen film. Yet, after staff members master the nuances of digital and the site builds a library of digital priors, the department will realize the true benefits of digital.

A final factor within digital mammography is the recent FDA approval of the first computed radiography mammography system in the United States by Fujifilm Medical Systems, which is a lower-cost option than full-field digital systems. “CR [computed radiography] mammography will have its place. It’s an option for small facilities that cannot afford digital,” notes Pinette. The system may not bring the throughput advantages of digital because it relies on cassettes, but it does allow facilities to move away from film libraries.

CR/DR in the spotlight

Mammography is not the sole modality clinging to film. Diagnostic radiography is another film bastion. Digital modalities — CT, MRI, and ultrasound — are typically the first to be incorporated into PACS. For many sites, x-ray remains relatively primitive and analog. That’s because converting radiography into PACS is a capital-intense proposition. But as sites move further into the PACS deployment, they’re beginning to tackle radiography.

Consider Roper St. Francis Healthcare, a 12-site system based in Charleston, S.C. Roper St. Francis implemented PACS three years ago and began converting to CR and digital radiography in the last 18 months. The time was right from the budget standpoint, and the radiology department had been waiting for advances in CR/DR technology. The most important refinement, says director of imaging services Mike Ricciardone, is the availability of a family of solutions that allow a seamless transition from CR to DR. The common user interface and consistent processes translate into additional workflow benefits among technologists.

Ricciardone and his colleagues made the case for DR by completing projections of cost savings and productivity increases. According to Ricciardone, the system anticipates a 40 percent to 60 percent gain in productivity with a combination of DR and CR; cost-savings will accrue as the system eliminates film and all of its associated costs — handling, transport, storage, and more. In addition, the increased throughput made possible by digital will allow the system’s two hospitals to reduce the number of radiography rooms by one-third to one-half.

Roper St. Francis Healthcare relies on a combination of CR and DR solutions. “Hospitals need to evaluate CR versus DR and decide on a threshold for each type of system,” says Ricciardone, who adds that CR can easily handle 40 to 50 exams daily. Roper St. Francis Hospital plans to equip its two hospitals with DR and deploy CR to support DR for specialized applications such as portables and cross-table laterals in the hospitals. “The higher volume justifies the additional expense of DR,” says Ricciardone. CR fits the bill in the system’s smaller imaging centers.

Roper St. Francis Healthcare is gathering data to quantify cost and labor savings associated with the move to digital, but Ricciardone points to an important intangible benefit: “Physician satisfaction has increased to more than 90 percent.”

Improved image quality fuels ultrasound growth

In many ways, ultrasound is in a class by itself. “Ultrasound has been in hospitals for more than 30 years. Hospitals are not discovering a new technology. There’s been an explosion in technology in the last several years. What we’re seeing is a change in cycles of equipment,” explains Greggory DeVore, MD, director, Fetal Diagnostic Center in Pasadena, Calif.

Hospitals and imaging centers adding or replacing ultrasound are fairly split on the type of system needed. Forty-four percent are looking for an OB/GYN solution, while 34 percent need an echocardiography system. The remainder aim to implement handheld ultrasound.

The development of 3D and 4D ultrasound and the addition of new algorithms to analyze data have changed the landscape. “There are new applications in OB/GYN, and physicians are able to extract more data,” says DeVore. The evolution of ultrasound technology is not the only force driving the market. Consumerism and competition are alive and well in the OB/GYN world. Hospitals must stay current. If they aren’t, they will lose patients to the practice around the corner that has the latest system, says DeVore.

Similar developments account for heightened interest in echocardiography. “In the last several years, image quality has improved markedly, which makes echocardiography more usable,” explains Cynthia Toher, MD, director of cardiology at Park Nicollet Heart and Vascular Center in Minneapolis. For example, systems that enable strain rate imaging and tissue Doppler are making their mark, facilitating more nuanced interpretations and allowing practitioners to answer clinical questions in a noninvasive manner.

Handheld ultrasound also is in a state of evolution. Traditionally, handheld users have been forced to trade portability for image quality. That tradeoff will be relegated to history, says DeVore. Improvements in image quality and resolution are making handhelds more versatile and cost-effective. GE Healthcare’s portable Voluson i, for example, delivers real-time 4D, multiplanar 3D, and 3D power Doppler in a portable package.

“We will see a significant surge in the handheld ultrasound market because image quality has reached the level of standalone machines,” predicts DeVore. That technical leap is great news for buyers, as they will no longer need to buy a separate system for each office.

MRI in evolution

MRI also rated fairly high on respondents’ priority list, but the market is divided with close to half of buyers shopping for 1.5T systems and another half looking for 3T systems. “3T is the way to go,” opines Marc Shapiro, MD, medical director of the Neuroskeletal Imaging Institutes in Winter Park, Fla.

According to Shapiro, developments including 16-channel systems and new coils are boosting 3T and enhancing its clinical utility. The combination of diffusion-tensor imaging, perfusion imaging, and spectroscopy enables better detection and follow-up of brain tumors than PET. 3T breast imaging is on the horizon and, in conjunction with CAD and spectroscopy, could help radiologists differentiate carcinomas from benign breast lesions.

New clinical applications aren’t the only factors driving 3T; other capabilities could aid throughput and workflow. Scan times, which can wreak havoc on workflow, are improving with 3T and parallel imaging. Parallel imaging can shorten the scan time but causes a loss of signal and information. 3T compensates for the signal loss.

Some facilities may not be ready for the leap to 3T and plan to deploy 1.5T MRI. The 1.5T magnets can meet many clinical needs and are easier on the budget than their 3T peers. The availability of wide-diameter ultra-short-bore 1.5T systems could reduce the appeal of open MRI. In fact, nearly three-quarters of Health Imaging & IT Top Trends respondents plan to purchase a closed bore system. “Ultra-short-bore with wide-diameter 1.5T MRI will replace opens completely,” predicts Shapiro.

Conclusion

2007 looks to be another busy year for imaging and IT professionals. Users are voicing universal concerns — taming the workflow beast and increasing procedure volume. Many hospitals and imaging centers are turning to new imaging and information technologies that promise to make the radiology profession more efficient and boost clinical care. The tools to achieve these lofty goals run the gamut from 64-slice CT to improved data storage and FFDM.

The challenge is to deploy new technologies in a concerted fashion, ensuring that the enterprise has considered all of the angles and issued posed by new systems. A comprehensive and proactive plan that addresses modality, IT, and workflow issues is likely to translate into success and meet those universal objectives.

Additional Data

PET/CT and SPECT CT

Cath Lab

CAD

Advanced Visualization

Workflow