Top 10 Trends

Most of this year's Top 10 Trends - as prioritized by our readers - spring from a single factor. What's that red-hot imaging technology? Why, 64-slice CT, of course. CT is proving to be the center of the universe as it pushes radiology, cardiology and healthcare IT departments to re-think image acquisition, processing, PACS, network strength and image storage. It's tangling in its web all by perhaps one of the other Top 10 Trends, including improving department workflow, increasing imaging procedure volume, managing multislice CT images, buying a multislice CT scanner, adding and improving web access to images, providing image access outside of radiology (OR, ER, ICU), adding advanced visualization, improving the speed and bandwidth of your network and adding enterprise storage. Network security is the sole Top Trend that doesn't directly relate, but sure does indirectly.

All four major CT vendors are in full-throttle production, and CT's big guns can be found in every corner of the country. In fact, when media mogul Oprah Winfrey underwent a cardiac scan this summer in Chicago, she mistakenly publicized the scanners as limited to big cities. In fact, the technology can be found at all types and sizes of healthcare enterprises in cities large and small.

The 'greater than 16-slice' category of CT scanners is the fastest growing and largest segment of CT right now. About 1,200 64-slice systems have been ordered since mid-2004, and the installed base hovers at a rapidly growing 600.

Large hospitals with more than 400 beds have shown the most interest in 64-slice scanners; however, clinical studies and positive feedback from early adopters has fueled growth in other arenas. Medium-size hospitals ranging from 150 to 400 beds have entered the market, and diagnostic imaging centers are eyeing and buying the technology, too. Private-practice cardiologists comprise the final market segment; they place approximately 25 to 30 percent of 64-slice orders, which has intensified the turf battle between radiology and cardiology. But 64-slice also has smoothed rifts between radiology and cardiology who now work in close collaboration, such as the tight-knit radiology-cardiology team at early-adopter Froedtert Memorial Lutheran Hospital in Milwaukee and Cardiology Associates in Mobile, Ala., that gains radiology insight from an off-site radiologist.

Despite the 64-slice hype, 16- and 32-slice scanners are still quite clinically valuable. And therefore, overall CT sales are booming - topping $1.3 billion in 2004, a 20 percent increase over the previous year. As facilities deploy 64-slice scanners, the lower-slice-count systems are moved to other areas such as oncology or urology.

Many of our survey respondents are grappling with issues related to 64-slice scanners. Some of the big questions include:

How do you research, purchase and install a multislice CT scanner? (No. 4)

Once the scanner is installed, how do you manage all of that data? (No. 3) And how do you increase procedure volume to ensure profits? (No. 2)

Moving hefty multislice CT datasets around a facility and even outside is no small challenge. Network speed and bandwidth must suffice and be ready for further increases in volume. (No. 8)

Advanced visualization solutions can optimize multislice results. 3D software and hardware are necessary to post-process certain multislice studies, and it can boost workflow. (No. 9)

Other hot topics transcend multislice madness and mimic timeless radiology challenges. Fine-tuning department workflow - which tops this year's trends - is an ongoing challenge, exacerbated by several forces: the increased volume of data generated per study by multislice scanners as well as companion 3D images, an aging population with greater needs for imaging services and the well-documented radiologist and technologist shortage.

Current technology puts radiologists at the top of their game by providing them with multiple tools to create beautiful, clinically relevant images. The challenge of disseminating those images is formidable. Web and enterprise image access (No. 5 and No. 7) keeps more than a few imaging and IT staffers awake at night. IT challenges round out the list. Network security (No. 6) is key, and managing patient images and information on an enterprise level (No. 10) may be the glue that holds imaging together as it provides the structure for rapid dissemination and a home for all of that data.

This month, Health Imaging & IT visits with a few leaders who have tackled the top challenges. Their experiences can serve as a strategic roadmap and provide practical guidelines as imaging and IT execs plan for the road ahead.

Getting your feet wet: Taking on 64-slice CT

It seems that everyone who is anyone, or at least considers themselves a serious radiology player, has entertained - or is hard-core planning for - the idea of a 64-slice scanner. Adoption has spread from large academic institutions to mid-size hospitals, cardiology practices and diagnostic imaging centers and practices aiming to specialize or advance their art in cardiac imaging. With price tags in the $1.2 million to $1.6 million range, the scanner is a hefty investment for any healthcare entity. And that's just the scanner - with serious image management and storage capabilities a must, too.

The four major CT vendors each offer their own twist on 64-slice scanning, says Norman Lepor, MD, cardiologist with West Side Cardiology in Beverly Hills, Calif. All of the systems on the market offer superb performance and significant improvements over 16- and 32-slice scanning. Image quality stands at an impressive 0.4 millimeters and scan time is minimal at fewer than 10 seconds, less than a breath-hold.

The differences in hardware and technical specs may be less relevant than the auxiliary equipment and supporting personnel. "It's important to invest in [all of the solutions needed] to get these images to a more finished point," states Lepor. This means adding advanced visualization tools for smooth post-processing. Advanced visualization is an essential ingredient for certain 64-slice studies such as CT angiography. These solutions also facilitate other up-and-coming studies like CT colonography.

There are a variety of post-processing paradigms. Many sites use a workstation as a short-term archive for acquired data and only save reconstructed data to PACS. 3D-PACS integration is in its early stages, with 3D and PACS vendors lining up partnerships and collaborative agreements. This brings some 3D functionality to the PACS workstations and eliminates some of the back and forth between PACS and 3D workstations, which can be a significant workflow disruption. Integration, however, may be more of a work-in-progress at this stage of the game, says Matthew Barish, MD, director of the 3D imaging processing center at Brigham and Women's Hospital in Boston. True 3D-PACS integration is on the horizon and promises greater integration and workflow improvements. This next step will provide radiologists with full access to advanced visualization tools as they remain in the PACS workflow.

Some facilities report significant pluses with the centralized 3D post-processing lab model. This model employs highly trained techs to complete many post-processing tasks. Sites develop a specific protocol for each 3D study, outlining responsibilities for the tech and radiologist or cardiologist, allowing the pair to function as a streamlined post-processing team.

Another big CT issue, says Lepor, is learning to use the technology well. The Society for Cardiovascular CT, American College of Cardiology and American Heart Association released a consensus statement recommending two months of training for sites that intend to independently perform cardiac CT and six months of training for cardiac CT labs. Currently, a handful of facilities offer training courses for physicians and ancillary staff. Courses cover technical issues, patient prep, interpretation and contraindications.

Image management is another key 64-slice consideration. How do facilities transmit and store these images? Part of the challenge is a simple technical question. How much information needs to be readily available? Many sites forego storage of all 64-slice CT data, selecting the best reconstructions for the archive. Still, the numbers of exams and volume of data can tax the average PACS, forcing a practice or department into the replacement market, which adds another layer of strategy - and distraction.

Manhattan Diagnostic Radiology in New York City upgraded its PACS after deploying a 64-slice scanner. The practice also beefed up its network, upgrading from two T1 lines to a fiber optic network between its two offices to meet cardiac CT requirements.

As facilities wrangle with the purchase and image management challenges, they also must consider imaging procedure volume. Sixty-four slice CT scanners, like other high dollar imaging investments, require minimum throughput levels to justify the expense. The best estimates indicate a minimum of 10 referring cardiologists to support the expense of a 64-slice CT scanner. But business can arrive via other avenues.

At West Side cardiology, coronary-based imaging accounts for 60 percent of the 64-slice business with peripheral vascular and extra-cardiovascular images such as abdominal studies and CT urograms each accounting for 20 percent of 64-slice volume. Other appropriate studies (and markets) include the ER-based triple rule-out and orthopedic work. Sixty-four slice CT has tremendous potential to impact cardiac management in the ER as the triple rule-out scan can quickly evaluate the patient who presents to the ER with chest pain for aortic dissection, pulmonary embolism and coronary disease.

Regardless of the applications, utilization equals return on the investment, and utilization requires patients. West Side Cardiology relies on patient and physician educational programs to increase its procedure volume. St. Dominic Jackson Memorial Hospital in Jackson, Miss., analyzed current procedures and new study options when it invested in a 64-slice CT scanner. The reality for some sites may be that new procedures must be developed and marketed to earn a return on investment. Popular and profitable 64-slice studies include cardiac CTA and CT angiographies.

The 64-slice rage has fueled competition between radiology and cardiology in some locales. Setting the stage for collaboration between radiology and cardiology may be one of the best ways to optimize patient outcomes with a 64-slice scanner.

The all-cardiologist practice of Cardiology Associates in Mobile, Ala., has developed a model collaborative program, deploying cardiac CT without an on-site radiologist. Staff cardiologists read the cardiovascular portion of CT angiographies. An offsite radiologist provides QA and reviews selected datasets for soft-tissue tumors and other problems. "The bottom line is patient care, and patients are best served by a collaborative effort between the two disciplines," adds Jeffery Goldman, MD, director of cardiac CT and MR at Manhattan Diagnostic Radiology.

Workflow woes

Workflow remains a top priority for hospital-based radiology departments and imaging centers. The transition to the digital department promises workflow benefits for both radiologists and technologists, but realizing those gains can be a challenge. Take for example Spectrum Health, a seven hospital system based in Grand Rapids, Mich., that performs 500,000 imaging exams a year. An enterprise PACS implementation several years ago failed to generate the expected workflow improvements.

PACS Manager George Vallillee says, "We envisioned a paperless environment with online requisitions and complete PACS/RIS/dictation integration." The systems, however, are not integrated, which necessitates a time-consuming barcode step for many radiology processes. The site has determined short-and long-term solutions to the problems. In the short run, Spectrum Health plans to implement a customized application protocol interface (API) to enable the data exchange necessary for PACS/RIS/dictation integration.

The longer-term, and universal solution, rests with Integrating the Healthcare Enterprise (IHE), says Vallillee. The healthcare system uses IHE interoperability parameters as part of medical informatics purchase negotiations. This insures future integration, which will allow the health system to achieve efficiencies and improve digital workflow, says Vallillee.

Enterprise image viewing

Radiology is not an island. The most effective departments and diagnostic imaging centers have developed sophisticated processes and deployed solutions to ensure that images are as readily available across the enterprise as they are within the department. Web access via web-based PACS is the solution du jour. Like other items on the Top 10 agenda, the challenge extends beyond hardware basics to include basic principles of customer service.

Sutter Health-Sacramento Sierra Region in Sacramento, Calif., has effectively deployed web-based PACS to provide referring physicians throughout the hospital with on-demand access to images. The hospital's one gigabyte network is an effective conduit for heavy image traffic. But moving images throughout the enterprise is only half of the challenge. The hospital must ensure adequate viewing conditions in areas that significantly differ from the sedentary image-centric world of the radiology department. The OR and the ER, for example, are veritable hives of activity. Often surgeons want to look at priors for comparison or more CT data than may be available on a single monitor. Sutter Health equipped its ORs with dual-monitor displays for viewing, and upgraded the video card and PCs to one gigabyte processors to make sure the equipment could perform the tasks.

The viewing mechanism is a key consideration in the OR. Options include large, wall-mounted displays, workstations and carts. Spectrum Health weighed all options and deployed 40-inch, wall-mounted LCD panels that allow side-by-side image display. The plus of this approach is that it does not consume valuable OR real estate and helps maintain an organized environment. On the downside, it can be difficult to find the right spot for the large displays. Mobile cart-mounted displays can bring cost efficiencies as they can be shared among ORs.

The reality of extra-radiology image access is that each of various customers - the ER, OR, ICU - have discrete and definite viewing needs. Some users, like orthopods and neurosurgeons, require high-end viewing stations and may require 5 megapixel PACS workstations and even larger displays for large body parts. Other referring physicians use images for reference and can manage with standard monitors. The upshot? The department that views options along a continuum and solicits user input is well-positioned for enterprise image viewing success.

Not all images originate within the hospital walls. Often, a fair share of exams are performed at outpatient imaging centers. Both institutions may have PACS, but often the PACS are of different flavors that don't quite sync. This can force hospitals and imaging centers into an old corner. Films and CDs are shuttled back and forth between the two organizations.

Sutter Health and local outpatient center Radiological Associates have overcome the challenge with a third-party centralized image server. Each partner sends and pulls DICOM-formatted images to and from the server, allowing physicians web access to all priors - whether they were taken at the hospital or at the imaging center. "This has improved patient care and relations between the hospital and radiology practice. Eventually, this model must be adopted from organization to organization," says Linda Womack, regional imaging systems manager for Sutter Health - Sacramento Sierra Region. As a true image-enabled, multi-enterprise electronic health record becomes a reality, healthcare providers must have a system and process for effectively sharing images beyond the enterprise.

Spectrum Health relies on a similar model to overcome the challenges associated with less than optimal network speed and bandwidth among referring physicians. "Referring physicians can't afford best of breed pipes, and PACS can be an all-consuming network stress," sums Vallillee. Many of the system's referring physicians tap into PACS via simple broadband connections and cable or DSL modems.

Spectrum Health mitigates bandwidth requirements with virtual sessions hosted on a Citrix farm. The server farm runs the PACS web application and allows a screen scrape of radiology images at a much lower bandwidth than conventional delivery mechanism. "Scrolling and loading strains are greatly reduced, too. This model decreases the total cost of ownership and extends the reach of PACS," explains Vallillee.

IT issues

IT is the glue that holds the enterprise together, so it's no surprise that a few IT items popped up in the Top 10 Trends. Enterprise storage is a hot item that can simplify and speed data and image management and delivery and trim costs over the long-term. For example, Children's Hospital of San Diego realized an immediate return on investment when it enhanced its enterprise storage; electronic chart retrieval time dropped from up to five minutes to less than one second. With results like this, it's no surprise that the days of departmental storage silos are numbered; many healthcare facilities have set their sights on developing an enterprise storage solution.

Austin Radiological Association in Texas deployed an enterprise storage solution four years ago. PACS was the driver for the decision to implement a storage area network (SAN). Enterprise storage solutions are typically blended and incorporate a variety of storage products. The Austin Radiological system also includes content-addressed storage, an archive and tape. Chief Information Officer Todd Thomas says the association adhered to a best practices approach and designed the solution with heavy radiologist input and for the future. North Bronx Healthcare Network Chief Information Officer Daniel Morreale says a proactive approach with a long-term vision and short-term steps suits many sites well.

Enterprise storage wannabes are advised to consider and prep for challenges beyond the initial design. Enterprise storage management may require additional, highly trained staff or staff training. There are technical glitches as well. Not all clinical systems can be easily migrated to the lifecycle data management model, so some vendor hand-holding or arm-twisting may be in order.

Storing healthcare data is just part of the challenge. Radiologists and clinicians across and beyond the enterprise need more data faster than ever before. This creates near-constant pressure to improve network speed and bandwidth (No. 9). "The network is the foundation for every high-tech solution, and it has to be sound," says Sheldon Hinkson, CIO of Children's Hospital of San Diego.

At Austin Radiological Association, IT staff used radiologists' image delivery specifications as guidelines for network improvements. The department looked at their needs and presented them with the network (and cost) required to meet those needs. Quality of service is one half on the network improvement process. It's also important to look at exam volume. Austin Radiological calculated image size for uncompressed CR images and MR and CT studies and also assessed which new technologies would be added in the next several years. Newer network hogs include video fluoroscopy, voice over IP and an upcoming 64-slice CT scanner. By looking into the future, the association deployed a network that suffices for the long haul.

Another factor in the network equation is "rush hour" traffic. Image volume is not spread evenly over the course of a day. Some facilities overcome traffic issues by designing the pipe to handle peak volume.

Aggressive, proactive implementations can pay off. Take for example North Bronx Healthcare Network, which upgraded from a 10-megabyte network to a 10-gigabyte core two years ago. The upgraded capacity provides nearly instantaneous access to images, a substantial improvement over previous delays of up to six seconds. Initially, capacity on the new network stood at a mere 3 percent, but the growing room was necessary for upcoming initiatives such order entry, speech recognition and additional cardiac imaging. Once again, a longer-term approach benefits the organization. Morreale suspects the 10-gig pipe will have a five-year lifespan, and the healthcare network could have a host of new options next time around.

Children's Hospital of San Diego addressed network speed and bandwidth issues before deploying PACS, says Hinkson. The hospital replaced the radiology department switch with a gigabyte-capable switch to facilitate gigabyte to the desktop traffic in radiology. A five year plan is essential, says Hinkson. "Look for flexibility, so if a new development throws a curve ball, the system can handle it." Other tips for enhancing or maximizing the network include:

• Buy the best available network solutions to maximize the investment for the longer term.
• Plan and build the network for capacity up to 50 percent beyond current needs.
• Invest in evaluations of the current network. A snapshot of capacity, type of data flow, utilities and back-ups can pinpoint problems and solutions. For example, setting policies and service levels for bandwidth priorities can help healthcare facilities gain a longer network lifespan, says Hinkson.

In recent years, Healthcare Insurance Portability and Accountability Act (HIPAA) regulations put network security in the hot seat. Little has changed. "Network security is hotter than ever," claim Vallillee. And that's No. 6 on the list. Austin Radiological Association adheres to a best-practices approach. The association relies on internal penetration testing equipment to pinpoint holes in the network, and hires an outside firm to attempt a network break-in annually. Smart intrusion detection systems can review signature for viruses and hackers and create central error logs and reports. Additional human resources can help counter security challenges. Children's Hospital of San Diego recently added two new IT positions; one targets HIPAA, and the other handles security.

Many healthcare facilities struggle with the security of shared systems such as central nurses' station computers. Multiple users may be on and off the system for brief periods of time; logging in with unique user identification is often viewed as a hassle and workflow disruption. Until improved security solutions are developed, users should comply with unique log-in.

Vallillee predicts new developments to help address current challenges. "Emerging technologies will provide security, convenience and accessibility," he notes. Possibilities include biometrics such as thumbprints and eyescans, which have not yet proven more convenient or reliable than existing mechanisms. Radio-frequency identification (RFID) is another intriguing possibility; physicians may be able to use an RFID tag to authenticate and log on to the network. Single sign-on solutions also can aid workflow by linking multiple user accounts.

Conclusion

Facilities uniting imaging and IT are juggling multiple, spinning plates with new technologies (and the corollary challenges) hitting the streets at breakneck speed. Solutions do exist; by collaborating and learning from their peers imaging and IT execs can stay on top of the game and deploy and optimize proactive solutions. The best advice includes:

• Look at the big picture. How are challenges (and potential solutions) related? What might come down the pipeline in the next few years?
• Talk to (and listen to) colleagues and users to determine the down-on-the-ground challenges, universal issues and success stories.
• Don't overlook vendors as potential allies. They understand the current market and future directions and may be able to provide needed insight and solutions.