Radiologists’ Wish List

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Since its inception, medical imaging has represented the forefront of everything that technology has to offer the business and practice of health care, and all the advancements that have transformed and expanded its reach have only entrenched it more deeply into a broader variety of clinical applications. That doesn’t mean, however, that imaging devices themselves couldn’t use a few improvements. Whether in terms of speed, accuracy, applicability, or breadth of service, radiologists continue to seek technological solutions to the challenges that affect their daily practices.

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Scott Seidelmann, founder and CEO of the Waltham, Massachusetts-based Candescent Health, foresees two significant challenges for radiologists that any technological solution will be aimed at ameliorating: declining reimbursement and growing patient volume. The industry anticipates a 25 to 30 percent greater workload at a 15 to 20 percent reduction in fees for those services, which Seidelmann says raises a larger question about the treatment of medical imaging as a commodity service in the context of value-based care.

As reimbursements are on the decline, “lots of radiologists are overworked and frustrated, feeling like they’re on a treadmill to nowhere,” Seidelmann said. As more clinical specialists take ever-more complicated imaging procedures in-house, there may be less of a need for general radiologists overall.

“One of the big challenges [for radiologists] is to figure out what real value they provide and how radiologists demonstrate outcomes in a quantifiable way,” Seidelmann said. “Unabated, incomes are going to decline, and life can get a lot worse if the risk- or value-based world determines [imaging is] a commodity.”

Seidelmann believes the technological advancements that free up radiologists to improve patient outcomes also create opportunities for medical imaging to demonstrate its downstream value. Any equipment that allows physicians to avoid unnecessarily invasive procedures or improves patient care at the point of treatment will yield greater returns on investment.

“I see the big technology needs are maybe decidedly very low-tech,” Seidelmann said. “How do we think about what [radiologists] do on a daily basis, and can we use non-radiologists to do some of these administrative things? Can we create new workflows that tie into the EMR that trigger the radiologist to do something different?”

Seidelmann believes that about one-quarter to one-third of a radiologist’s work is administrative. By removing those demands from the job, a skilled professional can focus more closely on point-of-care services and patient needs. Candescent Health provides a tech-enabled service that radiologists can use to offload the time spent tracking down clinicians or patient information in order to devote more of their hours to case readings or patient consultations.

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“The amount of information a radiologist has to process is growing exponentially,” Seidelmann said. “[It’s] creating an environment where people are spending more and more time on the technology, being more and more scrutinized, and nothing they can do is going to change the dynamic that they’re going to be making less money in five years than they are today.”

Advances in imaging technology “absolutely drive down-stream improvements,” he said, but without giving clinicians the ability to concentrate on processes instead of administrative work, patients won’t benefit from those advancements.

“There are things that we can do more efficiently, that we should be doing, that they don’t need to be doing,” he said. “Let’s get the physicians back to treating patients; let’s get them back to what they should be doing. It’s about process automation and getting the right support, and outsourcing a job that radiologists don’t need to be doing.”

Seidelmann said he believes that further improvements to RIS and PACS systems are long overdue, and “realistically haven’t seen any meaningful updates in a decade.” As the total cost of ownership of such systems are affected more greatly by the expansion of cloud-based storage and delivery technologies, he foresees offloading the licensing fees and associated costs of hardware, administration, and IT support that are currently tied up in RIS and PACS. Finding vendor-neutral PACS stations could also open up the marketplace to greater competition, whether through an open-source model or the tighter integration of such technologies at the manufacturer level.

“Think about what the cloud’s done in other industries, like financials and HR,” Seidelmann said. “I think the way hospitals’ margins are getting squeezed, the ability of a cloud-based PACS system to replace all that structurally ensures that the radiologist, from a workforce perspective, is connected with the episode and the outcome.”

Peter Weems, Director of Policy and Strategy at the Medical Imaging Technology Alliance (MITA), said that device-making trends in medical imaging have focused primarily on dose-reduction technologies and advanced, computing-aided diagnostics. From radiopharmaceuticals to higher-tesla magnets in imaging devices to more sophisticated detection equipment, advancements in imaging quality can be derived with lower doses of ionizing radiation and improved algorithms.

“On the analytics side, there’s a great hope that computer-assisted detection will continue to evolve, either allowing the computer to assist more in the diagnosis or make the diagnosis itself,” Weems said. “I think the expectation is that, thanks to big data and more powerful algorithms, the nuance and power of that computer-assisted diagnosis will increase.”

Being able to gather greater information from higher-resolution studies means additional advancements will come along the same lines, reducing the need for invasive surgeries, Weems said. Procedures like CT colonography and prostate MR are examples of improved information-gathering techniques that also improve patient comfort while minimizing their invasiveness.”

“It’s more patient-friendly, it’s less invasive,” Weems said. “[These therapies] can provide more information, better information, perhaps mitigating the need for biopsies, or making biopsies more minimally invasive.”

“I think the trend is that progress will continue,” he said. “We’ll be able to collect more and better information from the scans that patients receive, offering earlier and more accurate diagnosis.”

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Gloria Cascarino, Director of Medical Equipment Planning and a Senior Associate with the architecture and interior design firm Francis Cauffman, believes broader imaging technology trends are centered on automation, whether reducing keystrokes, improving image quality, or standardizing elements of procedures, trying to marry together “throughput and patient satisfaction and patient comfort,” Cascarino said.

“As a patient, I would prefer that they would concentrate on that than worry about image storage,” she said.

Cascarino said many hospitals and ambulatory care centers are also selecting technologies that either improve energy efficiency or offer a reduced equipment footprint. In environments where real estate costs are often prohibitive, purchasers embrace advancements that trend towards miniaturization; generationally, she said, MR and CT gear is trending 15 to 20 percent smaller than legacy scanners. Modular units that allow purchasers to expand on systems provide the option of starting out with a less-expensive investment that can reach sophisticated modalities like PET-CT in subsequent years and with additional investment. Alternately, hybrid operating rooms allow for the provision of an expanded range of minimally invasive interventional radiology services that hospitals and health systems are looking to provide.

“Using image guidance to find and ablate a tumor; brachytherapy, pain management – some of these procedures can be done in an outpatient setting or a short hospital stay,” Cascarino said. Howard Fleishon, MD, FACR, MMM, Director for Community Radiology Specialists for the Emory Department of Radiology and Imaging Services and Chief of Radiology Services at Emory Johns Creek Hospital in Johns Creek, Georgia, suggests that a practical clinical radiologist’s wish list would contain technologies that improve about eight or nine specific areas of the field. Chief among them is interoperability among EMR vendors for improved data exchange and image-sharing.

 “Right now the systems are inefficient and frustrating for everyone,” Fleishon said. “Lack of real interoperability creates barriers, which increases costs, takes additional time, and limits our capabilities.”

 When access is stymied by interoperability issues, patients can be subjected to repeat imaging and delays in care. Fleishon said consumers should demand the elimination of “vendor silos and proprietary walls.”

 “At this point in the evolution of radiology, barriers should be considered legacy issues,” he said. “We need to move forward. I think it’s incumbent on anybody who buys equipment to really make demands that interoperability is contingent on sales. There’s technical obsolescence that doesn’t make sense anymore.”

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Since clinical context is critical to the interpretation of images, Fleishon also believes radiologists need greater point-of-care access to clinical information. Despite the growing availability of electronic medical records, he criticized the user interfaces in which they are contained as being “difficult to navigate and time-consuming.”

 “There are some tools available, but they are not ubiquitous enough,” Fleishon said. “Being able to use clinical information is something that we want to do, and it is something that is going to be a quality performance metric going forward.”

 Along similar lines, Fleishon said he’s hopeful that OEMs will find ways to create more cost-effective cross-platform workstation communication tools to electronically send reports and images to a variety of health care providers as part of radiology workflow. Systems would have to be able to maintain accurate physician contact information amid complex organizational roles, which is admittedly a challenge, he said. But offering instantaneous communication, either by text, e-mail, or other electronic means, could spare radiologists the investment of sitting on hold with automated attendants trying to track down a piece of information, “which soaks up a lot of time,” he said.

 Among the most sophisticated and elusive technological advancements are the advancement of tumor-specific agents for therapy and diagnostic imaging, which Fleishon said remains the “holy grail of radiology.” Personalized medicine can help improve non-surgical options for cancer treatment so significantly that it “remains high on the hit list of what we really want to add,” he said.

Advanced detectors and post-processing algorithms will help drive continued reductions in radiation dose. Platforms that enable more innovative functions to be plugged right into radiologists’ workflow, rather than sitting outside of it, can also improve patient throughput and health outcomes. Modalities like PET-CT and nuclear medicine are prime candidates for these improvements.

“Supporting vendors who reduce dose will make our practices safer for our patients,” Fleishon said. “We need to keep pushing the physics as much as we can.”

 Fleishon also would like to see device-makers focus on finding ways to enhance voice recognition functionality with natural-language processing. Current platforms are error-prone and rely on self-editing “to avoid embarrassing if not impactful reporting mistakes based on inaccurate voice recognition,” he said.

 “Sometimes the word ‘no’ either gets inserted or left out,” Fleishon said. “You can imagine the impact of that. Clinicians want to sync reporting as well, so a lot of them only listen to the conclusions.”

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 Fleishon said he awaits next-generation software that can anticipate and auto-correct verbal miscues based on context and user profiles; such technology can increase reporting efficiency while reducing medical errors. Future improvements could also perhaps include real-time analysis tools that check for institutional goals like completeness, compliance, or billing information. The same technology could be used to create patient-level summaries of complex information; or even reformat an unstructured report into something consistent with in-house style.

 Also on the horizon, Fleishon said radiologists will be watching for imaging technologies to benefit from advancements in deep machine learning. The possibilities of more sophisticated pattern recognition yielded therein can help expand the toolset of clinicians to offer “more accurate and actionable reporting data” that he said will help advance patient care and automate elements of diagnosis.

 “When radiologists embrace this future, our practices and departments will be seen as even more critical in integrating care delivery systems,” Fleishon said. Such technologies can “really make [radiology] a mature, usable, functional, clinically relevant tool that can enhance the modalities that we bring to patient care,” he said.   

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