Published online before print August 9, 2007, 10.1148/radiol.2443070165
(Radiology 2007;244:633-638.)
© RSNA, 2007
Reinventing Radiology in a Digital and Molecular Age: Summary of Proceedings of the Sixth Biannual Symposium of the International Society for Strategic Studies in Radiology (IS3R), August 25–27, 20051
Gabriel P. Krestin, MD, PhD,
Janet C. Miller, DPhil,
Stephen J. Golding, FRCR,
Guy G. Frija, MD,
Gary M. Glazer, MD,
Hans G. Ringertz, MD, PhD, and
James H. Thrall, MD
1 From the Department of Radiology, Massachusetts General Hospital, Boston, Mass (J.C.M., J.H.T.); John Radcliffe Hospital, University of Oxford, Oxford, England (S.J.G.); French Society of Radiology, Paris, France (G.G.F.); Stanford University School of Medicine, Stanford, Calif (G.M.G.); Karolinska Hospital, Stockholm, Sweden (H.G.R.); and Department of Radiology, Erasmus Medical Center, University Hospital Rotterdam, Dr Molewaterplein 40, 3015 GD Rotterdam, the Netherlands (G.P.K.). Received January 25, 2007; final version accepted January 29.
Address correspondence to G.P.K. (e-mail: g.p.krestin{at}erasmusmc.nl).
Escalating costs and inadequate quality and safety are major concerns of health care at this time. The first, increasing cost of health care worldwide, can be attributed in part to the aging of populations, but it is also due to the successful treatment of acute illnesses and the resultant shift toward the expense of caring for the chronically ill, which now accounts for 75% of the costs (1). But with 2001 health care costs comprising 14% of the gross domestic product in the United States and with an expected increase to 18% by 2012 (2), there is considerable pressure from employers, insurance companies, and the government to limit health care spending to a sustainable amount and to make the system more accountable.
Radiology is not immune to these worldwide health care concerns. In 1990, U.S. radiology costs accounted for about 3.5% of the national spending on health care (3). Overall, diagnostic radiology utilization rate increases have been modest in the United States, with a 3.1% compound annual increase for Medicare enrollees in the period 1992–2001 (4). However, utilization of high-cost radiology services increased dramatically in the past decade, as has been demonstrated for Medicare enrollees (4–9), privately insured groups (4,6,8), and within individual institutions (10,11). Data for Medicare enrollees, which are more complete than those for other populations, show a trend of double-digit annual rate increases in utilization of computed tomography (CT), magnetic resonance (MR) imaging, and nuclear imaging in the years 1992–2001 (4).
The second major health care concern involves quality and safety. The rate of adverse events in medical care in the United States is 3%–4% (12,13), which may result in $28 billion in unnecessary expense and as many as 44 000–98 000 deaths per year due to provider error (14). In radiology practice, quality includes obtaining the best possible images through quality assurance programs and through the appropriate selection of modality and protocol. Safety issues include avoiding injury due to the effects of magnetic fields on metallic implants, contrast agent reactions, radiation exposure, and ensuring that there is adequate monitoring of patients for adverse events.
Rapid technologic advances in radiology have increased the concerns regarding utilization, as well as quality and safety. By the end of the second millennium, computerized workstations have now become commonplace, picture archiving and communications systems (PACS) and radiology information systems (RIS) are widespread, the Internet is almost essential for the transfer of images and other information, and computer-aided detection (CAD) has been developed as a useful tool. Recent innovations in imaging suggest that radiology will be a major catalyst for transforming medicine into an age of information technology and molecular medicine.
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ADVANCES IN TECHNOLOGY-DRIVEN INCREASED UTILIZATION
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As technology has improved, image acquisition has become faster and pixels have become smaller, leading to new applications such as cardiac imaging, CT colonography, CT pulmonary angiography, and many more (15,16). With so many technologic advances, it is not surprising that the radiologic utilization of high-cost studies, such as CT and MR imaging, is expanding rapidly worldwide. Overall, CT use in the United States increased from 9.2% to 15.3% of radiologic examinations, while conventional radiography decreased from 70% to 57.1% (17). This has resulted in larger and more complex workloads, but not proportionally higher costs to the consumer. In fact, radiology cost-to-service ratio decreased 19% in inflation-corrected dollars from 1992 to 1999 (18). The workload and complexity of radiology services have also increased in Europe. However, there is considerable disparity in the utilization rates of high-cost imaging not only among European countries but also between U.S. states (4,19).
The number of radiologists in the Unites States has not increased at the same rate as the number of examinations. During the past decade, the workforce has increased at a rate of 1%–1.5%, while the average workload increased from 11 100 to 13 900 procedures per year or 6000 to 9100 relative value units per year. This translates to a workload increase of 25.1% in terms of procedures per full-time equivalent and 52.2% relative value units per full-time equivalent from 1992 to 2002 (17). Despite this increase in workload, the shortage of radiologists does not appear to have worsened as judged by the number of job advertisements (20), although shortages of manpower are found in certain specialties, such as mammography, vascular and interventional radiology, and pediatric radiology (20). In Asia, the radiology workforce has increased substantially over the past few years, but the number of radiologists is grossly inadequate in many countries, especially in rural districts, because most radiologists work in the big cities (21). Among European countries, there are considerable disparities in the radiology workforce, and teleradiology is used to compensate for the lack of local radiologists (22) (Figure).
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IMPACT OF DIGITAL TECHNOLOGY AND INFORMATION MANAGEMENT ON PRODUCTIVITY
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Largely due to innovative technology, radiologists have been able to manage their increased workload by means of digital imaging, computer workstations, speech recognition technology, PACS, and the ease of communication via the Internet. PACS installations improve efficiency by providing a faster reading of images and quicker and more accurate diagnoses, which lead to prompt treatment and patient satisfaction (23). PACS and RIS aid communication both within and outside the hospital or radiology practice by facilitating the transfer of images and reports to all physicians involved in a patient's care. This decreases the need for personal consultation (24). However, only one-third of radiology practices in the United States have installed a PACS system, although another third have plans to purchase one (25).
Teleradiology increases productivity indirectly by reducing or eliminating the need for on-site radiologists in small hospitals and private practices during nights and weekends. The largest use of teleradiology is from base to home in both Europe and the United States (26). In some countries, teleradiology is used to compensate for a manpower shortage. For example, teleradiology is used to read some images generated in the United Kingdom by radiologists in Spain or Belgium (22). In much of Asia, most radiologists work in the cities, and teleradiology allows them to provide services for patients in rural areas (21).
Although the turnaround time for teleradiology can be rapid, there are concerns about its quality (27). An American College of Radiology Task Force on Teleradiology (28) has recommended that physicians reading studies on U.S. patients while outside the Unites States should be licensed in the states where the studies originated, should be credentialed and afforded privileges by the health care institutions contracting them, and should carry liability insurance. Nevertheless, the oversight of radiology practices thousands of miles away is difficult, and there are fears that these radiologists will not follow the rigorous quality assurance procedures just mentioned or observe privacy rules.
CAD, which uses software to distinguish between normal and abnormal patterns and for image enhancement, has been developed to draw the attention of the radiologist to possible lesions for evaluation. Radiologists regard CAD as a time saver that is comparable to a second opinion rather than a replacement for radiologists. Accumulating evidence indicates that a radiologist with CAD is better than a radiologist or CAD alone. For example, detection of breast cancer on mammograms with CAD assistance has been reported to be 16%–20% higher than the radiologist alone, with more tumors detected at an earlier stage, but no change in the pretest prediction rate for biopsy (29,30). The acceptance of CAD for mammography is illustrated by the fact that the number of ImageChecker (R2 Technology; Santa Clara, Calif) CAD installations increased from 200 in 2001 to 1600 in 2005, following reimbursement approval in 2001 (31).
CAD applications for diffuse lung disease classification have been developed and are accurate 88%–100% of the time compared with a reference standard (32). Applications in the detection of pulmonary nodules on chest radiographs and chest CT scans are also promising. Currently, there is considerable work on the development of new, selective enhancement filters to better distinguish blood vessels from nodules (33) and to detect aneurysms (34) and other abnormalities. A major goal for CAD is to reduce false-positive rates without reducing sensitivity through the use of Massive Training Artificial Neural Network (35), which is designed to detect differences between benign and malignant nodules (36,37).
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RADIOLOGY REPORTING AND COMMUNICATION
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Another form of digital technology, speech recognition, is steadily replacing audio recording and transcription for reporting. With speech recognition, dictated words are instantly seen on a computer screen and edited immediately by the radiologists, speeding the generation of radiology reports from days to hours (38,39). Although speech recognition technology requires additional radiologist time, especially during the learning process, newer software is much easier to use than earlier systems because it can "understand" contextual speech, learn words, and predict phrases based on previous speech. There is still a need to improve recognition rates because accuracy is estimated to be about 95%–96% (39); however, a study showed that one-third of conventionally dictated and transcribed reports had errors requiring editing and 6% had substantive errors (40). While the widespread implementation of speech recognition would be cost-effective, digital speech recognition has been met with resistance. Therefore, before speech recognition systems are installed, considerable time and effort must be spent on overcoming radiologists' concerns (41).
Despite the many changes in the practice of radiology, report format has changed little and a transcript of a 19th-century report could be mistaken for one of today: a lengthy descriptive narrative covering indications for the study, observations, analysis and/or diagnosis, and a recommendation for further imaging (if any). Although reports tend to be lengthy, the number of important concepts that are included is remarkably small, usually no more than three to four in a single report (42). Also, the current narrative radiology report format is far from ideal because the reports tend to be defensive, straightforward diagnoses are rare, and the language used is more suited to communicating with other radiologists than referring physicians (43).
Communication failures lead to patient alienation (44) and a reduced quality of care. Seventy to 80% of malpractice lawsuits involving radiologists cite communication problems (45). PACS systems minimize the numbers of unread images and reports, but there is still a need to ensure that reports reach ordering physicians, especially in emergent or other nonroutine clinical situations (46). Direct communication with a referring physician in person or by telephone is recommended by the American College of Radiology (46), but can be difficult and lengthy. Difficulties are compounded when medical care is not rendered by a single physician, when the referring physician is not clearly identified, or when the referring physician is a surgeon who takes no responsibility for medical problems unrelated to the planned surgery. Therefore, it would be helpful to have a fail-safe system of communication that automatically acknowledges report receipt when the referring physician opens the report file.
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REDESIGNING PATIENT CARE THROUGH DATA-DRIVEN MANAGEMENT
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PACS, RIS, and hospital information systems contain a wealth of information that can be used to drive improvements in health care. However, communication between the different information systems used in patient care is poorly developed. Special software, such as LEXIMER (Lexicon Mediated Entropy Reduction), has been developed that can analyze and classify unstructured radiology reports based on the presence of key words for clinically important findings, descriptors of severity, and recommendations (47). Data mining of this sort can generate huge amounts of information for quality and safety management in radiology practices, as well as for generating teaching files, retrieving previous images of unusual medical conditions to aid in diagnosis, and developing evidence-based medicine.
The potential value of standardized health care information exchange and interoperability between providers and others in the health care industry is enormous. Savings could accrue by eliminating test duplication and adverse drug interactions and by simplifying record chart processing. The net value of savings from preventing the duplication of radiology examinations would be approximately $8 billion per year in the United States (48). Achievement of these savings will require investing in interfaces to translate heterogeneous electronic vocabularies and developing seamless integration with both local and remote medical records.
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QUALITY AND SAFETY ISSUES
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Even in a radiologic practice with 99.9% reliability, quality and safety controls are a necessity. Missed diagnosis is, perhaps, the most important error in the practice of radiology (49–51). Peer review combined with RIS analysis for the number of changed reports has been used to assess the quality of diagnoses. Also, data mining using software such as LEXIMER (47) can provide information about the variations in the number of examinations ordered, findings, and recommendations. Furthermore, utilization management could be assessed by comparing the number of examinations ordered by individual referring physicians, and quality assurance could be accomplished by counting the number of findings in radiologists' reports. When substantial discrepancies occur without a reasonable explanation, practice standards of individual physicians should be examined. A system that systematically reports medical errors, near misses, complications, and discrepancies, in combination with meetings to identify causes of error, may lead to the prevention of future problems (49). For this strategy to be successful, the error reporting process should be nonthreatening and confidential. Radiology has been a pioneer in implementing such systems (52,53).
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EVIDENCE-BASED RADIOLOGY
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Practice guidelines on imaging applications vary among different radiologic societies, and the process of developing guidelines can be more political than scientific. At present, imaging protocols are passed from one radiologist to another like recipes from a neighbor and are freely adapted and changed. To improve diagnostic accuracy, image acquisition protocols that can achieve consistent image quality and reproducible diagnoses must be designed and validated through research. In addition, guidelines for the effective use of imaging need to be established to eliminate underuse, misuse, and overuse (54,55).
Computer-based decision support at the time of order entry has been found to improve performance by delivering preventative reminders and drug doses (56). Computerized order entry systems with embedded decision support have recently been introduced for radiology, and there is preliminary evidence that it does affect clinical ordering patterns (57,58). Decision support is particularly effective because it offers an alternate examination for any given clinical symptom, whenever possible.
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MOLECULAR MEDICINE
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The ultimate goal of molecular medicine is to treat disease in its early stages, with the appropriate therapy at the lowest possible cost. To achieve this goal, we envisage the use of genetic screening to identify those who are at risk for disease and to detect incipient disease by screening selected high-risk groups for specific illnesses. Through the early detection of disease, it will be theoretically possible to intervene before symptoms appear and before the loss of normal function. This strategy will be cost-effective by lowering the costs of disability and of treating advanced disease.
Scientists have already identified genes that predict and predispose individuals to future disease (59). Similarly, genes that are overexpressed in cancers have been discovered, and researchers have developed drugs that target the relevant gene product developed, such as trastuzumab (Herceptin; Genentech, San Francisco, Calif) for breast cancer (60) and bevacizumab (Avastin; Genentech) for rectal and colon cancer (61). In the future, molecular imaging methods that target gene products will be used to detect, localize, and quantify gene activity. Thus, noninvasive methods will be available to monitor changes in gene activity in order to predict and monitor therapeutic effectiveness. These methods are already in use for laboratory research on disease mechanisms and preclinical drug development.
The National Institutes of Health has recognized the importance of molecular imaging by founding an Imaging Probe Development Center to encourage the development of molecular libraries (62). The libraries will be made up of agents that target specific proteins and that gather data rapidly and noninvasively, leading to a better understanding of the molecular interactions in biology and the mechanisms of disease. The Imaging Probe Development Center is coordinating its efforts with molecular library screening centers to help overcome some of the roadblocks in the development of molecular agents, such as toxicity studies, as well as probe sensitivity and specificity. Once developed, the knowledge of molecular imaging agents and other contrast agents can be promulgated via the Web, through sites such as the National Institutes of Health Molecular Imaging and Contrast Agent database.
Both molecular imaging agents and functional imaging techniques show promise as surrogate end points for clinical trials. For cancer, determining the effectiveness of a new drug by using the clinical end point of extended survival requires clinical trials that take years. However, use of positron emission tomography (PET) to measure early changes in the uptake of fluorine 18 fluorodeoxyglucose (FDG) has been shown to be a predictor of survival for some cancers (63). Other biomarkers of cancer detectable with imaging include hypoxia, cell proliferation, and apoptosis. FDG PET has been shown to depict inflamed atherosclerotic plaque (64). By using this discovery, imaging biomarkers for another major killer, cardiovascular disease, are also being developed.
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EDUCATION AND RESEARCH TRAINING
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For radiology to play an important role in the development and application of new technologies and imaging methods, clinical research needs to be rejuvenated through the creation of new academic centers that are dedicated to translational research, positioned to understand the complexity of regulations, and committed to providing a sheltered environment for research. These centers will be integrated via the Internet through the National Electronic Clinical Trials and Research information system, which provides end-to-end clinical research data management tools and facilitates effective business practice, enhanced data sharing, and rapid translation and diffusion of research results.
Although support for radiology research has nearly quadrupled in the decade of 1995–2005, research programs are unevenly distributed in the United States. Of the 160 medical schools, half had no radiology research support, while 50% of the grant money went to only seven departments (65). Institutional leadership and radiology department commitment are needed to increase research training, develop research themes, and support those involved in the challenging and time-consuming process of translating basic research into clinical practice. Radiology departments should hire more researchers with PhD degrees in allied fields to develop multidisciplinary teams. Failure to achieve these goals will result in other medical specialties owning the advances in imaging, while radiology departments are relegated to trade schools. To preserve our future, radiologists should take advantage of the research support available both in Europe, through the European Institute for Biomedical Imaging Research, and in the United States, through the National Institute of Biomedical Imaging and Bioengineering.
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FOOTNOTES
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Authors stated no financial relationship to disclose.
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