The impact of Information Technology on Radiology Services
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In this thesis the impact of digitisation on radiology is analysed based upon diverse initiatives and research projects that were conducted in the period between the early days and now. Various topics such as web-based sharing of radiological images, teleradiology, digital communication and advanced processing of medical data, are discussed. Based on these findings the author formulates his vision and advises about the future role of the radiologist. In the dissertation The impact of information technology on radiology services the author describes the most important changes that took place in the field of information technology since the end of past century, and their impact on radiology. A real revolution has been provoked in radiology by the complete digitisation of medical imaging and the deep integration of Internet in both society and healthcare. Digital archiving, processing and distribution of radiological images, as well as the development of various types of teleradiology, are an important part of this change. Radiology is facing many new challenges and opportunities due to the on-going exchangeability, integration and automated analysis of medical data and images. Other major trends such as the increasing personalisation of medicine and growing engagement of patients in their healthcare process are also significantly influencing this turnaround in radiology.
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The impact of Information Technology on Radiology Services
- 3. Major trends • Growing digitisation of society & medicine. • Mobile communication. • Growing costs in HC. • Great faith in telemedicine. • Patient empowerment. • Holistic view in medicine and radiology.
- 5. WHEN WIRELESS IS PERFECTLY APPLIED THE WHOLE EARTH WILL BE CONVERTED INTO A HUGE BRAIN (Nikola Tesla, 1926)
- 7. Questions
- 8. Methodology Q1: What is the impact of digitisation and Internet on radiology services? Q2: Did Internet allow the creation of useful tools for radiologists and patients? Q1: What is the impact of digitisation and Internet on radiology services? Q2: Did Internet allow the creation of useful tools for radiologists and patients? Q3: What were the key factors for the development of teleradiology? Q4: What services are included in teleradiology? Q5: How did teleradiology develop in the EU vs. the US? Q6: What is the future of teleradiology? Q3: What were the key factors for the development of teleradiology? Q4: What services are included in teleradiology? Q5: How did teleradiology develop in the EU vs. the US? Q6: What is the future of teleradiology? Q7: How will the major trends influence radiology?Q7: How will the major trends influence radiology?
- 9. Radiology and internet: from the first steps to the revolution Chapter 3 and 4
- 10. Propositions 1. The widespread adoption of the Internet has resulted in the availability of new tools and services for both radiologists and patients. 2. The digitisation in medical imaging and availability of high-bandwidth Internet have a significant impact on the way radiology services can be delivered.
- 11. Radiology and Internet: first steps • Early days - Web 1.0 – “Static” web pages – Users are “consumers of content” – Social interaction only via e-mail, discussion groups, newsgroups • Web 2.0 – “Architecture of participation” – Users provide data & generate content – Development of social media, more social interaction between users – “Collective intelligence”
- 12. Web 1.0 example • EUFORA mailing list, 1998 – 2001 • Discussion group for radiologists • Linked to image database CONRAD (jpg) • Users: • 460 members • > 48 countries • 2-3 messages/day • “Collaborative” medium: • Exchange of information • Requests for second opinion • Group-wise presentation of cases • Objective : • Stimulate radiologists in using e-communication • Support them in their continuum of learning
- 13. Join the discussion! Create discussion
- 14. Web-based image sharing and distribution • Thanks to the WWW images and patient data can be shared more easily. • Web-based tools were created for displaying and manipulating medical images. • Images could be viewed on any PC or other (mobile) device. • It became possible to communicate and discuss images online.
- 15. Web-based image distribution PACS Viewing station Viewing station Web Server CR CT MRI US Viewing devicesRadiologists Modalities
- 16. Revolution in radiology • Information technology (IT) has led to the digitisation of radiology. • Images are created, stored, transmitted and analysed digitally. • The digitisation is associated with other technological developments, such as PACS, RIS and HIS.
- 19. The digital radiology department Billing HIS RIS Speech Bridge PACS Viewing station Modality DICOM HL-7 Patient Radiologist HIS = Hospital Information System RIS = Radiology Information System PACS = Picture Archiving and Communication System
- 20. New development: the Cloud Traditional image storage • “Siloed” architecture – Intensive & expensive to manage – Insufficient bandwidth – Vulnerable to failure & downtime – Different for each site Cloud-based image storage • “Virtualized” architecture – Shared & cost-effective storage capacity – High speed accessibility – Single point of access: EPR, Portals – Elimination of redundancy Site 1 Site 2 Site 3 … Site 1 Site 2 Site 3 …App 1App 1 App 2App 2 App 1App 1 App 1App 1 App 10App 10 App 1App 1 App 2App 2 App 1App 1 App 1App 1 App 10App 10 Cloud based storage platformCloud based storage platform Source: SIIM Webinar Jan 28, 2016: “Real world challenges and benefits of cloud technologies”
- 22. Propositions 1. The ability to electronically share patient-related information and radiological images has been key to the development of teleradiology 2. Teleradiology is a broad term for a variety of applications in which radiological images are shared electronically 3. Teleradiology has developed in a different way in the EU and the US 4. Teleradiology is here to stay, although the format by which teleradiology services are delivered is likely to change
- 23. Chapter 5 1. Teleradiology: evolution and concepts. 2. European teleradiology now and in the future: results of an online survey. 3. ESR White Paper on teleradiology: an update from the Teleradiology subgroup. 4. Comparison of European (ESR) and American (ACR) White Papers on teleradiology: patient primacy is paramount.
- 24. The doctor of the future “The doctor of the future” using radio and television to give a consultation to his patient aboard the ship ‘India’ in the South Seas. 1939, © Fritz Kahn - www.fritz-kahn.com “The doctor of the future” using radio and television to give a consultation to his patient aboard the ship ‘India’ in the South Seas. 1939, © Fritz Kahn - www.fritz-kahn.com TeleradiologyTeleradiology
- 25. Development of teleradiology • Key-factors: – Shift from analogue to digital imaging – PACS (Picture Archiving and Communication Systems) – High Bandwidth • Possible through availability of mechanisms to quickly and affordably transmit digital data over large distances
- 26. What is teleradiology? • Teleradiology is part of telemedicine. • Variant of radiology, existing medical practice. • Remote activity by radiologist. • Electronic transmission of patient data. – Examination request + relevant clinical information – Radiological images + priors – Patient-identifiable health-related information • Crossing boundaries of hospital/organisation. – Sometimes across national boundaries
- 27. Teleradiology applications 15. Social Media15. Social Media 13. Case presentations
- 28. Teleradiology models Peripheral Hospital Private Diagnostic Centre Peripheral Hospital Private Diagnostic Centre Hospital group Regional network of hospitals Hospital group Regional network of hospitals Teleradiology companyTeleradiology company • On-call radiologist’s home • Insourcing, distribution of workload • Intra- and inter-institutional • Emergency readings, expert opinions (trauma, stroke…) TR OutsourcingOutsourcing TR Commercial TR services OutsourcingOutsourcing LocalLocal Regional National Regional National National International National International Insourcing OutsourcingOutsourcing
- 29. Progressive shift of discussion 10 yrs
- 30. Chapter 5 1. Teleradiology: evolution and concepts. 2. European teleradiology now and in the future: results of an online survey. 3. ESR White Paper on teleradiology: an update from the Teleradiology subgroup. 4. Comparison of European (ESR) and American (ACR) White Papers on teleradiology: patient primacy is paramount.
- 31. Survey background • Overview of teleradiology usage in Europe • Evaluation of opinion about teleradiology • Evaluation of future role of teleradiology • Online survey • European radiologists • Sept. – Nov. 2011 • 32 multiple-choice + 3 open questions • 368 participants from 35 European countries Objectives Materials and Methods
- 32. Results • Majority uses teleradiology (TR) 65%* • Insourcing 71% • Outsourcing 35% • Most of TR is used for on-callpurposes 44% • Commercial TR services used by only 52% of those who do outsource • In 15% of outsourcing images are sent cross-border • Cross-border teleradiology needs better legislation, price regulation and QA framework * % of total number of participants
- 33. General advantages of teleradiology Agree % Disagree % Possibility to collaborate 74 11 Improves efficiency 70 13 Ability to sub-specialise 65 13 Better distribution of workload 65 10
- 34. Outsourcing Advantages • Greater capacity • Faster TAT, 24/7 service • Availability of subspecialty knowledge • Workload reduction, lifestyle improvement Disadvantages • Less communication with teleradiologist • Limited access to clinical data and priors • Less contact with radiographers • Legal issues to be solved e.g. cross-border in EU • Price competition
- 35. Ideas about future • 80% positive • 46% thinks its importance will grow • Most important reasons for growth: – Shortage in radiologists – Need for sub-speciality expertise – Growing need for emergency readings – Greater flexibility for smaller practices
- 36. Chapter 5 1. Teleradiology: evolution and concepts. 2. European teleradiology now and in the future: results of an online survey. 3. ESR White Paper on teleradiology: an update from the Teleradiology subgroup. 4. Comparison of European (ESR) and American (ACR) White Papers on teleradiology: patient primacy is paramount.
- 37. European agenda: e-Health • The 'Europe 2020 vision' is opening the way for e-Health. • e-Health is believed to have the potential to reduce public expenditure on healthcare. • Coordinated effort to overcome the current barriers. • Support of standards for seamless sharing of medical information (e.g. IHE-XDS). • Teleradiology is therefore very likely to become an integral part of healthcare delivery across Europe.
- 38. ESR position on teleradiology • 2004 EAR-UEMS Position Paper • 2006 ESR-UEMS White Paper • 2009 ESR response to EC communication on telemedicine COM(2008)689 • 2011 ESR response to public consultation on eHAP 2012-2020 • ESR position: – Medical act – Need for European accreditation criteria – Need for international quality standards – Responsibility of country where patient undergoes exam – Informed consent
- 39. ESR White Paper • e-Health and Informatics subcommittee • Teleradiology subgroup • Collective online discussion of topics, sharing of information and writing of paper • Approval from ESR executive council before publication • Update 2006 White Paper: – On-going digitisation – EU-promotion of telemedicine and e-Health • Comprehensive best- practice guideline for teleradiology usage in EU Objectives Materials & Methods
- 40. Topics white paper 1 Teleradiology usage in Europe 2 EU Legal framework 3 Licensing and registration 4 Teleradiology as a medical act 5 Patients’ rights and informed consent 6 Liability issues 7 Technology- and security-related issues 8 Work environment and ergonomics 9 Communication principles (incl. language, structured report) 10 Contracting and financing 11 European diploma (EDiR) 12 Teleradiology training
- 41. Key issues QA framework: Q standards and Q regulations International harmonisation of patient privacy regulations GDPR April ‘16 Seamless integration of PACS, RIS, EPR IHE-compliant IT-systems More uniform legislation: protection of patient’s rights, licensing and liability National financing and reimbursement systems need to be harmonised Semantic interoperability: international lexicon, standardised terminology, translation software
- 42. Chapter 5 1. Teleradiology: evolution and concepts. 2. European teleradiology now and in the future: results of an online survey. 3. ESR White Paper on teleradiology: an update from the Teleradiology subgroup. 4. Comparison of European (ESR) and American (ACR) White Papers on teleradiology: patient primacy is paramount.
- 43. Different teleradiology markets EU US Type of readings Final Preliminary Off-hour 44% 44% Outsourcing 35% 70% Insourcing 71% - Competitive pricing Moderate High Growth >15% Shrinking
- 44. Common viewpoints • Patient primacy: patients should come first. • Quality and safety are essential and have to be maintained. • TR services need to be fully compliant with local policies and procedures. • Access to prior imaging studies and patient information is important. • On-site radiology services are preferable to outsourced radiology services • Both have fear for further commoditization by outsourcing.
- 45. Different viewpoints • Teleradiology concept: outsourcing in US, outsourcing + insourcing in EU. • Different market situation and politics. • Cross-border / international vs. domestic teleradiology. • Informed consent: only in Europe. • Strengthening position of local radiologists in US vs. uniform European quality training (EDiR). • Local language requirements in EU, no language issues in US. • Communication of critical findings: highly regulated in the US, in EU recommendation for protocols.
- 46. Social media in radiology Chapter 6
- 47. Proposition • Major trends, such as the growing usage of mobile devices, the popularity of social media, the on-going implementation of telemedicine and increasing patient empowerment, will have a significant impact on the way radiological services are provided.
- 48. Chapter 6 1. Social media for radiologists, an introduction 2. Radiologists’ usage of social media: results of the RANSOM survey
- 49. Web 2.0 • Social media and networks are a typical Web 2.0 product • They replace traditional communication methods • Mobile devices have contributed to their success • They make use of public cloud services • On-going shift from Web 2.0 to Web 3.0 Web 2.0 Web 3.0 Real-time data “Think apps”, non- browser User-generated content Semantic and meaningful data Go social! Emphasis on personal data Content gathering Portability, clouding Mobile, WiFi Digital wearables, Internet of Things (IoT)
- 50. Major impact on healthcare • Radiological images are going mobile too • Interesting in emergency setting: – e.g. Telestroke network – CT images are sent to doctor on distance – Decisions for treatment are made based upon these images • Supported by Cloud-based technology • Patient safety and security needs to be protected Source: http://www.imedicalapps.com, Jul. 10, 2010 ER Ranschaert, Teleradiology
- 51. Secured cloud-based exchange Private Cloud MRI scanner Radiologist PACS server Institution A Community Hospital Physician office Institution B Specialty Hospital Radiologist Institution C Community Hospital Radiologist 51 Mobile device physician/radiologist/patient
- 52. Radiologists using WhatsApp • “At 11 PM I got this picture of an angiogram from another radiologist via WhatsApp. The patient was in coma, almost dead.” • “He wanted to know more about what he was seeing on the angiogram is, and he made a picture of the angiogram on the screen of the workstation. I’m specialised in cerebral stroke and saw that it was a thrombosis of the basilar artery with a rare anatomic variant of the vessel.” • “I could explain him how to deal with this abnormality. The patient could be treated quickly. After the treatment he woke up and could go home.” 52 Croonen H. Veilig whatsappen een must voor dokters. Med Contact 2015(48):2312-5. Geert Lycklama à Nijeholt, Bronovo ZH, Den Haag
- 53. Social media for radiologists Benefitsand opportunities • Improvement of radiologists’ visibility among clinicians and patients. • Increased interaction with clinicians. • Exchange of information and knowledge. • Distribution and discussion cases for education and research. • Sharing of radiological images with peers and clinicians. • Increased impact and influence in the medical community. • Active engagement during scientific meetings. • Augmenting the visibility of scientific publications .
- 54. Pitfallsanddangers • Insufficient or inappropriate legislation and policies in hospitals/practices • Insufficient separation of personal and professional data • Insufficient privacy settings (who can see/read what I post)? • Insufficient protection of patient privacy (informed consent?) • Lack of obvious guidelines • Lack of review of published material Social media for radiologists
- 55. RANSOM Survey • Objectives: – How many, how and why do radiologists use social media? – What are the differences between EU and US ? • Online March – May ’15 • 516 radiologists J Digit Imaging. 2016 Feb 3. [Epub ahead of print] Radiologists' Usage of Social Media: Results of the RANSOM Survey.
- 56. Radiologists and SoMe 56 J Digit Imaging. 2016 Feb 3. [Epub ahead of print] Radiologists' Usage of Social Media: Results of the RANSOM Survey.
- 57. Major concerns Insufficient legislation, guidelines and policies for SoMe in healthcare 75% Risk for privacy of the patients 39% Risk for privacy of radiologists 39% Insufficient knowledge about social media among radiologists 37% Distraction from clinical activities 28% Deprivation from real social contact with others 18% Danger of negative comments on our practice 13%
- 58. What did we learn? • Most radiologists use social media, private >> professional. • Most popular professional platforms: – in Europe -> LinkedIn – in the US -> Twitter • European radiologists – To keep up with the news – To discuss interesting cases • American radiologists – To make radiologists more visible – To market radiology services • Radiologists need guidelines and policies to use social media US EU
- 59. conclusionS and FUTURE PERSPECTIVES Chapter 7
- 60. Overall summary • 3 major innovations in IT 1. Internet 2. Broadband connections 3. Rise of mobile networking and data exchange • Impact on radiology – The filmless, full digital department is now reality – Teleradiology has many applications and is still evolving – Standards & guidelines are essential to share images and patient data efficiently, safely and securely – A digital & mobile society is developing in which health-related information can be shared more easily
- 61. Where are we going? • Availability of patient’s health-related data, independent of time and location • Shift from hospital-centric to patient-centric hospital The liquid hospital
- 62. The liquid hospital The journey of the autumn leaves, by Theo Bosboom – www.theobosboom.be
- 63. Shift of HC model Hospital-centric model Patient-centric model Hospital centric Episodic Departments Proprietary Data silos Patients
- 65. Redefine radiology • Easy & fast sharing of data • Use of mobile devices • Embracement of Artificial Intelligence • Imaging for personalised care • Image-guided treatments • Patient communication – e-Consultation – Multimedia reports Eliot Siegel, schooling IBM’s Watson at the University of Maryland; Image courtesy RSNA.org
- 68. “Replace ‘I’ with ‘we’ and illness becomes wellness.”
Editor's Notes
- De digitalisering en de algemene beschikbaarheid van technieken om op snelle én goedkope wijze digitale data te versturen over grote afstanden heeft het ontstaan van teleradiologie met zich meegebracht.
- Het is nodig deze veranderingen te situeren in de context van de veranderingen die op macro-niveau, plaatsvinden, maw in de samenleving, in de technologie en in de gezondheidszorg. Toenemende digitalisering van de samenleving en geneeskunde Communicatie wordt mobiel, gebruik van mobile devides en social media Toenemende kosten in de zorg – nieuwe financiering nodig Men gelooft zeer sterk in de mogelijkheden van telemedicine De term Telemedicine of telegeneeskunde verwijst naar het aanbod van medische diensten via het Internet, in in de breedste betekenis van het woord. Dit kan gaan van voeding- of slaapadvies tot bijv. een dermatologisch consult. Patient empowerment: De patienten zelf krijgen ook steeds meer toegang tot hun eigen medische gegevens – waar ze overigens ook recht op hebben. Dit betekent dat ze zelf ook meer actief betrokken kunnen worden in de behandeling van hun aandoening. More holistic view on medicine en radiologie: Different systems are integrated. Online access to medical data (mobile). Collection of big data for intelligent processing, rol van IoT en “wearing devices”. Multidisciplinary engagement of radiologists.
- Alle apparaten kunnen draadloos gekoppeld worden (Internet of Things) Alle data kunnen draadloos verstuurd en uitgewisseld worden Alle gegevens worden langzaam maar zeker meer integreerbaar
- Er ontstaat een collectief brein Dit wist Nikola TESLA reeds in 1926:
- De digitalisering en de algemene beschikbaarheid van technieken om op snelle én goedkope wijze digitale data te versturen over grote afstanden heeft het ontstaan van teleradiologie met zich meegebracht.
- De digitalisering en de algemene beschikbaarheid van technieken om op snelle én goedkope wijze digitale data te versturen over grote afstanden heeft het ontstaan van teleradiologie met zich meegebracht.
- OSIRIS, University Hospital of Geneva, 1997 Nu OSIRIX genaamd Open source software voor Apple computers Uitvinder = Osman Ratib and Antoine Rosset, Universiteit van Genève Is nu uitgewerkt tot volwaardig PACS systeem gebaseerd op Web-technologie
- De digitalisering end de IT hebben de laatste 15-20 jaar een enorme opmars gemaakt binnen de radiologie De eerste steen voor deze thesis werd eigenlijk gelegd door de combinatie van 2 innovaties die zich vrijwel tegelijk ontwikkelden: de toegang tot het Internet en de digitalisering van de radiologie. Vrijwel onmiddellijk zag ik de enorme mogelijkheden om deze technieken te combineren, en ik voelde dan ook meteen de onweerstaanbare drang om ermee aan de slag te gaan. Mijn eerste project was “The Belgian Radiology Link”, één van de eerste websites voor radiologen die vrij snel internationaal bekend werd. Hoewel ik nog niet over digitale radiologiebeelden beschikte, wilde ik toch aan collega’s radiologen uit de hele wereld de mogelijkheden van het Internet laten zien. Dit deed ik oa door interessante radiologische informatie via mijn website beschikbaar te stellen. Hieruit is later ook de EUFORA mailing list gegroeid, en dan later mijn activiteiten op het vlak van teleradiologie – wat ik nader zal toelichten in deze presentatie. PACS RIS = Radiologie informatie system HIS = hospitaal informatie systeem: gemaakt met als doel alle onderdelen van de in het ziekenhuis uitgevoerde handelingen te beheren, maw de verwerking van medische, administratieve, financiële en wettelijke gegevens van de patient, en de daarmee samenhangde verwerking van geleverde diensten
- De digitale radiologie-afdeling bestaat uit 2 onderdelen die met elkaar verbonden zijn Het administratieve gedeelte Het Beeldvormingsgedeelte
- De digitalisering en de algemene beschikbaarheid van technieken om op snelle én goedkope wijze digitale data te versturen over grote afstanden heeft het ontstaan van teleradiologie met zich meegebracht.
- Het idee van telemedicine op zich is niet erg nieuw: reeds in 1939 maakte Fritz Kahn een interessante tekening over het gebruik van telegeneeskunde om patiënten op cruise schepen op afstand te behandelen. Ook de longfoto kon op afstand bekenen worden, dus teleradiologie avant la lettre.
- De digitalisering en de algemene beschikbaarheid van technieken om op snelle én goedkope wijze digitale data te versturen over grote afstanden heeft het ontstaan van teleradiologie met zich meegebracht.
- Teleradiologie tijdens de diensten – meest gebruikte vorm van TR – van ZH naar thuis Finale vs voorlopige verslaglegging / protocollering Wegwerken van achterstallige verslaglegging = “reverse” Second opinions Gesubspecialiseerd advies Wetenschappelijk onderzoek
- Op 10 jaar tijd heeft een verschuiving plaatsgevonden in discussies over TR Management issues: Klinisch beleid of bestuur met TR Medicolegale aspecten Kwaliteitstoetsing Beveiliging
- Categories of questions: Demographics, types of TR, types of exams, Technical issues, Security, Communication, Advantages/disadvantages, threats/opportunities, Quality assurance, Future of TR
- Slechts 10% van alle deelnemers stuurt beelden buiten de organisatie voor second opinions en/of tijdens wachtdiensten Slechts 15% van de deelnemers die outsourcen doen dat via commerciële TR providers
- E-Health krijgt steeds meer vorm, de term verwijst naar de electronische uitwisseling van medische gegevens.
- Legal: Uniform EU-Legislation regarding teleradiology “Medical Act”, protection of patient’s rights Privacy regulations: Harmonisation of regulations regarding protection of personal data for cross-border services. Information privacy remains the greatest source of concern about medical outsourcing! General Data Protection Regulation GDPR Taalproblematiek en semantische interoperabiliteit (voor cross-border services): internationaal lexicon nodig, vertaalsoftware, structured reporting! IHE Integrating Health Enterprise. Standards for further seemless integration of information ZEER BELANGRIJK om gegevens uitwisselbaar te maken QA: Quality auditing, standaarden en regelgeving Financial: Reimbursement issues in socialized medicine, different reimbursement schemes need to be harmonised/adapted, vermijden van “prijzenoorlog” met progressieve devaluatie voor “commoditized services”
- De digitalisering en de algemene beschikbaarheid van technieken om op snelle én goedkope wijze digitale data te versturen over grote afstanden heeft het ontstaan van teleradiologie met zich meegebracht.
- Jikei University Hospital in Japan
- De digitalisering en de algemene beschikbaarheid van technieken om op snelle én goedkope wijze digitale data te versturen over grote afstanden heeft het ontstaan van teleradiologie met zich meegebracht.
- Gebruiken van mobile devices: Communicatie met collegae en patiënten Professionele apps Educatieve doeleinden, informatie bij de hand