Feature Report: Developments in medical imaging
By Andy Shaw
Recent advances in clinical imaging systems are astonishing. Just a few years ago, the only way a radiologist could truly share a diagnostic quality image with a specialist and a referring physician was to meet in a hospital and sit together at a $100,000+ radiological workstation. Today, that same radiologist could be at any computer in a Toronto hospital; the referring physician comfortably seated at a Mac or PC desktop in his or her Winnipeg office; and the specialist with an iPad in hand in the clubhouse of a Vancouver golf course. Via the web, they can each comment on, manipulate, and change the view of that brilliantly clear gall bladder image, just as if they were all huddled at that high-cost workstation.
Grateful as those physicians might be for the new ease, convenience, and efficiency of their workflow thus enabled, and however happy the patient with that troublesome gall bladder might be about an improved diagnosis and outcome, their thanks is due to a band of insightful, small-company innovators, including several Canadian entrepreneurs who started out as educators or video gamers.
Take, for example, the enterprise-wide, low-cost, highly accessible diagnostic imaging system at Toronto’s Sunnybrook Health Sciences Centre.
Since last February, Client Outlook Inc., a small Waterloo, Ontario company, has had its eUnity medical imaging and viewing integration platform installed at Sunnybrook, where its digital dexterity at handling images is dazzling several thousand clinician users, including Dr. Steven Shumak, an internal medicine specialist. Dr. Shumak says eUnity is “the single most important improvement in clinical care at Sunnybrook” that he has seen in his 15 years there.
Before, as the Sunnybrook day wore on, a cascade of diagnostic images choked Sunnybrook’s picture archiving and communications system (PACS), frustrating physician access to images and slowing diagnosis.
Today, eUnity zips out images to desktops throughout the hospital, where X-ray, CT, MRI, ultrasound, and even angiographic images can all be examined by Sunnybrook’s clinicians with speed and confidence.
But it was the mental image of two consulting clinicians and one medical student in a Sunnybrook hallway that was the genesis of eUnity.
“We are educators, really, and so at first we talked to Sunnybrook about using select diagnostic images as ‘teaching files’ that physicians keep as examples of interesting cases for use in grand rounds or otherwise educating interns and medical students,” says Steve Rankin, Client Outlook’s co-founder along with wife Brenda. “But one day I was watching those doctors talking, one holding paper and the other holding film. I saw also that the student intern was learning from the radiologist what was on the film. That was a very important event for us, because it was then that we began to think about including patient care.”
That notion immediately appealed to Andrew Volkening. An electronics engineering technologist by training, Mr. Volkening came to Sunnybrook from an IT vendor 10 years ago and is now in charge of informatics for the medical imaging department at Sunnybrook.
“What we had been trying to solve was how to provide reliable access to imaging outside of radiology,” says Mr. Volkening. “We have had a PACS for years and it has worked well enough inside radiology. But we were getting to where increasing outside access would mean putting PACS workstations all over the hospital. We had many requests for these extra stations, but it simply wasn’t financially viable for us.”
As a result, Volkening says Sunnybrook spent several years looking for less costly ways of sharing diagnostic imaging.
“What we were looking for specifically was something that didn’t install software on the client. An application you could just put up on a website. But that was something vendors didn’t seem to offer.”
Until, that is, the Rankins got in touch.
“What Client Outlook offered with its eUnity software was the ability to share the true DICOM image,” says Volkening. “That was very important to our clinicians. The reason they wanted more workstations was simply so they could see the very same images as the radiologists. They did not want to see some sort of dumbed-down version.”
Though discussions started with what Client Outlook could do for Sunnybrook by way of teaching files, another light bulb soon went on.
“We realized that what Client Outlook had already built for teaching files could be leveraged into a full-blown enterprise viewer,” says Volkening.
Consequently, Volkening and the Rankins have since integrated the eUnity platform and its viewer into Sunnybrook’s electronic patient record (EPR) system.
“The direct EPR access has been particularly successful because it makes it easy for clinicians to have all their information in one spot,” says Volkening. “You can have all your notes, all your patient’s lab work, and now all your imaging right at your fingertips.”
Volkening says most often clinicians access eUnity through Sunnybrook PCs at the hospital. But remote access via the web is rising.
“If clinicians are on call, they can see their imaging from their office or from home. Also, we have eUnity integrated into Sunnybrook’s MyChart system. So patients can now also see their diagnostic images.”
Soon to come from Client Outlook will be an app for access to eUnity via iPhones, iPads, and other tablets, says Steve Rankin.
While Sunnybrook has not begun any formal measurement of eUnity’s benefits, anecdotal evidence has been mounting over the past year.
“I can tell you just from the conversations I have, that the number of times imaging is accessed every day here has been skyrocketing. And you’ve got to think that’s good for patient care,” says Volkening.
What’s been most encouraging to Volkening is eUnity’s uptake by Sunnybrook physicians: “We know that doctors are often reluctant to try new technology. But one of our most resistant physicians just recently took the time to write us a letter and say what a great product eUnity is. He is no longer a Luddite.”
That’s because eUnity has made a difference in workflow. Rendering a diagnostic image for viewing on a web viewer or anything else but another workstation usually produces a lag, which busy clinicians are quick to notice and subsequently shun.
“We think any product that lags nowadays is selling the user short,” says Client Outlook’s Brenda Rankin. “We have Health Canada and FDA clearance for diagnostic use partly because we can even show an X-ray of a beating heart running at 30 frames a second and it will respond to users without any lag.”
There’s no lag either in how Calgary Scientific’s PureWeb platform is advancing the boundaries of anywhere-you-need-it imaging. Co-founded by a University of Calgary radiology educator, the company first showed what its PureWeb viewing could do with images in startling detail on iPads at RSNA 2010. The Calgary-based company has since gone on to sign up an array of global partners who were clearly impressed.
“We don’t sell ‘direct’ as others do, but instead we re-brand our software,” says Byron Osing, chair and CEO. “Our global partners now include GE Healthcare, having re-branded our software under its Centricity product and Siemens Healthcare, making it part of its WebReport. Also, AT&T has adopted our now FDA-cleared mobile viewer and, as we announced during RSNA 2011, Dell has added ResolutionMD and PureWeb to its UCA (United Clinical Archive) solution.”
Osing says ResolutionMD is superior not only because its images are fully 3D but also because they are truly virtual. Confidentiality is never at risk because the data are not physically present on the mobile device.
“All our products are now fully-FDA approved for primary diagnosis and we have ‘mobilized’ them not only on the iPad, but also on many Android devices. We will be covering off RIM devices soon as well,” says Osing. “So I think it is fair to say that we now have the industry’s most advanced, multi-party, multi-device, real-time collaboration capability.”
In simple terms, that enables any number of radiologists, physicians, and even patients to click a simple link in an email message sent to all, and all connect simultaneously to one instance of software where every participant can manipulate and examine the image together in real time – regardless of the device they are using.
How on earth is this possible, given that just a short while ago diagnostic images being so huge could only be handled on a workstation? And at best, images that would choke any attempt at an email transfer for purposes of sharing had to be clumsily downloaded onto a disk and snail-mailed out to others.
Adding to the wonder of this new technology, images that did manage to get shared in the past on some sort of high-powered network raised the risk of privacy invasion, since the images were being transferred out from a central repository to other devices. Now, the instant a web-based image-sharing session such as just described above ends, the images instantly disappear from all participants’ devices.
Well, part of the secret is that those images never went out to those far-flung participants and their mobile or other computing devices in the first place. Despite having detail-rich and perfectly accurate portrayals of those images to work with and share at their command, no images ever had to be transmitted.
So just how does that work?
Well, Sunnybrook’s Andrew Volkening has the start of the answer: “In our case it is the eUnity software that is rendering the image. So we are not relying on the remote browser to draw the image.”
And Dean Lester at Vizua knows the rest of the answer.
“What you are really doing with this generation of clinical information systems is not sending out images at all, but really just the calculations for them,” explains Lester.
So what the receiving laptop, iPad, or other remote device receives is a set of highly detailed, immutable arithmetic instructions for image forming that ensures consistently accurate images across all browsers, viewers, and devices. Such rigour also ensures that the application only uses only relatively small chunks of memory-sipping, encrypted data, making them highly scalable and secure. They fear not high numbers of users nor huge sizes of original images. And once the web-based consult ends, all the calculations at play vanish, leaving no images nor privacy and confidentiality concerns behind.
British-born and medically trained, Mr. Lester is CEO of Vizua, a fledgling company founded in Seattle just over a year ago but which has flown to the forefront of imaging with its Vizua for Life platform. From a pay-as-you-go, cloud-based server, it enables radiologists, consulting physicians, and patients themselves to view, share, and explore CT, MRI, PET, and ultrasound scans as 3D interactive models – intimately.
Just how intimately is memorably demonstrated by Lester and co-founder Ed Ventura, Vizua’s executive vice president, during a half-hour transcontinental “Webex” audio-visual web interview between Seattle and Toronto.
Lester is at the controls of an on-screen control panel for Vizua for Life, which at first shows a shadowy slice-view of a CT scan. But with one click, a bust-like 3D image of a female patient’s head, neck, and shoulders instantly springs to the screen. Lester easily rotates and flips the image in all directions, without any lag, despite the intervening face of the Webex software.
As he does, Lester provides background to an already impressed journalist: “Ed and I both have a background in video games and we found out we both shared the concern that while video games can do amazing graphic calculations and consequent manipulations, they seemed to be way ahead of the medical solutions that were out there. And, in our minds, that was just wrong.”
Lester and Ventura had a mind-meld on medical imaging’s shortcomings while they both worked for Microsoft. Through his video game connections in Britain, Lester, once a medical student at the University of London, headed to Redmond, Washington in 1996 and ended up running Microsoft’s simulation software group. Ventura was working on gaming software, but through some philanthropic work had seen what was thought to be state-of-the-art surgical simulation at the University of Washington, considered to be one of the country’s leading medical schools. “I was shocked to see that gaming technology was so far advanced compared to what they had for a medical school that is rated number one in the nation clinically,” says Ventura.
Now back on Webex, Lester begins to clinically “dissect” the bust on our screens with the patented Vizua software. First off comes the skin to reveal a remarkably detailed and colourful anatomy of skull, upper spine and muscle. Again, Lester rotates the figure to all angles – and I could have, too, had we been connected by the usual Vizua internet link, which normally would have been sent to me in an ordinary email. (The Webex connection had the compensating advantage of allowing me to record the conversation.)
Then away goes all the soft tissue, leaving behind only bones but in sharp detail.
“What I am doing is simply applying the various filters we have put on the control panel,” explains Lester. “I can even take out the bones, leaving just the teeth because they are made of the densest material in the body.” And there, instantly, is only a pearly set of uppers and lowers seemingly suspended in black space. We zoom in for a closer look from inside the now invisible surrounding mouth.
“I did two years of dissection on cadavers as a medical student and maybe that will never be completely replaced, but the difference is with this tool you can un-dissect your dissection and dissect over and over again. That has implications for improving medical education and lowering its costs,” says Lester.
In another brief demonstration, Lester pulls up an image of a real patient’s forearm, with a mysterious swelling just above the wrist. Again, Lester filters off the covering skin and there before your eyes is the problem – in bright red.
“You can see that the radial artery there running down the length of the arm is hugely distended because of the constrictions very visible near the wrist,” points out Lester. “So with views like this, there is never going to be a shadow of a doubt in either the physician’s or patient’s mind about what’s involved.”
New solution tracks, analyzes CT radiation dose levels
A start-up company in Toronto has created an innovative, web-based solution that tells hospitals how much radiation their patients have been getting from CT scans. The solution from Radimetrics, Inc., also reveals the average radiation dose ordered by physicians and the real dose given to patients when they visit a hospital radiology department.
It’s a powerful analytical tool, and one that has emerged at a time when radiation dose has become an enormous issue in Canada, the United States and around the world. Computed tomography (CT) scanners are viewed as incredibly helpful instruments in diagnosing all kinds of diseases and medical problems. But they also emit significant amounts of ionizing radiation.
“A few years ago, it was all about image quality, and radiation dose wasn’t even an issue,” commented Greg Couch, founder and president of Radimetrics. “Now, dose has become a huge issue, and you have to balance image quality and dose.”
Indeed, in the past two years the biggest theme for radiologists and the makers of imaging equipment has been reducing the dose. Many breakthroughs have been claimed – vendors say they have dramatically reduced the level of X-ray energy emitted by their CT scanners, and for their part, radiologists are trying to ‘image safely, image gently’.
Still, there hasn’t been an easy or accurate way to measure how much radiation hospitals have been zapping their patients with.
Until the appearance, that is, of the Radimetrics solution, called eXposure. “No other product estimates dose taking into account the patient’s size,” said Couch. What’s more, eXposure creates a cumulative record of a patient’s radiation dose, calculating the effect of CT exams on a patient over time.
By tapping into the data that’s fed by CT scanners to the RIS and PACS used in most hospitals, Radimetrics determines the radiation levels used in hundreds of exams. You can then do comparisons of your patient population, physicians, techs, or various hospital sites –all modeled in easy-to-read charts and graphs.
Couch, who was once employed at the University Health Network in Toronto, went on to develop various innovations and entered the private sector. Radimetrics is his latest project, and for the past three years the company has developed the software needed to model radiation dose levels from CT scanners.
Now, the system is ready for commercialization and Couch and his team exhibited last November at the Radiological Society of North America’s annual conference in Chicago, demonstrating the solution to an enthusiastic audience.
Testing has occurred in numerous sites, and to date, the solution is in place at St. Michael’s Hospital in Toronto, along with the University Health Network, Mount Sinai Hospital and the Osler Health Sciences Centre. In the United States, users include the Henry Ford Health Centre in Detroit, University of Pennsylvania, and Massachusetts General.
Couch noted that McKesson and Siemens are re-selling the product and have integrated it into their PACS and RIS systems.
Demonstrating the system at the company’s booth at the RSNA meeting in Chicago, Couch showed the dozens of protocols that can be measured, for dozens of body exams – head neck, chest, vascular, and others.
“What if, for example, you wanted to find women with the highest dose in the last month,” he said, entering a few clicks on the mouse. A list quickly appears on the screen, along with the X-ray levels absorbed by the women.
Zeroing in on the person at the top of the list, he says: “You can see this person had four pelvic exams in a short period of time. Her radiation dose looks quite high, so we want to find out why.”
Couch shows that two different technologists performed the four exams. “One of the techs adjusted the settings on the scanner, attempting to improve the image quality. What this technologist didn’t realize is that the patient would receive nearly twice the amount of radiation.
Using this information, a hospital can flag the patient and use caution when scanning that particular patient in the future. As well, the hospital could provide feedback to the radiology department, and to the tech, about using a better imaging protocol, one that results in lower radiation dose to the patients. “Quite a few sites have instituted protocol reviews after running this study,” said Couch.
In a recent news release issued by Radimetrics, Dr. Eliot Siegel, professor and vice chairman of the University of Maryland School of Medicine Department of Radiology said: “The onus is on the medical community to monitor and reduce unnecessary radiation exposure.
He added that, “Using technologies such as those from Radimetrics and Montage [a company with which Radimetrics entered an alliance], we have the potential to address this important challenge in a way not previously available.
“These tools help us to substantially reduce radiation exposure and respond more rapidly and effectively. This capability is especially important among subsets of patients who are vulnerable because they are subject to multiple, repeat CT exams, such as young patients with Crohn’s disease or kidney stones.”
There are various ways in which patients accumulate more radiation than expected. For example, Couch noted that the hospital at which you have a test performed can have a significant effect on the amount of radiation you receive. This is due to differences in the protocols used at individual hospitals for the same test.
“It is important for patients to understand that in the majority of cases, these tests are absolutely necessary and might even save their lives,” said Couch. “Our tool is designed to help hospitals perform these tests safely and with as little radiation as possible.”
eXposure can display the difference between ordered exams and the actual radiation dose for patients.
The system can even show the differing radiation levels emitted by different CT systems for the same exam type. In this way, they can monitor the levels of radiation produced by machines, rather than rely on the information given to them by vendors.
Hospitals can also look at the ordering physicians, to find out the average dose for a variety of exams, by medical specialty or by individual physician. If the levels are too high, doctors and staff can be informed.
It’s an effective method of educating and reminding physicians about the levels of radioactivity absorbed by patients when they order diagnostic images. “Most of them like having this feedback,” said Couch. “But, of course, there have been a few who think we’re trying to control their ordering.”
Couch emphasized that’s definitely not the case. Instead, the solution is designed to help hospitals, physicians, technologists and patients. By knowing the levels of radiation dose that patients are actually getting, practices can be modified so that physicians get the images they need to make decisions and patients are treated as safely as possible.
RSNA conference showcases innovations in diagnostic and surgical imaging
The annual RSNA conference continues to act as the key gathering point of imaging professionals, with nearly 60,000 flocking to Chicago last November to find out about the latest imaging techniques and technologies. Visitors were not disappointed, as there was plenty to discover. Among the highlights:
Enterprise-wide medical imaging
Building on its experience with PACS for radiology departments, Agfa HealthCare has now produced an enterprise solution to organize and access all types of medical images.
Called ICIS – short for Imaging Clinical Information System – the solution could solve a big problem for many hospitals. While most large medical centres operate a PACS in the radiology department and a cardioPACS for cardiology, there are a multitude of other images scattered about the hospital that are very hard to access.
“Outside of radiology, there are about 30 areas that generate a lot of images, but these departments have less ability to support imaging systems than radiology and cardiology,” said Charles Morris, senior technical marketing manager, Agfa HealthCare. “They’re fragmented and hard to get to, unless you’re in the department that took them.”
He said that ICIS can tie them all to a patient record, so that specialists and referring physicians can gain access to various types of images and results from anywhere in the hospital.
Various sites in the United States have started implementing ICIS, including the San Francisco General Hospital, University of California at Irvine, and the Cleveland Clinic.
Morris pointed out that for a single patient undergoing, for example, bowel cancer treatment, there are a whole host of images taken, including:
Using ICIS, physicians across the enterprise are able to see not just the images but also the reports that go along with them. All told, access to a variety of departmental images and reports can give them a better understanding of the patient’s situation.
Cleveland Clinic has started the process of consolidating images into a common ICIS platform so that physicians can have a more comprehensive picture of the patient’s experience.
“It’s answering a real need, and referring physicians and surgeons are driving all of this,” said Lou Lannum, director of enterprise imaging at the Cleveland Clinic. Lannum will be speaking about the implementation at the upcoming Health Information Management and Systems Society (HIMSS) conference, to be held in Las Vegas in February.
“Just the number of photographs taken in the hospital is enormous, and we currently can’t handle those images in our Epic system.” The Cleveland Clinic is turning to ICIS to consolidate the photos and images from various departments, making them available to doctors in a meaningful way through the Epic user interface.
Lannum estimated that Cleveland Clinic produces 2 million radiology images a year, along with 2.25 million cardiology images, 250,000 images in endoscopy and another 1.3 million in pathology (300,000 gross pathology and 1 million slides.)
The plan is bring all of these into ICIS, along with additional departmental images. To support the strategy, the Cleveland Clinic plans to deploy Agfa HealthCare’s XERO technology viewer, allowing imaging information to be viewed directly from the organization’s Epic electronic health record.
Not only are there numerous departments and ‘ologies’ producing images, but they’re spread over a variety of facilities – the Cleveland Clinic includes a large acute-care centre, 11 regional hospitals, 12 outpatient clinics and family practices at over 400 locations.
Consolidating the images they produce is a large project, and one that will take several years. “But the infrastructure is in place, and we’re already making progress on it,” said Lannum.
In Canada, the same problem exists – hospitals are generating massive numbers of images in many different departments, but it’s difficult for referring physicians and surgeons to access them. For its part, the Hospital for Sick Children has begun the process with its partner Apollo. Few others have yet attempted a solution.
On the PACS side of things, Agfa demonstrated IMPAX 6.5, which offers a number of improvements, including image-enabled instant messaging. Using this function, radiologists and technologists can message each other immediately, and referring physicians can quickly send questions to radiologists. “The radiologist can respond and include a link to the images, which can help answer the questions and speed up the whole process,” commented Jason Knox, solutions manager for radiology and regional health.
Last July, all hospitals in Nova Scotia began deploying the IMPAX 6.5 solution, which includes mammography workflow tools. Also included are tools such as colour-coding various exam types so that radiologists read them first. This could be done by exam type (i.e., neuro), or patient location (i.e., ER or ICU), or by institution name, if the radiologist is covering for a remote location.
A smart seek function allows decision support tools to automatically open with exams. Using this web-based function, a window can be set to automatically open, providing related content from STAT DX, Google or subspecialty sites. “The goal is to get radiologists reading images more easily,” said Knox.
One of the most exciting innovations to appear in recent times has been the fusion of PET and MR modalities by two of the biggest vendors, Philips and Siemens. For its part, Philips announced US FDA approval of its system, called the Ingenuity TF, just prior to the RSNA conference; it had already gained certification Europe. Seven sites have installed a Philips system, while seven more were to be delivered in the following six months. American orders include Mount Sinai School of Medicine and University Hospitals/Case Western Reserve University in Cleveland.
The hybrid system promises to deliver ultra-high resolution images of soft tissue anatomy, thanks to the powerful MRI scanner, with metabolic information superimposed on top, from the PET scanner.
An advantage over the current generation of hybrid PET/CT scanners is the reduction of radiation dose to the patient through the use of MRI instead of CT scanning. “Removing dose is the key,” said Steve Laczynski, executive vice president and CEO, North America, for Philips Healthcare. He said the system provides “no compromise” imaging for researchers and clinicians dealing with cancer, cardiology and paediatrics.
Laczynski also noted that hospitals with the Ingenuity TF can use the system strictly for MRI exams when PET isn’t required.
Philips and Siemens demonstrated their differing approaches to PET/MR on the show floor of the RSNA meeting. The Philips Ingenuity TF pairs a 3T MRI machine on one side with a PET scanner on the other, and uses a revolving table in the centre to position the patient. The table slides first into the MR scanner, takes images, then slides out and rotates 180 degrees so the patient can enter the PET scanner. The images are then fused.
In contrast, the Siemens approach uses a single machine containing both an MR scanner and a PET scanner. The company said it developed new technologies to merge MR and PET, which were previously regarded as difficult to combine in a single gantry. According to Siemens, “Prior to the Biograph mMR, the integration of MR and PET technologies was nearly impossible: The conventional PET detectors, which use photomultiplier tubes, could not be used in the strong magnetic field generated by an MR system. Integration was further limited by the lack of space inside the MR device. For this reason, previous MR-PET fusion imaging solutions relied not on simultaneous imaging but rather sequential imaging (or post-scan registration) of MR and PET data, resulting in a significant time lag.”
However, the Siemens Biograph mMR makes use of a single-gantry whole-body scanner, combining 3T MR technology with the company’s solid-state PET detector technology, which is said to resolve the incompatibility of MR and PET. With the Biograph mMR, patients can be scanned in as few as 30 minutes for a combined whole-body exam, compared to one hour or more for sequential MR and PET exams.”
What’s more, the Biograph mMR takes up the space of a standard, high-field MR scanner and can be sited in a typical MR room, eliminating renovation costs for facilities seeking to replace an existing MRI.
During his annual press briefing at the RSNA, Siemens Healthcare CEO, Hermann Requardt, emphasized that the Biograph mMR is the only simultaneous PET/MR that’s commercially available. He noted that the innovative machine is already installed at 10 sites around the world.
Surgical and Interventional Radiology systems
GE Healthcare announced a ‘mobile operating room’ with its NuBoom 4, a system that provides four monitors mounted on arms, along with a C-arm. All of this equipment is mobile – instead of being floor or ceiling mounted, it’s all attached to a solid beam that’s movable.
“When you’re not in need of a C-arm, you can wheel the system into another room where it can be used,” said Joe Shrawder, president and CEO, Surgery, for GE Healthcare. That can be extremely cost-effective for many hospitals, he said, noting it will allow them to reduce the waiting time for the proper room or equipment.
Shrawder also pointed out that the NuBoom system can be used by surgeons and interventional radiologists alike, giving them image-guidance in a sterile environment. As the C-arm isn’t ceiling mounted, it creates a much more sterile environment; it also provides much more maneuvering room than floor- or ceiling mounted systems.
“You can have open and interventional procedures in the same space,” said Shrawder, adding that interventional procedures can sometimes turn into open operations, due to complications, and a sterile environment is needed. When this happens, there’s no need to move the patient when using the NuBoom.
He noted that some hospitals have dedicated urology suites that sit idle for days because there are no urology cases. However, hospitals like the Wyckoff Heights Medical Center in Brooklyn, N.Y., have installed the NuBoom in these suites and they’re now using the urology space for multiple types of procedures, effectively doubling their urology room utilization rates.
The NuBoom system is equipped with the OEC 9900 elite C-arm, which provides a 12-inch field of view – a large image that’s useful for a wide range of purposes, including abdominal and hip procedures. It offers dose reduction features, with various pulse modes and the ability to reduce the X-ray dose by 75 percent, compared with full-powered fluoroscopy.
“Dose concerns not just the patient, but also the OR team,” said David Ferguson, global product manager for surgery. “We’re trying to train technologists about how to achieve the lowest dose possible. Most of the time, you can drive the dose down to half of what you’d normally use.”
Shrawder said the system has wireless capabilities and sends images from wherever it is sited. It also offers remote diagnostics in this way, too – users don’t need to find a LAN port to plug into.
The NuBoom sells for about $450,000 and is available in Canada. “For a quick retrofit, we can install it in a weekend and you don’t lose any productivity,” said Shrawder.
The focus of a great amount of buzz at the GE Healthcare booth was the global launch of the Discovery IGS 730, a high-end surgical imaging system that’s roboticized – the C-arm and monitors are mounted on a motorized vehicle with wheels. The whole system glides away from the patient and back when needed.
What’s more, it makes use of advanced laser-guided positioning, with laser sensors throughout the room to align the C-arm and patient in an exact position.
Moreover, “We keep the ceiling above the patient free, so no dust falls on the patient,” said Emmanuel Abate, global marketing manager, interventional radiology. “It’s sterile.”
There’s full patient access along the table and away from the table, said Abate. It’s said to offer advanced reconstruction of images, with CT-like clarity, for 20 applications including oncology, vascular and cardiac. “It’s interventional in a sterile, OR environment.” The Discovery IGS 730 fits into a standard-sized operating room or a traditional cath lab.
The breakthrough, according to GE Healthcare, is the combination of high-resolution imaging for surgical and interventional procedures with a sterile operating environment. “My first impression was that this system will allow us to have levels of access to patients in ways we have never had before. This particular unit removes the limitations of both ceiling and floor mounted systems without losing any of the advantages,” said Dr. Hal Folander, in a GE Healthcare news release.
Dr. Folander, chairman of the Radiology Department and Section Chief of Interventional Radiology at St. Luke’s Hospital and Health Network in Pennsylvania, has participated in clinical simulations on phantoms using the Discovery IGS 730. “Having been involved in research and development of this type of product for 25 years, I would say this is, probably, one of the most revolutionary interventional projects that I’ve seen. The innovation will be equivalent to or greater than the invention of flat panel technology.”
Magnetic Resonance Imaging
Toshiba showed several innovations in MR imaging, including the Vantage Titan 1.5T MR Series. In addition to the current 16-channel system, Toshiba will offer 8-channel (currently a works-in-progress) and 32-channel (also a WIP) systems. The Vantage Titan 1.5T MR series is a scalable solution with a full upgrade path from the 8-channel system to the 32-channel system, with high slew rate gradients.
Joel Urick, product manager for the MRI business unit, showed how the 71-cm bore of the machine can handle very large patients. He noted the Toshiba MRI has the shortest magnet and the quietest scanning in the industry. At the same time, Toshiba has devised a gurney that allows patients to be transferred to the MRI table much more easily – the gurney frame moves over the MRI table, and drops down while the gurney table and patient remain atop the MRI table.
This enables safer transport for both patient and hospital staff, as the patient doesn’t have to be lifted onto the MRI table. The solution is also effective for sedated and pediatric patients.
Toshiba showed a set of three innovative multi-element MSK coils – small, medium and large. They’re offered at a big reduction in price, Urick said, from the standard cost of coils. The flexible coils are ideally suited for pediatrics and general musculoskeletal applications. For pediatrics, where standard coils are often too large, the small and flexible coils can fit to nearly any body part, including the head, spine and extremities.
And in the Now for Something Completely Different category, Esaote was showing its 0.3T O-Scan MRI scanner. The O-scan is an MRI system developed specifically for imaging the extremities (knee, calf, ankle, foot, elbow, forearm, wrist, hand). The dedicated extremity MRI system provides excellent image quality by blending Phased Array RF coil technology with fast, optimized imaging sequences. According to the company, it’s simple to use and install, and it can be easily placed in a 10’ x 10’ space, plugs into the wall and typically doesn’t require any RF shielding. Patients insert just the extremity into the magnet. Canadian general manager Richard Boothroyd pointed out that by using a specialized scanner for extremities, larger MRIs can be freed up for other types of exams.
An exciting new ultrasound machine was recently created by a French company, SuperSonic Imagine, which offers both B-mode ultrasound and Shear Wave elastography technology on the same platform. The company’s Aixplorer ultrasound machine is being distributed in Canada by Christie InnoMed, the Montreal-based company with offices across the country. (Interestingly, SuperSonic Imagine has a Canadian connection, as one of the co-founders of the company, Claude Cohen-Bacrie, studied at Ecole Polytechnique de Montreal.)
At a discussion of the Aixplorer at the SuperSonic booth, product management director Dan Skyba said the device can be used for a wide variety of exams in B-mode, including musculoskeletal, abdominal, vascular and genitourinary.
For breast tumour detection and staging, the system’s innovative, software-driven Shear Wave technology can be used. The first step in a clinical breast exam is usually manual palpation; pressing lightly on the surface of the body to feel the organs or tissues underneath. It allows physicians to assess tissue stiffness that may indicate an underlying pathological disease, such as a solid tumour or tissue abscess. However, this approach is qualitative and highly dependent on physician training; hence, the results can be difficult to reproduce.
Providing an alternative to manual palpation, physicians using Aixplorer can simply place a transducer on the tissue – no compression is needed. Aixplorer produces an image called an elastography map showing the elasticity of stiffness in tissue by colour. This non-invasive procedure can lead to enhanced diagnostic confidence because it characterizes tissue in a reproducible way, the company said.
Skyba pointed out SuperSonic Imagine is now making advances in elastography for liver, thyroid and prostate cancer detection, as well. When it comes to confirming prostate cancer, the gold standard is currently the use of ultrasound guided biopsies. However, there are still false negatives using this technique, as the core samples extracted from the prostate can miss a lesion; elastography, however, can detect a tumour wherever it may be in the prostate. At the same time, it may in the future eliminate the need for extremely painful prostate biopsies.
Toshiba displayed some stunning innovations of its own in the ultrasound department. In particular, it showed off the new Aplio 500, with a fly-through imaging capability that’s unique to the company. Benoit Duchon, ultrasound product manager for Toshiba of Canada, demonstrated the application, which has the quality of a three-dimensional CT fly-through of hollow organs.
According to the company, the ‘Fly Thru’ technology uses 3D volume rendering to examine the interior of ducts and vessels for better exploration of lesions and masses, and to assist in planning interventional procedures.
Ob/Gyn is one application that’s proving useful. “Fly Thru is opening up completely new perspectives for non-invasive imaging diagnostics in the Ob/Gyn ultrasound lab,” said Bill Smith in a Toshiba news release. Smith is head of Ultrasound Services at Clinical Diagnostic Services in London, UK. “It offers the possibility to replace endoscopic examinations and may yield better results because the surrounding tissue can be seen at the same time, as well.”
The Aplio 500 also includes Smart Fusion, which shows both CT and ultrasound images side-by-side on a single screen. Indeed, Toshiba said Smart Fusion can read 3D DICOM data sets from all major imaging modalities, including MRI. A position-sensor with sub-millimetre accuracy is attached to the transducer shaft to provide free access during interventions. Matching the transducer position with the pre-acquired 3D data set is a simple and quick two-step process, the company said. Applications include locating hard-to-find lesions and aiding in ultrasound-guided biopsy without additional CT scans.
For its part, Esaote announced the release of the MyLab Seven and MyLab Alpha ultrasound systems, two new additions to the MyLab ultrasound family. Both systems are built on Esaote’s new Productivity-Oriented Platform (POP).
According to the company, MyLab Seven is a high-performance compact ultrasound system specifically designed to increase productivity of echo labs and offer high-level mobility, thanks to its compact footprint.
MyLab Alpha is a premium portable system. Esaote was able to miniaturize its high-level ultrasound platform to fit an extremely compact and light case without sacrificing performance, the company said.
The POP platform is the core of the new MyLab systems and is said to deliver ease-of-use, application specific customization and new levels of connectivity. The systems offer a simple and user-friendly interface, a wide LCD HD display screen, attention to ergonomic detail and an intelligent touch-screen which features Esaote’s exclusive e-touch technology.
While Esaote isn’t a household name like GE or Philips, Canadian general manager Richard Boothroyd asserts that Esaote ultrasound machines can be found in almost every hospital in Canada. Private-sector diagnostic labs are also major customers – one of its biggest clients is the CML chain of private imaging labs.
Siemens medical chief Dr. Gregory Sorenson noted at a press meeting that, for its part, Siemens has been making an “increased investment in ultrasound,” and recently introduced its top-of-the line S3000. It should be shipping in 2012, he said.
It will offer ‘one-click’ fusion with CT images, with significantly reduced registration time, he said. As well, the company is offering the S1000, a less expensive ultrasound machine.
Canon Medical Systems showed a solution that could make waves in Canada – an upgrade kit that converts GE AMX-4 Series portable X-ray units to wireless technology. The solution means that images from the mobile X-ray systems can be created and read much faster, as the Canon digital system produces the images within 3 to 5 seconds and can display them on the monitor. The wireless capabilities, moreover, mean the images can be instantly sent to a PACS where they can be accessed by radiologists for readings.
“We install a computer and monitor in the AMX and add the wireless panel,” said David Seeley, national program manager, Medical Systems Division at Canon Canada. Canon’s cesium iodide panel is the CXDI-70C Wireless, which weighs 7.5 lbs. and has a 14 x 17 inch imaging area. Seeley said it’s a major opportunity for Canon, as there are about 500 of the GE AMX 4 Series units across Canada, and hospitals would benefit greatly from the conversion to digital wireless for faster access to the images. The upgrade kit is awaiting Health Canada approval.
On another front, Canon announced a second wireless X-ray panel, the CXDI 80C Wireless, which is aimed at NICUs. “It’s the little brother to the CXDI 70C Wireless,” said Seeley. “It fits right into an incubator X-ray cassette tray.”
Weighing 5.1 pounds, the cesium iodide detector has an 11 x 14 inch imaging area. The benefit is that it allows for imaging of an infant at lower doses – something that’s especially important for young children. The CXDI 80C can also be used for patients with limited mobility, in wheelchairs or who require bedside care. The system, moreover, has already been approved for use by Health Canada.
Canon also showed a works-in-progress – its entry into the operating room with a new C-arm for surgeons and interventional radiologists. It’s expected to be available in 2012, pending approvals.
For its part, Carestream Health announced a new and improved wireless digital panel, the DRX-1, making it lighter and faster than before. The weight has been reduced to 7.9 lbs., and preview images are available in less than four seconds. The panel can support up to 375 lbs. of distributed weight and up to 250 pounds on a four-centimetre diameter. The battery now supports up to 190 exposures before needing a recharge. According to Carestream, more than 3,000 DRX detectors are in clinical use worldwide.
Carestream also demonstrated its works-in-progress portable X-ray system, the DRX-Revolution. The compact, motorized cart allows digital X-rays to be taken at the bedside. Using the wireless capabilities, images can be beamed within seconds to a PACS for reading by a radiologist. What’s more, the ergonomic design of the cart enables better handling and vision as employees are wheeling it throughout a hospital. The column supporting the X-ray camera retracts, so that shorter technologists can see over the machine and avoid collisions in hallways. In terms of workflow, the techs can see the worklist on the Revolution’s monitor, and they can also call up previous exams wirelessly from the PACS.
Carestream also has a patient portal in development as a works-in-progress; according to Cristine Kao, worldwide HCIS marketing manager, the solution should be available this summer. It will make use of a cloud, and will provide secure access to imaging records to both patients and referring physicians. This service, part of Carestream Vue for Cloud-Based Services, is designed to eliminate the need for patients to carry medical imaging exams to physicians on CDs, DVDs or X-ray film.
Brockville builds groundbreaking document management solution
The installation of a Microdea Synergize Clinical Document Repository (CDR) in Eastern Ontario’s Brockville General Hospital is attracting growing interest since it went live in May 2011.
The system, which electronically stores and delivers radiology reports and discharge summaries to physicians, has dramatically sped up the dissemination of patient information to family health providers. On average, about 300 reports have been sent out by Brockville per week since it was launched.
Instead of a time lag of one to two weeks for those paper reports to make their way to clinics, they arrive as fast as electrons can carry them. “As soon as the report is generated in the hospital, it is immediately sent to the physician’s office and is directly integrated to the patient’s file in the physician’s EHR (Electronic Health Record),” said Rene Melchers, Brockville’s IM-IT manager. “So they don’t have to do anything else to it, they don’t have to scan it in, it is right there in a patient’s history in their office.”
Patient records are securely stored in a robust and scalable data repository, enabling physicians and medical staff to immediately see data such as discharge summaries and DI reports for a newly transferred patient.
The installation made Brockville the first hospital in the province to have adopted the new HL7 V3 patient discharge summary specification, which is a new eHealth Ontario standard.
The CDR is also notable because the solution provides coverage for patients across both South East and Champlain LHINs, through built-in Master Patient Index (MPI) functionality. This means patients across the geography benefit from an online medical record.
By all accounts, the cross-LHIN installation was seamless and problem free and is well on its way to becoming a regional solution that will include a growing number of hospitals and clinics in the two eastern Ontario LHINs.
“That is just a matter of being able to acquire more funding and more support and we have a proposal in place to do that,” said Melchers.
Brockville is one of seven hospitals in the geographically sprawling South East LHIN. Its CDR partner, The Ottawa Hospital, is part of the equally large Champlain LHIN, which hugs the Quebec border and includes nine hospitals.
“This is a leading implementation of a regional health record in Ontario and it is eHealth standards-based,” said Colin Ruskin, vice-president of Microdea. “We are very excited that our technology is being used to improve health outcomes and are proud to add the healthcare providers within the South East and Champlain LHINs to our expanding list of reputable healthcare clients.”
The Microdea installation can trace its roots back to a “Kaizen” brainstorming event at one of the hospitals. “In that Kaizen we identified the fact that there was a lot of waste in the way that these documents were being handled between the two organizations, because it involved a lot of manual sorting, scanning, faxing, scanning it again, manual handling and then attaching it to the patient record,” said Melchers.
Today Brockville says it has dramatically cut down on physical paper views between the two hospitals, which typically send thousands of patient records back and forth, despite the fact that they are an hour and half driving time away from each other.
For Rowland Taylor, Brockville’s project manager, the success of the Clinical Document Repository can be measured by level of interest in it by facilities in the hospital’s LHIN and nearby Champlain. “The payoff has been that the physicians are getting the reports in their hands immediately and this has really generated interest for the project in the whole LHIN,” he said.
“Obviously what we really would like is a state whereby we can be paperless, that would be the end goal,” said Taylor. “And then we will really see the cost savings.”
For the first two family health teams receiving documents through their clinical management system, the Microdea CDR is seamless and “invisible,” said Glenn Alexander, chief information officer and eHealth lead of the Champlain LHIN. “All they know is their documents are showing up in their clinical management system as they log on.”
While the administrative savings for physicians and their staff are obvious, the real benefit of the CDR system is that important patient information gets to primary care physicians before their discharged patients, a situation that often was not the case before. “The biggest isn’t the financial one, it is the clinical one, the coordination of care, and it is an important part of the Electronic Health Record,” said Alexander.
The next phase of the project is not just to expand the geographic reach of the system by adding more hospitals and family physicians who can receive reports electronically, but to expand the types of reports being managed.
“There are 43 different specialty areas in Ontario that provide services to patients, so the plan is to download not just discharge summaries, but any specialist notes from anywhere could go into the CDR,” said Alexander.
The Ottawa Hospital is currently working on quantifying the savings it has derived from the new Clinical Document Repository. “Once we have all the primary care physicians that have clinical management systems in place, that will reduce the workload by about 40 percent,” said Alexander.
Microdea and Bell Healthcare Solutions partnered to provide the overall solution. “Microdea’s Synergize software was selected for the project, a provincial first, after an open RFP. It was based on the functionality Synergize provided and the fact that they had some history,” said Alexander.
The solution was implemented with the financial support and supervision of eHealth Ontario and the provincial health ministry. “We followed the provincial architecture that was laid out by the Ministry of Health and eHealth Ontario, we complied with all of the interface standards that were laid out in that architecture and eHealth Ontario not only funded it, they kind of shadowed us. They were on our steering committee and they helped us with procurement to make sure this went the way it was supposed to,” said Alexander.
“The result is we have an asset that was envisioned by eHealth Ontario, but was implemented by the LHINs,” said the Champlain CIO.
Medical practice makes use of Twitter and Facebook
BELLEVILLE, ONT. – How often do you see a doctor in a busy medical practice pausing to send out tweets? Not very.
But Dr. Paul Dempsey, a physician at Quinte Pediatrics and Adolescent Medicine, tweets throughout the day. What’s more, he also directs his office staff about how to post on Facebook.
When Dr. Dempsey uses Twitter and Facebook at the office, it’s not for fun – although he definitely likes the technology. Rather, his use of social media and other online tools keeps his office running more smoothly, and his patients better informed. “If we’re seeing a lot of kids coming in with croup, or fever, or diaper rash, I can send out a tweet telling moms about it, and I can also direct them to a really good website for more information.”
That’s helping worried mothers learn what their kids might be experiencing – and what to do about it. They also come into the office better informed than ever before, meaning they absorb more about what the doctors have to tell them.
For its use of social media and online tools, Quinte Pediatrics recently won the ‘B Social’ award in a contest sponsored by B Sharp, of Toronto, a developer of electronic healthcare solutions. The clinic was awarded $2,500, which Dr. Dempsey said will be invested in communication systems – including an upgraded web site.
Quinte Pediatrics and Adolescent Medicine is a pediatric walk-in clinic and consultation centre that takes referrals from primary care physicians in the eastern Ontario town of Belleville.
If the office is super-busy first thing in the morning, and there’s a one-hour wait, Dr. Dempsey can let patients know that it might be better to come into the walk-in clinic at 11 am or 12 noon rather than at 10 am with a quick tweet or a posting on Facebook.
“That’s making our patients happier, because they’re not waiting as long to see a doctor, and it’s helping with patient flow in the office.”
Ask most doctors why they don’t use Twitter or Facebook, and they’re likely to answer that it’s time consuming and there’s no payoff from it.
But Dr. Dempsey has a different point of view. It’s a big help in terms of patient education, and there’s a definite business angle.
“The biggest bottleneck for most patients, when they want to get through to the doctor, is the telephone,” says Dr. Dempsey, explaining that many patients complain of a busy switchboard or message machine.
Often, staff are tied up on the phone discussing with parents whether a child needs to see a doctor, what to bring to the appointment or what various tests or conditions mean. It’s all very time consuming for staff members to handle over the telephone, and much of the information can be disseminated more easily on the web site or blog, or via Facebook or Twitter.
As well, Quinte Pediatrics will soon re-launch its web site with a patient and physician portal. It will come equipped with the ability for patients and referring physicians to book appointments on their own.
“That will save time for our receptionist on the phone,” says Dr. Dempsey. And referring physicians will be able to book patient appointments at Quinte Pediatrics before those patients even leave their offices, instead of waiting through days of telephone tag.
There are several doctors and nurses at Quinte Pediatrics, but Dr. Dempsey has taken the lead with social media and electronic communications. In April, the practice hired Sara Hamil, who is trained in communications, including web technology and social media.
“That’s when we really started using the online tools intensively,” says Dr. Dempsey.
Not only does Dr. Dempsey send out tweets – usually when waiting for forms to print out for patients – but Hamil consults with him and other clinicians at the practice and sends out additional tweets.
She also posts on Facebook, informing patients about the length of clinic waits, letting them know about the types of cases coming to the clinic, and pointing parents to useful links on the web.
“You can go on your own to sites on the web using Google searches, but they often take you to a commercial site,” he says. “We can give you something that’s a little more evidence-based.”
The team produces a web site and blog, with articles that are often tied to current events in the Belleville area. For example, at the time of a big high school football game, the clinic published messages about concussions and sports injuries – topics that are on the minds of many parents.
Hamil says that, “Currently we have 426 followers on Twitter, 250 likes on Facebook and we receive about 50 visits to our blog every time we post new content.”
Not only will the updated web site enable self-booking of appointments by patients and referring physicians, it will also contain video.
That will be used to acquaint patients with the clinics, introducing them to staff, informing them about what to bring to appointments – such as lists of medications. It will also educate them about procedures they may be required to have as next steps, such as CT and ultrasound scans.
“This means that patients are better prepared when they come to the office, which saves time for all of us,” says Dr. Dempsey. It also means that doctors, nurses and administrative staff spend less time in person and on the phone informing patients about routine matters.
It’s all a matter of adapting to the times. “This is how patients and their parents are accessing information these days,” says Dr. Dempsey. “They’re on Facebook, websites, blogs and Twitter.”
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