Integrated diagnostics: proceedings from the 9th biennial symposium of the International Society for Strategic Studies in Radiology.

The International Society for Strategic Studies in Radiology held its 9th biennial meeting in August 2011. The focus of the programme was integrated diagnostics and massive computing. Participants discussed the opportunities, challenges, and consequences for the discipline of radiology that will likely arise from the integration of diagnostic technologies. Diagnostic technologies are increasing in scope, including advanced imaging techniques, new molecular imaging agents, and sophisticated point-of-use devices. Advanced information technology (IT), which is increasingly influencing the practice of medicine, will aid clinical communication and the development of "population images" that represent the phenotype of particular diseases, which will aid the development of diagnostic algorithms. Integrated diagnostics offer increased operational efficiency and benefits to patients through quicker and more accurate diagnoses. As physicians with the most expertise in IT, radiologists are well placed to take the lead in introducing IT solutions and cloud computing to promote integrated diagnostics. To achieve this, radiologists must adapt to include quantitative data on biomarkers in their reports. Radiologists must also increase their role as participating physicians, collaborating with other medical specialties, not only to avoid being sidelined by other specialties but also to better prepare as leaders in the selection and sequence of diagnostic procedures. Key Points • New diagnostic technologies are yielding unprecedented amounts of diagnostic information.• Advanced IT/cloud computing will aid integration and analysis of diagnostic data.• Better diagnostic algorithms will lead to faster diagnosis and more rapid treatment.

Effect of multislice CT technology on scanner productivity.

OBJECTIVE: In this study we analyzed the impact of multislice CT technology on scanner productivity in a tertiary care medical center. MATERIALS AND METHODS: We compared the productivity of two diagnostic CT scanners during the periods January 1 to August 31, 1999 (when both scanners had single-slice CT capability) and January 1 to August 31, 2000 (when one of these scanners was replaced with a multislice CT scanner). The scanners were used primarily for outpatients during the day shift and for inpatients during the evening shift; the demand for CT services was stable. For this analysis, we queried the hospital's radiology information system and identified the number of CT examinations performed during the two analysis periods. We also determined the examination mix, including proportion of enhanced and unenhanced examinations and the anatomic region examined, to ensure comparable patient populations. Statistical analysis was performed. RESULTS: The number of CT studies performed on the two scanners increased by 1772 (13.1%) from 13,548 (before multislice CT) to 15,320 (when multislice CT was available). The number of examinations enhanced with contrast media increased from 52% to 65%. Between 9:00 A.M. and 5:00 P.M., the number of CT examinations was similar on the single-slice scanners in the two periods (p > 0.05). However, in the period when multislice CT was available, the number of studies performed on the multislice scanner (5919) was 51.9% higher than those performed using the single-slice scanner (3896) (p < 0.0006). CONCLUSION: Using a multislice CT scanner leads to an increase in CT productivity, even though multislice studies are performed using more complicated protocols than are used on a single-slice CT scanner.

Technical cost of CT examinations.

PURPOSE: To measure the technical cost of different categories of computed tomographic (CT) examinations. MATERIALS AND METHODS: For fiscal year 1997, the technical costs of performing CT examinations in a tertiary care academic medical center were measured. Costs were divided into labor and nonlabor categories. Indirect departmental costs were fully allocated according to activity-based methods. Hospital overhead costs were set at 85% of the departmental budget. Physician costs, including those related to image interpretation were not included. The technical cost of CT was determined on a per technical relative value unit (RVU) basis and on a per examination basis. For the latter, the technical cost of nonenhanced CT, contrast material-enhanced diagnostic CT, and interventional CT procedures were determined. RESULTS: In fiscal year 1997, 45,599 examinations (22,158 [48.6%] abdominal and/or pelvic, 12,115 [26.6%] head and neck, 6,572 [14.4%] thoracic, 1,593 [3.5%] interventional, and 3,161 [6.9%] other) were performed with five CT scanners for a technical RVU output of 254,461. Of 45,599 examinations, 31,007 (68%) were performed with intravenously administered contrast medium. Overall labor costs were $1,744,653, and nonlabor costs were $2,912,282. The cost of a hypothetical CT examination with a mean technical RVU of 5.58 was $189. The overall cost per examination was $150 for nonenhanced CT, $237 for contrast-enhanced CT, and $462 for interventional CT. CONCLUSION: Although CT is based on sophisticated technology, the mean technical cost of a diagnostic CT examination is less than $200.

Technical cost of radiologic examinations: analysis across imaging modalities.

PURPOSE: To determine the individual technical costs of general diagnostic radiographic, ultrasonographic (US), computed tomographic (CT), magnetic resonance (MR) imaging, and scintigraphic examinations and interventional radiology. MATERIALS AND METHODS: The Radiology Cost and Productivity Benchmarking Study method of the University HealthSystem Consortium, a cooperative group of academic medical centers, was modified and extended to the six imaging modalities in a tertiary care academic setting. Hospital billing and cost records were analyzed for fiscal year 1996. Costs were divided into labor and nonlabor categories and were allocated to individual imaging modalities on the basis of resources consumed. Physician cost and hospital overhead were not included. Unit costs were analyzed per technical relative value unit (RVU) and per examination. RESULTS: The costs per technical RVU for diagnostic radiography, US, CT, MR imaging, scintigraphy, and interventional radiology were $65. 06, $28.74, $20.95, $17.69, $42.19, and $89.03, respectively. The technical costs per examination for diagnostic radiography, US, CT, MR imaging, scintigraphy, and interventional radiology were $41.92, $50.28, $112.32, $266.96, $196.88, and $692.60, respectively. CONCLUSION: The method of unit cost analysis for individual imaging modalities was successfully tested in a tertiary care setting. The method should be adopted to allow cost comparison across many institutions, which will permit the promotion of best practices.

Can academic radiology departments become more efficient and cost less?

PURPOSE: To determine how successful two large academic radiology departments have been in responding to market-driven pressures to reduce costs and improve productivity by downsizing their technical and support staffs while maintaining or increasing volume. MATERIALS AND METHODS: A longitudinal study was performed in which benchmarking techniques were used to assess the changes in cost and productivity of the two departments for 5 years (fiscal years 1992-1996). Cost per relative value unit and relative value units per full-time equivalent employee were tracked. RESULTS: Substantial cost reduction and productivity enhancement were realized as linear improvements in two key metrics, namely, cost per relative value unit (decline of 19.0% [decline of $7.60 on a base year cost of $40.00] to 28.8% [$12.18 of $42.21]; P < or = .001) and relative value unit per full-time equivalent employee (increase of 46.0% [increase of 759.55 units over a base year productivity of 1,651.45 units] to 55.8% [968.28 of 1,733.97 units]; P < .001), during the 5 years of study. CONCLUSION: Academic radiology departments have proved that they can "do more with less" over a sustained period.

Telemedicine in practice.

Telemedicine is defined as the "delivery of health care and sharing of medical knowledge over a distance using telecommunication systems." The concept of telemedicine is not new. Beyond the use of the telephone, there were numerous attempts to develop telemedicine programs in the 1960s mostly based on interactive television. The early experience was conceptionally encouraging but suffered inadequate technology. With a few notable exceptions such as the telemetry of medical data in the space program, there was very little advancement of telemedicine in the 1970s and 1980s. Interest in telemedicine has exploded in the 1990s with the development of medical devices suited to capturing images and other data in digital electronic form and the development and installation of high speed, high bandwidth telecommunication systems around the world. Clinical applications of telemedicine are now found in virtually every specialty. Teleradiology is the most common application followed by cardiology, dermatology, psychiatry, emergency medicine, home health care, pathology, and oncology. The technological basis and the practical issues are highly variable from one clinical application to another. Teleradiology, including telenuclear medicine, is one of the more well-defined telemedicine services. Techniques have been developed for the acquisition and digitization of images, image compression, image transmission, and image interpretation. The American College of Radiology has promulgated standards for teleradiology, including the requirement for the use of high resolution 2000 x 2000 pixel workstations for the interpretation of plain films. Other elements of the standard address image annotation, patient confidentiality, workstation functionality, cathode ray tube brightness, and image compression. Teleradiology systems are now widely deployed in clinical practice. Applications include providing service from larger to smaller institutions, coverage of outpatient clinics, imaging centers, and nursing homes. Teleradiology is also being used in international applications. Unresolved issues in telemedicine include licensure, the development of standards, reimbursement for services, patient confidentiality, and telecommunications infrastructure and cost. A number of states and medical boards have instituted policies and regulations to prevent physicians who are not licensed in the respective state to provide telemedicine services. This is a major impediment to the delivery of telemedicine between states. Telemedicine, including teleradiology, is here to stay and is changing the practice of medicine dramatically. National and international communications networks are being created that enable the sharing of information and knowledge at a distance. Technological barriers are being overcome leaving organizational, legal, financial, and special interest issues as the major impediments to the further development of telemedicine and realization of its benefits.

Achievement of substantial cost reduction through joint purchasing by the radiology departments of a large vertically integrated health care system.

RATIONALE AND OBJECTIVES: The authors sought to lower costs by coordinating the purchase of equipment, supplies, and services in the radiology departments of a vertically integrated health system formed by the merger of two of the largest academic medical centers in New England. METHODS: The radiology departments at Massachusetts General Hospital and Brigham & Women's Hospital formed a cost-reduction task force to explore opportunities to jointly decrease costs. Data from the operating budgets of both institutions were collected and analyzed to find specific items within the budgets that could yield substantial cost savings. RESULTS: The project's first phase yielded over $810,000 in reduced costs from a system-wide annual budget of only $7 million for film and contrast material. Ongoing additional projects suggest that longer term contracts that contain steeper discounts with a decreased number of vendors will result in further decreases in the cost of materials and supplies. CONCLUSION: Coordination of purchasing by the radiology members of an integrated delivery system can yield substantial savings.

Making global telemedicine practical and affordable: demonstrations from the Middle East.

OBJECTIVE: The purpose of this study was to demonstrate the first use of voice-grade telephone lines for the international transmission of both high-resolution digital images (radiology and pathology) and video in near real-time. MATERIALS AND METHODS: Eight live demonstrations were performed from the United Arab Emirates and the Kingdom of Saudi Arabia at the invitation of the respective ministries of health. Thirty radiologic studies (CT, MR, and radiographs) were digitized, compressed, and transmitted to Cambridge, MA, where they were interpreted on diagnostic workstations (1792 x 2252 display matrix) by a team of subspecialist radiologists. Near real-time image transmission was achieved by combining wavelet-based image compression (average compression ratio of 23:1) and multiplexing technology that used four phone lines simultaneously. During each demonstration, one pathology image was transmitted from Cambridge to the demonstration site, where it was interpreted by a visiting pathologist. Video-conferencing was implemented with a 64-kilobits-per-sec leased line from the United Arab Emirates and with four multiplexed telephone lines from Saudi Arabia. RESULTS: For teleradiology and telepathology, transmission times ranged from 2-5 min per image. Image fidelity was judged to be of diagnostic quality in all transmitted cases. The video link to the United Arab Emirates was highly reliable. Bandwidth for videoconferencing from Saudi Arabia was marginal on four voice-grade telephone lines, resulting in some downtime (10-20%). Live consultations provided by subspecialists in Cambridge assisted in the management of patients at both venues. The system was well received by both the referring physicians in the Middle East and the participants in the United States. CONCLUSION: Image compression and multiplexing technologies enabled high-resolution teleradiology and telepathology as well as real-time video consultations over international telephone lines. While telecommunications systems are advancing rapidly in many parts of the world, those areas most in need of telemedicine services are likely to be the last to upgrade their telecommunications infrastructures. This "proof of concept" article outlines a practical and affordable approach that makes telemedicine more accessible to underserved areas worldwide.