What Generation Y radiologists want: the PACS of 2015

Sep 21, 2010

NEW YORK CITY - Physicians of Generation Y, the Millennial generation, are starting to fill the shoes of radiologists for whom the word "film" was synonymous with an x-ray exam. In less than two decades, radiology departments and imaging centers have gone digital in many countries. PACS prevails.

But is this digital conversion to imaging informatics good enough to meet the expectations of young radiologists starting careers in a profession already grappling with image overload? No, it is not, according to Eliot Siegel, MD, professor of radiology and nuclear medicine and associate vice chair of the radiology department at the University of Maryland School of Medicine in Baltimore.

Siegel, who in 1993 implemented one of the first three full-hospital PACS networks in the U.S. at the Baltimore Veterans Affairs Medical Center (VAMC), where he has been chief of imaging services, offered his ideas of what's needed for the PACS of 2015 in an address on Monday at the Medical Imaging Informatics Symposium.

Imaging informatics will increasingly define what is unique and important about the specialty of radiology, Siegel said. A radiologist needs to be perceived as a specialist who not only makes an accurate diagnosis, but who also:

Knows the diagnostic imaging procedures that are most appropriate for a patient
Determines the radiation dose needed to attain diagnostic image quality with the least amount of radiation exposure
Understands the capabilities and limitations of computer-assisted diagnostic (CAD) and advanced visualization tools and appropriately utilizes them
Keeps images safe and secure
Communicates findings in a timely manner to all healthcare providers who need them

Generation Y radiologists in the U.S. represent a slice of 70 million people born between the mid-1970s and the mid-1990s. This 28% of the U.S. population grew up with the Internet, cell phones, and texting. Theirs is a world dominated by instant gratification. They are adept at multitasking and characterized by a high level of adaptability, but also impatience.

"Radiologists in today's workforce are beginning to see reimbursement tied to practice performance, and this requirement will continue to increase," he said. "To deal with an increasing workload, the new generation of radiologists will expect to have electronic diagnostic workstations that will boost productivity and real-time reporting communications tools and information delivery."

"Imaging informatics has the potential to provide this," Siegel said. "It needs to do so."

Questions are being asked by imaging informatics professionals and vendors about how radiologists can be more productive without compromising accuracy, the trade-off between optimal image quality and image dose, the most effective way to obtain clinical information about a patient that can aid diagnosis, and the best ways to convey findings and recommendations and ensure they are acted upon.

A productivity crisis exists right now, Siegel said. Using the University of Maryland Medical Center (UMMC) in Baltimore as an example, it seems that anyone who walks into the emergency department gets a CT scan. In 1998, 60 CT scans were performed for every 1,000 patients admitted to the emergency department. This increased to 270 per 1,000 in 2004, and it's estimated that in 2010 it will be 450 to 500 CT scans performed for every 1,000 patients. "Radiologists are getting overwhelmed," Siegel said.

The escalating use of increasingly sophisticated multislice CT scanners is dramatically increasing the number of images being acquired. Siegel noted that the typical trauma CT study at the University of Maryland generated 2,240 slices in 2009. The hospital now uses a cardiac CT scanner that produces about 15,000 images per CT exam.

"The model of evaluating one image at a time is broken," Siegel said, using an assembly line metaphor, with a conveyor belt delivering images that continues to increase in speed. Add to this the fact that the traditional radiology department is not run efficiently.

Harnessing PACS

The technology of PACS can be harnessed to make improvements. As an example, the Baltimore VAMC reduced the 59 steps required to produce an in-patient chest radiograph to nine steps once a PACS was in use.

Dashboards are heavily utilized at UMMC, providing valuable information for real-time monitoring of practice management and quality assurance. Siegel predicted that business intelligence tools will be much more commonplace in the radiology information systems and PACS of 2015. Individual performance -- with respect to productivity, accuracy, and overall quality of patient care -- will be monitored and tied to pay-for-performance criteria.

Already in use at UMMC is a peer-to-peer evaluation system used by technologists to evaluate the quality of images and repeat-exam discard rates. This electronic anonymous evaluation system is used in a constructive way to improve image quality in the department. Siegel expects more of these types of tools to be integrated into PACS in the near future.

Other changes needed by 2015, according to Siegel, include:

Ergonomically designed reading rooms conducive to productivity
Single workstations that incorporate the best features of specialty workstations
More server-side versus client advanced visualization rendering, more automated functions, and a new generation of intelligent postprocessing software for 3D hanging protocols
Smarter CAD software to identify and measure microcalcifications and lung nodules
Intelligent use of sound integrated in workstation software
Automated and integrated decision-support functionality
Drag-and-drop touchscreen capabilities, and use of gaming technology to make interfaces more interesting, intuitive, and fun to use; the original diagnostic workstation toolbox was adopted from the Adobe Photoshop paradigm of the 1980s
Integrated critical-results reporting and follow-up recommendations that are more automated, and that track referring or specialty physician responses to them
An intelligent patient template extrapolated from a patient's electronic health record containing all of the information relevant to the exam being interpreted

How will social media be used? It needs to be used to enhance communication between radiologists and clinicians and to improve the perceived and actual value of the specialty.

But at the same time, it can't impede workflow, Siegel said. Mobile display devices offer great promise, but very little testing has been done regarding diagnostic utilization.

The Generation Y radiologists probably will be the ones to figure this out, Siegel concluded.

By Cynthia E. Keen
AuntMinnie.com staff writer
September 22, 2010

SIIM opening session highlights advances driving informatics, June 3, 2010

Electronic technologist peer review program enhances QC, October 16, 2009

Web-based radiology dashboard aids in practice management, December 1, 2008