Imaging in the Future
MRIs. CT scans. Digital mammograms. Teleradiology. Virtual colonoscopies. One thing is for certain: radiology has grown far beyond the classic X-ray.
By Kelly Fodel
The face of radiology is changing, and as it does, the military is staying on the cutting edge. Military Medical Technology has interviewed the leaders in bringing this field of medicine to military and VA hospitals, as well as some of the companies who define what the future of radiology will be.
Teleradiology
In the “old days,” a radiologist would develop an image on film and review it onsite, transcribing notes on a patient’s chart. This required a large amount of time, staffing and storage space. Today, the use of teleradiology allows radiology professionals to acquire images, store them digitally, and most importantly, transport those images anywhere in the world via a local area or wide area network. Teleradiology itself is not a new concept; it originated in the 1980s and is widely used in the military. However, new strides in technology are making the next generation of teleradiology the focus of the future.
In particular, the Department of Veterans Affairs is positioning itself to rely heavily upon teleradiology in the future, with the creation of a brand new National Teleradiology Center. The center links VA hospitals together and produces a solution to the problem of staffing. A rapidly declining roster of radiologists, as well as an increasing workload, presents a challenge that can be handled via teleradiology.
“We just opened the center in San Bruno, Calif. We did our first read about a month ago,” said Dr. Charles Anderson, director of radiology for the VA. “We’ll be branching out to other locations. We’re building a facility in Menlo Park, and we’re planning on having a Hawaii center and an East Coast center.”
The center currently employs eight radiologists. They use a teleradiology information system that gathers the images on a central national server. The radiologist can examine the images and issue a report, which immediately is entered into the VA’s hospital information system, called VistA. What differentiates this process from other teleradiology systems is that this is an entirely automated process, which operates completely on voice recognition software. There is no transcription, which means instant access to the records. The VA teleradiology system also offers national privileges. The radiologists are privileged once, and then can read for any hospital in the system.
Anderson says this new system will be the wave of the future for radiology. The plan is for the system to grow over time and eventually cover all VA hospitals. “There’s an awful lot of interest. We’re letting it grow organically. I would not be surprised if we had 20 radiologists [staffing the center] within two years,” he said.
Anderson looks forward to a time when there is always a radiologist available to do an instant read, without forcing anyone to work overnight hours. “If we were to go to midnight in Hawaii and start up at 5 a.m. in New York, then you would cover all night long [without staff working all night],” he said.
In the Navy, teleradiology has been in use for a while, but a more recent development has been the servicing of Navy ships by radiologists at naval hospitals. “Here at our institution, we have people assigned every day… who read the studies coming in from ships all over the world,” said Dr. Kevin McCarthy with the National Naval Medical Center. “We’re able to create reports and reply back as quickly as we could for any study we read here.”
New Uses for Current Modalities
In terms of new modalities that could change the face of radiology, “there is not anything really revolutionary. It is mostly improvements to old technology,” according to Anderson. But that “old technology” is finding new and improved uses, particularly in diagnostic work.
The digital mammogram is perhaps the most promising screening that will gain rapid momentum in the future. The evolution from film mammography to digital first gained interest a few years ago, when a federal study found that digital could detect more breast cancers than the conventional screening. This year, VA made a conversion to full-field digital mammography. The next step is 3-D mammographic imaging, which has yet to be FDA approved.
The Department of Veteran’s Affairs is also considering the use of virtual colonography, which employs the CT scanner to look for polyps in the colon. The traditional colonoscopy remains the gold standard, but staffing remains an issue. Virtual colonographies can offload some of the work to the CT scanner in a screening mode, and then use the colonoscope for actual biopsies. In addition, a virtual scan impacts patient care. Many patients would prefer the virtual scan to the invasive colonoscopy.
The National Naval Medical Center currently performs the virtual colonography. “We do quite a few of those here, in fact, we are one of the busier places for that technique,” said McCarthy. “[Despite being non-invasive] it’s not nearly as common a technique as you might think.” The reason why? It all comes down to the insurance companies. The procedure currently is not fully reimbursable by all medical insurers, because it is relatively new procedure. “I think five years from now, you will see a change. There is a potential for the radiology department to be extremely busy in the future, particularly with CT,” McCarthy said.
Colonel Jim Breitweser, the Army radiology specialty advisor, says radiologists at Walter Reed Army Medical Center have been “pioneers in virtual colonography... as we’ve been increasing the number of detector probes on our CT scanners, and training on the software packages. They are also very much on the cutting edge with coronary artery computed tomography.” Computed tomography appears to provide high accuracy for detecting coronary artery disease, with the added benefit that it is non-invasive, unlike the classic method of coronary angiography.
And the CT might not stop there: it could find more work in the mouths of soldiers. Carestream Health (formerly Kodak Health Group) is marketing a new CT scanner that provides undistorted, 3-D high-resolution anatomical information to dentists. According to Carestream representative Toby Smith, the Iluma ultra cone beam CT Scanner has a promising future in surgery for soldiers returning home needing dental reconstruction due to battlefield injury.
The CT could also see an increase of usage in the future for lung cancer screening. Studies have shown that using the spiral CT, a computerized X-ray scan that takes hundreds of pictures of the chest in mere seconds, can spot lung tumors smaller than a pea. Current studies are evaluating if lung cancer screening should become as commonplace as colon, breast or cervical screenings.
However, the CT isn’t the only modality that may be used for lung screenings. You need look no further than the X-ray, with some digital tweaking thrown in. Through software algorithms, a dual energy X-ray can differentiate bone from flesh. According to David Whidmann of GE Healthcare, “By taking the bones out of the X-ray exam you can now see lung nodules and lung tumors that would have otherwise been hidden by bone in your x-ray.”
Whidmann points out that this type of X-ray may be better suited for use on troops who may require long-term screening for lung issues, after being exposed to dangerous environments. “You wouldn’t want to use the high dose of a CT if you can get great results using a dual energy X-ray exam.”
Molecular Imaging
A number of research dollars are currently being directed toward molecular imaging. Molecular imaging uses probes known as biomarkers to help image various targets, whereas traditional imaging basically looks at the differences in qualities like densities or water content. Molecular imaging can image very fine molecular changes, which opens the door to early detection and treatment of diseases. Much of the current research is looking at the molecular states that occur before symptoms of disease are detected.
“It is a very exciting field, and it is going to change medicine, particularly in the field of oncology. I can see it in the future having a huge impact on medical technology and imaging technology,” said McCarthy of the NNMC.
Improvements to Current Modalities
The CT is the most recognizable study, which has changed remarkably over the last 20 years in both quality and speed.
“We are bumping up against the limits of that technology right now,” said McCarthy. “They really cannot get too much faster and have the ability to show very small abnormalities. But the engineers are being very creative in how they use the technology to study an organ in a different way.”
In MRI, there are continual refinements to image quality. In the future, one can expect a number of software improvements that allow for varied usage of the modalities, as well as faster imaging. Speed, of course, is important for the business aspect of efficiency. It also improves patient care, by reducing the time a patient must spend in the MRI machine and reducing the claustrophobic effects of the scan.
“A lot of the focus is on enhancing productivity,” according to Carestream’s Smith. “Tools to make image management and reading faster. That is truly important, if we can double the productivity of a radiologist.”
Even the X-ray can expect some big changes. “There is no question that your basic X-ray will be fundamentally transformed in the next five to 10 years. And what you can do with it, manipulate it, you can gauge the rest of the health care system around that initial diagnosis,” says Whidmann of GE Healthcare. “60 to 70 percent of all diagnostic exams are still a basic X-ray, because it is the most cost effective and low dose of the diagnostic exams.” Changes and refinements to the classic X-ray will drive a faster and more accurate diagnosis.
Looking to the Future
As technologies are continuing to evolve, how does the military decide where and when to spend money on emerging methods of imaging?
“We do not have unlimited resources available in terms of procuring equipment, so we need to be responsible… if you look at the curve of technology development, we in the military do not want to be the first medical users or even doing the clinical trials,” says Breitweser, the Army radiology specialty advisor. “But we also do not want to be the late adapters.”
Breitweser is involved in a Diagnostic Imaging and Radial Therapy Subcommittee, which evaluates and recommends emerging technology based on two important criteria: will it improve patient care, and is it the best use of taxpayer dollars in terms of applying medical care?
“We do not want to get too far behind in terms of being obsolescent, compared to what is going on in civilian practice, but we want to be responsible and make sure that we are not procuring equipment that is going down the wrong road,” said Breitweser. For example, the subcommittee has been studying digital mammography, and based on observed successes in the field, recently decided to take the first steps to switch to full field digital mammography.
“It is incremental, but if you look back a decade or if you look forward over a decade, where we are now is considerably different from where we were, and where we are going to be will be considerably different as well,” said Breitweser. “We are basically emulating what is happening in the civilian sector. We do try to make sure our decisions are the best interest of the entire Army medical department, so that a Walter Reed does not have all the high tech new equipment, but rather you can find it wherever the troops are [located].”
“The military is ahead of the curve by a lot,” said Carestream’s Smith. “They really are at the cutting edge.” ♦